Associations of acute conflict with equity in maternal healthcare: an uncontrolled before-and-after analysis of Egypt demographic and health survey data

Saji Saraswathy Gopalan, Richard Silverwood, Natasha Howard

Equity of usage of maternal services during conflict is considered key to reducing maternal health risks globally. However, evidence showing how conflict affects maternal care use among different population groups is minimal. This study examined how the Egyptian acute conflict of 2011-2012 affected maternal care use among different socioeconomic, demographic, and geographic groups. An 'uncontrolled before-and-after' study design was used to perform multi-level modelling regression analysis on 2014 Egypt Demographic and Health Survey data. The pre-conflict sample included 2569 births occurring from January 2009 to January 2011 and the peri-conflict sample included 4641 births from February 2011 to December 2012. Interaction analysis indicated that the effect of conflict on some aspects of maternal care differed by mother's age, residential status, employment, education level and household wealth. In the stratum-specific analysis, increased odds of skilled delivery during conflict was relatively greater among women who were rural (odds ratio [OR] 1.02; 95%CI 1.02-1.03), educated to primary level (OR 1.04; 95%CI 1.01-1.07), employed (OR 1.04; 95%CI 1.01-1.07), less poor (OR 1.03; 95%CI 1.02-1.05) or middle-income (OR 1.02; 95%CI 1.01-1.04), than pre-conflict. Similarly, increased odds of physician-assisted delivery during conflict was relatively greater for women who were rural (OR 1.03; 95%CI 1.02-1.04), educated to primary level (OR 1.05; 95% CI 1.01-1.10), employed (OR 1.07; 95%CI 1.02-1.11), or from less poor/middle-income (OR 1.03; 95%CI 1.01-1.05 each), and richest quintiles (OR 1.02; 95%CI 1.00-1.03). Decreased odds of postnatal care during conflict was relatively greater among women aged 25-29 (OR 0.92; 95%CI 0.88-0.96) compared to older women. The association between acute conflict and maternal services usage indicated some vertical equity, as equity patterns during conflict differed from recent trends in Egypt. The association between conflict and maternal care usage among potentially marginalised groups was minimal and not notably inequitable. Specific strategies should be included in maternal health policies to mitigate the unpredictable effect of conflict on maternal care equity. Further research is needed to determine how conflict affects out-of-pocket expenditures and quality-of-care among different socioeconomic groups.