Equity analysis for Group-ANC in Ethiopia: Exploring how wealth and educational status interact with ANC attendance and facility delivery

BackgroundGroup antenatal care promotes positive maternal health outcomes. We consider a health-equity perspective and ask whether group antenatal care at the health-post level in the rural Amhara region of Ethiopia can offer equal practicality and efficacy in elevating maternal health outcomes across socio-economic and educational levels. MethodsSecondary analysis of a stepped-wedge trial was conducted in 36 health-posts in 2021-2023. Randomization of the order of the intervention introduction was done at the health-center level. Multivariable generalized estimating equation regression models were applied to analyze the two primary outcomes of at least four antenatal care visits and facility delivery, while exploring whether mothers wealth level and mothers education status as equity variables are associated with the outcomes through an interaction effect. ResultsMothers in G-ANC in the middle wealth class had 82% lower odds of attending at least four ANC visits (OR= 0.18; 95% CI = [0.09, 0.34]; p <0.001), compared to the low wealth class. Mothers in G-ANC in the high wealth class had 92% lower odds of attending at least four ANC visits (OR= 0.08; 95% CI = [0.02, 0.32]; p <0.001), compared to the low wealth class. The intervention appeared more effective among mothers with formal education, who had over twice the odds of completing ANC visits compared to their counterparts with no schooling, though the association was marginally non-significant (OR = 2.36; 95% CI= [0.98-5.70]; p = 0.057). The interactions between the intervention and equity variables for facility delivery were non-significant. ConclusionPoorer mothers in G-ANC significantly benefitted more than those in higher wealth classes. It was less effective among mothers with no education, but not statistically significant. No effect was found of wealth or education on facility delivery.