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Not all inequalities are equal: differences in coverage across the continuum of reproductive health services
  1. Elizabeth A Sully,
  2. Ann Biddlecom,
  3. Jacqueline E Darroch
  1. Guttmacher Institute, New York City, New York, USA
  1. Correspondence to Dr Ann Biddlecom; abiddlecom{at}


Reducing inequalities in health service coverage is central to achieving the larger goal of universal health coverage. Reproductive health services are part of evidence-based health interventions that comprise a minimum set of essential health interventions that all countries should be able to provide. This paper shows patterns in inequalities in three essential reproductive health services that span a continuum of care—contraceptive use, antenatal care during pregnancy and delivery at a health facility. We highlight coverage gaps and their impacts across geographical regions, key population subgroups and measures of inequality. We focus on reproductive age women (15–49 years) in 10 geographical regions in Africa, Asia and Latin America and the Caribbean. We examine inequalities by age (15–19, 20–24, 25–34 and 35–49 years), household wealth quintile, residence (rural or urban) and parity. Data on service coverage and the population in need are from 84 nationally representative surveys. Our results show that dominant inequalities in contraceptive coverage are varied, and include large disparities and impact by age group, compared with maternal health services, where inequalities are largest by economic status and urban–rural residence. Using multiple measures of inequality (relative, absolute and population impact) not only helps to show if there are consistent patterns in inequalities but also whether few or many different approaches are needed to reduce these inequalities and where resources could be prioritised to reach the largest number of people in need.

  • Reproductive health services
  • maternal health services
  • contraception
  • universal coverage

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Handling editor Lei Si

  • Contributors ES participated in the conception of the study, performed the analyses, interpreted the results and was a major contributor in writing the manuscript. AB participated in the conception of the study, interpreted the results and was a major contributor in writing the manuscript. JD participated in the conception of the study, acquisition of the data, performed the analyses and interpreted the results. All authors read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work.

  • Funding This study was made possible by UK Aid from the UK Government and grants from the Bill & Melinda Gates Foundation, the Children’s Investment Fund Foundation and the Dutch Ministry of Foreign Affairs.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data on service coverage are available in the online supplementary table 3. All other data will be made available upon reasonable request.

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