Maternal health equity across stages of care: analysis of national surveys in 25 sub-Saharan African settings

Dr. Amina K. Abebe¹, Prof. Samuel T. Ndlovu², Dr. Grace M. Owusu³, Dr. Jean-Paul Mbarga⁴, Dr. Helen R. Kamau⁵

¹ School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
² Department of Community Health, University of KwaZulu-Natal, Durban, South Africa
³ Department of Population and Reproductive Health, University of Ghana, Accra, Ghana
⁴ Faculty of Health Sciences, University of Yaoundé I, Yaoundé, Cameroon
⁵ Institute of Tropical Medicine and Public Health, University of Nairobi, Nairobi, Kenya

Correspondence
Correspondence to: Dr. Amina K. Abebe, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia.
Email: [email protected]

Abstract

Securing access to maternal, neonatal, and child health services throughout the continuum of care is a proven approach for lowering maternal and child mortality. This study examined the scale of service dropout, socioeconomic disparities, and factors influencing inequality in maternal healthcare utilization across sub-Saharan Africa. We analysed Demographic and Health Surveys (DHS) conducted between 2013 and 2019 from 25 sub-Saharan African nations. Continuum of care for maternal services was defined as women who accessed a minimum of four antenatal visits (ANC 4+contacts), skilled birth attendance, and immediate postnatal care (PNC). Wealth-related inequalities across this continuum were measured using the concentration index. Multilevel logistic regression models identified determinants of inequality in completing the continuum of care. Data from 196,717 women with their most recent live birth were assessed. While 87% of women reported at least one ANC visit, only 30% obtained the full package comprising ANC 4+contacts, skilled delivery care, and PNC. Completion of the continuum ranged from 6.5% in Chad to 69.5% in Sierra Leone. Nearly 9% of women had no interaction with the health system during pregnancy or childbirth, with country-level variation from 0.1% in Burundi to 34% in Chad. Women from poorer households were more likely to lack contact with services and less likely to complete the recommended care package than wealthier counterparts. Higher education, greater exposure to mass media (radio and television), and higher household wealth increased the likelihood of completing the continuum of care. Substantial and persistent disparities were evident across the continuum of care, with socioeconomically disadvantaged women experiencing greater dropout at multiple stages. Enhancing service integration and equitable access is vital for improving maternal health outcomes. Strategies to strengthen maternal health should specifically address populations and communities with consistently low service coverage.

Keywords: Equity, Socioeconomic disparities, Maternal health, Continuum of care, Sub-Saharan Africa.

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INTRODUCTION

Preventable maternal mortality remains a major global concern, particularly in low- and lower-middle-income countries (LLMICs) [1, 2]. Women in sub-Saharan Africa face the greatest vulnerability, with pregnancy- and childbirth-related complications contributing to 70% of all maternal deaths worldwide in 2020 [3].

Over the last twenty years, numerous reforms have been introduced worldwide to strengthen health systems and meet population needs [4]. In many low- and middle-income contexts, these reforms have focused on promoting equity, expanding infrastructure, and reducing maternal and child mortality [4, 5]. Nonetheless, the anticipated reductions in maternal deaths have not been fully realized. Between 1990 and 2022, global coverage rose substantially—ANC 1+ from 65% to 88%, ANC 4+ from 37% to 66%, and skilled birth attendance from 57% to 86% [6, 7]. Despite such progress, maternal mortality has stagnated since 2015, with extreme disparities persisting: a woman’s lifetime risk of dying from pregnancy or childbirth remains over 100 times higher in sub-Saharan Africa compared to high-income regions [3].

This divergence between service coverage and mortality reduction underscores gaps in care quality. Availability alone is insufficient; poor quality limits improvements in maternal and child health (MCH) outcomes [8, 9]. For instance, a study of 192 DHS datasets revealed that institutional deliveries had only a weak relationship with reductions in early neonatal deaths, suggesting that both service use and quality need strengthening to further decrease maternal and child mortality [10].

Although access to services has expanded globally, care quality continues to lag behind, becoming a central obstacle to improving MCH outcomes in many low-income countries [7, 8]. Disadvantaged groups are especially affected—when they can reach services, the care provided is often substandard [3, 7]. In fragile, conflict-affected, or politically unstable settings, inadequate quality overlaps with limited access, amplifying inequities and disproportionately harming vulnerable populations [11].

Another barrier is the lack of continuity across pregnancy, childbirth, and the postnatal phase [12, 13]. Ensuring equitable access to quality care along this continuum is essential for better outcomes and for achieving the maternal health–related Sustainable Development Goal (SDG) target [12, 14]. Yet, in many LLMICs, health services remain fragmented and weakly integrated, particularly during delivery and the immediate postnatal stage [2, 15]. Moreover, inequalities in MCH coverage persist within and across countries, shaped by geography, gender, religion, ethnicity, wealth, and other socioeconomic factors [16].

To effectively address these disparities, there is a need to generate evidence on inequality and its underlying drivers. This study investigates inequities and dropout patterns along the maternal healthcare continuum. We assess levels of discontinuity in the care pathway, examine wealth-related inequalities within countries, identify factors associated with inequitable access, and discuss their implications for strengthening health systems.

Methods

Data
This study utilised the most recent DHS datasets from 25 sub-Saharan African countries conducted between 2013 and 2019. The surveys included were Angola (2015), Burundi (2016–17), Cameroon (2018), Chad (2014–15), Democratic Republic of Congo (2013–14), Benin (2018), Ethiopia (2016), Ghana (2014), Guinea (2018), Kenya (2014), Lesotho (2014), Malawi (2015–16), Mali (2018), Namibia (2013), Nigeria (2018), Rwanda (2014–15), Senegal (2017), South Africa (2016), Zimbabwe (2015), Uganda (2016), Tanzania (2015), Zambia (2018), Gambia (2013), Togo (2013–14), and Sierra Leone (2019).

The DHS program applies harmonised protocols and standardised questionnaires to ensure comparability across time and countries. Survey design and sampling procedures are consistent across participating nations, with detailed methodologies reported elsewhere [17]. For this analysis, we included women who had experienced at least one live birth within the five years preceding their respective surveys. To minimise recall bias, we restricted the analysis to the most recent live birth.

Measures

The principal outcome was the continuum of care for maternal health services. We defined this continuum as completion of three services: at least four antenatal contacts (ANC 4+contacts), skilled birth attendance, and postnatal care (PNC) within two days after delivery. ANC 4+contacts was used since all surveys in our dataset followed the earlier WHO recommendation of four antenatal visits.

Coverage of ANC 4+contacts was calculated as the share of women reporting four or more ANC visits with a qualified provider during their last pregnancy. To assess adequacy of ANC, we examined five standard interventions consistently available across all DHS surveys: iron supplementation, blood pressure measurement, urine testing, blood testing, and tetanus immunisation at delivery. Early ANC initiation was defined as contact before 12 weeks of gestation; women with no ANC or first contact after 12 weeks were classified as having delayed initiation.

Skilled birth attendance (SBA) was defined as the proportion of deliveries assisted by qualified health personnel, such as doctors, nurses, midwives, auxiliary midwives, or cadres officially recognised as skilled providers in each country. PNC coverage was measured as the proportion of women receiving a check from a skilled professional (doctor, nurse, midwife, auxiliary midwife, or country-recognised cadres) within two days of childbirth. Examples of these cadres include health extension workers in Ethiopia and maternal and child health (MCH) aides in Tanzania.

Covariates

To explore the factors shaping inequality in completing the continuum of care, we applied the framework proposed by the WHO Commission on Social Determinants of Health [16]. Women’s socioeconomic position was assessed using household wealth index and educational attainment. The DHS wealth index is constructed through principal component analysis of household assets, including television (TV), radio, refrigerator, and vehicle ownership, housing materials, and access to sanitation and clean water. Based on this index, households were classified into quintiles, ranging from poorest to richest.

Maternal education was grouped into four categories: no education, primary, secondary, and higher. Women were also asked whether they faced serious difficulties in accessing healthcare when ill. We identified distance to facilities and cost of treatment as barriers and categorised these as “not a big problem” or “big problem.” Exposure to media was measured through the reported frequency of reading newspapers, listening to the radio, or watching TV, grouped as “not at all,” “less than once a week,” or “once a week or more.” Place of residence was classified as urban or rural. Additional covariates included maternal age (15–24, 25–29, 30–49) and parity (1–6).

Statistical analysis

We mapped geographic patterns of maternal health services—including ANC 4+contacts, skilled delivery care, and PNC—at national and subnational levels using ArcGIS version 10.7.1.

To investigate attrition across the continuum of care, we computed frequencies and proportions at each service contact point: at least one ANC visit, ANC 4+contacts, skilled care during delivery, and immediate PNC. A decision tree framework was applied to illustrate women’s service use trajectories across the care pathway.

We assessed wealth-related inequalities using the concentration index (CCI) [18]. This index quantifies the distribution of a health outcome (e.g., ANC 4+contacts) across socioeconomic groups, with values between −1 and +1. A value of zero denotes equality, positive values reflect pro-rich distribution, and negative values indicate concentration among poorer women.

To identify determinants of inequality in care completion, we employed multilevel logistic regression models. Because DHS surveys rely on multistage cluster sampling, with women nested within Primary Sampling Units (PSUs) and PSUs within countries, we applied a three-level model: women at level 1, clusters at level 2, and countries at level 3 [17, 19, 20].

Model building began with an unconditional model (no predictors) and proceeded stepwise. Analyses were conducted using a Generalized Latent Linear Mixed Model (GLLMM) in Stata, which accounted for hierarchical data and survey weights [19]. The full model specified three levels: level 1 included women (184,567) and household factors; level 2 accounted for 14,590 PSUs; and level 3 adjusted for country. The initial weighted sample comprised 196,717 women, but due to missing responses, the analytic sample for regression was reduced to 184,567.

Model construction followed four stages. In the first stage, community-level barriers (distance, financial difficulties, residence type) were included in the baseline model, and significant variables were retained. In Model 2, socioeconomic factors—wealth, education, and healthcare access barriers—were added. Model 3 incorporated maternal characteristics (age, parity). The final model (Model 4) added exposure to media. Only predictors with statistical significance (p<0.05) were retained at each stage.

To check robustness, we validated results with univariable analysis and backward elimination. Variables with p<0.20 in univariable analysis were entered into backward elimination. Multicollinearity was assessed using variance inflation factors, with no evidence detected. Correlations among covariates were summarised using a correlation matrix (Fig. 1). Findings are presented as adjusted odds ratios (ORs), with significance set at p<0.05. All analyses were performed in Stata version 16.1 and IBM SPSS Statistics version 27.0 (Chicago, IL, USA).

Results

Coverage of maternal health services

The analysis included 196,717 women who had experienced a live birth within the five years preceding the surveys. Overall, 87% of women reported at least one ANC visit (ANC 1+), 56% had four or more ANC contacts, 70% delivered with skilled assistance, and 48.2% received PNC within two days of delivery. Coverage of ANC 4+contacts was highest in Sierra Leone (89.5%) and lowest in Chad (31.7%) (Fig. 2). Skilled birth attendance ranged widely, from 21.9% in Chad to 95.9% in South Africa (Fig. 3). Postnatal care coverage peaked in Gambia at 87.9% but was lowest in Ethiopia at 16.5% (Fig. 4).

Only one-third of women (33.2%, 95% CI: 32.7–33.7) initiated ANC early. Country-specific rates varied, with Ghana reporting the highest early initiation (61%) and the Democratic Republic of Congo the lowest (17%). Regarding ANC content, 43% (95% CI: 42.4–43.7) received all five essential services—iron supplementation, blood pressure screening, urine testing, blood testing, and tetanus immunisation at birth. This ranged from 9.2% in Burundi to 68% in Sierra Leone. Across interventions, 87.3% of women had blood drawn, 84.6% had blood pressure assessed, 67% underwent urine testing, and 83% received iron tablets, but only half reported receiving medication for intestinal parasites during pregnancy.

 

Continuum of care coverage

Less than half of women (44.6%, 95% CI: 44–45) received both ANC 4+contacts and skilled delivery care. A similar proportion (44.6%, 95% CI: 44–45.2) had at least one ANC visit, skilled birth assistance, and PNC within two days postpartum. Only 29.8% (95% CI: 29.2–30.3) completed the full recommended care package of ANC 4+contacts, skilled birth attendance, and timely PNC (Fig. 5). Coverage of the full continuum varied substantially, from 69.5% in Sierra Leone to just 6.5% in Chad. Namibia (53.4%), Gambia (52.1%), Ghana (65.2%), and South Africa (65.4%) also reported relatively high completion rates (Fig. 6).

Progression along the care continuum showed a consistent decline, with dropout ranging from 30.5% in Sierra Leone to 93.5% in Chad. Overall, 8.5% of women (95% CI: 8.2–8.9) had no contact with the health system during pregnancy or childbirth. Country-level variation was stark, from 0.1% in Burundi to 34% in Chad. High rates of no contact were also observed in Mali (12%), Angola (15%), Nigeria (21.3%), and Ethiopia (33.5%).

 

Inequalities in the continuum of care

Across the 25 countries, wealth-related disparities in the continuum of care were substantial, with an absolute gap of 29 percentage points between the poorest quintile (18.4%) and the richest quintile (47.4%). In some settings, the difference was even greater, surpassing 50 percentage points in Ghana (50.4%), Togo (54.8%), Cameroon (57.7%), and Nigeria (60.1%). Figures 6 and 7 illustrate inequities in service coverage along the continuum of care. Positive CCI values indicated a disproportionate concentration of coverage among wealthier groups, while negative values reflected higher use among poorer groups.

As shown in Fig. 7, disparities grew wider at successive points of care. Coverage and inequality were lowest for ANC 1+, but inequalities became more pronounced for ANC 4+contacts, and even greater for skilled birth attendance across nearly all countries. Figure 8 presents concentration indices for women with no service contact, those with ANC 4+contacts, and women completing the full care package. In most contexts, inequalities persisted and widened as women progressed along the continuum. Poorer women were disproportionately likely to lack contact with skilled providers during pregnancy and childbirth. Having no contact with health services was concentrated among the poorest households.

Inequalities in ANC 4+contacts were evident in nearly every country, except Burundi, Gambia, and Zambia, where wealth differences were negligible. In Sierra Leone, ANC 4+ coverage was slightly concentrated among poorer women (CCI = −0.031), whereas Guinea showed the highest pro-rich inequality (CCI = 0.222). Strong pro-rich concentration was also observed in Angola, Nigeria, and Ethiopia. Overall, the largest disparities in the continuum of care were recorded in Angola (CCI = 0.37), Chad (CCI = 0.342), Guinea (CCI = 0.362), Nigeria (CCI = 0.384), and Ethiopia (CCI = 0.404).

Predictors of inequality are summarised in Table 1. Older age, higher education, media exposure, and wealthier household status were all positively associated with completing the continuum of care. Compared with women aged 15–24, those aged 25–29 (AOR 1.28, 95% CI: 1.21–1.36), 30–34 (AOR 1.58, 95% CI: 1.44–1.74), and 35–49 (AOR 1.81, 95% CI: 1.54–2.12) were more likely to complete care. Education had a strong positive effect: women with secondary or higher education (AOR 1.77, 95% CI: 1.46–2.15) and those with primary education (AOR 1.36, 95% CI: 1.16–1.59) had higher odds compared to those with no education. Exposure to newspapers at least weekly increased the likelihood of completion (AOR 1.23, 95% CI: 1.11–1.38).

Household wealth showed a graded effect. Women in the richest quintile had the highest odds of completing the continuum (AOR 1.87, 95% CI: 1.39–2.52), followed by those in Q4 (AOR 1.52, 95% CI: 1.21–1.91) and Q3 (AOR 1.29, 95% CI: 1.10–1.51), relative to women in the poorest quintile. Conversely, barriers such as financial difficulties, distance to facilities, and rural residence were negatively associated with care completion. Women citing cost as a problem had 9% lower odds of completion (AOR 0.91, 95% CI: 0.86–0.97). Long travel distances reduced odds by 10% (AOR 0.90, 95% CI: 0.83–0.98). Rural residence was strongly disadvantageous, with women from rural areas having 28% lower odds (AOR 0.72, 95% CI: 0.62–0.85) compared to urban women.

 

Discussion

Sustained engagement with ANC, SBA, and PNC services is vital for improving maternal and child health (MCH) outcomes [12]. Despite this, utilization of these services in many sub-Saharan African countries remains either limited or fragmented. In our analysis, while 87% of women made at least one antenatal contact, only 30% completed the full continuum of care.

Globally, more than half of maternal and newborn deaths occur during birth and the first few days thereafter [21]. This period represents the highest risk for both mothers and infants, yet access to appropriate care is often restricted. In our study, just 48% of women reported receiving PNC within two days of delivery. This limited uptake may reflect the tendency of national MCH programs to emphasize skilled birth attendance (SBA) over other essential services [13]. We observed that SBA coverage was higher than ANC 4+contacts, with the lowest service coverage occurring during the postpartum stage.

Marked disparities were evident by geography and wealth. Geographic inequalities are often linked to underdeveloped regions lacking adequate facilities, infrastructure, and educational opportunities, contributing to poor service utilization [22]. Populations in remote or marginalized communities are disproportionately affected.

Dropout from care across the continuum was notable, consistent with earlier studies [23–25]. One explanation for the gap between ANC1 and ANC4+contacts is delayed initiation and limited quality of care at early visits. In our sample, 63% of women began ANC late, and the content of care was inadequate across all countries and socioeconomic levels. Even among women completing four or more visits, fewer than half reported receiving essential interventions such as blood and urine testing, iron supplementation, blood pressure checks, and tetanus vaccination. This highlights deficiencies in ANC quality, aligning with earlier findings from the region [26]. Although WHO’s 2016 guidance increased the recommended minimum contacts from four to eight, expanding visit numbers alone will not enhance outcomes without parallel improvements in service quality [27].

Strengthening postpartum care offers one of the greatest opportunities to reduce maternal and neonatal mortality [2, 28]. Yet, postpartum services often receive less attention, despite the fact that this period is highly dangerous: over 60% of maternal deaths and nearly half (47%) of under-five deaths occur then [1, 13, 29]. Many women and infants are discharged within hours of delivery, leaving critical needs unmet [13, 30]. Inadequate follow-up, weak program linkages, and unclear professional responsibilities further contribute to poor postnatal coverage [2, 12].

Our findings confirm that coverage across the continuum is low, with sharp inequalities by socioeconomic status. Women with the fewest resources face the greatest barriers to care, even though they shoulder the heaviest burden of mortality and morbidity [2, 31]. For instance, rates of no maternal contact were 14% higher among the poorest than the richest. In Chad (39%), Angola (40%), Nigeria (43%), and Ethiopia (50%), more than one-third of women in the poorest quintile reported no care at all, while fewer than 1% of the richest did so in 20 of the 25 countries examined. Overall, the gap in full continuum coverage reached 29 percentage points between the poorest (18.4%) and richest (47.4%) groups.

Countries such as Nigeria, Ethiopia, Chad, Guinea, Angola, and the Democratic Republic of Congo showed particularly low coverage and high inequality, reflecting fragile health systems [32]. In 2018, their access and quality of care scores were among the lowest worldwide, with Nigeria ranked 142nd, Angola 162nd, DRC 181st, Ethiopia 184th, Guinea 190th, and Chad 192nd of 195 nations. These same countries also scored poorly on the Universal Health Coverage (UHC) index, with Nigeria (42), Angola (39), Ethiopia (38), DRC (39), Guinea (37), and Chad (28), all below 45 [33]. Conversely, stronger health systems in South Africa, Ghana, Kenya, and Rwanda supported better coverage and lower inequalities [32].

The high proportion of women initiating contact (87%) indicates an opportunity to improve MCH by delivering integrated, high-quality services spanning ANC, skilled birth care, PNC, and linked neonatal and child health interventions. Yet, persistent challenges—including poorly implemented service packages, weak linkages across care stages, and neglect of essential interventions—undermine progress [2, 13]. Delays in care-seeking, financial barriers, and inadequate quality of facility-based services further exacerbate poor outcomes [12, 29].

Consistent evidence highlights poor quality of care as the greatest barrier to advancing maternal health outcomes. Expanding access alone cannot achieve the necessary improvements. Our findings suggest that inadequate quality substantially contributed to the high dropout observed across the continuum of care. Although 87% of women accessed services, most failed to complete the pathway. This underscores that improved access, even when equitably distributed, will not translate into better health unless the services delivered are effective and of sufficient quality. Moreover, quality initiatives that overlook vulnerable groups risk perpetuating inequities. Achieving meaningful maternal health gains requires ensuring that all women, regardless of socioeconomic status or place of residence, have access to high-quality care—including those currently excluded from the system.

Several factors were associated with inequalities in MCH service use. Women who were older, had fewer children, attained primary or higher education, belonged to wealthier households, or were exposed to mass media had higher odds of completing the continuum. Education and media exposure likely reduce knowledge gaps, promote awareness, and shape positive attitudes toward care, thereby facilitating early ANC initiation and service completion. This aligns with earlier studies [23, 24, 26, 34].

Conversely, women in rural or remote areas, those traveling long distances to facilities, and those lacking financial resources were less likely to complete care. Rural and marginalized groups remain the most underserved [35–37]. In sub-Saharan Africa, rural women consistently reported lower SBA rates than their urban peers [34]. Yet urban disadvantage also persists, as poverty remains a key driver of inequality in access. For instance, caesarean section rates are lowest among the poorest women across both rural and urban settings [34].

Inequities extend beyond access. Mistreatment during pregnancy and childbirth—ranging from verbal to physical abuse—is widespread, disproportionately affecting poor women [38–41]. Such experiences undermine trust in health systems and discourage service use, further entrenching disparities [38].

This study has several strengths. It draws on large, nationally representative DHS datasets across multiple sub-Saharan African countries and employs diverse approaches to examine inequalities along the maternal health continuum. Nonetheless, limitations exist. DHS data are self-reported and subject to recall bias over a five-year period. Additionally, the most recent surveys for some countries date back to 2013, meaning current patterns may differ. Finally, as DHS datasets only include surviving women, maternal deaths along the care pathway could not be assessed.

Policy Considerations

Positioning the continuum of care as a central strategy is key to achieving broad coverage of maternal, neonatal, and child health interventions [12]. To reduce deaths and morbidity most effectively, these services must reach mothers and children at the right level and at the right time. Based on our findings, we outline the following policy priorities.

First, strengthen access across the continuum by ensuring better integration of services by location and timing to minimize dropouts [2, 12, 13]. Our results highlight that women who were poorest, rural-based, and lacking education or media exposure had the highest attrition. Meeting the needs of these underserved groups requires bridging home- and community-based care with quality services at primary facilities and referral hospitals. This is essential to bring women closer to care and care closer to women.

One promising approach is the use of maternal waiting homes—community-based accommodations near health centers or hospitals that allow pregnant women to stay close to services as delivery approaches, reducing delays in labor and emergencies. Another is the implementation of Birth Preparedness and Complication Readiness (BP/CR) programs, which empower families and communities to prepare for childbirth, recognize danger signs, and identify where to seek timely treatment. Strengthening these linkages would increase community engagement, improve service utilization, and ensure timely referrals for women and newborns with complications, ultimately enhancing survival.

Second, improving quality across the continuum is critical to boosting service uptake. Weak service quality remains a major challenge in health systems worldwide [42]. For poor and marginalized populations, the problem is even greater, as they may not only receive substandard technical care but also face disrespect or mistreatment [38]. Such negative experiences discourage women from continuing care and reduce trust in the health system.

Third, prioritize access for vulnerable populations by implementing equity-oriented interventions tailored to their poverty status, geography, and other markers of vulnerability [14, 43]. This ensures that the women most at risk of exclusion are specifically targeted.

Fourth, provide financial and structural support for disadvantaged women. Investments in transport infrastructure and user subsidies can significantly reduce barriers to care. Conditional cash transfer (CCT) programs, in particular, have shown promise. By directing financial support to poor households, these programs encourage uptake of essential health services. Evidence confirms that well-targeted CCT schemes increase healthcare utilization among the poorest women and children [44, 45].

 

Conclusion

The overall coverage of the continuum of care remained low across all study countries and socioeconomic groups. Our analysis revealed persistent and widening disparities, with women from disadvantaged backgrounds disproportionately discontinuing care during pregnancy, childbirth, and the postnatal period. These women were also more likely to have no interaction with the health system at all, while wealthier women were better able to complete the continuum of care. Women who successfully accessed care throughout the continuum were typically wealthier, educated, urban-based, exposed to mass media, and lived closer to health facilities. To improve outcomes for mothers and children, stronger service integration and broader access to high-quality care are essential. Policy and program efforts to enhance maternal health should prioritize underserved groups and communities with the lowest levels of service coverage.

 

 

 

4. BASIS OF ANTIBIOTIC RESISTANCE

Antibiotic resistance represents an evolutionary adaptation of bacteria to survive exposure to antimicrobial agents. Clinically, pathogens are initially susceptible when an antibiotic is introduced, but with repeated exposure, bacteria develop resistance. From an evolutionary standpoint, resistance arises either through chromosomal mutations or the acquisition of foreign genetic material via horizontal gene transfer (HGT), which carries resistance determinants. Mutations typically target three types of genes: those encoding antibiotic targets, transport proteins involved in drug influx/efflux, and regulators that control expression of efflux pumps or antibiotic-modifying enzymes, thereby enabling resistance. Evidence suggests that commensal or environmental bacteria act as reservoirs of resistance genes, which are subsequently transferred to pathogenic bacteria through HGT [24]. Many antibiotics are naturally produced by environmental microorganisms. To prevent self-toxicity, these organisms inherently possess resistance genes, allowing them to survive their own antibiotic production [25]. Resistance in bacteria can arise from intrinsic, acquired, or adaptive mechanisms [26].

Intrinsic resistance refers to the inherent ability of bacteria to resist specific classes of antibiotics due to naturally occurring chromosomal genes, without requiring mutations or external gene acquisition. This form of resistance often involves efflux pumps and reduced membrane permeability, and may affect multidrug efflux systems [27,28]. Acquired resistance occurs when previously susceptible bacteria gain resistance through chromosomal mutations or the uptake of exogenous genes via HGT. HGT can occur through transformation, transposition, or conjugation, with plasmid-mediated conjugation being the most common. Acquired resistance can be either temporary or permanent, depending on the genetic context [29,30]. Adaptive resistance is a conditional, environmentally induced phenotype that may be transient or persistent depending on selection pressures. Exposure to subinhibitory concentrations of antibiotics, along with environmental cues such as nutrient availability, stress, pH, and ion concentrations, can induce adaptive resistance in bacteria found in humans and livestock. Unlike intrinsic and acquired resistance, adaptive resistance generally reverts to the original phenotype when the inducing conditions are removed. Although the underlying biological mechanisms remain incompletely understood, factors such as high mutation rates, gene amplification, efflux pumps, biofilm formation, epigenetic inheritance, population heterogeneity, and microbial community structure have been implicated in its development [31,32].

 

5. SOURCES AND ROUTES OF TRANSMISSION OF AMR

The spread and acquisition of antimicrobial resistance (AMR) primarily occur through human-to-human interactions, both within healthcare settings and in the community. Various reservoirs—including humans, animals, water, and the broader environment—harbor antimicrobial-resistant genes, which can transfer between and within these reservoirs. Transmission patterns vary significantly depending on the bacterial species and the specific resistance determinants involved [33]. Certain hotspot sources significantly facilitate the dissemination of resistant bacteria, such as wastewater and sludge from urban treatment plants, and natural fertilizers including pig slurry, cow manure, and poultry-derived fertilizers [34]. Another direct route involves the use of antibiotic-treated animal feeds, with resistant bacteria subsequently transmitted to humans through the consumption of these animals [35]. Additional transmission pathways include ingestion of fecal-contaminated food or water and direct human-animal contact, which further promote the movement of resistance genes across species [36].

 

6. MECHANISMS OF DRUG RESISTANCE

In natural ecosystems, antimicrobials and bacteria coexist, and bacteria have evolved various strategies to counteract the inhibitory effects of antibiotic molecules. Antibiotics primarily target four essential bacterial components: the cell wall, cell membrane, protein synthesis machinery, and nucleic acid synthesis. The primary mechanisms by which bacteria acquire resistance include: reducing drug uptake, modifying drug targets, inactivating the drug, and enhancing active drug efflux (Figure 2). Intrinsic resistance mechanisms often rely on restricted drug entry, enzymatic drug inactivation, and efflux pumps. Structural differences between Gram-positive and Gram-negative bacteria contribute to variations in their resistance strategies. Gram-positive bacteria, lacking an outer lipopolysaccharide (LPS) membrane, rely less on restricting drug uptake and have a limited capacity for efflux of certain antibiotics [37,38]. In contrast, Gram-negative bacteria employ all four primary resistance mechanisms, including limiting uptake, modifying targets, drug inactivation, and active efflux, making them particularly adept at surviving in the presence of diverse antibiotics.

6.1. Limiting Drug Uptake

In Gram-negative bacteria, lipopolysaccharide (LPS), a highly acylated glycolipid, constitutes a major part of the outer membrane and acts as a permeability barrier to numerous compounds, including antibiotics. This intrinsic feature reduces the entry of certain antibiotics, contributing to natural resistance. Additionally, alterations in outer-membrane proteins, particularly porins, can result in acquired resistance. Porins function as primary channels for hydrophilic antibiotics such as β-lactams, fluoroquinolones, tetracyclines, and chloramphenicol. The number and type of porin proteins influence antibiotic uptake, directly affecting bacterial susceptibility [39]. Acquired resistance can also arise from mutations that reduce porin expression or impair their function. When these mutations coincide with other resistance mechanisms—such as efflux pumps or enzymatic antibiotic degradation—they can confer high-level resistance [40]. Another important mechanism is biofilm formation by bacteria including Enterococcus faecalis, Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus viridans, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa. Biofilms are structured communities of microbial cells embedded in self-produced exopolysaccharide matrices attached to biotic or abiotic surfaces. Biofilms confer enhanced tolerance and resistance to antibiotics by obstructing drug penetration and preventing the maintenance of bactericidal concentrations throughout the microbial community [41,42].

 

6.2. Modification of Targets for Drug

Bacteria can evade antibiotics by modifying the drug’s target, thereby preventing effective binding. These modifications typically arise from spontaneous mutations in genes encoding the target proteins. For example, mutations in the quinolone-resistance-determining region (QRDR) of DNA gyrase (topoisomerase II and IV) result in fluoroquinolone resistance in both Gram-positive and Gram-negative bacteria [43]. Methylation represents another efficient strategy for target modification. Methylases such as erm genes confer resistance to macrolides, lincosamides, and streptogramin B antibiotics across Gram-positive and Gram-negative species. Similarly, methylation of the cfr gene has been associated with resistance in multiple bacterial genera, including Proteus vulgaris, Staphylococcus spp., Enterococcus spp., Bacillus spp., and E. coli [44]. In Staphylococcus spp., resistance to β-lactam antibiotics is significantly enhanced by the expression of alternative penicillin-binding proteins, encoded by the mecA and mecC genes, which reduce the drug’s binding affinity [45,46].

 

6.3. Inactivation of Drug

Bacteria can acquire antibiotic resistance by inactivating drugs, which occurs through two main mechanisms: either the antibiotic molecule is chemically degraded, or a functional chemical group is transferred onto it. A well-known example involves β-lactamases, hydrolyzing enzymes produced by members of the Enterobacterales family, which effectively inactivate β-lactam antibiotics. Initially referred to as penicillinases and cephalosporinases, these enzymes open the β-lactam ring, preventing the antibiotic from binding to its target, the penicillin-binding proteins. Many Enterobacterales species, as well as Gram-positive bacteria like Staphylococcus aureus, Enterococcus faecalis, and Enterococcus faecium, carry β-lactamase genes, often transmitted via horizontal gene transfer (HGT). Similarly, tetracycline inactivation occurs through hydrolysis mediated by an enzyme encoded by the tetX gene in certain bacterial strains [47]. Other common chemical modifications for drug inactivation include acetylation, phosphorylation, and adenylation. Phosphorylation and adenylation are frequently employed against aminoglycosides, while acetylation is a versatile mechanism acting on aminoglycosides, chloramphenicol, streptogramins, and fluoroquinolones [38].

 

 

 

6.4. Efflux of Drug

Bacteria use energy-dependent efflux pumps located in the cytoplasmic membrane to regulate the intracellular concentration of antibiotics and other toxic compounds. By actively expelling harmful agents, including antibiotics, metabolic byproducts, and quorum-sensing molecules, efflux pumps help bacteria maintain homeostasis. The first plasmid-encoded efflux pump was described in Escherichia coli in 1980, which transported tetracycline out of the cell. Since then, a wide range of Gram-positive and Gram-negative bacteria with diverse efflux mechanisms have been identified. Most efflux systems are multidrug pumps that are chromosomally encoded, contributing to intrinsic bacterial resistance [48]. In contrast, substrate-specific pumps targeting antibiotics like chloramphenicol, tetracyclines, and macrolides are often carried on mobile genetic elements [38,49]. Based on structure and energy source, six major families of efflux pumps exist: ATP-binding cassette (ABC) superfamily, major facilitator superfamily (MFS), multidrug and toxic compound extrusion (MATE) family, small multidrug resistance (SMR) family, resistance–nodulation–division (RND) superfamily, and drug/metabolite transporter (DMT) superfamily. In Gram-positive bacteria, most efflux pumps belong to the ABC and MFS families, encoded either chromosomally or on plasmids. Conversely, in Gram-negative bacteria, the clinically significant pumps are primarily members of the RND superfamily, composed of an outer-membrane channel, a periplasmic adaptor, and a cytoplasmic membrane pump [50].

 

7. DRIVERS OF AMR

Antimicrobial resistance (AMR) is driven by a complex interplay of microbial traits and environmental factors, encompassing behaviors of both prescribers and consumers. Broadly, the factors contributing to AMR can be classified into four categories: environmental factors (e.g., overcrowded populations, rapid transmission through travel, poor sanitation, ineffective infection control programs, and extensive agricultural antibiotic use), drug-related factors (e.g., counterfeit or substandard medications, and over-the-counter availability), patient-related factors (e.g., poor compliance, poverty, lack of education, self-medication, and misconceptions), and physician-related factors (e.g., inappropriate prescription, inadequate dosing, and lack of updated training) [38,51]. The major AMR-driving factors are elaborated below.

 

7.1. Misuse and Overuse of Antibiotics

Although antibiotic resistance naturally occurs as part of microbial evolution, its rate has been significantly accelerated by misuse in humans and animals. Epidemiological studies reveal a causal relationship between overuse and the emergence of resistance [52]. Despite repeated warnings from health organizations, antibiotic misuse continues at alarming levels worldwide, with the current scenario approaching a critical tipping point. Global surveys indicate that misconceptions about antibiotics are widespread, particularly among less-educated populations, including the belief that antibiotics are effective against common viral infections such as colds or flu. In many developing countries, antibiotics are overprescribed, partly due to inadequate diagnostic facilities [53]. Examples of misuse include administering antibiotics without proper indication. The unregulated over-the-counter availability of antibiotics for both humans and animals further accelerates resistance. Lack of national antibiotic policies and standard treatment guidelines exacerbates the problem, while substandard or poor-quality antibiotics in supply chains worsen AMR in several developing nations. Additionally, physicians may prescribe prolonged courses or inappropriate doses, sometimes influenced by financial incentives or patient expectations [53,54].

 

7.2. Increase in Gross Domestic Product (GDP)

The global rise in antibiotic use has been closely linked to increases in GDP, particularly in developing countries. Economic growth has improved living standards in low- and middle-income countries, which correlates with higher consumption of antibiotics. Between 2000 and 2015, global antibiotic use rose by approximately 65% [55]. Alongside this, greater consumption of animal protein has contributed to the transmission of AMR from animal sources in these countries [56].

 

7.3. Inappropriate Prescribing Patterns

Improper prescription practices are a major driver of AMR [57]. This includes prescribing antibiotics unnecessarily, selecting the wrong antibiotic, or using incorrect doses and durations [58]. Studies have shown that at least 50% of hospital patients receive antibiotics without compelling clinical indications. Ideally, antibiotic therapy should be guided by isolation and antimicrobial susceptibility testing, yet a CDC report (2017) found that roughly one-third of hospital patients received antibiotics without proper testing, often continued for excessive durations [59]. Nursing homes display even higher rates of misprescription, with approximately 75% of antibiotics prescribed incorrectly in terms of drug, dose, or duration [60].

 

7.4. Paucity of Futuristic Antibiotics

The growing threat of antibiotic resistance underscores the urgent need for novel drug development [61]. Unfortunately, despite repeated calls from the WHO, the pharmaceutical pipeline remains sparse. Of 51 newly developed antibiotics, only 8 are truly innovative, with the majority being reformulations of older drugs. Consequently, resistance may emerge rapidly against these new agents. The limited availability of new drugs has seriously compromised treatment of drug-resistant TB, urinary tract infections, pneumonia, and Gram-negative infections, leaving vulnerable populations, such as the very young and elderly, at heightened risk [62]. Regulatory constraints and economic considerations are major barriers to antibiotic innovation. Many pharmaceutical companies have reduced investments in antibiotic R&D, and 18 major firms have abandoned production entirely. Prioritizing profitability, pharma companies have shifted focus to drugs for chronic diseases rather than infectious diseases, further limiting the development of lifesaving antibiotics.

 

7.5. Agricultural Use of Antibiotics

The use of antibiotics in livestock farming has increased substantially in many developing countries, largely driven by the growing demand for animal protein. This practice contributes to the rise of AMR due to residues of antibiotics in animal-derived products, such as muscles, kidney, liver, fat, milk, and eggs. Antibiotics are commonly applied for various purposes, including treating animal illnesses, supplementing feed to promote growth, enhancing feed conversion efficiency, and disease prevention [63]. The widespread and often unregulated use of antibiotics in food animal production, particularly in developing countries seeking higher farm incomes and lacking strict government policies, has become a significant contributor to human AMR [64]. In the United States, approximately 70% of medically important antibiotics are sold for use in animals [65]. A major concern is that antibiotics used in veterinary practice often share types, mechanisms of action, or classes with human-prescribed antibiotics, raising the risk of cross-resistance.

 

7.6. Easy Travel Routes

The global spread of antibiotic-resistant bacteria is increasingly facilitated by human mobility. Modern travel, including the movement of humans, animals, and goods, contributes significantly to the dissemination of AMR worldwide [66]. Travelers to regions with high endemicity of resistant pathogens may unknowingly carry antimicrobial-resistant organisms back to their home countries. Studies show that such bacteria can persist in the human body for up to 12 months after travel, creating a prolonged window for transmission to susceptible populations [67].

 

7.7. Knowledge Gap

Evidence indicates that both healthcare workers (HCWs) and the general public have substantial gaps in knowledge regarding appropriate antibiotic use and the mechanisms driving antibiotic resistance [68]. Effective surveillance is essential to quantify the burden of AMR and design targeted intervention strategies, such as antimicrobial stewardship programs. However, comprehensive statistical data on antibiotic consumption and AMR prevalence in both healthcare and agricultural sectors remain lacking worldwide [69]. Surveillance data are critical for identifying priority areas for intervention and guiding cooperative efforts across international agencies, human and veterinary medicine, agriculture, animal production industries, and consumers. Addressing this knowledge gap is a prerequisite for launching effective AMR containment strategies.

8. Clinical Implications of AMR

Antimicrobial resistance has significant clinical implications that threaten the effective management of infectious diseases [70]. Successful treatment of microbial infections, including bacterial, fungal, and viral infections, is increasingly hindered by the emergence of resistant pathogens. The development and dissemination of new resistance mechanisms jeopardize the treatment of common illnesses such as urinary tract infections, upper respiratory tract infections, typhoid, and influenza, often resulting in treatment failure, permanent disability, or even death. Furthermore, the effectiveness of critical medical interventions, including cancer chemotherapy, transplantation surgeries, and even minor dental procedures, is compromised in the absence of novel antimicrobial drugs. Infections caused by resistant microorganisms frequently require prolonged therapy with higher healthcare costs and may necessitate the use of expensive alternative drugs, further straining healthcare systems and patient resources.

 

9. How to Combat AMR

Antimicrobial resistance is a pressing concern that affects not only humans but also animals, plants, and the broader environment. Animals can serve as potential reservoirs of multidrug-resistant (MDR) pathogens, which may be transmitted to humans through direct contact or the consumption of animal-derived foods. Addressing AMR is not a challenge that can be managed by a single government department or independent organization; it requires coordinated efforts and collaboration across multiple sectors, including healthcare industries, pharmacy, agriculture, finance, trade, education, and non-governmental organizations at both national and international levels. Multisectoral collaboration can operate horizontally, across sectors and departments within a country through multistakeholder forums, and vertically, across different administrative levels within a country, a region, or internationally [71]. One of the key measures to combat AMR includes curbing the inappropriate prescription of broad-spectrum antibiotics for trivial conditions, alongside careful monitoring of antimicrobial use in animals by veterinarians. Rational antibiotic prescription, limited prophylactic use of antimicrobials, patient education, compliance with therapy, and proper hospital hygiene via antimicrobial stewardship programs are among the main interventions [72]. The development and deployment of rapid diagnostic tools and precise antimicrobial profiling for targeted therapy are also essential components.

The World Health Assembly has adopted five strategic action plans to combat AMR: (1) improving awareness and understanding of antimicrobial resistance, (2) strengthening knowledge through surveillance and research in infection control, (3) implementing effective sanitation, hygiene, and infection prevention measures, (4) optimizing antimicrobial use in both human and animal health, and (5) encouraging sustainable investment in new medicines, diagnostic tools, and vaccines [73]. On an international scale, measures include establishing and strengthening collaborations among agencies, governments, NGOs, and professional groups; creating global surveillance networks for antimicrobial use and AMR; enhancing laboratory capacity for detecting and reporting AMR pathogens; developing international tracking systems for early identification and mitigation of emerging pathogens; monitoring and controlling counterfeit antimicrobials worldwide; and investing in research, drug discovery, and vaccine development. At the national level, strategies involve implementing comprehensive antibiotic policies for judicious use in healthcare and agricultural settings, strengthening surveillance and monitoring through integration of public health and veterinary sectors, developing innovative point-of-care diagnostic tests for pathogen detection and resistance monitoring, investing in research on new antibiotics and vaccines, building capacity and fostering international collaboration, and adopting antimicrobial stewardship programs aligned with essential drug lists [69].

Rational use of antibiotics is essential to minimize the development of antimicrobial resistance. The World Health Organization (WHO) defines the rational use of medicine as using appropriate medications, including antibiotics, tailored to patients’ clinical needs, at correct doses, for adequate durations, and at the lowest possible cost [70]. Optimal outcomes in infection treatment can only be achieved when pathogen selection, drug toxicity, and resistance development are minimized through rational antibiotic use. Antibiotic stewardship programs (ASPs) in healthcare settings are primarily aimed at ensuring such rational use. In parallel, stringent regulatory control over over-the-counter (OTC) sales of oral and injectable antibiotics must be enforced, as uncontrolled access remains common in many underdeveloped and developing countries. Antibiotics should only be dispensed upon prescription by qualified physicians, accompanied by ongoing awareness programs for both patients and pharmacy personnel, and continuous reappraisal of local antibiotic policies based on regional AMR surveillance data [74].

Infection prevention and control (IPC) is another cornerstone in combating AMR, as it protects both patients and healthcare workers from avoidable infections, including those caused by drug-resistant pathogens. Physicians, nurses, pharmacists, and other healthcare providers play pivotal roles in IPC, including compliance with hospital infection control and antibiotic policies, timely reporting of resistant cases, and educating patients on treatment compliance [75]. Recommended IPC measures in healthcare facilities include forming infection prevention committees, practicing good hand hygiene, accurate diagnosis and treatment, responsible antimicrobial use, continuous surveillance of antibiotic use and resistance, ensuring a quality antimicrobial supply chain, and maintaining good microbiological laboratory practices. Antimicrobial stewardship programs further support these measures by guiding prescribers on proper antibiotic selection, dosage, and duration, reducing overuse and misuse, and minimizing resistance development. The CDC’s “Core Elements” for antimicrobial stewardship provide structured guidance applicable to hospitals of all sizes [76,77].

The use of antibiotics in animals also demands regulation, as the WHO emphasizes strict legislation on medically important antibiotics to limit their use for growth promotion and disease prevention, advocating alternative measures such as improved hygiene, probiotics, vaccination, and optimized husbandry practices [78]. Research and development of new drugs and vaccines are vital to stay ahead of rapidly evolving resistance, with vaccines reducing antimicrobial demand and posing no risk for resistance development. Novel vaccines against drug-resistant pathogens, including carbapenem-resistant Enterobacterales and Acinetobacter baumannii, are especially important [73,75].

Additional measures include establishing checkpoints to prevent illegal sales and self-medication of antibiotics, especially in low-income countries, and introducing strategies such as delayed antibiotic prescribing where appropriate [58,60]. Community engagement is critical, as local practices related to hygiene, food production, health-seeking behavior, and waste disposal influence AMR. Behavioral change programs tailored to communities can help safeguard treatment options and reduce AMR propagation [79].

Alternatives to antibiotics are being explored, including natural compounds from plants such as polyphenolics, alkaloids, and flavonoids, though many remain in preclinical stages [80–86]. Advanced biotechnological approaches offer opportunities to harness microbial interactions for discovering new antimicrobial therapies [87]. Phage therapy, employing bacteriophages to target pathogenic bacteria, shows promise due to its specificity, autodosing, and low toxicity, though challenges such as phage selection and immune responses must be addressed [88]. Antivirulence drugs represent another strategy, disarming bacteria by targeting virulence factors without promoting resistance or disturbing microbiota, with some FDA-approved applications and promising results against MRSA in animal studies [89]. Bacteriocins, natural antimicrobial peptides, are increasingly explored for both clinical and food preservation applications, with nisin showing activity against multiple drug-resistant pathogens including MRSA, Streptococcus pneumoniae, Enterococci, Clostridioides difficile, and Enterobacterales [79].

The One Health approach integrates human, animal, and environmental health to combat AMR through communication, coordination, and collaboration. Established in 2008 by WHO in partnership with the FAO and OIE, One Health promotes multisectoral strategies for surveillance, evidence-based interventions, and policy implementation. Key stakeholders include healthcare professionals, veterinarians, ecologists, and agricultural workers, all collaborating to monitor, prevent, and control AMR across domains [90,91]. Advanced tools such as whole-genome sequencing (WGS) and next-generation sequencing (NGS) further support surveillance and research under the One Health framework, helping to guide targeted interventions and optimize outcomes.

 

 

 

10. CONCLUSIONS

The evolution of antimicrobial resistance (AMR) in bacteria is a continuous process occurring either through new chromosomal mutations or the acquisition of drug-resistance genes via horizontal gene transfer (HGT). Over the past two decades, the incremental development of AMR has emerged as a serious global public health threat, now recognized as one of the highest health dangers of the 21st century, severely limiting treatment options. Multidrug-resistant (MDR) bacteria are frequently implicated in common infections, including respiratory, urinary, sexually transmitted, and tuberculosis infections worldwide. Meanwhile, the development and supply of new antibiotics have lagged significantly since the 1980s and are not keeping pace with the rapid emergence of resistant pathogens. In this context, the future of successful antimicrobial therapy appears bleak, and without coordinated global action, the prospect of a postantibiotic era is more plausible than a hypothetical scenario. Multiple drivers contribute to the global emergence and dissemination of AMR, posing a significant concern for both human and animal health. Infections caused by antimicrobial-resistant organisms are more difficult to treat, resulting in higher rates of treatment failure, complications, prolonged hospital stays, and substantial economic costs for individuals and society. Prudent and rational use of antibiotics—including appropriate dosage and duration—remains among the most effective strategies to reduce selective pressure and curb the emergence of resistance. Equally critical is the strict implementation of infection prevention and control measures in all healthcare facilities, which is vital for containing the spread of MDR organisms [57,58].

Combating AMR requires a coordinated and sustained global effort involving international governmental and nongovernmental agencies, underpinned by strong political commitment. Integration and collaboration among policymakers, researchers, public health practitioners, pharmaceutical companies, hospital administrators, agricultural industry leaders, and the general public are essential. The overarching goal of this collaboration is to slow the progression of AMR and mitigate its health and economic burdens. Key strategies include the establishment of antimicrobial stewardship programs, strict adherence to antibiotic policies in healthcare settings, good microbiology practices, surveillance and monitoring of resistance patterns, minimizing over-the-counter antibiotic use and use in food animals, and ensuring access to quality and affordable medicines, vaccines, and diagnostics [73,75–78]. Prevention remains the most effective approach to reduce antimicrobial-resistant infections and their transmission. While the rational use of existing antibiotics is essential to restore their efficacy, urgent efforts must focus on the development of new antibiotics, alternative therapies, and innovative technologies in diagnostics and vaccine development. Despite numerous initiatives to address antibiotic resistance, coordinated global action, particularly political will at national and international levels, remains insufficient. The persistent rise of antimicrobial-resistant infections indicates that, without immediate intervention, we may soon face severe setbacks in medical, social, and economic sectors, potentially undermining critical achievements in modern medicine, including major surgeries, organ transplantation, care of preterm infants, and cancer chemotherapy.

 

Author Contributions

Amina K. Abebe: Conceptualization, methodology, formal analysis, writing—original draft. Samuel T. Ndlovu: Data curation, validation, writing—review and editing. Grace M. Owusu: Supervision, project administration, critical revision of the manuscript. Jean-Paul Mbarga: Interpretation of findings, contextual analysis, writing—review. Helen R. Kamau: Literature review, data interpretation, editing. All authors read and approved the final version of the manuscript.

Acknowledgments:

The authors gratefully acknowledge the Demographic and Health Surveys (DHS) Program for providing access to the datasets analyzed in this study. We also extend appreciation to the field teams and survey participants across the 25 countries whose contributions made this research possible.

Funding: This study did not receive financial support from any funding agency, whether public, private, or non-profit.

Conflict of Interest: The authors declare that there are no conflicts of interest regarding the publication of this paper.

 

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