Subnational inequalities have received limited attention in the monitoring of progress towards national and global health targets during the past two decades. Yet, such data are often a critical basis for health planning and monitoring in countries, in support of efforts to reach all with essential interventions. Household surveys provide a rich basis for interventions coverage indicators on reproductive, maternal, newborn and child health (RMNCH) at the country first administrative level (regions or provinces). In this paper, we show the large subnational inequalities that exist in RMNCH coverage within 39 countries in sub-Saharan Africa, using a composite coverage index which has been used extensively by Countdown to 2030 for Women’s, Children’s and Adolescent’s Health. The analyses show the wide range of subnational inequality patterns such as low overall national coverage with very large top inequality involving the capital city, intermediate national coverage with bottom inequality in disadvantaged regions, and high coverage in all regions with little inequality. Even though nearly half of the 34 countries with surveys around 2004 and again around 2015 appear to have been successful in reducing subnational inequalities in RMNCH coverage, the general picture shows persistence of large inequalities between subnational units within many countries. Poor governance and conflict settings were identified as potential contributing factors. Major efforts to reduce within-country inequalities are required to reach all women and children with essential interventions.

SummaryEpidemiological studies have shown that food plays an important role in the transmission of Vibrio cholerae, and different foods have been incriminated in many epidemic outbreaks of cholera. Storing contaminated meals at ambient temperatures allows growth of V. cholerae. Some ingredients such as lime juice may inhibit the survival of V. cholerae in foods. During an epidemic caused by V. cholerae O1 in Guinea-Bissau in 1996, a case control study was conducted in the capital Bissau, the main affected region with an attack rate of 7.4%. Cases were hospitalized patients and controls were matched for area, gender and age. Lime juice in the sauce eaten with rice gave a strong protective effect (odds ratio [OR] ϭ 0.31, 95% confidence interval [CI] ϭ 0.17-0.56), and tomato sauce was also protective (OR ϭ 0.36, 95% CI ϭ 0.24-0.54). On the other hand, use of a bucket for storage of water in the house was associated with increased risk (OR ϭ 4.4, CI ϭ 2.21-8.74). Laboratory experiments to elucidate the inhibitory effect of different concentrations of lime juice on survival of V. cholerae in meals showed that V. cholerae thrives in rice with peanut sauce, but lime juice inhibited its growth. Since lime juice is a common ingredient of sauces, its use should be further encouraged to prevent foodborne transmission in the household during cholera outbreaks.

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IntroductionEvidence on the rate at which the double burden of malnutrition unfolds is limited. We quantified trends and inequalities in the nutritional status of adolescent girls and adult women in sub-Saharan Africa.MethodsWe analysed 102 Demographic and Health Surveys between 1993 and 2017 from 35 countries. We assessed regional trends through cross-sectional series analyses and ran multilevel linear regression models to estimate the average annual rate of change (AARC) in the prevalence of underweight, anaemia, anaemia during pregnancy, overweight and obesity among women by their age, residence, wealth and education levels. We quantified current absolute inequalities in these indicators and wealth-inequality trends.ResultsThere was a modest decline in underweight prevalence (AARC=−0.14 percentage points (pp), 95% CI −0.17 to -0.11). Anaemia declined fastest among adult women and the richest pregnant women with an AARC of −0.67 pp (95% CI −1.06 to -0.28) and −0.97 pp (95% CI −1.60 to -0.34), respectively, although it affects all women with no marked disparities. Overweight is increasing rapidly among adult women and women with no education. Capital city residents had a threefold more rapid rise in obesity (AARC=0.47 pp, 95% CI 0.39, 0.55), compared with their rural counterparts. Absolute inequalities suggest that Ethiopia and South Africa have the largest gap in underweight (15.4 pp) and obesity (28.5 pp) respectively, between adult and adolescent women. Regional wealth inequalities in obesity are widening by 0.34 pp annually.ConclusionUnderweight persists, while overweight and obesity are rising among adult women, the rich and capital city residents. Adolescent girls do not present adverse nutritional outcomes except anaemia, remaining high among all women. Multifaceted responses with an equity lens are needed to ensure no woman is left behind.

The place of residence is a major determinant of RMNCH outcomes, with rural areas often lagging in sub-Saharan Africa. This long-held pattern may be changing given differential progress across areas and increasing urbanization. We assessed inequalities in child mortality and RMNCH coverage across capital cities, other urban and rural areas. We analyzed mortality data from 162 DHS and MICS in 39 countries with the most recent survey conducted between 1990 and 2020, and RMNCH coverage data from 39 countries. We assessed inequality trends in neonatal and under-five mortality and in RMNCH coverage using multilevel linear regression models. Under-five mortality and RMNCH service coverage inequalities by place of residence have reduced substantially in sub-Saharan Africa, with rural areas experiencing faster progress than other areas. The absolute gap in child mortality between rural areas and capital cities, and that between rural and other urban areas reduced respectively from 41 and 26 deaths per 1000 live births in 2000 to 23 and 15 by 2015. Capital cities are losing their primacy in child survival and RMNCH coverage over other urban areas and rural areas, especially in Eastern Africa where under-five mortality gap between capital cities and rural areas closed almost completely by 2015. While child mortality and RMNCH coverage inequalities are closing rapidly by place of residence; slow trends in capital cities and urban areas suggest gradual erosion of capital city and urban health advantage. Monitoring child mortality and RMNCH coverage trends in urban areas, especially among the urban poor, and addressing factors of within urban inequalities are urgently needed.