Equity and Determinants of Optimal Maternal Continuum of Care in Cambodia: Evidence from the 2000–2022 Demographic and Health Surveys

Abstract

AbstractBackground: The maternal continuum of care (CoC), including antenatal care (ANC), facility-based delivery, and postnatal care (PNC), is essential for improving maternal and newborn outcomes. In Cambodia, while service coverage has improved over the past two decades, significant gaps remain in the completion of the full continuum of care (CoC), especially among disadvantaged groups. This study assessed trends in CoC coverage, identified socio-demographic determinants of service utilization, and examined gaps by urban and non-urban residence and socioeconomic class across survey years from 2000 to 2022. Methods: This study used repeated cross-sectional data from five rounds of the Cambodia Demographic and Health Survey (DHS), covering 2000 to 2022. Descriptive statistics were used to examine trends in the utilization of ANC, facility-based delivery, PNC, and optimal CoC, Disparity analyses were conducted to evaluate service utilization gaps between urban–rural and wealth subgroups. Multivariable logistic regression models were applied to identify factors associated with service completion, using both single-year (2021–2022) and pooled-year (2010–2022) datasets. Results: Utilization of maternity care improved significantly between 2000 and 2022. The proportion of women receiving ≥4 ANC visits increased from 6.72% to 82.23%, facility-based delivery from 5.79% to 96.54% and optimal CoC rose from 1.6% in 2000 to a peak of 68.9% in 2014, before declining to 46.3% in 2021. However, disparities by educational level and household wealth remained persistent across all services. For example, in 2021, 56.59% of women from the richest households had optimal CoC, comparing to only 30.83% from the poorest group. While urban–rural gaps have narrowed, women with higher socioeconomic status—including higher education, greater household wealth, and health insurance coverage—were significantly more likely to receive optimal ANC and CoC. Wealth-related disparities remained persistent across these services. The notably low PNC proportion in 2021–2022 contributed to the decline in full CoC coverage, underscoring the postnatal stage as a crucial point of dropout within the continuum. Insurance coverage was also a significant predictor of optimal CoC. In 2021–2022, 53.7% of insured women completed the full CoC, compared to 44.3% of uninsured women, highlighting the advantage associated with insurance coverage. Logistic regression analysis also showed that lower parity, older maternal age, and formal employment were significantly associated with higher odds of optimal CoC. Conclusions: Despite significant progress since the year 2000, inequities in utilization of maternity care persisted by socio-economic factors. The results underscore the need for more targeted strategies to support underserved populations, particularly women with low education, income and with no insurance. Future policies should prioritize improving postnatal care uptake and addressing structural barriers to achieving full continuum of maternal care.