The study, published in Discover Sustainability, examined trends and socioeconomic inequalities in household access to electricity and clean cooking fuels in Ghana from 2003 to 2022. A research team led by Yula Salifu of the University of Ghana analyzed repeated cross-sectional data from the Ghana Demographic and Health Surveys and Malaria Indicator Surveys, processed through the World Health Organization’s Health Equity Assessment Toolkit. Rather than simply tracking national averages, the researchers deployed a sophisticated battery of inequality metrics, including difference and ratio measures, population attributable risk and fraction, absolute and relative concentration indices, and the Theil Index, each presented alongside 95 percent confidence intervals to support rigorous inferential interpretation.

The electricity results are genuinely remarkable. Household electricity access climbed from 60.5 percent in 2008 to 85.1 percent in 2022, an achievement that places Ghana among the leading performers in the region. More striking still is what happened to inequality during that expansion. The Absolute Concentration Index, a measure that captures how strongly access is concentrated among wealthier households, fell from 19.6 to 11.4, indicating that the gains were distributed substantially across the wealth spectrum rather than captured exclusively by the privileged. The Theil Index, which quantifies regional disparities, collapsed from 203.5 to 7.0, an extraordinary reduction suggesting that geographic inequality in electricity access has been nearly eliminated over the period.

This relatively inclusive electricity expansion reflects deliberate policy architecture. Ghana’s national electrification schemes, implemented through the Electricity Company of Ghana and the Northern Electricity Distribution Company, combined grid extension programs with targeted investments in underserved northern regions. The near-convergence of regional Theil Index values implies that these distribution companies, working across vastly different geographic and economic terrain, managed to bring connection rates in historically disadvantaged areas closer to national norms. For a country where northern households have long trailed southern counterparts in nearly every development indicator, the electricity story represents a genuine equity success.

Clean cooking fuels tell a profoundly different story. Use of modern cooking fuels, primarily liquefied petroleum gas, rose from just 13.6 percent of households in 2003 to 28.7 percent in 2022. That means nearly three-quarters of Ghanaian families still cook with biomass, charcoal, or other polluting fuels that release harmful particulates and contribute to deforestation. The pace of change, roughly 0.7 percentage points per year, would need to accelerate several-fold for Ghana to approach the Sustainable Development Goal 7 target of universal access to clean cooking by 2030. At the current trajectory, the country would not reach even half of households until well beyond mid-century.

But the raw adoption numbers understate the true problem, because inequality in clean cooking access has been widening, not narrowing. The gap between the richest and poorest wealth quintiles expanded from 55.0 percentage points in 2003 to 82.0 percentage points in 2022. The Absolute Concentration Index rose from 6.1 to 16.6, confirming that access has become increasingly concentrated among wealthier households. The Gini coefficient for clean cooking fuel access, calculated from quintile-based estimates, increased from 0.59 in 2003 to 0.61 in 2022, further corroborating the trend of widening wealth-related inequality. In plain terms, the benefits of LPG expansion have flowed disproportionately to families who were already better positioned to afford cylinders, refills, and the upfront costs of switching away from charcoal and firewood.

Persistent urban-rural and regional disparities compound the wealth divide. Northern households have remained consistently disadvantaged in clean cooking access throughout the entire study period, mirroring historical patterns of underinvestment in the country’s northern savannah zones. Rural families, who face longer supply chains for LPG distribution and higher per-unit costs, continue to lag urban counterparts by wide margins. The concentration of clean cooking access among southern, urban, and affluent populations means that the health and environmental benefits of modern fuels, including reduced household air pollution exposure and lower respiratory disease burden, have been distributed along the same fault lines of privilege that characterize other dimensions of Ghanaian development.

The technical architecture of the inequality analysis deserves attention because it moves beyond simple gap measures. Population attributable risk and fraction estimates quantify how much national clean cooking access would improve if the disparities between wealth quintiles were eliminated, providing a direct policy-relevant metric. Concentration indices, calculated by ranking households by wealth and plotting access against cumulative population share, capture the direction and magnitude of socioeconomic gradients with sensitivity to the entire distribution rather than just the extremes. The Theil Index, drawn from information theory, decomposes regional inequality into within-region and between-region components, allowing researchers to pinpoint where geographic disparities originate. Applying this full toolkit to energy access data, rather than the health outcomes for which it was originally designed, represents a methodological extension with significant implications for how energy equity is monitored across the region.

Why has clean cooking proven so much harder to equalize than electricity? The economics differ fundamentally. Electricity connection is largely a one-time infrastructure investment, subsidized through national programs and amortized over decades, whereas clean cooking requires recurring expenditure on cylinders, regulators, and refills that families must budget continuously. LPG supply chains depend on import infrastructure, distribution networks, and retail presence that thin out rapidly in rural and northern areas. Upfront switching costs, cultural preferences for traditional cooking methods, and uncertainty about fuel availability all reinforce the wealth gradient. The widening inequality suggests that Ghana’s LPG expansion has operated more as a market phenomenon than a public program, rewarding households with purchasing power rather than extending access as a universal service.

The authors conclude that while electricity expansion has been relatively inclusive, progress in clean cooking fuels has been slow with widening inequalities, and they call for accelerated, equity-focused clean cooking policies to ensure that no population group is left behind. The findings arrive at a pivotal moment, as Ghana and its neighbors confront the intertwined challenges of household air pollution, deforestation, and climate commitments under Sustainable Development Goals 7 and 10. The Ghanaian experience offers a sobering lesson for the broader sub-Saharan African region, where clean cooking access remains among the lowest in the world: expanding modern energy is not the same as expanding it equitably, and the two goals demand distinct policy instruments. Without deliberate intervention to subsidize access for poor and rural households, strengthen LPG distribution in northern regions, and address the recurring cost burden that keeps biomass in the kitchen, the wealth divide in clean cooking will continue to widen even as national averages inch upward.

Subject of Research: Three decades of trends and socioeconomic inequalities in household access to electricity and clean cooking fuels in Ghana from 2003 to 2022

Article Title: Three decades of trends and socioeconomic inequalities in household access to electricity and clean cooking fuels in Ghana from 2003 to 2022

Article References: Salifu, Y., Moro, A., Yakubu, M., Atubiga, B. A., Koomson, I. K., Salifu, T., Lasong, J., & Adong, J. W. (2026). Three decades of trends and socioeconomic inequalities in household access to electricity and clean cooking fuels in Ghana from 2003 to 2022. Discover Sustainability. https://doi.org/10.1007/s43621-026-04498-7

Image Credits: AI Generated

DOI: 10.1007/s43621-026-04498-7

Keywords: Three, decades, trends, socioeconomic, inequalities, household, access, electricity, clean, cooking, fuels, Ghana

The World Health Organization originally advised pregnant women to attend at least four antenatal visits, a target that shaped maternal health programming across sub-Saharan Africa for decades. In 2016, however, the organization overhauled its guidance, replacing the four-visit model with a recommendation of eight or more individual contacts with a health provider over the course of pregnancy. The change reflected growing evidence that more frequent contact allows clinicians to detect complications such as preeclampsia, anemia, and fetal growth restriction earlier, and to intervene before they become fatal. The revised standard also shifted the language from ‘visits’ to ‘contacts’ to emphasize that every interaction between a pregnant woman and her health system matters.

Most research on antenatal care in Nigeria has relied on a binary measure, simply asking whether a woman attended any sessions at all or at least four. That approach, the study’s authors argue, obscures how far along the care continuum women actually progress and makes it impossible to track national movement toward the current WHO guideline. To close that gap, the research team from Obafemi Awolowo University and Federal University Birnin Kebbi categorized utilization into three ordered levels: fewer than four visits, four to seven visits, and eight or more visits. This ordinal framework allowed them to simultaneously evaluate adherence to both the old and new WHO benchmarks and to identify which factors push women across each successive threshold.

The data set covered women aged 15 to 49 who had at least one live birth in the reference period, a nationally representative sample designed to reflect Nigeria’s enormous demographic and geographic diversity. The descriptive results alone paint a sobering picture. Among all women surveyed, 47 percent reported fewer than four antenatal visits for their most recent pregnancy, 36 percent reported four to seven visits, and a mere 17 percent attained eight or more contacts. Combined with the 28 percent who received no care whatsoever, the figures mean that fewer than one in five Nigerian pregnancies currently meet the international standard that global health authorities consider the minimum for protecting maternal and newborn lives.

To understand who reaches each level of care, the researchers employed a generalized ordered logistic regression model, a statistical technique suited to outcomes that fall along a natural hierarchy. Unlike a standard logistic regression that collapses the outcome into two categories, the generalized ordered model estimates how each sociodemographic factor relates to crossing each cumulative threshold, from no care to any care, from minimal to adequate care, and from adequate to the full WHO-recommended schedule. The model adjusted for a battery of confounders, and design-based chi-square tests were first used to confirm that utilization varied significantly across social and regional strata in the raw data.

Education emerged as one of the most powerful predictors of care. Women with higher education had more than five times the odds of achieving at least four antenatal visits compared with their less-educated counterparts, with an adjusted odds ratio of 5.33 and a 95 percent confidence interval of 4.26 to 6.66. Wealth told a similar but distinct story. Women in the richest households were more than four times as likely as the poorest to reach eight or more contacts, with an adjusted odds ratio of 4.38 and a confidence interval of 3.34 to 5.74. Intriguingly, the factors that help women cross the four-visit threshold are not always the same factors, or of the same magnitude, that carry them to the eight-contact level, a nuance the binary analyses of previous studies could never reveal.

Geography proved to be perhaps the starkest divider of all. Nigeria’s South West region, home to Lagos and some of the country’s best-resourced health infrastructure, showed dramatically better outcomes than the North Central zone used as the reference. Women in the South West had nearly seven times the odds of attaining eight or more antenatal visits compared with their North Central counterparts, with an adjusted odds ratio of 6.91 and a 95 percent confidence interval of 5.74 to 8.31. The pattern reflects deep, long-standing inequalities between southern and northern Nigeria in educational attainment, health facility density, and the availability of skilled birth attendants, divisions that shape health outcomes long before a woman ever becomes pregnant.

The implications of these findings reach well beyond Nigerian borders. As low- and middle-income countries begin to realign their maternal health monitoring systems with the 2016 WHO guideline, Nigeria’s experience offers a warning about how much progress may be masked when success is defined as four visits rather than eight. A country that appears close to universal basic antenatal coverage under the old standard may, in truth, be serving only a small fraction of pregnant women at the level now considered necessary. The authors suggest that policies aimed at improving utilization must simultaneously tackle socioeconomic and regional inequality while strengthening the supply side, ensuring that facilities exist, are stocked, and are staffed close enough to home for women to complete the full contact schedule.

For the roughly seven million Nigerian women who give birth each year, the arithmetic of the study translates into a concrete risk. Antenatal care is a key determinant of maternal survival because it is the principal channel through which danger signs are detected, iron and tetanus prophylaxis are delivered, hypertension is managed, and women are connected to skilled delivery services. Nigeria already accounts for a disproportionate share of the world’s maternal deaths, and the new analysis suggests that the country’s path to reducing that toll runs through both classrooms and clinics. Raising female educational attainment, narrowing the wealth gap, and investing specifically in the underserved northern regions would, the evidence indicates, do more to lift women from a handful of visits to the full recommended schedule than any single clinical intervention.

The study also demonstrates the value of the ordinal analytical approach itself. By modeling antenatal utilization as a graded outcome aligned with both WHO eras of guidance, the researchers produced estimates that policymakers can act on at every point along the care continuum, identifying where women drop out and which characteristics distinguish those who persist. The dataset was drawn from the Demographic and Health Survey Program, whose anonymized, publicly accessible surveys are conducted with approval from national ethical review boards and the ICF Institutional Review Board, with informed consent obtained from all participants. The research received no specific external funding, and the authors declare no competing interests. As Nigeria and its neighbors grapple with the gap between the four-visit past and the eight-contact future, this analysis provides both the baseline measurement and the analytical roadmap for tracking, honestly and precisely, whether the world’s most vulnerable pregnant women are finally getting the care they were promised.

Subject of Research: Sociodemographic and regional inequalities in antenatal care utilization in Nigeria relative to WHO guideline thresholds

Article Title: Inequalities in antenatal care utilization in Nigeria: an ordinal analysis aligned with WHO guidelines

Article References: Sani, J., Adesina, A. N., Awoniyi, A., Otitoju, O., Ajibade, T. O., Boboye, I., & Bisiriyu, L. A. (2026). Inequalities in antenatal care utilization in Nigeria: an ordinal analysis aligned with WHO guidelines. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15606-8

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15606-8

Keywords: antenatal care, Nigeria, WHO guidelines, maternal health, health inequalities, ordinal regression, Demographic and Health Survey, maternal health services, health services research, Africa, Inequalities, antenatal