Urban–Rural Disparities in Non-Adherence to Iron Supplementation Among Pregnant Women Aged 15 to 49 in Sub-Saharan Africa

Background: Adherence to iron supplementation is influenced by systemic barriers, including poor healthcare infrastructure, shortage of healthcare providers, and limited access to antenatal care (ANC) services. These challenges are more pronounced in rural areas. However, evidence on urban–rural disparities in non-adherence to iron supplementation remains limited, particularly in sub-Saharan Africa. This study examined these regional differences, stratified by income levels and national contexts. Method: This analysis utilised Demographic Health Survey (DHS) data conducted between 2015 and 2023 from 26 sub-Saharan African countries, including 287,642 women from urban ( n = 91,566) and rural areas ( n = 196,076). The outcome of this study was non-adherence to iron supplementation, defined as taking iron supplementation for less than 90 days during pregnancy. This study examines urban–rural differences in non-adherence stratified by country income levels based on World Bank 2022 income classifications and national context. A chi-square test was used to assess urban–rural differences, with a p -value of <0.05 considered statistically significant. Results: Non-adherence was significantly higher in rural areas (68.42%) than in urban areas (51.32%) ( p < 0.001), with the disparity more pronounced in low-income countries (LICs). Ethiopia, Madagascar, Uganda, and Burundi were among the countries with the highest rural non-adherence, reflecting severe poverty and limited access to ANC. In contrast, Zimbabwe showed an inverse trend, where rural adherence was higher than urban. Conclusions: Rural sub-Saharan Africa has significantly higher non-adherence to iron supplementation, particularly in LICs, likely driven by systemic barriers such as poor infrastructure and limited access to healthcare. This non-adherence in rural areas undermines efforts to improve pregnancy and birth outcomes across the region. Targeted interventions, like those in Zimbabwe, can help address these inequities and improve maternal health outcomes.