BACKGROUND: Delivery in health facilities is crucial for reducing maternal and neonatal morbidities and mortalities. Despite efforts to improve access to maternal health services, inequalities in health facility delivery persist in The Gambia. This study aimed to examine the inequality gaps in delivery in health facilities and associated factors among women of reproductive age in The Gambia between 2013 and 2019/20. METHODS: A secondary analysis of cross-sectional study data was conducted using data from the 2013 and 2019/20 Gambia Demographic and Health Survey. The outcome variable was delivery in the health facility, and the inequality dimensions included age, economic status, education, place of residence, and subnational region. The World Health Organization's Health Equity Assessment Toolkit (HEAT) was used to calculate inequality measures, including Difference (D), Population Attributable Fraction (PAF), Population Attributable Risk (PAR), Ratio (R), Relative Index of Inequality (RII), Slope Index of Inequality (SII), and Absolute Concentration Index (ACI). RESULTS: The prevalence of maternal health facility deliveries increased across all sociodemographic dimensions in The Gambia between 2013 and 2019/20. However, inequalities persisted, with lower prevalence observed among women who were younger, poorer, less educated, living in rural areas, and residing in certain subnational regions. Economic status-related inequality had the most substantial impact on health facility delivery in both survey years (PAF: 42.79 in 2013, 12.87 in 2019/20
PAR: 27.09 in 2013, 10.99 in 2019/20), followed by education-related inequality (PAF: 42.12 in 2013, 12.31 in 2019/20
PAR: 26.67 in 2013, 10.52 in 2019/20) and subnational region-related inequality (PAF: 48.92 in 2013, 9.61 in 2019/20
PAR: 30.98 in 2013, 8.20 in 2019/20). Place of residence-related inequality decreased substantially between the two survey years (D: 37.80 in 2013, 10.00 in 2019/20
R: 1.83 in 2013, 1.13 in 2019/20). Age-related inequality had a minimal impact on health facility delivery in both survey years. CONCLUSION: Despite overall increase in the prevalence of health facility deliveries across all sociodemographic dimensions, significant disparities persist in The Gambia, particularly in relation to economic status, education, and subnational region. Targeted interventions and policies that address the social determinants of maternal health and promote equitable access to health facility delivery services are needed to bridge the inequality gaps and improve maternal health outcomes in The Gambia.