Academic journal article Bulletin of the World Health Organization

Huge Poor-Rich Inequalities in Maternity Care: An International Comparative Study of Maternity and Child Care in Developing countries/Giantes Inegalites Entre Riches et Pauvres Dans le Domaine Des Soins Maternels: Etude Comparative Internationale Des Soins Delivres a la Mere et Au Nouveau-Ne Dans Les Pays En developpement/Grandes Desigualdades Entre Pobres Y Ricos En Atencion De Maternidad

Academic journal article Bulletin of the World Health Organization

Huge Poor-Rich Inequalities in Maternity Care: An International Comparative Study of Maternity and Child Care in Developing countries/Giantes Inegalites Entre Riches et Pauvres Dans le Domaine Des Soins Maternels: Etude Comparative Internationale Des Soins Delivres a la Mere et Au Nouveau-Ne Dans Les Pays En developpement/Grandes Desigualdades Entre Pobres Y Ricos En Atencion De Maternidad

Article excerpt

Introduction

Over half a million women die each year during pregnancy, delivery or shortly thereafter; (1) the Millennium Development Goals (MDGs) call for reducing maternal mortality by 75% by 2015. (2) Since maternal mortality is costly to measure (3) and professional attendance at delivery is assumed to reduce maternal mortality, (4) the proportion of deliveries with a professional or skilled attendant is used as a progress indicator. (5) Slow progress towards the MDG for maternal health (6) has led to calls for accelerated progress in scaling up professional delivery care. (7)

Poorer groups within developing countries use less health care (8) and poor-rich inequalities in maternity care and maternal mortality have been described. (9-11) Within-country inequalities in maternity care have, however, not been described in detail for a broad range of dimensions using an international comparative perspective. Nor have they been systematically compared with inequalities in other forms of care. A better understanding of the magnitude and determinants of inequalities in maternity care may help contribute to tackling these disparities and to reaching the MDGs for maternal health. They may also contribute to the MDGs for child health, as skilled attendance at delivery is an important contributor to neonatal survival. (1)

This paper describes poor--rich inequalities in use of professional delivery and antenatal care for 45 developing countries and compares these to inequalities in use of child health services. By presenting various aspects of inequalities in the use of maternity care, and by contrasting these to inequalities in the use of child health care, this paper seeks possible explanations for the inequalities observed in maternity care.

Data and methods

Data on health care use, stratified for five wealth groups, were obtained for 45 developing countries from World Bank Country Reports. (12) All countries for which these reports were available at the time of analysis were included in our study (Table 1).

Data for these reports were derived from Demographic and Health Surveys (DHS) conducted between 1990 and 1998. (13) These are nationally representative household surveys that usually cover between 5 000-10 000 women aged 15-49 years. They include information on health care use and household ownership of assets. All the types of health care use available in these reports were included in this paper. Table 1 defines the health care use indicators included in this study.

Household ownership of durable consumer goods, housing quality, and water and sanitation facilities were combined into a wealth index using principal components-derived weights. (8,14) Wealth groups were constructed such that each consisted of 20% of the survey population unless otherwise indicated. Despite limitations, (15) this index has been used fairly widely as a measure of economic status in developing countries. (14,16)

The main inequality measures we used are the rate ratio (RR) and the rate difference (RD). The RR gives the ratio of health care use among the richest to the poorest group within a country, whereas the RD gives the absolute difference in health care use between these groups.

We estimated the distribution of the total number of births without a professional delivery attendant across the rural poor, rural rich, urban poor and urban rich. This was done by calculating the total number of deliveries without a professional delivery attendant in each of the groups as a proportion of the total number of deliveries without such an attendant in the total survey population. For this analysis, the poor were defined as the bottom 50% of the total survey population.

To assess the relationship between the magnitude of poor-rich inequalities in health care use and the overall level of such use, we plotted, for each of the five types of health care, the RR in health care use against the overall level of health care use for the 45 countries. …

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