Socioeconomic inequality in maternal healthcare: An analysis of regional variation in Bangladesh

Quality of antenatal care in 13 sub-Saharan African countries in the SDG era: evidence from Demographic and Health Surveys

BACKGROUND

Maternal and neonatal mortality remains high in sub-Saharan Africa (SSA) with women having 1 in 36 lifetime risk. The WHO launched the new comprehensive recommendations/guidelines on antenatal care (ANC) in 2016, which stresses the essence of quality antenatal care. Consequently, the objective of this cross-sectional study is to investigate the quality of ANC in 13 SSA countries.

METHODS

This is a cross-sectional study that is premised on pre-existing secondary data, spanning 2015 to 2021. Data for the study was obtained from the Measure DHS Programme and included a total of 79,725 women aged 15-49 were included. The outcome variable was quality ANC and it was derived as a composite variable from four main ANC services: blood pressure taken, urine taken, receipt of iron supplementation and blood sample taken. Thirteen independent variables were included and broadly categorised into individual and community-level characteristics. Descriptive statistics were used to present the proportion of women who had quality ANC across the respective countries. A two-level multilevel regression analysis was conducted to ascertain the direction of association between quality ANC and the independent variables.

RESULTS

The overall average of women who had quality ANC was 53.8% [CI = 51.2,57.5] spanning from 82.3% [CI = 80.6,85.3] in Cameroon to 11% [CI = 10.0, 11.4] in Burundi. Women with secondary/higher education had higher odds of obtaining quality ANC compared with those without formal education [aOR = 1.23, Credible Interval [Crl] = 1.10,1.37]. Poorest women were more likely to have quality ANC relative to the richest women [aOR = 1.21, Crl = 1.14,1.27]. Married women were more likely to receive quality ANC relative to those cohabiting [aOR = 2.04, Crl = 1.94,3.05]. Women who had four or more ANC visits had higher odds of quality ANC [aOR = 2.21, Crl = 2.04,2.38]. Variation existed in receipt of quality ANC at the community-level [σ2 = 0.29, Crl = 0.24,0.33]. The findings also indicated that a 36.2% variation in quality ANC is attributable to community-level factors.

CONCLUSION

To achieve significant improvement in the coverage of quality ANC, the focus of maternal health interventions ought to prioritise uneducated women, those cohabiting, and those who are unable to have at least four ANCs. Further, ample recognition should be accorded to the existing and potential facilitators and barriers to quality ANC across and within countries.

Socioeconomic inequality and urban-rural disparity of antenatal care visits in Bangladesh: A trend and decomposition analysis

BACKGROUND

Socioeconomic inequality in antenatal care visits is a great concern in developing countries including Bangladesh; however, there is a scarcity of investigation to assess the factors of inequality and these changes over time. In this study, we investigated the trend of socioeconomic inequalities (2004-2017) in 1+ANC and 4+ANC visits, and extracted determinants contributions to the observed inequalities and urban-rural disparities in Bangladesh over the period from 2011 to 2017.

METHODS

The data from the Bangladesh Demographic and Health Surveys (BDHS) conducted in 2004, 2007, 2011 and 2017 were analyzed in this study. The analysis began with exploratory and bivariate analysis, followed by the application of logistic regression models. To measure the inequalities, the Erreygers concentration index was used, and regression-based decomposition analyses were utilized to unravel the determinant's contribution to the observed inequalities. The Blinder-Oaxaca type decomposition is also used to decompose the urban-rural disparity into the factors.

RESULTS

Our analysis results showed that the prevalence of 1+ANC and 4+ANC visits has increased across all the determinants, although the rate of 4+ANC visits remains notably low. The magnitudes of socioeconomic inequality in 4+ANC visits represented an irregular pattern at both the national and urban levels, whereas it increased gradually in rural Bangladesh. However, inequalities in 1+ANC visits declined substantially after 2011 across the national, rural and urban areas of Bangladesh. Decomposition analyses have suggested that wealth status, women's education, place of residence (only for 4+ANC visits), caesarean delivery, husband education, and watching television (TV) are the main determinants to attribute and changes in the level of inequality and urban-rural disparity between the years 2011 and 2017.

CONCLUSIONS

According to the findings of our study, it is imperative for authorities to ensure antenatal care visits are more accessible for rural and underprivileged women. Additionally, should focus on delivering high-quality education, ensuring the completion of education, reducing income disparity as well as launching a program to enhance awareness about health facilities, and the impact of caesarean delivery.

Nutritional awareness of pregnant women and the underlying influencing factors

Nutritional awareness is described as having knowledge or understanding of nutrition. It is often related to the ability of an individual to make an accurate estimate of their food intake, which involves comparing their actual nutritional behavior with the recommended food consumption. Nutritional awareness of women during the various phases of pregnancy may vary significantly across countries due to cultural and lifestyle differences. There has been extensive research on nutritional awareness of pregnant women in selected countries or regions; however, relatively few studies have explored it during different stages of pregnancy. To fill this gap, this article reviews the existing literature and draws together insights into the following areas: changes in nutritional awareness during various phases of pregnancy, nutritional awareness of pregnant women and its underlying factors in various nations, and the research methods used to study nutritional awareness of pregnant women.

Socioeconomic and geographical inequalities in delivery by cesarean section among women in Bangladesh, 2004-2017

BACKGROUND

There is a dearth of evidence on the trends and inequalities in utilizing cesarean section (CS) among women in Bangladesh. Hence, this study aimed to estimate the socioeconomic and geographical inequalities in delivery by CS among Bangladeshi women from 2004 to 2017.

METHODS

Data from Bangladesh Demographic and Health Survey 2004, 2007, 2011, 2014, and 2017 were analyzed using the WHO's Health Equity Assessment Toolkit (HEAT) software. Inequalities were measured using four summary measures: Difference (D), Population Attributable Risk (PAR), Population Attributable Fraction (PAF), and Ratio (R). Socioeconomic inequalities were assessed using two equity dimensions: household wealth status, and level of education, while geographical disparities were measured using two equity dimensions: place of residence, and sub-national regions. For each measure, point estimates and their 95% confidence intervals were reported.

RESULTS

An increasing trend in the prevalence (weighted) of CS in Bangladesh use was found from 4.50% in 2004 to 32.73% in 2017 We found significant socioeconomic inequalities in CS in every survey point, with a higher concentration of CS among the rich (in 2017, PAR = 28.57; 95% CI: 26.69-30.46) indicating a pro-rich inequality, and higher educated (in 2017, PAF = 23.97; 95% CI: 12.26-35.68) sub-groups. We also identified significant geographical disparities in CS with a higher concentration of CS among people from urban areas (in 2017, PAR = 10.99; 95% CI: 10.19-11.79), and a coastal region (Khulna division) (in 2017, PAF: 30.48 (95% CI: 18.66-42.30).

CONCLUSION

We observed both socioeconomic and geographical inequalities in CS exist in Bangladesh, though the trends of these inequalities were curved over time. Thus, it is important to comprehend these pro-rich and geographical inequalities better and implement appropriate interventions and policies to alleviate them.

Reproductive health service access and utilisation among migrant women in Dhaka's urban slums: a qualitative study

This study explores the impact of migration on the access and utilisation of sexual and reproductive health services by women living in an informal settlement in Dhaka, Bangladesh. A total of 16 in-depth interviews were conducted in March and April of 2019 with women (18-49 years old) who had migrated from rural areas to Dhaka. They reported continued economic insecurity while receiving minimal support from the state. All women reported financial and infrastructural barriers to accessing formal sexual and reproductive health services and tended to seek resources and support through social networks within the slum and from informal health services. Compared with more recent migrants, women who had migrated and resided in the slums for longer found it easier to utilise social networks and resources for sexual and reproductive health. Women had more agency in experimenting with contraceptives but had less power in making decisions during pregnancy and when seeking health care. Menstrual health was a neglected aspect of public health. The study indicates that public health policy targeting the urban poor needs to address the unique challenges faced by migrant women in informal settlements to rectify inequities in health services that leave significant portions of the urban poor population behind.

Women's Sexual Empowerment and Its Relationship to Contraceptive Use in Bangladesh: Findings From a Recent National Survey

Objectives: This study aimed to assess the relationship between women's sexual empowerment and contraceptive use among married Bangladeshi women from a nationally representative sample. Methods: Secondary data analysis was conducted using the Bangladesh Demographic and Health Survey (BDHS) 2017-18. The investigation covered a total of 14,515 married, non-pregnant women who were residing with their spouses. Multivariable logistic regression analysis was fitted to assess the relationship between the variables of interest. Results: A unit increase in the sexual empowerment scale increases the odds of contraceptive use by 13%. While increasing age, being Muslim, having a spouse who is older by more than 10 years, and living in rural areas are associated with lower odds of using contraceptives than their respective counterparts, secondary or higher levels of education, having more living children, exposure to TV or radio, and employment are associated with higher odds of using contraceptives. Conclusion: The study's findings point to the need for addressing women's perceptions of their right to sexual and reproductive health and equity in order to further efforts to achieve universal access to reproductive health services.

Inequalities in adequate maternal healthcare opportunities: evidence from Bangladesh Demographic and Health Survey 2017-2018

OBJECTIVES

This study investigated the inequalities in access to maternal healthcare services in Bangladesh.

DESIGN AND SETTING

This study used cross-sectional data from the nationally representative Bangladesh Demographic and Health Survey conducted in 2017-2018. The survey encompassed diverse regions and households across Bangladesh. The study used the Human Opportunity Index (HOI) and Shapley's decomposition technique to measure the inequality in access to maternal healthcare opportunities.

PARTICIPANTS

This study included 20 127 women aged 15-49 years. Among them, 5012 women had live births in the preceding 3 years of the survey, forming the study sample.

PRIMARY AND SECONDARY OUTCOME MEASURES

This study has no secondary outcome variable. The primary dependent variable is 'adequate maternal healthcare', a dichotomous variable.

RESULTS

Household wealth status contributed the highest to inequality in accessing adequate maternal healthcare services (41.4%) such as receiving at least four antenatal care (ANC) visits (39.7%), access to proper ANC (50.7% and 44.0%) and health facility birth (43.4%). Maternal educational status contributes the second highest inequality among all factors in accessing adequate maternal healthcare (29.5%). Adequate maternal healthcare presented the lowest coverage rate and opportunity index among all (approximately 24% with HOI=17.2).

CONCLUSIONS

We found that attained adequate maternal healthcare had the lowest coverage and widest dissimilarity, while wealth index, education and place of residence are the major factors that contribute to inequalities in accessibility to maternal healthcare services in Bangladesh. These findings underscore a need for pro-poor interventions to narrow the economic inequalities between the poor and rich in terms of accessibility to maternal healthcare services. The results indicate the need for the Bangladeshi government and its health department to strengthen their commitment to improving female education. Investments should be made in initiatives that facilitate the proximity of maternal healthcare services to women in rural areas.

Socioeconomic inequalities in maternal healthcare utilization: An analysis of the interaction between wealth status and education, a population-based surveys in Tanzania

Limited scientific, evidence has so far described the interactions between socioeconomic factors and the gap of inequalities in maternal healthcare utilization. This study assessed the interaction between wealth status and education to identify women with greater disadvantage. This analysis used secondary data from the three most recent rounds (2004, 2010, and 2016) of the Tanzania Demographic Health Survey (TDHS). Maternal healthcare utilization was assessed based on six services (outcomes) which are i) booking during the first trimester (bANC), ii) at least four antenatal visits (ANC4+), iii) adequate antenatal care (aANC), iv) facility-based delivery (FBD), v) skilled birth attendance (SBA), vi) cesarean section delivery (CSD). The concentration curve and the concentration index were used to measure socioeconomic inequality in maternal healthcare utilization outcomes. The interaction coefficients suggest that each unit increase in the wealth status is significantly associated with higher odds of utilizing all maternal healthcare services for women with primary and secondary or higher education compared to those with no education (booking during the first trimester [AOR = 1.30; 95% CI: 1.08-1.57], at least four antenatal visits [AOR = 1.16; 95% CI: 1.01-1.33], facility-based delivery [AOR = 1.29; 95% CI: 1.12-1.48], skilled birth attendance [AOR = 1.31; 95% CI: 1.15-1.49]). The highest wealth-related inequality in bANC (EI: 0.166), at least four antenatal visits (EI: 0.259), FBD (EI: 0.323) and skilled birth attendance (EI: 0.328) (P < 0.05) was observed among women with primary and secondary or higher education. These findings provide strong evidence that there is an interaction effect between education attainment and wealth status in socioeconomic inequalities of maternal health services utilization. Therefore, any approach which will address both women's education and wealth status might be the first step to reducing socioeconomic inequalities in maternal health services utilization in Tanzania.

Exploring the factors contributing to increase in facility child births in Bangladesh between 2004 and 2017-2018

Background

Although Bangladesh has gained rapid improvement in births at health facilities, yet far behind to achieve the SDG target. Assessing the contribution of factors in increased use of delivery at facilities are important to demonstrate.

Objective

To explore the determinants and their contribution in explaining increased use of facility child births in Bangladesh.

Participants

Reproductive-aged women (15-49 years) of Bangladesh.

Methods and materials

We used the latest five rounds (2004, 2007, 2011, 2014, 2017-2018) of Bangladesh Demographic and Health Surveys (BDHSs). The regression based classical decomposition approach has been used to explore the determinants and their contribution in explaining the increased use of facility child birth.

Results

A sample of 26,686 reproductive-aged women were included in the analysis, 32.90% (8780) from the urban and 67.10% (17,906) from the rural area. We observed a 2.4-fold increase in delivery at facilities from 2004 to 2017-2018, in rural areas it is more than three times higher than the urban areas. The change in mean delivery at facilities is about 1.8 whereas, the predicted change is 1.4. In our full sample model antenatal care visits contribute the largest predicted change of 22.3%, wealth and education contributes 17.3% and 15.3% respectively. For the rural area health indicator (prenatal doctor visit) is the largest drivers contributing 42.7% of the predicted change, hereafter education, demography and wealth. However, in urban area education and health contributed equally 32.0% of the change followed by demography (26.3%) and wealth (9.7%). Demographic variables (maternal BMI, birth order, age at marriage) contributing more than two-thirds (41.2%) of the predicted change in the model without the health variables. All models showed more than 60.0% predictive power.

Conclusion

Health sector interventions should focus both coverage and quality of maternal health care services to sustain steady improvements in child birth facilities.

Unmet healthcare needs and health inequalities in people with spinal cord injury: a direct regression inequality decomposition

BACKGROUND

Inequality in health is a prevalent and growing concern among countries where people with disabilities are disproportionately affected. Unmet healthcare needs explain a large part of the observed inequalities between and within countries; however, there are other causes, many non-modifiable, that also play a role.

AIM

This article explores the difference in health across income levels in populations with spinal cord injury (SCI). SCI is of special interest in the study of health systems, as it is an irreversible, long-term health condition that combines a high level of impairment with subsequent comorbidities.

METHODS

We estimated the importance of modifiable and non-modifiable factors that explain health inequalities through a direct regression approach. We used two health outcomes: years living with the injury and a comorbidity index. Data come from the International Spinal Cord Injury Survey (InSCI), which has individual data on people with SCI in 22 countries around the world. Due to the heterogeneity of the data, the results were estimated country by country.

RESULTS

On average, the results exhibit a prevalence of pro-rich inequalities, i.e., better health outcomes are more likely observed among high-income groups. For the years living with the injury, the inequality is mostly explained by non-modifiable factors, like the age at the time of the injury. In contrast, for the comorbidity index, inequality is mostly explained by unmet healthcare needs and the cause of the injury, which are modifiable factors.

CONCLUSIONS

A significant portion of health inequalities is explained by modifiable factors like unmet healthcare needs or the type of accident. This result is prevalent in low, middle, and high-income countries, with pervasive effects for vulnerable populations like people with SCI, who, at the same time are highly dependent on the health system. To reduce inequity, it is important not only to address problems from public health but from inequalities of opportunities, risks, and income in the population.

HIGHLIGHTS

• Better health status is evident among high-income groups, which is reflected in pro-rich inequalities. • Age at the time of the injury is the most important factor to explain inequalities in years living with the injury. • Unmet health care needs are the most important factor to explain inequalities in comorbidities. • The inequality in health varies by country dependent upon socioeconomic factors.

Comparison of inequality in utilization of maternal healthcare services between Bangladesh and Pakistan: evidence from the demographic health survey 2017-2018

BACKGROUND

Inequality in maternal health has remained a challenge in many low-income countries, like Bangladesh and Pakistan. The study examines within-country and between-country inequality in utilization of maternal healthcare services for Bangladesh and Pakistan.

METHODS

The study used the latest Demographic Health Surveys (DHS, 2017-2018) datasets of Bangladesh and Pakistan for women aged 15-49 years who had given at least one live birth in three years preceding the survey. Equity strata were identified from the literature and conformed by binary logistic regressions. For ordered equity strata with more than two categories, the relative concentration index (RCI), absolute concentration index (ACI) and the slope index of inequality (SII) were calculated to measure inequalities in the utilization of four maternal healthcare services. For two-categories equity strata, rate ratio (RR), and rate difference (RD) were calculated. Concentration curves and equiplots were constructed to visually demonstrate inequality in maternal healthcare services.

RESULTS

In Bangladesh, there was greater inequality in skilled birth attendance (SBA) based on wealth (RCI: 0.424, ACI: 0.423, and SII: 0.612), women's education (RCI: 0.380, ACI: 0.379 and SII: 0.591), husband's education (RCI: 0.375, ACI: 0.373 and SII: 0.554) and birth order (RCI: - 0.242, ACI: - 0.241, and SII: -0.393). According to RCI, ACI, and SII, there was inequality in Pakistan for at least four ANC visits by the skilled provider based on wealth (RCI: 0.516, ACI: 0.516 and SII: 0.738), women's education (RCI: 0.470, ACI: 0.470 and SII: 0.757), and husband's education (RCI: 0.380, ACI: 0.379 and SII: 0.572). For Bangladesh, the RR (1.422) and RD (0.201) imply more significant urban-rural inequality in SBA. In Pakistan, urban-rural inequality was greater for at least four ANC visits by the skilled provider (RR: 1.650 and RD 0.279).

CONCLUSION

Inequality in maternal healthcare is greater among the underprivileged group in Pakistan than in Bangladesh. In Bangladesh, the SBA is the most inequitable maternal healthcare, while for Pakistan it is at least four ANC visits by the skilled provider. Customized policies based on country context would be more effective in bridging the gap between the privileged and underprivileged groups.

Provincial variations in catastrophic health expenditure and medical impoverishment in China: a nationwide population-based study

Background

Financial protection, as a key dimension of Universal Health Coverage (UHC), has been under increasing attention in recent years. A series of studies have examined the nationwide extent of catastrophic health expenditure (CHE) and medical impoverishment (MI) in China. However, disparities in financial protection at the province level have rarely been studied. The aim of this study was to investigate provincial variations in financial protection as well as its inequality across provinces.

Methods

Using data from the 2017 China Household Finance Survey (CHFS), this study estimated the incidence and intensity of CHE and MI for 28 Chinese provinces. Ordinary least square (OLS) estimation, using robust standard errors, was used to explore the factors associated with financial protection at the province level. Moreover, this study examined the urban-rural differences in financial protection within each province, and calculated the concentration index of CHE and MI indicators for each province using household income per capita.

Findings

The study revealed large provincial variations in financial protection within the nation. The nationwide CHE incidence was 11.0% (95% CI: 10.7%, 11.3%), ranging from 6.3% (95% CI: 5.0%, 7.6%) in Beijing to 16.0% (95% CI: 14.0%, 18.0%) in Heilongjiang; the national MI incidence was 2.0% (95% CI: 1.8%, 2.1%), ranging from 0.03% (95% CI: 0.00%, 0.06%) in Shanghai to 4.6% (95% CI: 3.3%, 5.9%) in Anhui province. We also found similar patterns for provincial variations in intensity of CHE and MI. Moreover, substantial provincial variations in income-related inequality and urban-rural gap existed across provinces. Eastern developed provinces in general had much lower inequality within them, compared with central and western provinces.

Interpretation

Despite the great advances towards UHC in China, substantial provincial variations exist in financial protection across provinces. Policymakers should pay special attention to low-income households in central and western provinces. Provision of better financial protection for these vulnerable groups will be key to achieving UHC in China.

Funding

This research was supported by the National Natural Science Foundation of China (Grant Number: 72074049) and the Shanghai Pujiang Program (2020PJC013).

Determinants and Projections of Minimum Acceptable Diet among Children Aged 6-23 Months: A National and Subnational Inequality Assessment in Bangladesh

Subnational evidence on the level of inequality in receiving complementary feeding practice among Bangladeshi children is lacking. This study estimated inequality in the minimum acceptable diet (MAD) among Bangladeshi children aged 6-23 months, and identified risk factors for and developed projections of the MAD up to 2030. Data from the Bangladesh Demographic and Health Survey 2017-2018 were used in this cross-sectional study. Regression-based slope (SII) and relative index of inequality (RII) were used to quantify the level of absolute and relative inequality, respectively. A Bayesian logistic regression model was used to identify the potential determinants of a MAD and project prevalence up to 2030. About 38% of children aged 6-23 months received a MAD. The national prevalence of a MAD was 26.0 percentage points higher among children from the richest compared to the poorest households, and 32.1 percentage points higher among children of higher-educated over illiterate mothers. Socioeconomic inequality was found to be the highest in the Chattogram division (SII: 43.9), while education-based inequality was highest in the Sylhet division (SII: 47.7). Maternal employment and the number of ANC visits were also identified as significant determinants of a MAD, and the prevalence of a MAD was projected to increase from 42.5% in 2020 to 67.9% in 2030. Approximately two out of five children received a MAD in Bangladesh and significant socioeconomic and education-based inequalities in the MAD were observed. Subnational variation in socioeconomic and education-based inequalities in the MAD requires further public health attention, and poverty reduction programs need to be strengthened.

Common factors influencing childhood undernutrition and their comparison between Sylhet, the most vulnerable region, and other parts of Bangladesh: Evidence from BDHS 2007-18 rounds

Introduction

Undernourishment is disproportionately spread within Bangladesh, making some regions like Sylhet more vulnerable than the rest of the country. We aimed to assess the trend of diverse associated factors related to childhood stunting, wasting, and being underweight. Furthermore, we have compared the estimated factors between Sylhet, the most vulnerable region, and other parts of Bangladesh.

Methods

We performed a secondary data analysis where data were derived from the nationally representative cross-sectional surveys: Bangladesh demographic and health survey (BDHS) 2007, 2011, 2014, and 2017-18 rounds. The outcome variables were childhood undernutrition, including stunting, wasting, and being underweight. Descriptive statistics such as mean, standard deviation, frequency, and proportion were used to summarize the data. All variables were summarized by BDHS survey time points. We used multiple logistic regression models to measure the associated factors with childhood stunting, wasting, and being underweight.

Results

The percentage of children under the age of 5 years who were stunted declined from 40% in 2007 to 31% in 2018. Similar trends are observed in the decrease in the percentage of underweight children, dropping from 39% in 2007 to 22% in 2018. Wasting dropped to 8% in 2018 after years of critically high levels (17%). According to the results of the regression analyses, urban residence, child's age and gender, morbidity, maternal BMI, maternal and paternal education, decision-making ability, use of contraceptives, the occurrence of domestic violence, antenatal care, c-section, and birth interval, as well as geographic region, were all linked to childhood malnutrition.

Conclusion

The Sylhet division falls short in several critical associated indicators, including parental education, maternal BMI, obtaining at least four ANC, women empowerment, and usage of contraceptives. Policymakers must concentrate on region-specific planning and proper intervention to achieve a more uniform improvement across the country.

Identifying geographical inequalities of maternal care utilization in Ethiopia: a Spatio-temporal analysis from 2005 to 2019

INTRODUCTION

Inequalities in maternal care utilization pose a significant threat to maternal health programs. This study aimed to describe and explain the spatial variation in maternal care utilization among pregnant women in Ethiopia. Accordingly, this study focuses on identifying hotspots of underutilization and mapping maternal care utilization, as well as identifying predictors of spatial clustering in maternal care utilization.

METHODS

We evaluated three key indicators of maternal care utilization: pregnant women who received no antenatal care (ANC) service from a skilled provider, utilization of four or more ANC visits, and births attended in a health facility, based the Ethiopian National Demographic and Health Survey (EDHS5) to 2019. Spatial autocorrelation analysis was used to measure whether maternal care utilization was dispersed, clustered, or randomly distributed in the study area. Getis-Ord Gi statistics examined how Spatio-temporal variations differed through the study location and ordinary Kriging interpolation predicted maternal care utilization in the unsampled areas. Ordinary least squares (OLS) regression was used to identify predictors of geographic variation, and geographically weighted regression (GWR) examined the spatial variability relationships between maternal care utilization and selected predictors.

RESULT

A total of 26,702 pregnant women were included, maternal care utilization varies geographically across surveys. Overall, statistically significant low maternal care utilization hotspots were identified in the Somali region. Low hotspot areas were also identified in northern Ethiopia, stretching into the Amhara, Afar, and Beneshangul-Gumuz regions; and the southern part of Ethiopia and the Gambella region. Spatial regression analysis revealed that geographical variations in maternal care utilization indicators were commonly explained by the number of under-five children, the wealth index, and media access. In addition, the mother's educational status significantly explained pregnant women, received no ANC service and utilized ANC service four or more times. Whereas, the age of a mother at first birth was a spatial predictor of pregnant who received no ANC service from a skilled provider.

CONCLUSION

In Ethiopia, it is vital to plan to combat maternal care inequalities in a manner suitable for the district-specific variations. Predictors of geographical variation identified during spatial regression analysis can inform efforts to achieve geographical equity in maternal care utilization.

Socioeconomic inequalities in low birth weight in South Asia: A comparative analysis using Demographic and Health Surveys

Background

Low Birth Weight (LBW) continues to be a prominent universal cause of various short- and long-term health hazards throughout infancy and adulthood. However, no study has revealed the socioeconomic inequalities in LBW among South Asian countries. This study assesses the socioeconomic inequalities among under-five South Asian children with LBW.

Methods

Secondary data were derived from six (Afghanistan, Bangladesh, India, Maldives, Nepal, and Pakistan) nationally representative South Asian Demographic and Health Surveys conducted between 2015 and 2021, and included 170,547 under-five years of age children. The study employed the concentration curve and concentration index to assess the socioeconomic inequalities of those with LBW. Additionally, mixed-effect logistic regression was applied to determine the factors associated with LBW.

Results

A significant negative concentration index indicates the wealth-related and education-related inequalities of LBW among under-five South Asian children. LBW is highly concentrated in the socio-economically poor section of the society. Our study found statistically significant negative concentration index in all South Asian countries: Afghanistan (Education: -0.108), Bangladesh (wealth: -0.070 & education: -0.083), India (wealth: -0.059 & education: -0.052), Nepal (by wealth: -0.064 & by education: -0.080), and Pakistan (by wealth: -0.080 & by education: -0.095). Findings from the mixed-effects logistic regression model also show that children from the poorest quintiles (AOR: 1.53, 95% CI: 1.41-1.67) and illiterate mothers (AOR: 1.39, 95% CI: 1.29-1.51) had higher odds of being afflicted with LBW compared to the wealthiest quintiles and educated mothers respectively. Women's pregnancy assessments, such as antenatal care utilisation, iron supplementation intake, and normal delivery mode, are significantly correlated with decreased odds of children's LBW.

Conclusion

There exists a strong association between LBW cases and socioeconomic inequalities among South-Asian children below five years of age. This indicates the urgent need for health education and prenatal care services for women from Afghanistan, Bangladesh, India, Nepal, and Pakistan, especially those with lower socioeconomic status.

Young mothers’ attitudes towards domestic violence and their maternal healthcare services utilization in Bangladesh: A multilevel cluster analysis

This paper examined the association between young mothers’ attitudes towards domestic violence and four or more antenatal care (ANC) and health-center-based delivery service utilization using two cross-sectional waves of the Bangladesh Demographic and Health Surveys (2014 and 2018) data. We carried out a multilevel logistic regression analysis. Findings show that a strong cluster variation exists in four or more ANC and health-center-based delivery service utilization. Although the utilization of four or more ANC and health-center-based delivery services has increased over the years, it is far behind the targets of SDGs, particularly for young mothers with justified attitudes towards domestic violence. Extension of maternity allowance coverage and motivational programs are important policy recommendations.

A multilevel assessment of the influence of education on women's uptake of institutional delivery services during childbirth in Bangladesh

OBJECTIVES

Despite a significant decline over time, maternal mortality remains high in Bangladesh. Institutional delivery during childbirth is crucial to reducing maternal mortality, but uptake of institutional delivery services (IDS) remains suboptimal in Bangladesh. Though women's education plays a crucial role in the use of IDS, the educational status of the household head and area-level literacy rate also appear to act as predictors of IDS uptake. This study aims to assess the effect of the educational status of women and household heads as well as district-level adult literacy rates on the use of IDS during childbirth among women in Bangladesh.

DESIGN

This study analyzed nationally representative cross-sectional survey data from the 2019 Bangladesh Multiple Indicator Cluster Survey.

SETTING

Bangladesh.

PARTICIPANTS

9,207 currently married women aged 15-49 years who had at least one live birth in the two years preceding the survey were included in the study. The outcome measure was women's use of IDS during their last childbirth. A multilevel logistic regression model was used to explore the association between education status of women and household heads, and district (i.e., area unit) adult literacy rates and uptake of IDS among women in Bangladesh by controlling for other sociodemographic covariates and clustering.

RESULTS

About 53% of women used IDS during childbirth. Adjusting for other factors and clustering, women with higher educational status, those living in households with higher-educated heads, and those in districts with greater adult literacy rates are more likely to use IDS, after controlling for key sociodemographic variables including wealth.

CONCLUSIONS

Uptake of IDS in Bangladesh remains low, with education playing an important independent role in determining rates. The findings of the study provide empirical evidence for policymakers to design multi-modal educational programs targeted not only at literate women but also at household head (especially male) and communities where literacy (and equally importantly health literacy) may be variable or absent.

Regional education and wealth-related inequalities in malnutrition among women in Bangladesh

OBJECTIVES

This paper examines the associations of socio-economic and demographic correlates with malnutrition among women and investigates education and wealth-related inequalities in malnutrition among women by region.

DESIGN

We utilise a two-level mixed-effects logistic regression model to evaluate the associations and employ the concentration, Wagstaff and Erreygers's correction indices to measure socio-economic inequalities in malnutrition among women.

SETTING

Bangladesh Demographic and Health Survey data.

PARTICIPANTS

Non-pregnant women aged 15-49 years.

RESULTS

We find evidence of a significant cluster effect in the data. Women's age, marital status, total children ever born, education level, husband's/partner's education level, residence and wealth index appear to be significantly associated with women underweight and overweight/obesity status. Underweight status is higher among less-educated women and women from poor households, whereas overweight/obesity is more concentrated among higher educated women and women from wealthy households. The southwestern region of the country demonstrates lower education and wealth-related inequalities in malnutrition among women. In contrast, the central and the northeastern areas apparently experience the highest education and wealth-related inequalities in malnutrition among women. The regional differences in predicted probabilities of being underweight shrink at higher education level and the richest quintile, whereas the differences in overweight/obese diminish at the primary education level and lower quintile households.

CONCLUSIONS

Our findings strengthen the evidence base for effective regional policy interventions to mitigate education and wealth-related inequalities in malnutrition among women. There is a need for developing regional awareness programmes and establishing regional monitoring cells to ensure proper health and nutrition facilities in underprivileged regions.

Socio-economic inequalities in diabetes and prediabetes among Bangladeshi adults

Diabetes and prediabetes are overwhelming public health concerns in Bangladesh. However, there is a paucity of the literature examining and measuring socioeconomic inequalities in the prevalence of diabetes in Bangladesh. To provide reliable data and contribute to a nationwide scenario analysis, this study aims to estimate the inequality in prevalence of diabetes and prediabetes and to identify factors potentially contributing to socioeconomic inequalities in Bangladesh. This study used data from the latest Bangladesh Demographic and Health Survey (BDHS) 2017-18, a nationally representative survey. A regression-based decomposition method was applied to assess the socioeconomic contributors to inequality. The prevalence of diabetes and prediabetes were about 10 and 15% among Bangladeshi adults, respectively. Both diabetes and prediabetes were significantly associated with age, wealth status, suffering from overweight or obesity and administrative divisions of the respondents (p < 0.001). Respondents' household wealth status accounted for about 74 and 81% of the total inequality in diabetes and prediabetes in Bangladesh, respectively. Administrative region contributed 24.85% of the inequality in prediabetes and 12.26% of the inequality in diabetes. In addition, overweight or obesity status contributed 11.37% and exposure to television contributed 5.17% of the inequality in diabetes. Diabetes and prediabetes affect a substantial proportion of the Bangladeshi adult population. Therefore, these findings should be considered in the context of current and proposed policy decision making and for tracking its progression with economic development in Bangladesh.

Determinants of optimal antenatal care visit among pregnant women in Ethiopia: a multilevel analysis of Ethiopian mini demographic health survey 2019 data

Background

Optimal antenatal care (ANC4+) needs to be used throughout pregnancy to reduce pregnancy complications and maternal mortality. The World Health Organization (WHO) recommends eight ANC contacts, while Ethiopia has the lowest coverage of at least four ANC visits. Therefore, this study aimed to identify factors associated with optimal ANC visits among pregnant women in Ethiopia.

Methods

This study is a secondary data analysis of the 2019 Ethiopian Mini Demographic and Health Survey (EMDHS). A multilevel logistic regression model is set up to identify factors associated with optimal ANC visits. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were calculated to estimate the strength of the association between the outcome and the predictor variables.

Results

Overall, 43% of women had optimal ANC visits during their last pregnancy. Higher educated women are 3.99 times more likely (AOR = 3.99; 95% CI: 2.62–6.02) to have optimal ANC visits than women with no formal education. The wealthiest women are 2.09 times more likely (AOR = 2.09; 95% CI: 1.56–2.82) to have optimal ANC visits than women in the poorest quintile. The odds of optimal ANC visit is 42 percent lower in rural women (AOR = 0.58, 95% CI: 0.41–0.83) compared to women living in urban areas.

Conclusion

Women's educational status, wealth status, mass media exposure, place of residence and region are factors that are significantly associated with optimal ANC visit. These findings help health care programmers and policymakers to introduce appropriate policies and programs to ensure optimal ANC coverage. Priority should be given to addressing economic and educational interventions.

Optimal antenatal care means attending at least four antenatal care visits during pregnancy. In Ethiopia, evidence on factors affecting the use of at least four antenatal care services has not been adequately documented. Using the 2019 Ethiopian Mini Demographic and Health Survey data, this study attempted to uncover factors associated with optimal antenatal care visits among pregnant women in Ethiopia.

Data for women aged 15–49 who gave birth five years before the survey and attended antenatal care visits for their last pregnancy were taken from the 2019 Ethiopian Mini Demographic and Health Survey. Accordingly, 3927 women were included in the analysis.

Coverage of optimal antenatal care visits is low among pregnant women in Ethiopia. In this study, only 43% of pregnant women received optimal antenatal care. Women’s educational status, household wealth status, household size, mass media exposure, place of residence, and administrative region were associated with optimal antenatal care visits.

Strategies to increase access and availability of antenatal care services are important, especially for communities in rural areas and disadvantageous regions. Financial assistance that allows mothers from poor families to access antenatal care services can be beneficial. Health promotion programs targeting uneducated mothers are important to raise awareness of the importance of receiving a minimum of four antenatal care services.

Inequalities in women's utilization of postnatal care services in Bangladesh from 2004 to 2017

Postnatal care (PNC) is an essential component of maternity care. Appropriate and timely care immediately after childbirth can save lives and help to prevent or treat comorbidities resulting from pregnancy and childbirth. Despite its importance, PNC coverage is still low in Bangladesh. The aim of this study was to analyse the trends, inequalities, and factors associated with PNC for mothers in Bangladesh. Data from the last five Bangladesh Demographic and Health Surveys (BDHS) were used. Descriptive statistics were used to report PNC outcome rates and trends across six inequality indicators. Modified Poisson regression analyses were used to identify factors associated with PNC use in the most recent BDHS. A total of 21,240 women were included for the analysis. The rate of PNC by ‘medically trained provider’ within 2 days of birth increased between 2004 and 2017, from 16 to 52%. There were wide inequalities across socio-demographic factors. The regression analyses found women giving birth at home, women from the poorest wealth quintile and women receiving no antenatal care (ANC) were least likely to receive PNC. The findings emphasize the need to improve public health programs supporting women who have the least access to PNC. The identified inequalities can inform policy formulation to ensure more equitable provision of PNC to women in Bangladesh.

Mother's care-seeking behavior for neonatal danger signs from qualified providers in rural Bangladesh: A generalized structural equation modeling and mediation analysis

BACKGROUND

Neonatal deaths contribute to nearly half (47%) of under-five mortality globally and 67% in Bangladesh. Despite high neonatal mortality, care-seeking from qualified providers for newborn danger signs remains low. Identification of direct and indirect factors and their pathways affecting care-seeking will help to design a well-targeted intervention. This study assessed the direct, indirect, and total effect of the predictive factors on neonatal care-seeking in Bangladesh.

MATERIALS AND METHODS

This was a cross-sectional baseline household survey conducted in 14 districts of Bangladesh in 2019 with 17,251 recently delivered women (RDW) with a live birth outcome in the preceding 15 months. We used a two-stage stratified cluster sampling process to select the samples from 14 districts. We investigated the inter-relationship of maternal background characteristics, maternal health utilizations, child/neonate factors, health service delivery-related factors and newborn danger sign knowledge with newborn care-seeking practices and estimated the direct, indirect, and total effects using Generalized Structural Equation Modeling (GSEM) and mediation analysis. p-value = 0.05 was considered statistically significant. The result of the mediation analysis was reported in Log Odds (LOD). The positive LOD (LOD > 0) implies a positive association.

RESULTS

Half of the mothers (50.8%) reported a neonatal illness and among them, only 36.5% mothers of sick neonates sought care from qualified providers. Our mediation analysis showed that maternal health utilization factors, i.e., 4 + antenatal care visits (ANC) from a qualified provider (LOD: 0.63, 95% CI: 0.49, 0.78), facility delivery (LOD: 0.74, 95% CI: 0.30, 1.17) and postnatal care (PNC) from a qualified provider (LOD: 0.50, 95% CI: 0.21, 0.78) showed the highest total effect over other factors domains, and therefore, were the most important modifiable predictors for qualified neonatal care-seeking. Other important factors that directly and/or indirectly increased the chance of newborn care-seeking from qualified providers were household wealth (LOD: 0.86, 95% CI: 0.70, 1.02), maternal education (LOD: 0.48, 95% CI: 0.32, 0.63), distance to nearest health facility (LOD: 0.20, 95% CI: 0.10, 0.30), community health worker's (CHWs) home visits during ANC (LOD: 0.24, 95% CI: 0.13, 0.36), neonatal danger sign counseling after delivery (LOD: 0.20, 95% CI: 0.06, 0.34) and women's knowledge of neonatal danger signs (LOD: 0.37, 95% CI: 0.09, 0.64).

CONCLUSION

The inter-relationship and highest summative effect of ANC, facility delivery, and PNC on newborn care-seeking suggested the maternal care continuum altogether from ANC to facility delivery and PNC to improve care-seeking for the sick newborn. Additionally, referral training for unqualified providers, targeted intervention for poorer households, increasing CHWs home visits and neonatal danger sign counseling at the facility and community should also be considered.

Private Healthcare Expenditure in China: A Regional Comparative Analysis

Private (out-of-pocket) healthcare expenditure (PHCE) is a complex phenomenon that is shaped by many different factors. In this paper, we analyzed the influencing factors of PHCE in China, with a specific focus on regional differences. We found that old-age dependency ratio, income, and education have significant impacts on PHCE in all regions, whereas public HCE, number of beds in medical institutions, and economic development levels have significant impacts only in some regions. The results indicate that the government should pay attention to regional inequality and implement targeted adjustments for improving the health service system. In particular, we recommend: (1) monitoring regional inequality in PHCE and other healthcare issues to unmask geographical differences in healthcare interventions; (2) adopting regional-specific policy measures—the government should divert some resources from eastern to western and central regions to increasing the support for public health undertakings and improve the quality of the local health services while providing matching medical resources by targeting the needs of the residents; (3) paying more attention to the healthcare demand of the elderly population; and (4) improving the education level of residents to improve public health and avoid high PHCE.

Prevalence of Eight or More Antenatal Care Contacts: Findings From Multi-Country Nationally Representative Data

Optimal antenatal care is an important service required by women and babies. To promote healthy motherhood and for positive pregnancy outcomes, World Health Organization recently recommended a minimum of 8 ANC contacts. We aim to explore the prevalence of 8 or more ANC contacts using multi-country data. Urban dwellers, mothers with secondary or higher education, women from high household wealth, early birth order, and older mothers at childbirth had higher prevalence of 8 or more ANC contacts respectively. The pooled prevalence of 8 or more ANC contacts was 13.0%. Jordan had the leading prevalence of 8 or more ANC contacts (74.0%), followed by Ghana (43.0%) and Albania (30.0%). On the other hand, Senegal, Uganda, and Zambia had very low prevalence of 8 or more ANC contacts. There was heterogeneity in the prevalence of 8 or more ANC contacts across countries. There was low prevalence of 8 or more ANC contacts.

The contribution of service density and proximity to geographical inequalities in health care utilisation in Indonesia: A nation-wide multilevel analysis

Background

Geographical inequalities in access to health care have only recently become a global health issue. Little evidence is available about their determinants. This study investigates the associations of service density and service proximity with health care utilisation in Indonesia and the parts they may play in geographic inequalities in health care use.

Methods

Using data from a nationally representative survey (N = 649 625), we conducted a cross-sectional study and employed multilevel logistic regression to assess whether supply-side factors relating to service density and service proximity affect the variability of outpatient and inpatient care utilisation across 497 Indonesian districts. We used median odds ratios (MORs) to estimate the extent of geographical inequalities. Changes in the MOR values indicated the role played by the supply-side factors in the inequalities.

Results

Wide variations in the density and proximity of health care services were observed between districts. Outpatient care utilisation was associated with travel costs (odds ratio (OR) = 0.82, 95% confidence interval (CI) = 0.70-0.97). Inpatient care utilisation was associated with ratios of hospital beds to district population (OR = 1.23, 95% CI = 1.05-1.43) and with travel times (OR = 0.72 95% CI = 0.61-0.86). All in all, service density and proximity provided little explanation for district-level geographic inequalities in either outpatient (MOR = 1.65, 95% CrI = 1.59-1.70 decreasing to 1.61, 95% CrI = 1.56-1.67) or inpatient care utilisation (MOR = 1.63, 95% CrI = 1.55-1.69 decreasing to 1.60 95% CrI = 1.54-1.66).

Conclusions

Supply-side factors play important roles in individual health care utilisation but do not explain geographical inequalities. Variations in other factors, such as the price and responsiveness of services, may also contribute to the inequalities. Further efforts to address geographical inequalities in health care should go beyond the physical presence of health care infrastructures to target issues such as regional variations in the prices and responsiveness of services.

Socioeconomic inequalities in HIV knowledge, HIV testing, and condom use among adolescent and young women in Latin America and the Caribbean

Objective.

To appraise the presence and magnitude of inter- and intra-country health inequalities related to HIV in Latin America and the Caribbean (LAC) among young females.

Methods.

We analyzed household surveys in twenty LAC countries, that included data from female adolescents and young women (ages 15-24) between 2008 and 2018, measuring inequality with the concentration index of 4 indicators: 1) whether individuals have heard of HIV or not, 2) a composite variable of correct knowledge, 3) reported condom use with the last partner, and 4) whether individuals were ever tested for HIV.

Results.

Participants from households in countries with higher socioeconomic status are more likely to have heard of HIV, have correct knowledge of HIV transmission, and have used condoms during their last sexual intercourse. The inter-country concentration index for those indicators were 0.352, 0.302 and 0.110, respectively.

Conclusions.

Economically disadvantaged female adolescents and young women in LAC face an increased risk for HIV, as they are less aware of HIV and its actual transmission mechanism and are less likely to use condoms with their sexual partners. There is an urgent need to tailor prevention strategies of sexually transmitted infections and HIV for adolescents and young women that are sensitive to their socioeconomic context.

Twelve-year persistence of inequalities in antenatal care utilisation among women in Tanzania: a decomposition analysis of population-based cross-sectional surveys

OBJECTIVE

This study was undertaken to assess the trend and contributors of socioeconomic inequalities in antenatal care (ANC) utilisation among women of reproductive age in Tanzania from 2004 to 2016.

DESIGN

Population-based cross-sectional surveys.

SETTING

This study analysed nationally representative data for women of reproductive age obtained from the 2004-2016 Tanzania Demographic Health Surveys.

PRIMARY OUTCOME MEASURE

The outcome variables analysed in this study are: (1) attendance of ANC and (2) accessing adequate antenatal care.

ANALYTICAL METHODS

The concentration curve and the concentration index were used to measure socioeconomic inequality in attending and accessing adequate ANC. The concentration index was decomposed to identify the factors explaining the observed socioeconomic inequality of these two outcomes.

RESULTS

The concentration index for attending at least four ANC visits increased from 0.169 in 2004 to 0.243 in 2016 (p<0.01). Similarly, for accessing adequate care, the index increased from 0.147 in 2004 to 0.355 in 2016 (p<0.01). This indicates the significant increase in socioeconomic inequalities (favouring wealthier women) for these two outcomes over time. Furthermore, the results show that wealth status was the largest contributor to inequality in both attending at least four visits (71%, 50% and 70%) and accessing adequate ANC (50%, 42% and 51%) in 2004, 2010 and 2016, respectively, in favour of wealthier women (p<0.05). The other contributors to socioeconomic inequalities in ANC utilisation were maternal education and type of residence.

CONCLUSION

Over the 12 years of surveys, there was no reduction in socioeconomic inequalities in ANC utilisation in Tanzania. Therefore, the efforts of achieving universal health coverage should focus on reducing wealth-related inequality and improving women's education from poor households.

Prevalence and Socioeconomic Inequalities in Eight or More Antenatal Care Contacts in Ghana: Findings from 2019 Population-Based Data

Background

For the prevention of complications and death during pregnancy, adequate antenatal care (ANC) contacts are important. To achieve optimal obstetric care, the latest ANC guidance recommends eight or more ANC contacts. The aim of this analysis is to investigate the prevalence and socio-economic differences of eight or more Ghanaian ANC contacts.

Methods

A total sample of 1404 women of reproductive age who had given birth after eight or more ANC contacts had been initiated, taking into account 9 months of gestation, was studied. The Ghana Malaria Indicator Survey of 2019 (GMIS) was used. In the univariate analysis, percentage was used. The curve and concentration index of Lorenz were used to assess socio-economic disparities for eight or more ANC contacts. Statistical significance was set at 5%.

Results

The weighted prevalence of eight or more ANC contacts was 41.9% (95% CI: 37.9–45.9%). The prevalence of eight or more ANC contacts among the poorest, poorer, middle, richer and richest households was 34.0%, 36.1%, 35.8%, 42.4% and 59.6%, respectively. Similarly, 33.0%, 37.7% and 42.6% prevalence of eight or more ANC contacts were estimated among women with no formal education, primary, secondary or higher, respectively. In addition, women from rich household had greater coverage of eight or more ANC contacts (Conc. Index= 0.089; SE= 0.019) and educated women had greater coverage of eight or more ANC contacts in Ghana (Conc. Index= 0.053; SE= 0.017) (all p<0.001).

Conclusion

Eight or more ANC contacts from the WHO in 2016 have yet to be fully institutionalized in Ghana. In order to increase access to the recommended prenatal care and for a healthy pregnancy experience, measures that resolve disparities in healthcare usage need to be prioritized for the country. Efforts should be made to expand the health insurance services available, as well as to enact policies that will increase free health care particularly among the poor and uneducated women.

Levels of and changes in socioeconomic inequality in delivery care service: A decomposition analysis using Bangladesh Demographic Health Surveys

BACKGROUND

Socioeconomic inequality in maternity care is well-evident in many developing countries including Bangladesh, but there is a paucity of research to examine the determinants of inequality and the changes in the factors of inequality over time. This study examines the factors accounting for the levels of and changes in wealth-related inequality in three outcomes of delivery care service: health facility delivery, skilled birth attendance, and C-section delivery in Bangladesh.

METHODS

This study uses from the Bangladesh Demographic and Health Survey of 2011 and 2014. We apply logistic regression models to examine the association between household wealth status and delivery care measures, controlling for a wide range of sociodemographic variables. The Erreygers normalised concentration index is used to measure the level of inequalities and decomposition method is applied to disentangle the determinants contributing to the levels of and changes in the observed inequalities.

RESULTS

We find a substantial inequality in delivery care service utilisation favouring woman from wealthier households. The extent of inequality increased in health facility delivery and C-section delivery in 2014 while increase in skilled birth attendance was not statistically significant. Wealth and education were the main factors explaining both the extent of and the increase in the degree of inequality between 2011 and 2014. Four or more antenatal care (ANC4+) visits accounted for about 8% to 14% of the observed inequality, but the contribution of ANC4+ visits declined in 2014.

CONCLUSION

This study reveals no progress in equity gain in the use of delivery care services in this decade compared to a declining trend in inequity in the last decade in Bangladesh. Policies need to focus on improving the provision of delivery care services among women from poorer socioeconomic groups. In addition, policy initiatives for promoting the completion of quality education are important to address the stalemate of equity gain in delivery care services in Bangladesh.

Geographical and socioeconomic inequalities in the utilization of maternal healthcare services in Nigeria: 2003-2017

Background

Maternal mortality has remained a challenge in many low-income countries, especially in Africa and in Nigeria in particular. This study examines the geographical and socioeconomic inequalities in maternal healthcare utilization in Nigeria over the period between 2003 and 2017.

Methods

The study used four rounds of Nigeria Demographic Health Surveys (DHS, 2003, 2008, 2013, and 2018) for women aged 15–49 years old. The rate ratios and differences (RR and RD) were used to measure differences between urban and rural areas in terms of the utilization of the three maternal healthcare services including antenatal care (ANC), facility-based delivery (FBD), and skilled-birth attendance (SBA). The Theil index (T), between-group variance (BGV) were used to measure relative and absolute inequalities in the utilization of maternal healthcare across the six geopolitical zones in Nigeria. The relative and absolute concentration index (RC and AC) were used to measure education-and wealth-related inequalities in the utilization of maternal healthcare services.

Results

The RD shows that the gap in the utilization of FBD between urban and rural areas significantly increased by 0.3% per year over the study period. The Theil index suggests a decline in relative inequalities in ANC and FBD across the six geopolitical zones by 7, and 1.8% per year, respectively. The BGV results do not suggest any changes in absolute inequalities in ANC, FBD, and SBA utilization across the geopolitical zones over time. The results of the RC and the AC suggest a persistently higher concentration of maternal healthcare use among well-educated and wealthier mothers in Nigeria over the study period.

Conclusion

We found that the utilization of maternal healthcare is lower among poorer and less-educated women, as well as those living in rural areas and North West and North East geopolitical zones. Thus, the focus should be on implementing strategies that increase the uptake of maternal healthcare services among these groups.

Decomposing socioeconomic inequality in dental caries in Iran: cross-sectional results from the PERSIAN cohort study

Background

The current study aimed to measure and decompose socioeconomic-related inequalities in DMFT (decayed, missing, and filled teeth) index among adults in Iran.

Methods

The study data were extracted from the adult component of Prospective Epidemiological Research Studies in IrAN (PERSIAN) from 17 centers in 14 different provinces of Iran. DMFT score was used as a measure of dental caries among adults in Iran. The concentration curve and relative concentration index (RC) was used to quantify and decompose socioeconomic-related inequalities in DMFT.

Results

A total of 128,813 adults aged 35 and older were included in the study. The mean (Standard Deviation [SD]) score of D, M, F and DMFT of the adults was 3.3 (4.6), 12.6 (10.5), 2.1 (3.4) and 18.0 (9.5), respectively. The findings suggested that DMFT was mainly concentrated among the socioeconomically disadvantaged adults (RC = - 0.064; 95% confidence interval [CI), - 0.066 to - 0.063). Socioeconomic status, being male, older age and being a widow or divorced were identified as the main factors contributing to the concentration of DMFT among the worse-off adults.

Conclusions

It is recommended to focus on the dental caries status of socioeconomically disadvantaged groups in order to reduce socioeconomic-related inequality in oral health among Iranian adults. Reducing socioeconomic-related inequalities in dental caries should be accompanied by appropriate health promotion policies that focus actions on the fundamental socioeconomic causes of dental disease.

Prevalence and factors associated with knowledge and access to delivery services at primary health care facilities amongst indigenous women in Khagrachhari district Bangladesh - A cross-sectional study

OBJECTIVE

To estimate the prevalence of facility delivery knowledge and access during childbirth amongst Indigenous women in the Chittagong Hill Tracts, Bangladesh and to identify factors associated with facility delivery service utilisation.

DESIGN

A cross-sectional study design using a structured self-report survey.

SETTING

Two Upazilas (subdistricts) of Kharachhari hill district of the Chittagong Hill Tracts.

PARTICIPANTS

Indigenous women of reproductive age (15-49 years) within 36 months of delivery.

MEASUREMENTS AND FINDINGS

A modified national survey about accessing maternal health services, including delivery services was administered to all Indigenous women that met eligibility, guided by community leaders. Data collected included socio-demographic characteristics and reproductive history. Main outcome variables were the proportion of women having prior knowledge about and access to facility delivery services for childbirth in the three years prior to the survey. Secondary outcomes were sources of information about facility delivery services, decision making about delivery place, and factors associated with knowledge and attendance at facility delivery services. Factors associated with knowledge and attendance were estimated using logistic regression with results reported as adjusted odds ratios and 95% confidence intervals. With an 89% response rate, a total of 438 Indigenous women (220 Chakma, 100 Marma, 118 Tripura) participated in the survey, and 75% were aged 16-29 years. Relatives played a vital role as a source of information about delivery services (59%). Nearly three-quarters (73%) were aware of facility delivery services, however, prevalence of accessing delivery services was 33% (n = 143; 95% CI 0.28-0.37). Relatives were the key decision-makers for accessing facility delivery services (60%). Independent factors associated with knowledge about facility delivery were higher household income (AOR 5.3, 95%CI 2.2-13); having knowledge of nearest health care facilities (AOR 5.8, 95%CI 3.0-11); and attending antenatal care visits during last pregnancy (four or more AOR 3.1, 95% CI 1.3-7.2 and one to three visits AOR 2.7, 95% CI 1.5-5.0). Independent factors associated with accessing facility delivery services at childbirth were attending antenatal care visit; having access to media; higher level of education of partners; and residing at Khagrachhari Sadar compared to Matiranga subdistrict.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Indigenous women in Chittagong Hill Tracts, Bangladesh have sub-optimal knowledge of, and attendance at, facility delivery services for childbirth. Maternal health related interventions should target Indigenous women in order to educate and motivate them to access facility delivery services at childbirth. Rigorous research is needed to explore Indigenous cultural practices related to childbirth that might influence their access to facility delivery services.

Socioeconomic Inequalities in Uptake of Breast Cancer Screening among Saudi Women: A Cross-Sectional Analysis of a National Survey

Timely and adequate screening for breast cancer could improve health outcomes and reduce health costs. However, the utilization of free breast cancer screening services among Saudi women is very low. This study aims to investigate socioeconomic inequalities in breast cancer screening among Saudi women. The data of this study were extracted from the nationally representative Saudi Health Interview Survey, conducted in 2013; the study included 2786 Saudi women. Multivariate logistic regression, the concentration curve, and the concentration index were used to examine, illustrate, and quantify income- and education-related inequalities in three outcomes: Knowledge about self-breast examination (SBE), clinical breast examination (CBE) received in the last year, and mammography, that has ever been previously carried out. Results showed a marked socioeconomic gradient in breast cancer screening services. The concentration index by income was 0.229 (SBE), 0.171 (CBE), and 0.163 (mammography). The concentration index by education was 0.292 (SBE), 0.149 (CBE), and 0.138 (mammography). Therefore, knowledge about breast cancer screening, and the utilization of screening services, were more concentrated among richer and better-educated women. Poorer and less educated women had less knowledge about self-breast examination, and had considerably less adherence to clinical breast examination and mammography. The findings are helpful for policy makers to devise and implement strategies to promote equity in breast cancer screening among Saudi women.

Regional disparities in antenatal care utilization in Indonesia

INTRODUCTION

The main strategy for decreasing maternal morbidity and mortality has been antenatal care (ANC). ANC aims to monitor and maintain the health and safety of the mother and the fetus, detect all complications of pregnancy and take the necessary actions, respond to complaints, prepare for birth, and promote a healthy lifestyle. This study aims to analyze interregional disparities in ≥4 ANC visits during pregnancy in Indonesia.

METHODS

Data was acquired from the 2017 Indonesian Demographic and Health Survey (IDHS). The unit of analysis was women aged 15-49 years old, and a sample of 15,351 women was obtained. In addition to ANC as the dependent variable, the other variables analyzed in this study were a place of residence, age, husband/partner, education, parity, wealth status, and health insurance. For the final analysis, binary logistic regression was used to determine disparity.

RESULTS

With the Papua region as a reference, all regions showed a gap except for the Maluku region, which was not significantly different in the use of ANC compared to the Papua region. Women in the Nusa Tenggara have 4.365 times the chance of making ≥4 ANC visits compared to those in the Papua region (95% CI 3.229-5.899). Women in Java-Bali have 3.607 times the chance of making ≥4 ANC visits compared to women in the Papua region (95% CI 2.741-4.746). Women in Sumatra have 1.370 times the chance of making ≥4 ANC visits compared to women in the Papua region (95% CI 1.066-1.761). Women in Kalimantan have 2.232 times the chance of making ≥4 ANC visits compared to women in the Papua region (1.664-2.994). Women in Sulawesi have 1.980 times more chance of making ≥4 ANC visits compared to women in the Papua region (1.523-2.574). In addition to the region category, other variables that contributed to the predictor were age, husband/partner, education, parity, wealth and insurance.

CONCLUSION

There were disparities in ANC utilization between the various regions of Indonesia. The structured policy is needed to reach regions that have low coverage of ≥4 ANC. Policymakers need to use the results of this study to take the necessary policies. Policies that focus on service equality to reduce disparities.

Regional disparities in antenatal care utilization in Indonesia

INTRODUCTION

The main strategy for decreasing maternal morbidity and mortality has been antenatal care (ANC). ANC aims to monitor and maintain the health and safety of the mother and the fetus, detect all complications of pregnancy and take the necessary actions, respond to complaints, prepare for birth, and promote a healthy lifestyle. This study aims to analyze interregional disparities in ≥4 ANC visits during pregnancy in Indonesia.

METHODS

Data was acquired from the 2017 Indonesian Demographic and Health Survey (IDHS). The unit of analysis was women aged 15-49 years old, and a sample of 15,351 women was obtained. In addition to ANC as the dependent variable, the other variables analyzed in this study were a place of residence, age, husband/partner, education, parity, wealth status, and health insurance. For the final analysis, binary logistic regression was used to determine disparity.

RESULTS

With the Papua region as a reference, all regions showed a gap except for the Maluku region, which was not significantly different in the use of ANC compared to the Papua region. Women in the Nusa Tenggara have 4.365 times the chance of making ≥4 ANC visits compared to those in the Papua region (95% CI 3.229-5.899). Women in Java-Bali have 3.607 times the chance of making ≥4 ANC visits compared to women in the Papua region (95% CI 2.741-4.746). Women in Sumatra have 1.370 times the chance of making ≥4 ANC visits compared to women in the Papua region (95% CI 1.066-1.761). Women in Kalimantan have 2.232 times the chance of making ≥4 ANC visits compared to women in the Papua region (1.664-2.994). Women in Sulawesi have 1.980 times more chance of making ≥4 ANC visits compared to women in the Papua region (1.523-2.574). In addition to the region category, other variables that contributed to the predictor were age, husband/partner, education, parity, wealth and insurance.

CONCLUSION

There were disparities in ANC utilization between the various regions of Indonesia. The structured policy is needed to reach regions that have low coverage of ≥4 ANC. Policymakers need to use the results of this study to take the necessary policies. Policies that focus on service equality to reduce disparities.

Socioeconomic Inequalities in Child Malnutrition in Bangladesh: Do They Differ by Region?

Socioeconomic inequality in child malnutrition is well-evident in Bangladesh. However, little is known about whether this inequality differs by regional contexts. We used pooled data from the 2011 and 2014 Bangladesh Demographic and Health Survey to examine regional differences in socioeconomic inequalities in stunting and underweight among children under five. The analysis included 14,602 children aged 0–59 months. We used logistic regression models and the Concentration index to assess and quantify wealth- and education-related inequalities in child malnutrition. We found stunting and underweight to be more concentrated among children from poorer households and born to less-educated mothers. Although the poverty level was low in the eastern regions, socioeconomic inequalities were greater in these regions compared to the western regions. The extent of socioeconomic inequality was the highest in Sylhet and Chittagong for stunting and underweight, respectively, while it was the lowest in Khulna. Regression results demonstrated the protective effects of socioeconomic status (SES) on child malnutrition. The regional differences in the effects of SES tend to diverge at the lower levels of SES, while they converge or attenuate at the highest levels. Our findings have policy implications for developing programs and interventions targeted to reduce socioeconomic inequalities in child malnutrition in subnational regions of Bangladesh.

Socioeconomic inequalities in maternal health care utilization in Ghana

Background

Improving maternal and child health remains a public health priority in Ghana. Despite efforts made towards universal coverage, there are still challenges with access to and utilization of maternal health care. This study examined socioeconomic inequalities in maternal health care utilization related to pregnancy and identified factors that account for these inequalities.

Methods

We used data from three rounds of the Ghana Demographic and Health Surveys (2003, 2008 and 2014). Two health care utilization measures were used; (i) four or more antenatal care (ANC) visits and (ii) delivery by trained attendants (DTA). We first constructed the concentration curve (CC) and estimated concentration indices (CI) to examine the trend in inequality. Secondly, the CI was decomposed to estimate the contribution of various factors to inequality in these outcomes.

Results

The CCs show that utilization of at least four ANC visits and DTA were concentrated among women from wealthier households. However, the trends show the levels of inequality decreased in 2014. The CI of at least four ANC visits was 0.30 in 2003 and 0.18 in 2014. Similarly, the CIs for DTA was 0.60 in 2003 and 0.42 in 2014. The decomposition results show that access to National Health Insurance Scheme (NHIS) and women’s education levels were the most important contributors to the reduction in inequality in maternal health care utilization.

Conclusions

The findings highlight the importance of the NHIS and formal education in bridging the socioeconomic gap in maternal health care utilization.

Social inequality in sexual and reproductive health in Ecuador: an analysis of gaps by levels of provincial poverty 2009-2015

Background

Adequate access to sexual and reproductive health services is associated with better results. Analyzing the differences in access and outcomes of sexual and reproductive health (SRH) by share of poverty at the regional level makes it possible to measure the magnitude of the challenge of inequity. This paper aims to estimate the magnitude of health inequality in SRH in Ecuador for the period 2009–2015.

Methods

This study analyzed health inequalities in sexual and reproductive health indicators (obstetric and abortion complications, caesarean and home deliveries, adolescent fertility, and maternal mortality) for 2009 and 2015 comparing provinces in Ecuador. The absolute and relative gaps were estimated between provinces grouped by the percentage of individuals in multidimensional poverty; the slope index of inequality and the relative index of inequality were estimated as measures of gradient; and finally, the concentration index was also estimated.

Results

The analysis identified that obstetric complications, abortion complications, and cesareans have tended to increase from 2009 to 2015, without relevant differences between provinces ordered by poverty. Adolescent fertility decreased in the country as well as the inequality in its distribution among provinces: the CI was − 0.046 in 2015, down from − 0.084 in 2009. Home deliveries as a ratio of total deliveries have a decreasing trend with mixed results in terms of inequality: while there is a decrease in the absolute gap from − 211.06 to 184.4 between 2009 and 2015, the concentration index increased from − 0.331 to − 0.496. Finally, the maternal mortality rate increased in the period, also with greater inequality: from an absolute gap of − 39.30 in 2019, up to − 46.7 in 2015. In the same direction, the CI went from − 0.127 to − 0.174.

Conclusions

Ecuador faces major challenges in terms of both levels and inequalities in SRH outcomes and access to services. These inequalities related to poverty highlight the persistence of social inequities in the country. These health inequalities affect the wellbeing of Ecuadorian women but they are amendable. There is a need for pro-equity interventions, with stronger efforts in areas (provinces) with larger socioeconomic vulnerabilities.

Transnational wealth-related health inequality measurement

The study of international differences in wealth-related health inequalities has traditionally consisted of country-by-country comparisons using own-country relative measures of socioeconomic status, which effectively ignores absolute differences in both wealth and health that can differ between and within countries. To address these limitations, we propose an alternative approach: that of constructing a transnational measure of wealth-related health inequality. To illustrate the limitations of the country-by-country approach, we simulate the impact of changes in wealth and health inequalities both between and within countries on cross-country measures of health inequality and find at least five errors that may arise using country-by-country methods. We then empirically demonstrate the transnational approach to wealth-related health inequalities between and within Haiti and the Dominican Republic, the two constituent countries of the island of Hispaniola, using data from their respective Demographic and Health Surveys. Transnational socioeconomic rankings reveal a large and increasing divergence in wealth between the two countries, which would be ignored using the county-by-country approach. We find that wealth-related inequalities in long-term children’s health outcomes are larger than inequalities in short-term health outcomes, and decompositions of the influence of place-based variables on these inequalities reveal country of residence to be the most important factor for long-term outcomes, while urban/rural residence and subnational regions are more important for short-term health outcomes. The significance of this novel methodological approach in relation to conventional health inequality research, including hidden dimensions of wealth-related health inequalities, for example the urbanized “middle class” distribution of HIV and a hidden unequal burden of wasting among children uncovered by the transnational approach are discussed, and errors in gauging changes in inequality over time using a country-by-country approach are highlighted. Using the transnational approach can help to measure important trends in wealth-related health inequalities across countries that more commonly used methods traditionally overlook.

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Simulated data reveals limitations in measuring health inequalities across countries.

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We calculate transnational measures of SES-related health inequalities for Hispaniola.

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Country residence drives child health inequalities, subregions drive HIV inequality.

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Hidden HIV and wasting inequalities are uncovered with the transnational approach.

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Country-by-country methods misidentify secular transnational inequality trends.