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Inequity in utilisation of maternal health services

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Bangladesh is on track to achieve the target to reduce the maternal mortality ratio by three-fourths as indicated in the Millennium Development Goal (MDG) 5 but better understanding of inequity in maternal health indicators could improve progress. This study reported trends of inequity in the use of maternal health services using Bangladesh Demographic and Health Survey data. Though coverage of antenatal care increased in 2007, 31% of women in the lowest wealth quintile received antenatal care compared to 84% in the highest wealth quintile. In the rural lowest wealth quintile, there was a 2% decline in the proportion of home deliveries between 2004 and 2007 compared to a 12% decline in the urban highest wealth quintile. There are similar trends for postnatal care. Inequity in use of maternal health services is remaining static or increasing; government, non-government organizations, and donors should prioritize access to maternal health services, especially for the poorest populations in rural and urban areas.
Approximately 1,500 women die each day around the world from complications of pregnancy and childbirth, with an estimated 536,000 maternal deaths in 2005. Most of these deaths occurred in low-income countries, and most were avoidable. In Bangladesh, approximately 12,000 women die each year from such complications. Millennium Development Goal (MDG) 5 focuses on improving maternal health including eliminating inequity by ensuring universal access to maternal health services. The MDG 5 target for Bangladesh is to reduce the maternal mortality ratio to 143 per 100,000 live births by 2015. During 1990 to 2010, the maternal mortality ratio in Bangladesh decreased from 570 to 194, providing encouraging evidence that Bangladesh is on track to achieve MDG 5. However, while Bangladesh has made significant progress in improving maternal health during the last two decades, the challenge of eliminating the inequity in utilization of maternal health services remains.
We performed a secondary analysis of the Bangladesh Demographic and Health Survey (BDHS) data from 1993 to 1994, 1996 to 1997, 1999 to 2000,  2004, and 2007. These were a series of national-level population and health surveys conducted as part of the global Demographic and Health Surveys (DHS) programme. We analyzed the data focusing on three broad aspects Inequity in utilization of maternal health services: a challenge for achieving Millennium Development Goal 5 in Bangladesh.
Bangladesh is on track to achieve the target to reduce the maternal mortality ratio by three-fourths as indicated in the Millennium Development Goal (MDG) 5 but better understanding of inequity in maternal health indicators could improve progress. This study reported trends of inequity in the use of maternal health services using Bangladesh Demographic and Health Survey data. Though coverage of antenatal care increased in 2007, 31% of women in the lowest wealth quintile received antenatal care compared to 84% in the highest wealth quintile. In the rural lowest wealth quintile, there was a 2% decline in the proportion of home deliveries between 2004 and 2007 compared to a 12% decline in the urban highest wealth quintile. There are similar trends for postnatal care. Inequity in use of maternal health services is remaining static or increasing; government, non-government organizations, and donors should prioritize access to maternal health services, especially for the poorest populations in rural and urban areas.
March 2012 of utilization of maternal health services: antenatal, delivery and postnatal.  We focused on the context of rural-urban and rich-poor inequities. Data on service utilization by wealth quintile were not available from 1993 to 2000.  Therefore, only data from 2004 and 2007 were analyzed to investigate richpoor inequities.
The overall coverage for completing at least one visit for antenatal care increased from 28% in 1993 to 1994 to 60% in 2007 (4,5). Although the proportion of women receiving antenatal care increased, the gap between rural-urban areas and poor-rich populations remained high. The difference between rural and urban in antenatal care coverage was 30% in 1993/94, 35% in 1996/97, 31% in 1999/2000, 28% in 2004, and 20% in 2007. So the rural-urban difference in antenatal care coverage has decreased somewhat, albeit with some fluctuations. In 2007, 42% of women in the lowest wealth quintile received antenatal care compared to 86% in the highest wealth quintile; the difference between these two wealth quintiles was 44%, only slightly lower than that of 50% in 2004.
In 2007, 89% of childbirths occurred at home in rural areas compared to 69% in urban areas. Only 2% of deliveries occurred in a facility in rural areas in 1996 to 1997 as opposed to 23% in urban areas. In 2007, 10% of deliveries took place in facilities in rural areas compared to 30% in urban areas. The rural-urban gap for facility delivery remained unchanged between 1997 and 2007. As shown in Figure 1, the gap was consistently about 20% between 1996 and 2007.
Only 2% of deliveries occurred at facilities in the lowest wealth quintile in 2004, compared to 30% in the highest wealth quintile. Similarly, in 2007 only 4% of deliveries in the lowest wealth quintile occurred in a facility compared to 43% in the highest wealth quintile. Therefore, the gap in facility delivery between these two wealth quintiles increased from 28% in 2004 to 39% in 2007.
In terms of delivery by skilled attendants, the gap between rural and urban areas has, overall, decreased since 1997, but it has fluctuated over time. Data from BDHS 1996 to 1997 showed only 5% of deliveries were conducted by a medically trained provider in rural areas, while 35% of deliveries in urban areas were conducted by a medically trained provider. Between 1999 and 2004 the rate of skilled attendance declined or remained static in urban areas, while it continued to improve at each time point for rural areas. However, the rural-urban gap was estimated to be 21% in 2004 and it increased to 24% in 2007, and this gap did not decrease between 2000 and 2007 (Figure 3).  While the rate of improvement for delivery by medically trained provider in rural areas has improved, the difference between urban and rural has not decreased since 2000.
Similarly, mothers from wealthier households were more likely to have their children delivered with the support of medically trained providers. In 2004, only 3% of deliveries in the lowest wealth quintile were attended by medically trained providers versus 40% in the highest wealth quintile. The difference between these two wealth quintiles for skilled attendance during delivery was 37% in 2004, which increased to 46% in 2007.
There were similar disparities in utilization of postnatal care between rural and urban areas and between the rich and poor population. Only 13% of women received any postnatal care in rural areas in 2004 compared to 34% in urban areas; in 2007, 16% of women received any postnatal care in rural areas compared to 36% in urban areas. In 2007, the proportion of women receiving postnatal care increased slightly and the rural-urban gap of 21% in 2004 remained almost the same (20%). Likewise, in 2004 only 5% of women received postnatal care in the lowest wealth quintile compared to 47% of women in the highest wealth quintile. This remained the same in 2007.
Despite encouraging progress in improving maternal health, this upward trend masks underlying and persistent inequities in the use of maternal health services. Although the proportion of women receiving antenatal care, delivering in facilities, and receiving skilled assistance during delivery has increased over time, the inequity in utilization of services has remained static. The analysis presented here shows that Bangladesh is achieving MDG 5 targets in higher socio-economic quintiles, but is l