A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context
Lale Say, Rosalind Raine
Volume 85, Number 10, October 2007, 812-819
Table 1. Inequalities in use of skilled health worker at delivery
| Study | Country | Sample size | Comparison groups | OR(95% CI orsignificance) | Adjusted analysis donea | Qualityb | Contextual issuesc |
|---|---|---|---|---|---|---|---|
| Celik (2005) |
Turkey |
2002 |
Urban, rural |
4.37 (3.44–5.55),1.00 |
– |
– |
– |
| Falkingham (2003) |
Tajikistan |
1840 |
Urban, rural |
3.48 (1.50–8.06),1.00 |
+ |
+ |
Deterioration of economy and health services since independence; rural women disproportionately affected. |
| Hotchkiss (2001) |
Nepal |
1434 |
Urban, rural |
Higher in urban (P < 0.01) |
+ |
+ |
Rural women might prefer traditional care. |
| Magadi (2000) |
Kenya |
5290 |
Urban, rural |
4.52 (3.65–5.59),1.00 |
– |
– |
– |
| Mekonnen (2003) |
Ethiopia |
7830 |
Urban, rural |
8.50 (5.80–12.40),1.00 |
+ |
– |
– |
| Navaneetham (2002) |
IndiaAndra Pradesh |
1571 |
Urban, rural |
1.42 (P < 0.10),1.00 |
+ |
+ |
Different patterns between states due to differential availability and accessibility of services. General lack of access for socially excluded communities (caste) due to residential segregation and limited availability of services. |
| Karnataka |
1925 |
1.80 (P < 0.01),1.00 |
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| Kerala |
1101 |
1.29 (NS),1.00 |
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| Tamil Nadu |
1416 |
2.30 (P < 0.01),1.00 |
|||||
| Tsui (2002) |
Paraguay |
722 |
Urban, rural |
NS |
+ |
– |
– |
| Uganda |
1224 |
NS |
|||||
| United Republic of Tanzania |
4157 |
Higher in urban (P < 0.10) |
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| India |
3129 |
Lower in urban (P < 0.10) |
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| Bloom (2001) |
India |
300 |
Low, high |
1.00,2.87 (1.70–4.84) |
+ |
+ |
Women’s autonomy, often determined by continued links with parental family, facilitates their leaving home when needed, thus their use of skilled care at delivery. |
| Hotchkiss (2001) |
Nepal |
1434 |
Continuous |
Higher with high (P < 0.01) |
+ |
+ |
Limited broader socioeconomic development. |
| Li (2004) |
China |
915 |
Continuous |
1.38 (1.06–1.79) |
+ |
+ |
Gender inequality and women’s position in society (measured with the extent of husband sharing work, women’s exposure to outside world and son preference) are important issues. Non-compliance with family planning policy limits contact with health services (to avoid discrimination). Limited access for women with low income and those from remote areas exists; freedom of movement not found significant. |
| Magadi (2000) |
Kenya |
5290 |
Low, medium, high |
1.00,2.00 (1.77–2.27)6.88 (5.56–8.50) |
– |
– |
– |
| Navaneetham (2002) |
IndiaAndra Pradesh |
1571 |
Low, medium,high |
1.00,1.21 (NS),3.75 (P < 0.01) |
+ |
+ |
Different patterns between states due to differential availability and accessibility of services. General lack of access for socially excluded (lower-caste) communities due to residential segregation and limited availability of services. |
| Karnataka |
1925 |
1.00,1.67 (P < 0.01),4.34 (P < 0.01) |
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| Kerala |
1101 |
1.00,1.95 (P < 0.01),2.80 (NS) |
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| Tamil Nadu |
1416 |
1.00,1.28 (NS),3.43 (P < 0.01) |
|||||
| Tsui (2002) |
Paraguay |
722 |
Low, medium, high |
NS |
+ |
– |
– |
| United Republic of Tanzania |
4157 |
Higher in high (P < 0.10) |
|||||
| India |
3129 |
Higher in high (P < 0.10) |
|||||
| Paul (2002) |
Bangladesh |
2334 |
Landless,small, medium, large land holdings |
NS |
+ |
++ |
Strongest determinant of use is the expectation or encounter of delivery complications. Lack of information about the services provided could be a potential barrier. |
| Phoxay (2001) |
Lao People’s Democratic Republic |
205 |
Low, middle, high |
1.00,2.07 (0.71–6.01),2.56 (0.50–13.03) |
+ |
– |
– |
| Falkingham (2003) | Tajikistan | 1840 | Poorest,2nd quintile,3rd quintile,4th quintile,richest | 3.41 (1.58–7.06),2.36 (1.11–5.02),2.23 (1.06–4.72),2.09 (0.98–4.46),1.00 | + | + | Health care is free, but due to deterioration of health care (and general economic status) and therefore the payments of health professionals, informal user charges limit poor women’s use of skilled health workers. |
CI, confidence interval; NS, not significant; OR, odds ratio.a Includes a range of factors related to the individual (e.g. age, marital status, number of children, education, autonomy, health beliefs), community (e.g. type of the roads, village) and health service (distance/time to care, availability of doctors), varying across studies.b Indicates how well the study was done to minimize the risk of bias or confounding, and to establish an association between exposure (examined non-clinical factor) and effect (outcome measure). Code: ++ high quality; + moderate quality; – low quality.c Contextual influences that could explain the differences found in studies of moderate and high quality.