Bulletin of the World Health Organization

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 2. Inequalities in the use of medical settings for delivery

Study Country Sample size Comparison groups OR(95% CI orsignificance) Adjusted analysis donea Qualityb Contextual issuesc
Urban-rural variations
Addai (1998)
 Ghana
 4562
 Urban, rural
 1.76 (P < 0.01),1.00
 +
 –
 –
Bhatia (1995)
 India
 3595
 Urban, rural
 2.57 (P < 0.01),1.00
 +
 +
 Limited physical access to facilities for rural women. Self-reported hygiene emerged as a significant factor. Increasing importance of private sector due to poor reputation of government hospitals.
Bolam (1998)
 Nepal
 334
 Urban, rural
 0.90 (0.52–1.56), 1.00
 –
 –
 –
Falkingham (2003)
 Tajikistan
 1982
 Urban, rural
 2.67 (1.76–4.08), 1.00
 +
 +
 Deterioration of economy and health services since independence; rural women disproportionately affected.
Gertler (1993)
 Jamaica
 823
 Urban, rural
 Higher in urban (P < 0.01)
 +
 ++
 Accessibility (transport, work responsibilities) is limited for poor and rural women, and informal care alternatives exist. Midwives’ advice as to the place of delivery is not followed because of what some subjects call their authoritarian attitudes.
Hotchkiss (2003)
 Morocco
 1609
 Urban, rural
 2.13 (1.21–3.76), 1.00
 +
 +
 Low geographical accessibility and costs of services limited use. Women living in households with another adult woman are more likely to give birth in hospitals because they can get advice and are accompanied to the hospital.
Magadi (2000)
 Kenya
 5290
 Urban, rural
 2.66 (P < 0.05),1.00
 +
 –
 –
Navaneetham (2002)
 India Andra Pradesh
 1571
 Urban, rural
 2.21 (P < 0.01),1.00
 +
 +
 Different patterns between states due to differential availability and accessibility of services. General lack of access for socially excluded (caste) communities because of residential segregation and limited availability of services.
Karnataka
 1925
 2.41 (P < 0.01),1.00
Kerala
 1101
 1.65 (NS),1.00
Tamil Nadu
 1416
 3.64 (P < 0.01),1.00
Stupp (1994)
 Belize
 977
 Urban, rural
 7.14 (P < 0.001),1.00
 +
 –
 –
Tsui (2002) Paraguay
 722
 Urban, rural
 NS
 +
 –
 –
Uganda
 1224
 Higher in urban (P < 0.10)
United Republic of Tanzania
 4055
 Higher in urban (P < 0.10)
India
 3165
 NS
Economic variations
Anson (2004)
 China
 4273
 Continuous
 0.96 (NS)
 +
 –
 –
Barbhuiya (2001)
 Bangladesh
 505
 Lower, higher
 1.00,2.43 (1.29–4.59)
 –
 –
 –
Bhatia (1995)
 India
 3595
 Low, middle, high
 1.00,1.23 (P < 0.05),1.55 (P < 0.001)
 +
 +
 Increasing importance of private sector and decreased functioning of public services. Those who cannot afford private care do not deliver at facilities. Differences by caste show segregation of some groups.
Duong (2004)
 Viet Nam
 200
 Continuous
 NS
 +
 –
 –
Falkingham(2003)
 Tajikistan
 1840
 Poorest,2nd quintile,3rd quintile,4th quintile,Richest
 NS
 +
 +
 Deterioration of economy and health services since independence; quality of care is very low. Women, particularly those who are wealthier, perceive giving birth at home as safer than in hospitals that lack running water or heating.
Gertler (1995)
 Jamaica
 823
 Continuous
 Higher with high (P < 0.01)
 +
 ++
 Accessibility (transport, work responsibilities) is limited for poor and rural women; informal care alternatives exist. Midwives’ advice as to the place of delivery is not followed because of what some subjects call their authoritarian attitudes.
Glei (1999)
 Guatemala
 3253
 Continuous
 1.00
 +
 +
 Other factors (clinical risk, openness to outside world) in particular cultural differences between ethnic groups (for example, indigenous women prefer traditional midwives because of the social support they provide) determine maternal health-care use.
Hodgkin (1996)
 Kenya
 149
 Continuous
 Higher with high (P < 0.10)
 +
 –
 –
Hotchkiss (2003)
 Morocco
 1609
 Lower half,higher half
 1.00,2.94 (1.45–6.04)
 +
 +
 User fees limit access for poor people. Women living in households with another adult woman are more likely to give birth in hospitals, because they can get advice and are accompanied to the hospital.
Kavitha (1997)
 India
 172
 1000,1001–2000,> 2000
 NS
 +
 –
 –
Navaneetham (2002)
 India,Andra Pradesh
 1571
 Low, medium,high
 1.00,1.40 (P < 0.05),3.37 (P < 0.01)
 +
 +
 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
 1.00,1.72 (P < 0.01),3.61 (P < 0.01)
Kerala
 1101
 1.00,1.85 (P < 0.01),4.92 (P < 0.05)
Tamil Nadu
 1416
 1.00,1.33 (P < 0.01),3.91 (P < 0.01)
Toan (1996)
 Viet Nam
 1151
 Not good,good
 1.00,1.26 (0.97–1.63)
 –
 –
 –
Tsui (2002)
 Paraguay
 722
 Low, medium,high
 Higher in high (P < 0.10)
 +
 –
 –
United Republic of Tanzania
 4055
 Higher in high (P < 0.10)
India
 3165
 Higher in high (P < 0.10)
Van der Heuvel (1999)
 Zimbabwe
 235
 Lower, low,middle
 NS,NS
 +
 –
 –
Wagle (2004)
 Nepal
 308
 Low, high
 4.4 (1.8–10.6)
 +
 –
 –
Home delivery
Letamo (2003)
 Botswana
 1184
 Low, medium,high
 4.14 (3.45–4.96),1.28 (1.06–1.54),1.00
 +
 –
 –
Magadi (2000) Kenya 5290 Low, medium,high 1.00,0.54 (P < 0.05),0.19 (P < 0.05) + – –

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 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.