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 3. Inequalities in antenatal care attendance in the first trimester

Study	Country	Sample size	Comparison groups	OR(95% CI orsignificance)	Adjusted analysis done^a	Quality^b	Contextual issues^c
Urban-rural variations
Bhatia (1995)	India	3230	Urban, rural	1.05 (NS),1.00	+	+	Community-based health workers extend the provision of antenatal care to total areas. Women’s autonomy and personal hygiene are related to antenatal care use.
Burgard (2004)	Brazil	4958	Urban, rural	1.37 (P = 0.005)1.00	+	+	Targeted interventions to improve maternal health services did not benefit rural and poor communities.
Eggleston (2000)	Ecuador	3041	Urban, rural	1.38 (1.15–1.65),1.00	+	–	–
Gertler (1993)	Jamaica	823	Urban, rural	Lower in urban (P < 0.05)	+	++	Urban women do not want to be treated as ill, therefore initiate pregnancy care later. Another reason is the poor quality of preventive care, particularly in the capital area.
Navaneetham (2002)	India,Andra Pradesh	1571	Urban, rural	0.66 (NS),1.00	+	+	Community-based health workers extend antenatal care provision to remote rural areas. Strong determinants include birth order and education.
	Karnataka	1925		1.21 (NS),1.00
	Kerala	1101		1.11 (NS),1.00
	Tamil Nadu	1416		1.09 (NS),1.00
Economic variations
Bhatia (1995)	India	3230	Low, middlehigh	1.00,1.11 (NS),1.17 (NS)	+	+	Community-based health workers extend antenatal care provision.
Burgard (2004)	South Africa	4800	Continuous	2.88 (P < 0.001)	+	+	Health providers’ attitudes (unhelpful and even abusive) towards poor women limit their reception of accurate information. Previous bad experiences with the health-care system, provider preferences in relation to service provision and working conditions, and the low value attached to prenatal care by women are other possible issues.
Burgard (2004)	Brazil	4958	Continuous	3.51 (P < 0.001)	+	+	Targeted interventions to improve maternal health care benefited higher socioeconomic groups.
Eggleston (2000)	Ecuador	3041	Low, medium,high	0.87 (0.71–1.08)1.001.61 (1.31–1.98)	+	–	–
Gertler (1995)	Jamaica	823	Continuous	Higher in high (P < 0.01)	+	++	Despite the availability of free health care, the quality of maternal health care is poor (i.e. long waiting times).
McCaw Binns (1995)	Jamaica	9968	Poorest,2nd quartile,3rd quartile,richest	0.5 (0.4–0.6)0.6 (0.5–0.7),0.7 (0.6–0.8)1.00	+	++	Antenatal care is not a priority for women living in multiple deprivation. Pregnancy is viewed as a normal process. Pregnancy care is free and there are programmes providing incentives for antenatal care use, but economic and social costs of attendance outweigh the benefits.
Navaneetham (2002)	India,Andra Pradesh	1571	Low, medium,high	1.00,0.97 (NS),1.48 (NS)	+	+	Community-based health workers extend antenatal care provision to remote rural areas and poor women.
	Karnataka	1925		1.00,0.85 (NS),0.98 (NS)
	Kerala	1101		1.00,1.51 (P < 0.05),1.51 (NS)
	Tamil Nadu	1416		1.00,1.08 (NS),1.24 (NS)

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).^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.