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Investigating Health Inequality Using Trend, Decomposition and Spatial Analyses: A Study of Maternal Health Service Use in Nepal.

ABSTRACT: Objectives: (a) To quantify the level and changes in socioeconomic inequality in the utilization of antenatal care (ANC), institutional delivery (ID) and postnatal care (PNC) in Nepal over a 20-year period; (b) identify key drivers of inequality using decomposition analysis; and (c) identify geographical clusters with low service utilization to inform policy. Methods: Data from the most recent five waves of the Demographic Health Survey were used. All outcomes were defined as binary variables: ANC (=1 if ≥4 visits), ID (=1 if place of delivery was a public or private healthcare facility), and PNC (=1 if ≥1 visits). Indices of inequality were computed at national and provincial-level. Inequality was decomposed into explanatory components using Fairile decomposition. Spatial maps identified clusters of low service utilization. Results: During 1996-2016, socioeconomic inequality in ANC and ID reduced by 10 and 23 percentage points, respectively. For PND, the gap remained unchanged at 40 percentage points. Parity, maternal education, and travel time to health facility were the key drivers of inequality. Clusters of low utilization were displayed on spatial maps, alongside deprivation and travel time to health facility. Conclusion: Inequalities in the utilization of ANC, ID and PNC are significant and persistent. Interventions targeting maternal education and distance to health facilities can significantly reduce the gap.

SUBMITTER: Ali S

PROVIDER: S-EPMC10272384 | biostudies-literature | 2023

REPOSITORIES: biostudies-literature

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Investigating Health Inequality Using Trend, Decomposition and Spatial Analyses: A Study of Maternal Health Service Use in Nepal.

Ali Shehzad S Thind Amardeep A Stranges Saverio S Campbell M Karen MK Sharma Ishor I

International journal of public health 20230602

<b>Objectives:</b> (a) To quantify the level and changes in socioeconomic inequality in the utilization of antenatal care (ANC), institutional delivery (ID) and postnatal care (PNC) in Nepal over a 20-year period; (b) identify key drivers of inequality using decomposition analysis; and (c) identify geographical clusters with low service utilization to inform policy. <b>Methods:</b> Data from the most recent five waves of the Demographic Health Survey were used. All outcomes were defined as binar ...[more]

PMID: 37332772

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Project description:Background About 75.5% of women in Nepal’s urban areas receive at least four ANC visits, compared to 61.7% of women in the country’s rural areas. Similarly, just 34% of women in the lowest wealth quintile give birth in a medical facility compared to 90% of women in the richest group. As a result of this inequality, the poor in emerging nations suffer since those who are better off can make greater use of the healthcare than those who are less fortunate. This study aims to examine and decompose the contributions of various socioeconomic factors towards MCH service inequality in Nepal in the years 2011 and 2016. Methods Inequality in MCH services was estimated using concentration curves and their corresponding indices using data from Nepal Demographic Health Survey (NDHS) 2011 and 2016. We examined the inequality across three MCH service outcomes: less than 4 ANC visits, no postnatal checkups within 2 months of delivery and no SBA delivery and decomposed them across observed characteristics of the mothers aged between 15 and 49. Furthermore, Oaxaca-blinder decomposition approach was used to measure and decompose the inequality differential between two time periods. Results Inequality in MCH services was prevalent for all 3 MCH outcomes in 2011 and 2016, respectively. However, the concentration indices for <4 ANC visits, no SBA delivery, and no postnatal checkups within 2 months of birth increased from -0.2184, -0.1643, and -0.1284 to -0.1871, -0.0504, and -0.0218 correspondingly, showing the decrease in MCH services inequality over two time periods. Wealth index, women’s literacy, place of living, mother’s employment status, and problem of distance to reach nearest health facility were the main contributors. Conclusion We find that MCH services are clearly biased towards the women with higher living standards. National policies should focus on empowering women through education and employment, along with the creation of health facilities and improved educational institutions, in order to address inequalities in living standards, women’s education levels, and the problem of distance. Leveraging these factors can reduce inequality in MCH services. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-023-15906-2.

Project description:BackgroundSocioeconomic 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.MethodsThis 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.ResultsWe 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.ConclusionThis 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.

Project description:BackgroundPersistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region.MethodsWe conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality.ResultsThe percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor.ConclusionsAddressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.

Project description:BackgroundSocioeconomic 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.MethodsThe 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.ResultsOur 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.ConclusionsAccording 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.

Project description:ObjectiveOral health is often overlooked in ageing health issues, despite its impact on overall health and quality of life. Older Australians, especially those in rural and remote areas, face difficulties accessing oral health services. The aim of the study was to investigate the factors that contribute to financial barriers to accessing dental services among the ageing population in Australia in relation to their residential location.MethodThe study included a weighted sample of Australian adults aged 65 years and over from a population-based survey called the National Study of Adult Oral Health (NSAOH) conducted in 2017-18. Descriptive analysis was conducted and generated cross-tabulation tables to investigate the distributions of the outcome, exposure and covariates, including Sex, Education level (the highest level of education), Equivalised household income, Dental insurance, Concession card ownership, Difficulty paying a dental bill and last dental visit. Blinder-Oaxaca decomposition counterfactual analysis was used to explore the potential impact of a person's residence on their financial difficulty accessing dental services.ResultsThe findings showed that 26.2% (95% CI: 24.3-29.3) of major city residents and 30.1% (95% CI: 26.9-33.3) of rural residents avoided or delayed dental visits due to cost. The decomposition analysis indicated that 53.8% of the disparities in the prevalence of avoided or delayed dental visits due to cost were explained by the selected variables, while 46.2% remained unexplained. The explanatory variable with the largest contribution was difficulty paying a $200 dental bill, accounting for 62.4% of the differences, followed by dental insurance, last dental visit and equivalised household income, which explained 42.1%, 20.8% and 14.9% of the differences, respectively.ConclusionRegional/remote populations experience more financial barriers to accessing dental care than major city populations and the identified factors explain a significant proportion of these disparities. Based on the study findings, recommendations include expanding public dental service coverage, evaluating concession card mechanisms and advocating for regular dental visits to mitigate disparities in dental care access.

Project description:BackgroundThe magnitude of unintended pregnancy is unacceptably high and more than half of it end up with abortions. This may limit lower and middle-income countries to achieve the sustainable development goal targets of reduction of neonatal and maternal mortalities. Evidence on trends and spatial distribution of unintended pregnancy is limited. Therefore, this study aimed to assess the trend, multivariate decomposition, and spatial variations of unintended pregnancy among reproductive-age women in Ethiopia from 2000 to 2016.MethodsEthiopian Demographic and Health Data of 2000 to 2016 were used. A total weighted sample of 30,780 reproductive-age women participated. A multivariate decomposition analysis was employed to identify factors contributing to the change in the rate of unintended pregnancy in Ethiopia for 20 years from (1996 to 2016). The concentration index and graph were used to assess wealth-related inequalities, whereas spatial analysis was done to identify the hotspot of unintended pregnancy in Ethiopia.ResultsThe 20-year trend analysis showed that the magnitude of unintended pregnancy among reproductive-age women decreased by 13.19 percentage points (from 39.76% in 2000 to 26.57% in 2016 EDHS). About 84.97% of the overall decrement was due to the difference in coefficient of the variables, whereas the remaining 15.03% was due to the difference in composition of the respondent. The differences in coefficient of the variables were decomposed by living metropolitan cities, having previous terminated pregnancy, and not having exposure to media; whereas, the change due to the composition, was expressed by having a household size of 1-3, living in metropolitan cities, being multipara and grand para, being unmarried and having no terminated pregnancy. Moreover, unintended pregnancies were more clustered in Addis Ababa and disproportionately concentrated in the poor groups.ConclusionsIn Ethiopia, a substantial decrement in unintended pregnancy was observed in the past decade. More than four-fifths of this overall decrement was due to the difference in the coefficient of the variables. There was spatial clustering of unintended pregnancy in Ethiopia. A program intervention is needed for high-risk regions such as Addis Ababa. Health education and media campaign should perform for high-risk women such as those having terminated pregnancy, and professing Islam faith.

Project description:BackgroundInequality in maternal healthcare use is a major concern for low-and middle-income countries (LMICs). Maternal health indicators at the national level have markedly improved in the last couple of decades in Nepal. However, the progress is not uniform across different population sub-groups. This study aims to identify the determinants of institutional delivery, measure wealth-related inequality, and examine the key components that explain the inequality.MethodsMost recent nationally representative Multiple Indicator Cluster Survey (MICS) 2019 was used to extract data about married women (15-49 years) with a live birth within two years preceding the survey. Logistic regression models were employed to assess the association of independent variables with the institutional delivery. The concentration curve (CC) and concentration index (CIX) were used to analyze the inequality in institutional delivery. Wealth index scores were used as a socio-economic variable to rank households. Decomposition was performed to identify the determinants that explain socio-economic inequality.ResultsThe socio-economic status of households to which women belong was a significant predictor of institutional delivery, along with age, parity, four or more ANC visits, education status of women, area of residence, sex of household head, religious belief, and province. The concentration curve was below the line of equality and the relative concentration index (CIX) was 0.097 (p < 0.001), meaning the institutional delivery was disproportionately higher among women from wealthy groups. The decomposition analysis showed the following variables as the most significant contributor to the inequality: wealth status of women (53.20%), education of women (17.02%), residence (8.64%) and ANC visit (6.84%).ConclusionsTo reduce the existing socio-economic inequality in institutional delivery, health policies and strategies should focus more on poorest and poor quintiles of the population. The strategies should also focus on raising the education level of women especially from the rural and relatively backward province (Province 2). Increasing antenatal care (ANC) coverage through outreach campaigns is likely to increase facility-based delivery and decrease inequality. Monitoring of healthcare indicators at different sub-population levels (for example wealth, residence, province) is key to ensure equitable improvement in health status and achieve universal health coverage (UHC).

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Investigating Health Inequality Using Trend, Decomposition and Spatial Analyses: A Study of Maternal Health Service Use in Nepal.

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Investigating Health Inequality Using Trend, Decomposition and Spatial Analyses: A Study of Maternal Health Service Use in Nepal.

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