Sydney School of Public Health, University of Sydney, Sydney, Australia.
Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh.
J Glob Health. 2018 Jun;8(1):010416. doi: 10.7189/jogh.08.010416.
The utilization of maternal health care services has increased in many developing countries, but persistent wealth-related inequalities in use of maternal services remained an important public health issue. The paper examined the horizontal inequities and identified the key social determinants that can potentially explain such wealth-related inequalities in use of facility delivery services.
The countries studied are Bangladesh, Pakistan and Nepal. We used horizontal inequity index to measure the horizontal inequity and decomposition of concentration index method to assess the contribution of different social determinants towards the wealth-related inequality. We have used household and women data from demographic and health surveys of Bangladesh (BDHS 2014), Pakistan (PDHS 2012-13) and Nepal (NDHS 2010-11).
All three countries showed pro-rich inequality in use of facility delivery services (Observed Concentration Index: Bangladesh = 0.235; Pakistan = 0.141; Nepal = 0.263). The study showed if the utilization were solely based on need factors there would have been little disparity between the rich and the poor (Need expected Concentration Index: Bangladesh = 0.004; Pakistan = 0.004; Nepal = 0.008). The use of facility delivery remained pro-rich in all three countries after taking the need factors into account (Horizontal inequity Index: Bangladesh = 0.231; Pakistan = 0.137; Nepal = 0.254). The decomposition analysis revealed that facility delivery is driven mostly by the social determinants of health rather than the individual health risk. Household socioeconomic condition, parental education, place of residence and parity emerged as the most important factors.
Our study reiterates the importance of addressing social determinants of health in tackling wealth-related inequalities in use of facility delivery services. Health policy makers should acknowledge the importance of social determinants in determining individual health-seeking behaviour and accordingly set their strategies to improve access to facility delivery.
许多发展中国家的孕产妇保健服务利用率有所提高，但服务利用方面持续存在的与财富相关的不平等现象仍然是一个重要的公共卫生问题。本文研究了横向不平等，并确定了可能导致利用医疗机构分娩服务方面存在与财富相关不平等现象的关键社会决定因素。
所研究的国家为孟加拉国、巴基斯坦和尼泊尔。我们使用水平不公平指数衡量水平不公平，并使用集中指数分解方法评估不同社会决定因素对与财富相关的不平等现象的贡献。我们使用了孟加拉国（BDHS 2014 年）、巴基斯坦（PDHS 2012-13 年）和尼泊尔（NDHS 2010-11 年）人口与健康调查中的家庭和妇女数据。
这三个国家的医疗机构分娩服务利用均存在有利于富人的不平等现象（观察到的集中指数：孟加拉国=0.235；巴基斯坦=0.141；尼泊尔=0.263）。研究表明，如果服务的利用完全基于需求因素，那么贫富之间的差距将会很小（需求预期集中指数：孟加拉国=0.004；巴基斯坦=0.004；尼泊尔=0.008）。在考虑到需求因素后，所有三个国家的医疗机构分娩服务的利用仍然有利于富人（水平不公平指数：孟加拉国=0.231；巴基斯坦=0.137；尼泊尔=0.254）。分解分析表明，医疗机构分娩主要受健康的社会决定因素驱动，而不是个人健康风险。家庭社会经济状况、父母教育程度、居住地和生育子女数成为最重要的因素。
本研究再次强调，在解决利用医疗机构分娩服务方面与财富相关的不平等现象时，应重视健康的社会决定因素。卫生政策制定者应认识到社会决定因素在确定个人寻求卫生服务行为方面的重要性，并据此制定改善获得医疗机构分娩服务的策略。
