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Objectives: The aim of this paper is to share the results of a systematic review on the state of inequalities in access to and utilization of maternal, newborn and child health (MNCH) services in the sub-Saharan African region. The focus of the review was on urban settings where growing needs and challenges have been registered over the past few years due to rapid increase in urban populations and urban slums. Methods: The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies published in English between 2000 and 2019 were included. A narrative synthesis of both qualitative and quantitative data was undertaken. The record for registration in PROSPERO was CRD42019122066. Results: The review highlights a great variation in MNCH services utilization across urban sub-Saharan Africa (SSA). The main aspects of vulnerability to unequal and poor MNCH services utilization in urban settings of the region include poverty, low level of education, unemployment, lower socioeconomic status and poor livelihoods, younger maternal age, low social integration and social support, socio-cultural taboos, residing in slums, and being displaced, refugee, or migrant. At the health system level, persistent inequalities are associated with distance to health facility, availability of quality services and discriminating attitudes from health care personnel. Conclusion: Context-specific intervention programs that aim at resolving the identified barriers to access and use MNCH services, particularly for the most vulnerable segments of urban populations, are essential to improve the overall health of the region and universal health coverage (UHC) targets. [ABSTRACT FROM AUTHOR]

This paper aims to describe a trend in coverage of maternal care services, and provides a detailed analysis of socio-economic correlations to the existing inequities. The paper uses data from the Vietnam Multiple Indicator Cluster Survey 2000, 2006, 2011, and 2014. In the MICS, there were 9,117 women in 2000, 9,473 women in 2006, 11,614 women in 2011, and 9,827 women in 2014 participated in. We found the coverage of antenatal care increase from 68.6% in 2000 to 95.9% in 2014. Similarly, the percentages of women who gave birth with the assistance of skilled staff increased during the studied period ( from 69.9% in 2000, 87.7% to 94.5% in 2014). However, improvements in antenatal care and skilled birth attendance in Vietnam have been uneven across different segments of the population. In all the four surveys, the proportions of women who received ANC by a skilled staff and percentages of women who gave birth with the assistance of a skilled health personnel were much higher among those with higher education, belonged to Kinh majority tribe, had better economic status, and lived in an urban area. The degrees of inequity in both antenatal and delivery care in Vietnam are likely to increase over time. [ABSTRACT FROM AUTHOR]

Objectives The maternal and child health (MCH) community, partnering with women and their families, has the potential to play a critical role in advancing a new multi-sector social movement focused on creating a women's reproductive and economic justice agenda. Since the turn of the twenty-first century, the MCH field has been planting seeds for change. The time has come for this work to bear fruit as many states are facing stagnant or slow progress in reducing infant mortality, increasing maternal death rates, and growing health inequities. Methods This paper synthesizes three current, interrelated approaches to addressing MCH challenges-life course theory, preconception health, and social justice/reproductive equity. Conclusion Based on these core constructs, the authors offer four directions for advancing efforts to improve MCH outcomes. The first is to ensure access to quality health care for all. The second is to facilitate change through critical conversations about challenging issues such as poverty, racism, sexism, and immigration; the relevance of evidence-based practice in disenfranchised communities; and how we might be perpetuating inequities in our institutions. The third is to develop collaborative spaces in which leaders across diverse sectors can see their roles in creating equitable neighborhood conditions that ensure optimal reproductive choices and outcomes for women and their families. Last, the authors suggest that leaders engage the MCH workforce and its consumers in dialogue and action about local and national policies that address the social determinants of health and how these policies influence reproductive and early childhood outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Achieving a fair and equitable distribution of health in the population while progressing toward universal health coverage (UHC) is a key focus of health policy in Vietnam. This paper describes health barriers experienced by women (and children by inference) in Vietnam, and measures how UHC, with reference to maternal health services and child mortality rates, is affected by selected social determinants of health (SDH), termed 'barriers'. Methods: Our study uses a cross-sectional design with data from the 2011 Vietnam Multiple Indicator Cluster Survey. The study sample includes 11,663 women, aged 15-49 years. Weighted frequency statistics are cross-tabulated with socioeconomic characteristics of the population to describe the extent and distribution of health barriers experienced by disadvantaged women and children in Vietnam. A subset of women who had a live birth in the preceding two years (n_1,383) was studied to assess the impact of barriers to UHC and health. Six multiple logistic regressions were run using three dependent variables in the previous two years: 1) antenatal care, 2) skilled birth attendants, and 3) child death in the previous 15 years. Independent predictor variables were: 1) low education (incomplete secondary education), 2) lack of access to one of four basic amenities. In a second set of regressions, a constructed composite barrier index replaced these variables. Odds ratios (ORs) and 95% confidence intervals (95% CI) were used to report regression results. Results: In Vietnam, about 54% of women aged 15-49 years in 2011, had low education or lacked access to one of four basic amenities. About 38% of poor rural women from ethnic minorities experienced both barriers, compared with less than 1% of rich urban women from the ethnic majority. Incomplete secondary education or lack of one of four basic amenities was a factor significantly associated with lower access to skilled birth attendants (OR_0.28, 95% CI: 0.14-0.55; OR-0.19, 95% CI: 0.05-0.80) and a higher risk of having had a child death in the previous two years (OR-1.71, 95% CI: 1.28_2.30; OR-1.59, 95% CI: 1.20-2.10). Conclusions: Our study shows the need for accelerating education and infrastructure investments for ethnic minority communities living in rural areas so as to be able to contribute to equity-oriented progress toward UHC. [ABSTRACT FROM AUTHOR]

Background: Knowledge of the aggregate effects of multiple socioeconomic vulnerabilities is important for shedding light on the determinants of growing health inequalities and inequities in maternal healthcare. Objective: This paper describes patterns of inequity in maternal healthcare utilization and analyzes associations between inequity and multiple socioeconomic vulnerabilities among women in Vietnam. Design: This is a repeated cross-sectional study using data from the Vietnam Multiple Indicator Cluster Surveys 2000, 2006, and 2011. Two maternal healthcare indicators were selected: (1) skilled antenatal care and (2) skilled delivery care. Four types of socioeconomic vulnerabilities -- low education, ethnic minority, poverty, and rural location -- were assessed both as separate explanatory variables and as composite indicators (combinations of three and four vulnerabilities). Pairwise comparisons and adjusted odds ratios were used to assess socioeconomic inequities in maternal healthcare. Results: In all three surveys, there were increases across the survey years in both the proportions of women who received antenatal care by skilled staff (68.6% in 2000, 90.8% in 2006, and 93.7% in 2011) and the proportions of women who gave birth with assistance from skilled staff (69.9% in 2000, 87.7% in 2006, and 92.9% in 2011). The receipt of antenatal care by skilled staff and birth assistance from skilled health personnel were less common among vulnerable women, especially those with multiple vulnerabilities. Conclusions: Even thoughVietnam has improved its coverage of maternal healthcare on average, policies should target maternal healthcare utilization among women with multiple socioeconomic vulnerabilities. Both multisectoral social policies and health policies are needed to tackle multiple vulnerabilities more effectively by identifying those who are poor, less educated, live in rural areas, and belong to ethnic minority groups. [ABSTRACT FROM AUTHOR]

The purpose of this paper is two-fold. First, to give an overview of the size and measure trends in health inequalities in the Comoros islands (Comoros) since 1996. Second, to assess the wide differences in health and health care across rural/urban areas and islands in Comoros, by using available and comparable leading indicators, in order to promote regular monitoring of policy goals. This assessment is aimed at reducing health inequalities and providing adequate or equal access to health care between islands. Data from the Demographic and Health Survey, Multiple Indicators Cluster Surveys from 1996, 2000 and 2012, the World Health Organization, the World Bank, the African Development Bank data sources, were analyzed for a population health-oriented approach characterized by measuring health differences from the population average, taking account of the population size of the social groups on both relative and absolute scales. The results showed that there exist geographic disparities in health in Comoros, mainly in maternal and child health. [ABSTRACT FROM AUTHOR]

Objective: To explore rural residents' experiences of access to maternity care with consideration of the policy context. Design: This paper describes findings from focus groups with parents which formed part of case study data from a larger study. Setting: Four north Queensland rural towns. Participants: Thirty-three parents living in one of the four rural towns. Main outcome measures: Identifying prevalent themes in case studies regarding rural parents' expectations and experiences in accessing maternity care. Results: Parents desired a local, safe and consistent maternity service. Removing or downgrading rural services introduced new barriers to care for rural residents: (i) increased financial costs; (ii) family issues; and (iii) safety concerns. Conclusions: Although concerns about rural residents' health status and health care access have received significant policy attention for over a decade, many of the problems which prompted these policy initiatives remain today. Current policy approaches should be re-evaluated in order to improve rural Australians' access to vital health services such as maternity care. [ABSTRACT FROM AUTHOR]

Background: The Philippines failed to achieve its Millennium Development Goal (MDG) commitment to reduce maternal deaths by three quarters. This, together with the recently launched Sustainable Development Goals (SDGs), reinforces the need for the country to keep up in improving reach of maternal and child health (MCH) services. Inequitable use of health services is a risk factor for the differences in health outcomes across socio-economic groups. This study aims to explore the extent of inequities in the use of MCH services in the Philippines after pro-poor national health policy reforms. Methods: This paper uses data from the 2008 and 2013 Demographic and Health Survey (DHS) in the Philippines. Socio-economic inequality in MCH services use was measured using the concentration index. The concentration index was also decomposed in order to examine the contribution of different factors to the inequalities in the use of MCH services. Results: In absolute figures, women who delivered in facilities increased from 2008 to 2013. Little change was noted for women who received complete antenatal care and caesarean births. Facility deliveries remain pro-rich although a pro-poor shift was noted. Women who received complete antenatal care services also remain concentrated to the rich. Further, there is a highly pro-rich inequality in caesarean deliveries which did not change much from 2008 to 2013. Household income remains as the most important contributor to the resulting inequalities in health services use, followed by maternal education. For complete antenatal care use and deliveries in government facilities, regional differences also showed to have important contribution. Conclusion: The findings suggest inequality in the use of MCH services had limited pro-poor improvements. Household income remains to be the major driver of inequities in MCH services use in the Philippines. This is despite the recent national government-led subsidy for the health insurance of the poor. The highly pro-rich caesarean deliveries may also warrant the need for future studies to determine the prevalence of medically unindicated caesarean births among high-income women. Trial registration: Not applicable. [ABSTRACT FROM AUTHOR]

A rapid reduction in under-five mortality has put Bangladesh on-track to reach Millennium Development Goal 4. Little research, however, has been conducted into neonatal reductions and sub-national rates in the country, with considerable disparities potentially masked by national reductions. The aim of this paper is to estimate national and sub-national rates of neonatal mortality to compute relative and absolute inequalities between sub-national groups and draw comparisons with rates of under-five mortality. Mortality rates for under-five children and neonates were estimated directly for 1980-1981 to 2010-2011 using data from six waves of the Demographic and Health Survey. Rates were stratified by levels of rural/urban location, household wealth and maternal education. Absolute and relative inequalities within these groups were measured by rate differences and ratios, and where possible, slope and relative indices of inequality. National mortality was shown to have decreased dramatically although at differential rates for under-fives and neonates. Across all equity markers, a general pattern of declining absolute but constant relative inequalities was found. For mortality rates stratified by education and wealth mixed evidence suggests that relative inequalities may have also fallen. Although disparities remain, Bangladesh has achieved a rare combination of substantive reductions in mortality levels without increases in relative inequalities. A coalescence of substantial increases in coverage and equitable distribution of key child and neonatal interventions with widespread health sectoral and policy changes over the last 30 years may in part explain this exceptional pattern. [ABSTRACT FROM AUTHOR]

Background: Reducing inequality in maternal, neonatal and infant mortality are key targets in the Sustainable Development Goals. This study is the first to evaluate the impact of Indonesia's national health insurance scheme, Jaminan Kesehatan Nasional (JKN), on access to maternal health services by sociodemographic status.Methods: Using data from the 2017 Indonesia Demographic and Health Survey (IDHS) on women with live births in 2016-2017, we conducted propensity score matching (PSM) analysis to evaluate the association of JKN enrollment on the following maternal health care utilisation outcomes: (1) at least four antenatal care (ANC4+) visits; (2) ANC4+ visits and received essential components of ANC; (3) skilled birth attendance; (4) facility-based delivery; (5) post-natal care (PNC); and (6) PNC with skilled provider. Analyses were conducted at the national level and by economic subgroup and region of residence. Additionally, we investigated the potential negative impact of JKN on access to maternal health services among the uninsured population by looking at trends over time using data from the 2012 and 2017 IDHS.Results: Of the 5429 women who had recently given birth, 61% were insured by JKN in 2017. After matching treated and untreated women on key sociodemographic characteristics, enrollment in JKN was associated with a higher prevalence of receiving ANC4+ visits (7.4%, 95% confidence interval (CI) = 4.8-9.39); ANC4+ visits and received essential components of ANC (5.6%, 95% CI = 3.3-7.9); skilled birth attendance (3.0%, 95% CI = 1.5-4.5; facility-based delivery (10.2%, 95% CI = 7.5-12.7); PNC (4.0%, 95% CI = 2.2-5.7); PNC with skilled provider (4.5%, 95% CI = 2.6-6.5). Effect sizes were larger among the poor and those living in less-developed areas, such as Eastern Indonesia and Sulawesi, except for at least ANC4+ and received clinical components.Conclusions: Expansion of health insurance coverage was associated with reductions in sociodemographic inequalities in access to maternal health services in Indonesia. However, large differences in utilisation persist across regions and by economic subgroup. Accelerating progress toward universal health coverage may reduce health inequalities in other low and middle-income countries. [ABSTRACT FROM AUTHOR]

Proponents of life course comment that while the theory is persuasive, translating theory to practice is daunting. This paper speaks to the challenges and possibilities of intervention based on life course theory. It describes Healthy Start in Housing (HSiH), a partnership between the Boston Public Health Commission (BPHC) and the Boston Housing Authority (BHA) to reduce stress due to housing insecurity among low-income, pregnant women. HSiH seeks improved birth outcomes and long term health of mothers and infants. BHA goals are improved quality of life for participants, greater public housing stability and enhanced impact of housing on community well-being. HSiH is a 1 year pilot offering 75 housing units to pregnant women at risk of adverse birth outcomes and homelessness. BHA provides housing and expedites processing of HSiH applications; BPHC staff oversee enrollment, guide women through the application process, and provide enhanced, long-term case management. Of 130 women referred to HSiH to date, 53 were ineligible, 59 have submitted applications, 13 are preparing applications and 5 dropped out. Nineteen women have been housed. Among eligible women, 58 % had medical conditions, 56 % mental health conditions, and 14 % prior adverse outcomes; 30 % had multiple risks. Standardized assessments reflected high levels of depressive symptoms; 41 % had symptoms consistent with post-traumatic stress disorder. Life course theory provides both the framework and the rationale for HSiH. HSiH experience confirms the salience of daily social experience to women's health and the importance of addressing stressors and stress in women's lives. [ABSTRACT FROM AUTHOR]

AimIn this paper, we assess the degree to which the observed consistency in maternal health-care utilization can be accounted for by social and economic demand determinants at individual and household level on the one hand and community access to health services in terms of health, road and education facilities on the other.Data and methodsData from the three rounds of national family health survey of India (NFHS-1, -2 and -3) conducted in 1992–93, 1998–99 and 2005–06 are used in this analysis. The results of the analysis are presented in two sections. First, statewise profiles of maternal health-care utilization from NFHS-1, -2 and -3 are presented to compare the trends. Second, the influence of demand and access factors estimated from multi-level logistic regression models are presented for selected states of India.ResultsResults reveal that inequalities in maternal health-care utilization by socio-economic status have narrowed because of the impact of complementing factors of greater community access, and social and economical advancement in the south Indian states, where overall maternal health-care coverage is at the top end of the scale. In contrast, in the demographically lagging northern states of India, which are at the bottom end of the health coverage scale, both access and socio-economic demand determinants indicate greater inequalities in maternal health-care utilization.ConclusionLack of access to health care, slow progress in socio-economic conditions and cultural constraints are major determinants of poor maternal health-care coverage among Indian states. [ABSTRACT FROM AUTHOR]

Background: Millennium Development Goal (MDG) 5 is focused on reducing maternal mortality and achieving universal access to reproductive health care. India has made extensive efforts to achieve MDG 5 and in some regions much progress has been achieved. Progress has been uneven and inequitable however, and many women still lack access to maternal and reproductive health care. Objective: In this review, a framework developed by the Commission on Social Determinants of Health (CSDH) is used to categorize and explain determinants of inequity in maternal and reproductive health in India. Design: A review of peer-reviewed, published literature was conducted using the electronic databases PubMed and Popline. The search was performed using a carefully developed list of search terms designed to capture published papers from India on: 1) maternal and reproductive health, and 2) equity, including disadvantaged populations. A matrix was developed to sort the relevant information, which was extracted and categorized based on the CSDH framework. In this way, the main sources of inequity in maternal and reproductive health in India and their inter-relationships were determined. Results: Five main structural determinants emerged from the analysis as important in understanding equity in India: economic status, gender, education, social status (registered caste or tribe), and age (adolescents). These five determinants were found to be closely interrelated, a feature which was reflected in the literature. Conclusion: In India, economic status, gender, and social status are all closely interrelated when influencing use of and access to maternal and reproductive health care. Appropriate attention should be given to how these social determinants interplay in generating and sustaining inequity when designing policies and programs to reach equitable progress toward improved maternal and reproductive health. [ABSTRACT FROM AUTHOR]

Background: Globally, progress in Maternal and Child Health (MCH) has been inconsistent, with several evidence showing both between and within country disparities in several RMNCH outcome measures. In this study, we aim to meta-analyse existing literature on association between three major equity stratifiers and a selection of RMNCH indicators.Methods: We searched PubMed, Embase, Scopus databases and grey literatures from the WHO, UNICEF and World Bank publications. Using the PRISMA guidelines, we identified and reviewed studies from low and middle-income countries, that explored the effects of inequalities on RMNCH, with focus on studies that utilised data from a nationally representative survey. The review protocol was registered at the PROSPERO international prospective register of systematic reviews.Results: A total of 28 studies were included in the meta-analysis. Results revealed the existence of marked inequality based on income levels, education and place of residence. The most significant level of disparity was with regards to unmet need for contraception and antenatal coverage. For both respective indicators, those with secondary or higher education were 6 times more likely to have better coverage, than those with lesser level of education; (odds ratio (OR) = 6.25 (95% confidence interval (CI) = 1.68-23.23; I2 = 98%, P = 0.006) and (OR = 6.17 (95% CI = 3.03-12.56; I2 = 97%, P < 0.00001) respectively. In contrast, the lowest inequality was in the completion of 3 doses of diphtheria, pertussis and tetanus vaccines (DPT3), those with primary or no education, were equally as likely as those with secondary or higher education to have received DPT3; (OR = 1.21, 95% CI = 0.34-4.27; I2 = 96%, P = 0.77).Conclusions: In developing countries, maternal and child health coverage remains highly inequitable and assess to maternal and child health services are governed by factors such as income, level of education, and place of residence. [ABSTRACT FROM AUTHOR]

"Categorical thinking" in social science research has been widely criticised by feminist scholars for conceptualising social categories as natural, de-contextualised, and internally homogeneous. This paper develops and applies a mixed-methods approach to the study of health inequalities, using social categories meaningfully in order to challenge categorical thinking. The approach is demonstrated through a case study of socio-economic (SES) inequalities in maternal healthcare access in Zambia. This paper's approach responds to the research agenda set by intersectional social epidemiologists by considering potential heterogeneity within categories, but also by exploring the context-specific meaning of categories, examining explanations at multiple levels, and interpreting results according to mutually constitutive social processes. The study finds that meso-level institutions, "health service environments", explain a large share of SES inequalities in maternal healthcare access. Women's work, marital status, and levels of "autonomy" have heterogeneous implications for healthcare access across SES categories. Disadvantaged categories and their reproductive behaviours are stigmatised as 'backwards', in contrast to advantaged categories and their behaviours, which are associated with 'modernity' and 'development'. Challenging categorical thinking has important implications for social justice and health, by rejecting framings of a specific category as problematic or non-compliant, highlighting the possibility of change, and emphasising the political and structural nature of progress. • The paper applies a mixed-methods approach to challenge categorical thinking. • Challenging categorical thinking is important for social justice and health. • Health service environments explain SES inequalities in facility delivery in Zambia. • "Less educated", "poor" and "rural" social categories are stigmatised. • Women's work, marital status, and "autonomy" have heterogeneous effects on access. [ABSTRACT FROM AUTHOR]

Background The 'Five Year Forward View' (NHS England) calls for a radical upgrade in public health provision. Inequalities in maternal health may perpetuate general patterns of health inequalities across generations; therefore equitable access to general practice (GP) provision during maternity is important. This paper explores variation in GP consultation rates for disadvantaged mothers. Method Data from the Born in Bradford cohort (around 12 000 women), combined with GP records and GP practice variables, were modelled to predict GP consultation rates, before and after adjusting for individual health and GP provision. Results Observed GP consultation rates are higher for women in materially deprived neighbourhoods and Pakistani women. However these groups were found to consult less often after controlling for individual health. This difference, around one appointment per year, is 'explained' by the nature of GP provision. Women in practices with a low GP to patient ratio had around 09 fewer consultations over the six year period compared to women in practices with the highest ratio. Conclusions Equitable access to GP services, particularly for women during the maternal period, is essential for tackling deep-rooted health inequalities. Future GP funding should take account of neighbourhood material deprivation to focus resources on areas of the greatest need. [ABSTRACT FROM AUTHOR]

Background: Continuum of Maternal Health Care Services (CMHS) has garnered attention in recent times and reducing socio-economic disparity and geographical variations in its utilisation becomes crucial from an egalitarian perspective. In this study, we estimate inequity in the utilisation of CMHS in India between 2005 and 06 and 2015-16. Methods: We used two rounds of National Family Health Survey (NFHS) - 2005-06 and 2015-16 encompassing a sample size of 34,560 and 178,857 pregnant women respectively. The magnitude of horizontal inequities (HI) in the utilisation of CMHS was captured by adopting the Erreygers Corrected Concentration indices method. Need-based standardisation was conducted to disentangle the variations in the utilisation of CMHS across different wealth quintiles and state groups. Further, a decomposition analysis was undertaken to enumerate the contribution of legitimate and illegitimate factors towards health inequity. Results: The study indicates that the pro-rich inequity in the utilisation of CMHS has increased by around 2 percentage points since the implementation of National Rural Health Mission (NRHM), where illegitimate factors are dominant. Decomposition analysis reveals that the contribution of access related barriers plummeted in the considered period of time. The results also indicate that mother's education and access to media continue to remain major contributors of pro-rich inequity in India. Considering, regional variations, it is found that the percentage of pro-rich inequity in high focus group states increased by around 3% between 2005 and 06 and 2015-16. The performance of southern states of India is commendable. Conclusions: Our study concludes that there exists a pro-rich inequity in the utilisation of CMHS with marked variations across state boundaries. The pro-rich inequity in India has increased between 2005 and 06 and high focus group states suffered predominantly. Decentralisation of healthcare policies and granting greater power to the states might lead to equitable distribution of CMHS. [ABSTRACT FROM AUTHOR]

This paper addresses equity in health and health care in Brazil, examining unjust disparities between women and men, and between women from different social strata, with a focus on services for contraception, abortion and pregnancy. In 2010 women's life expectancy was 7Z6 years, men's was 69.7 years. Women are two-thirds of public hospital services users and assess their health status less positively than men. The total fertility rate was 1.8 in 2011, and contraceptive prevalence has been high among women at all income levels. The proportion of sterilizations has decreased; lower-income women are more frequently sterilized. Abortions are mostly illegal; women with more money have better access to safe abortions in private clinics. Poorer women generally self-induce abortion with misoprostol, seeking treatment of complications from public clinics. Institutional violence on the part of health professionals is reported by half of women receiving abortion care and a quarter of women during childbirth. Maternity care is virtually universal. The public sector has fewer caesarean sections, fewer low birthweight babies, and more rooming-in, but excessive episiotomies and inductions. Privacy, continuity of care and companionship during birth are more common in the private sector. To achieve equity, the health system must go beyond universal, unregulated access to technology, and move towards safe, effective and transparent care. [ABSTRACT FROM AUTHOR]

For decades, epidemiologists have documented a health advantage among Hispanic/Latinx individuals who live in the United States, despite their significant socioeconomic barriers. This observation is often described as the "Hispanic paradox." In this scoping review, we aimed to summarize literature published on Hispanic/Latinx perinatal outcomes over the past two decades and place these findings within the context of the overarching "Healthy Immigrant" paradox. Studies were eligible for inclusion if they utilized large population datasets to describe rates of preterm birth, low birth weight and infant mortality among Hispanic/Latinx women living in the United States. To focus on the most recent trends, studies were excluded if they were published prior to the year 2000. Globally, Hispanic/Latinx women appear to continue to have improved perinatal outcomes compared to non-Hispanic Black infants, while rates of adverse outcomes appear similar for Hispanic/Latinx and non-Hispanic White women. However, our review emphasizes the heterogeneity of outcomes experienced by Hispanic/Latinx women. The epidemiologic advantage among Hispanic/Latinx women and their infants may be largely concentrated among specific national origin subgroups or among recently arrived foreign-born Hispanic/Latinx women. Given the disparities that exist among Hispanic/Latinx women, we provide a summary of themes to explore in future research and methodologic recommendations that may assist in identifying important subgroup differences and their determinants. [ABSTRACT FROM AUTHOR]

Background: Maternal health care utilization is at the core of global public health provision and an area of focus in the now-concluded Millennium Development Goal agenda. Objective: This study aims to examine trends in maternal health care utilization over the last 15 years in Nepal, focusing on coverage and equity. Methods: This paper used data from the Demographic Health Survey (DHS) 2001, 2006 and 2011 and Multiple Indicator Cluster Survey (MICS), 2014. Coverage rates were calculated and logistic regression models used to examine inequity. Results: Impressive gains were found in antenatal care (ANC) attendance, which increased from nearly half of women attending (49%) in 2001 to 88% in 2014, and the rate of facility delivery increased from just 7–44%. This development did not, however, influence the equity gap in ANC and skilled attendance at birth, as women from low socioeconomic backgrounds were six times more likely to deliver without skilled assistance than those from high socioeconomic backgrounds (AdjOR 6.38 CI 95% 4.57–8.90) in 2014. Conclusion: These persistent equity gaps call for targeted interventions focusing on the most disadvantaged and vulnerable women in order to achieve the new Sustainable Development Goal of universal health coverage. [ABSTRACT FROM PUBLISHER]

Background. Addressing inequalities in accessing emergency obstetric care is crucial for reducing the maternal mortality ratio. This study was undertaken to examine the time trends and sociodemographic correlates of cesarean section (CS) utilization in Nepal between 2006 and 2016. Methods. Data from the Nepal Demographic and Health Surveys (NDHS) 2006, 2011, and 2016 were sourced for this study. Women who had a live birth in the last five years of the survey were the unit of analysis for this study. Absolute and relative inequalities in CS utilization were expressed in terms of rate difference and rate ratios, respectively. We used multivariable regression models to assess the CS rate by background sociodemographic characteristics of women. Results. Age and parity-adjusted CS rates were found to have increased almost threefold (from 3.2%, 95% CI: 2.1-4.3 in 2006 to 10.5%; 95% CI: 8.9-11.9 in 2016) over the decade. In 2016, women from mountain region (3.0%), those from the lowest wealth quintile (2.4%), and those living in Karnali province (2.4%) had CS rate below 5%. Whereas women from the highest wealth quintile (25.1%), with higher education (21.2%), and those delivering in private facilities (37.1%) had CS rate above 15%. Women from the highest wealth quintile (OR-3.3; 95% CI: 1.6-7.0) compared to women from the lowest wealth quintile and those delivered in private/NGO-run facilities (OR-3.6; 95% CI: 2.7-4.9) compared to women delivering in public facilities were more than three times more likely to deliver by CS. Conclusion. To improve maternal and newborn health, strategies need to be revised to address the underuse of CS among poor, those living in mountain region and Province 2, Lumbini province, Karnali province, and Sudhurpaschim province. Simultaneously, there is a pressing need for policies, guidelines, and continuous monitoring of CS rates to reduce overuse among rich women, women with higher education, and those giving childbirth in private facilities. [ABSTRACT FROM AUTHOR]

Background: Antenatal care (ANC) is an essential intervention associated with a reduction of maternal and new-born morbidity and mortality. However, evidence suggested substantial inequalities in maternal and child health, mainly in low- and middle-income countries (LMICs). We aimed to conduct a global analysis of socioeconomic inequalities in ANC using national surveys from LMICs. Methods: ANC was measured using the ANCq, a novel content-qualified ANC coverage indicator, created and validated using national surveys, based upon contact with the health services and content of care received. We performed stratified analysis to explore the socioeconomic inequalities in ANCq. We also estimated the slope index of inequality, which measures the difference in coverage along the wealth spectrum. Results: We analyzed 63 national surveys carried out from 2010 to 2017. There were large inequalities between and within countries. Higher ANCq scores were observed among women living in urban areas, with secondary or more level of education, belonging to wealthier families and with higher empowerment in nearly all countries. Countries with higher ANCq mean presented lower inequalities; while countries with average ANCq scores presented wide range of inequality, with some managing to achieve very low inequality. Conclusions: Despite all efforts in ANC programs, important inequalities in coverage and quality of ANC services persist. If maternal and child mortality Sustainable Development Goals are to be achieved, those gaps we documented must be bridged. [ABSTRACT FROM AUTHOR]

Background: Despite substantial reductions in perinatal deaths (stillbirths and early neonatal deaths), India's perinatal mortality rates remain high, both nationally and in individual states. Rates are highest among disadvantaged socio-economic groups. To address this, India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to counsel and support women by visiting them at home before and after childbirth. We conducted a qualitative study to explore the roles of ASHAs' home visits in improving equity in perinatal health between socio-economic position groups in rural Uttar Pradesh (UP), India. Methods: We conducted social mapping in four villages of two districts in UP, followed by three focus group discussions in each village (12 in total) with ASHAs and women who had recently given birth belonging to 'higher' and 'lower' socio-economic position groups (n = 134 participants). We analysed the data in NVivo and Dedoose using a thematic framework approach. Results: Home visits enabled ASHAs to build trusting relationships with women, offer information about health services, schemes and preventive care, and provide practical support for accessing maternity care. This helped many women and families prepare for birth and motivated them to deliver in health facilities. In particular, ASHAs encouraged women who were poorer, less educated or from lower caste groups to give birth in public Community Health Centres (CHCs). However, women who gave birth at CHCs often experienced insufficient emergency obstetric care, mistreatment from staff, indirect costs, lack of medicines, and referrals to higher-level facilities when complications occurred. Referrals often led to delays and higher fees that placed the greatest burden on families who were considered of lower socio-economic position or living in remote areas, and increased their risk of experiencing perinatal loss. Conclusions: The study found that ASHAs built relationships, counselled and supported many pregnant women of lower socio-economic positions. Ongoing inequities in health facility births and perinatal mortality were perpetuated by overlapping contextual issues beyond the ASHAs' purview. Supporting ASHAs' integration with community organisations and health system strategies more broadly is needed to address these issues and optimise pathways between equity in intervention coverage, processes and perinatal health outcomes. [ABSTRACT FROM AUTHOR]

Background: The pursuit of health equity is a priority in Ethiopia, especially with regards to maternal, newborn, and child health (MNCH). To date, there has been little characterization of the 'problem' of health inequity, and the normative assumptions implicit in the representation of the problem. Yet, such insights have implications for shaping the framing, incentivization, and implementation of health policies and their wider impact. Objective: In this article, we characterize how health (in)equity is represented as a policy issue, how this representation came about, and the underlying assumptions. Methods: We draw from Bacchi's 'what is the problem represented to be' approach to explore how national-level actors in the health sector constitute the problem. The data for our analysis encompass 23 key informant interviews with national health sector actors working in leadership positions on MNCH in Ethiopia, and six policy documents. Findings were derived from thematic and content analysis. Results: Health inequity is a normalized and inevitable concern that is regarded as actionable (can be altered) but not fully resolvable (can never be fully achieved). Operationally, health equity is viewed as a technocratic matter, reflected in the widespread use of metrics to motivate and measure progress. These representations are shaped by Ethiopia's rapid expansion of health services into rural areas during the 2000s leading to the positive international attention and funding the country received for improved MNCH indicators. Expanding the coverage and efficiency of health service provision, especially in rural areas, is associated with economic productivity. Conclusion: The metrication of health equity may detract from the fairness, justice, and morality underpinnings of the concept. The findings of this study point to the implications of global pressures in terms of maximizing health investments, and call into question how social, political, and economic determinants of health are addressed through broader development agendas. [ABSTRACT FROM AUTHOR]

The launch of the Millennium Development Goals in 2000, followed by the Sustainable Development Goals in 2015, and the increasing focus on achieving universal health coverage has led to numerous interventions on both supply- and demand-sides of health systems in low- and middle-income countries. While tremendous progress has been achieved, inequities in access to healthcare persist, leading to calls for a closer examination of the equity implications of these interventions. This paper examines the equity implications of two such interventions in the context of maternal healthcare in Senegal. The first intervention on the supply-side focuses on improving the availability of maternal health services while the second intervention, on the demand-side, abolished user fees for facility deliveries. Using three rounds of Demographic Health Surveys covering the period 1992 to 2010 and employing three measures of socioeconomic status (SES) based on household wealth, mothers' education and rural/urban residence – we find that although both interventions increase utilisation of maternal health services, the rich benefit more from the supply-side intervention, thereby increasing inequity, while those living in poverty benefit more from the demand-side intervention i.e. reducing inequity. Both interventions positively influence facility deliveries in rural areas although the increase in facility deliveries after the demand-side intervention is more than the increase after the supply-side intervention. There is no significant difference in utilisation based on mothers' education. Since people from different SES categories are likely to respond differently to interventions on the supply- and demand-side of the health system, policymakers involved in the design of health programmes should pay closer attention to concerns of inequity and elite capture that may unintentionally result from these interventions. • We study equity implications of demand- and supply-side interventions in the context of maternal healthcare in Senegal. • People from different socioeconomic groups respond differently to supply and demand-side interventions. • The supply-side intervention benefitted the richer households more, thereby increasing inequity. • The demand-side intervention benefitted the poorer households more, thereby reducing inequity. • Policymakers should pay closer attention to concerns of inequity that may unintentionally result from these interventions. [ABSTRACT FROM AUTHOR]

Background Poor countries, such as Sierra Leone, often have poor health outcomes, whereby the majority of the population cannot access lifesaving health services. Access to, and use of, maternal and reproductive health services is crucial for human development, especially in developing regions. However, inequality remains a persistent problem for many developing countries. Moreover, we have not found empirical studies, which have examined inequalities in maternal and reproductive health in Sierra Leone. Method We used data collected from the Sierra Leone Demographic and Health Surveys (DHS) conducted in 2008 and 2013. Five maternal and reproductive health indicators were selected for this study, including four or more antenatal care visits, skilled antenatal care provider, births delivered in a facility, births assisted by a skilled birth attendant, and any method of contraception. To measure inequalities, we adopted the Human Opportunity Index (HOI). Using this measure, we measured differentials over the two periods, and decomposed it to measure the contribution of the selected circumstance variables to inequality. Results Inequalities declined over time, as shown by the decrease in the dissimilarity index. Due to the drop in the dissimilarity index, the HOI increased for all the selected maternal and reproductive health indicators. Moreover, antenatal services were closer to equality compared to the other selected services. Overall, we found that household wealth status, maternal education and place of residence, are the most important factors contributing to the inequality in the use of maternal and reproductive health services. Conclusions Even though there are improvements in inequalities over time, there are variations in the way in which inequality within the different indicators has improved. In order to improve the use of maternal and reproductive health services, and to reduce inequalities in these services, the government will have to invest in: (i) increasing the educational levels of women, (ii) improving the standard of living, as well as (iii) bringing maternal and reproductive health services closer to rural populations. [ABSTRACT FROM AUTHOR]

Background: The healthcare system in Mozambique is striving to reduce the high maternal and child mortality rates and stay on par with the Sustainable Development Goals (SDG 3.1). A key strategy to curb maternal and child mortality is to promote the use of professional childbirth services proven to be highly effective in averting maternal deaths. Currently, little is known about the use of childbirth services in Mozambique. The present study investigated the prevalence of professional healthcare delivery services and identified their sociodemographic correlates. Methods: This study used cross-sectional data on 7080 women aged 15–49 years who reported having a child during the past 5 years. The data were collected from the 2011Mozambique Demographic and Health Survey. The outcome variables were the choice of childbirth services that included 1) place of delivery (respondent's home versus health facility), and mode of delivery (caesarean section versus vaginal birth). Data were analyzed using descriptive and multivariate regression methods. Results: The prevalence of health facility and C-section delivery was 70.7 and 5.6%, respectively. There was a difference in the use of professional birthing services between urban and rural areas. Having better educational status and living in households of higher wealth quintiles showed a positive association with the use of facility delivery services among both urban and rural residents. Regarding ethnicity, women of Portugais [2.688,1.540,4.692], Cindau [1.876,1.423,2.474] and Xichangana [1.557,1.215,1.996] had relatively higher odds of using facility delivery services than others. Antenatal care (ANC) visits were a significant predictor of facility delivery services both in urban [OR = 1.655, 95%CI = 1.235,2.218] and rural [OR = 1.265, 95%CI = 1.108,1.445] areas. Among rural women, ANC visit was a significant predictor of C-section delivery [1.570,1.042,2.365]. Conclusion: More than a quarter of the women in Mozambique were not using health facility delivery services, with the prevalence being noticeably lower in the rural areas. [ABSTRACT FROM AUTHOR]

Background: As India already missed maternal and child health related millennium development goals, the maternal and child health outcomes are a matter of concern to achieve sustainable development goals (SDGs). This study is focused to assess the gap in coverage and inequality of various reproductive, maternal, neonatal and child health (RMNCH) indicators in 640 districts of India, using data from most recent round of National Family Health Survey.Methods: A composite index named Coverage Gap Index (CGI) was calculated, as the weighted average of eight preventive maternal and child care interventions at different administrative levels. Bivariate and spatial analysis were used to understand the geographical diversity and spatial clustering in districts of India. A socio-economic development index (SDI) was also derived and used to assess the interlinkages between CGI and development. The ratio method was used to assess the socio-economic inequality in CGI and its component at the national level.Results: The average national CGI was 26.23% with the lowest in Kerala (10.48%) and highest in Nagaland (55.07%). Almost half of the Indian districts had CGI above the national average and mainly concentrated in high focus states and north-eastern part. From the geospatial analysis of CGI, 122 districts formed hotspots and 164 districts were in cold spot. The poorest households had 2.5 times higher CGI in comparison to the richest households and rural households have 1.5 times higher CGI as compared to urban households.Conclusion: Evidence from the study suggests that many districts in India are lagging in terms of CGI and prioritize to achieve the desired level of maternal and child health outcomes. Efforts are needed to reduce the CGI among the poorest and rural resident which may curtail the inequality. [ABSTRACT FROM AUTHOR]

We describe how mass incarceration directly undermines the core values of reproductive justice and how this affects incarcerated and nonincarcerated women. Mass incarceration, by its very nature, compromises and undermines bodily autonomy and the capacity for incarcerated people to make decisions about their reproductive well-being and bodies; this is done through institutionalized racism and is disproportionately done to the bodies of women of color. This violates the most basic tenets of reproductive justice—the right to have a child, not to have a child, and to parent the children you have with dignity and in safety. By undermining motherhood and safe pregnancy care, denying access to abortion and contraception, and preventing people from parenting their children at all and by doing so in overpoliced, unsafe environments, mass incarceration has become a driver of forms of reproductive oppression for people in prison and jails and in the community. [ABSTRACT FROM AUTHOR]

A research partnership between Iwi (tribal group) Ngāti Pāhauwera and a university-based research centre specialising in Kaupapa Māori (by Māori, for Māori) research was formed in response to an invitation from Ngāti Pāhauwera. The initial partnership goal was to address health inequities experienced by Māori women and infants in Te Wairoa (the home place of the Iwi), a predominantly Māori, rural region in Aotearoa (New Zealand). The research developed by the partnership is an example of a culturally responsive research methodology. Key features include: being Iwi-initiated; community identification of strengths and assets; guidance by a community steering group; contribution to local Māori research capacity; and the development of a community-led augmented maternity care pathway that is now being delivered through primary care. These features have strengthened the engagement of the Iwi, researchers and community, and provided opportunities for transformative change. [ABSTRACT FROM AUTHOR]

Objectives The end of the era of millennium development goals (MDGs) ushered in the sustainable development goals (SDGs) with a new target for the reduction of under-five mortality rates (U5MR). Although U5MR decreased globally, the reduction was insufficient to meet MDGs targets because significant socioeconomic inequities remain unaddressed across and within countries. Thus, further progress in achieving the new SDGs target will be hindered if there is no adequate prioritization of important socioeconomic, healthcare, and environmental factors. The objective of this study was to assess factors that account most for the differences in U5MR between countries around the globe. Methods We conducted an ordinary least squares (OLS) regression-based prioritization analysis of socioeconomic, healthcare, and environmental variables from 109 countries to understand which factors explain the differences in U5MR best. Results All indicators examined individually affected differences in U5MR between countries. However, the results of multivariate OLS regression showed that the most important factors that accounted for the differences were, in order: fertility rate, total health expenditure per capita, access to improved water and sanitation, and female employment rate. Conclusions To achieve the new global target for U5MR, policymakers must focus on certain priority areas, such as interventions that address access to affordable maternal healthcare services, educational programs for mothers, especially those who are adolescents, and safe drinking water and sanitation. [ABSTRACT FROM AUTHOR]

Low delivery care utilization continues to be a public health problem that significantly contributes to maternal morbidity and mortality, especially in developing countries like Ethiopia. The aim of the study is to determine the extent of urban-rural disparity of delivery care utilization and its determinants. A community-based cross-sectional quantitative study supplemented with qualitative data was conducted from February 15 to March 10, 2014. Data were collected from eligible woman using interviewer-guided semistructured questionnaires and focus group discussions. Logistic regression analysis with 95% confidence interval and p-value less than 5% was used to identify potential determinant variables. From 567 women, institutional delivery care was attended by 45.9% (260) respondents of whom 69.3% were urban and 21.3% were rural. Mass media and antenatal care attendance were the major determinants in urban respondents, whereas children ever born, partners' occupation, women's autonomy, and pregnancy-related health problems were statistically significant associations in rural women. The need for maternal health care is not met to the required level. There is a significant disparity in delivery care attendance among urban and rural women of the study area. Women's empowerment and awareness creation should be extensively worked on through mass media and posters or health information. [ABSTRACT FROM AUTHOR]

Background: The Brazilian SUS (Unified Health System) was created in 1988 within the new constitution, based on the premises of being universal, comprehensive, and equitable. The SUS offers free health care, independent of contribution or affiliation. Since then, great efforts and increasing investments have been made for the system to achieve its goals. We assessed how coverage and equity in selected reproductive and maternal interventions progressed in Brazil from 1986 to 2013. Methods: We reanalysed data from four national health surveys carried out in Brazil in 1986, 1996, 2006 and 2013. We estimated coverage for six interventions [use of modern contraceptives; antenatal care (ANC) 1+ visits by any provider; ANC 4+ visits by any provider; first ANC visit during the first trimester of pregnancy; institutional delivery; and Caesarean sections] using standard international definitions, and stratified results by wealth quintile, urban or rural residence and country regions. We also calculated two inequality indicators: the slope index of inequality (SII) and the concentration index (CIX). Results: All indicators showed steady increases in coverage over time. ANC 1+ and 4+ and institutional delivery reached coverage above 90 % in 2013. Prevalence of use of modern contraceptives was 83 % in 2013, indicating nearly universal satisfaction of need for contraception. On a less positive note, the proportion of C-sections has also grown continuously, reaching 55 % in 2013. There were marked reductions in wealth inequalities for all preventive interventions. Inequalities were significantly reduced for all indicators except for the C-section rate (p = 0.06), particularly in absolute terms (SII). Conclusions: Despite the difficulties faced in the implementation of SUS, coverage of essential interventions increased and equity has improved dramatically, due in most cases to marked increase in coverage among the poorest 40 %. An increase in unnecessary Caesarean sections was also observed during the period. Further evaluation on the quality of healthcare provided is needed. [ABSTRACT FROM AUTHOR]

Background: Rates of maternal mortality and morbidity vary markedly, both between and within countries. Documenting these variations, in a very unequal society like South Africa, provides useful information to direct initiatives to improve services. The study describes inequalities over time in access to maternal health services in South Africa, and identifies differences in maternal health outcomes between population groups and across geographical areas.Methods: Data were analysed from serial population-level household surveys that applied multistage-stratified sampling. Access to maternal health services and health outcomes in 2008 (n = 1121) were compared with those in 2012 (n = 1648). Differences between socio-economic quartiles were quantified using the relative (RII) and slope (SII) index of inequality, based on survey weights.Results: High levels of inequalities were noted in most measures of service access in both 2008 and 2012. Inequalities between socio-economic quartiles worsened over time in antenatal clinic attendance, with overall coverage falling from 97.0 to 90.2 %. Nationally, skilled birth attendance remained about 95 %, with persistent high inequalities (SII = 0.11, RII = 1.12 in 2012). In 2012, having a doctor present at childbirth was higher than in 2008 (34.4 % versus 27.8 %), but inequalities worsened. Countrywide, levels of planned pregnancy declined from 44.6 % in 2008 to 34.7 % in 2012. The RII and SII rose over this period and in 2012, only 22.4 % of the poorest quartile had a planned pregnancy. HIV testing increased substantially by 2012, though remains low in groups with a high HIV prevalence, such as women in rural formal areas, and from Gauteng and Mpumalanga provinces. Marked deficiencies in service access were noted in the Eastern Cape ad North West provinces.Conclusions: Though some population-level improvements occurred in access to services, inequalities generally worsened. Low levels of planned pregnancy, antenatal clinic access and having a doctor present at childbirth among poor women are of most concern. Policy makers should carefully balance efforts to increase service access nationally, against the need for programs targeting underserved populations. [ABSTRACT FROM AUTHOR]

Objectives Four antenatal visits, delivery in a health facility, and three postnatal visits are the World Health Organization recommendations for women to optimize maternal health outcomes. This study examines maternal compliance with the full recommended maternal health visits in rural Tanzania with the goal of illuminating interventions to reduce inequalities in maternal health. Methods Analysis included 907 women who had given birth within two years preceding a survey of women of reproductive age. Multinomial logistic regression was used to assess the influence of maternal, household, and community-level characteristics on four alternative classes defining relative compliance with optimal configuration of maternal health care seeking behavior. Results Parity, wealth index, timeliness of ANC initiation, nearest health facility type, religion, and district of residence were significant predictors of maternal health care seeking when adjusted for other factors. Multiparous women compared to primiparous were less likely to seek care at the high level [RRR 0.16, 95 % confidence interval (CI) 0.06-0.46], at the mid-level (RRR 0.22, 95 % CI 0.09-0.58), and the mid-low level (RRR 0.27, 95 % CI 0.09-0.80). Women in the highest wealth index compared to those in the poorest group were almost three times more likely to seek the highest two levels of care versus the lowest level (high RRR 2.92, 95 % CI 1.27-6.71, mid-level RRR 2.71, 95 % 1.31-5.62). Conclusion Results suggest that efforts to improve the overall impact of services on the continuum of care in rural Tanzania would derive particular benefit from strategies that improve maternal health coverage among multiparous and low socioeconomic status women. [ABSTRACT FROM AUTHOR]

Background: Universal access to health care services does not automatically guarantee equity in the health system. In the post Millennium Development Goals (MDGs) era, the progress towards universal access to maternal health care services in a developing country, like Bangladesh requires an evaluation in terms of equity lens. This study, therefore, analysed the trend in inequity and identified the equity gap in the utilization of antenatal care (ANC) and delivery care services in Bangladesh between 2004 and 2011.Methods: The data of this study came from the Bangladesh Demographic and Health Survey. We employed rate ratio, concentration curve and concentration index to examine the trend in inequity of ANC and delivery care services. We also used logistic regression models to analyse the relationship between socioeconomic factors and maternal health care services.Results: The concentration index for 4+ ANC visits dropped from 0.42 in 2004 to 0.31 in 2011 with a greater decline in urban area. There was almost no change in the concentration index for ANC services from medically trained providers during this period. We also found a decreasing trend in inequity in the utilization of both health facility delivery and skilled birth assistance but this trend was again more pronounced in urban area compared to rural area. The concentration index for C-section delivery decreased by about 33 % over 2004-2011 with a similar rate in both urban and rural areas. Women from the richest households were about 3 times more likely to have 4+ ANC visits, delivery at a health facility and skilled birth assistance compared to women from the poorest households. Women's and their husbands' education were significantly associated with greater use of maternal health care services. In addition, women's exposure to mass media, their involvement in microcredit programs and autonomy in healthcare decision-making appeared as significant predictors of using some of these health care services.Conclusions: Bangladesh faces not only a persistent pro-rich inequity but also a significant rural-urban equity gap in the uptake of maternal health care services. An equity perspective in policy interventions is much needed to ensure safe motherhood and childbirth in Bangladesh. [ABSTRACT FROM AUTHOR]

Background: Despite achieving some success, wealth-related disparities in the utilisation of maternal and child health services persist in the Philippines. The aim of this study is to decompose the principal factors driving the wealth-based utilisation gap.Methods: Using national representative data from the 2013 Philippines Demographic and Health Survey, we examine the extent overall differences in the utilisation of maternal health services can be explained by observable factors. We apply nonlinear Blinder-Oaxaca-type decomposition methods to quantify the effect of differences in measurable characteristics on the wealth-based coverage gap in facility-based delivery.Results: The mean coverage of facility-based deliveries was respectively 41.1 % and 74.6 % for poor and non-poor households. Between 67 and 69 % of the wealth-based coverage gap was explained by differences in observed characteristics. After controlling for factors characterising the socioeconomic status of the household (i.e. the mothers' and her partners' education and occupation), the birth order of the child was the major factor contributing to the disparity. Mothers' religion and the subjective distance to the health facility were also noteworthy.Conclusions: This study has found moderate wealth-based disparities in the utilisation of institutional delivery in the Philippines. The results confirm the importance of recent efforts made by the Philippine government to implement equitable, pro-poor focused health programs in the most deprived geographic areas of the country. The importance of addressing the social determinants of health, particularly education, as well as developing and implementing effective strategies to encourage institutional delivery for higher order births, should be prioritised. [ABSTRACT FROM AUTHOR]

Objectives Ectopic pregnancy is an important cause of maternal morbidity and mortality. Women who experience fragmented care may undergo unnecessary delays to diagnosis and treatment. Based on ectopic pregnancy cases observed in clinical practice that raised our concern about fragmentation of care, we designed an exploratory study to describe the number, characteristics, and outcomes of fragmented care among patients with ectopic pregnancy at one urban academic hospital. Methods Chart review with descriptive statistics. Fragmented care was defined as a patient being evaluated at an outside facility for possible ectopic pregnancy and transferred, referred, or discharged before receiving care at the study institution. Results Of 191 women seen for possible or definite ectopic pregnancy during the study period, 42 (22 %) met the study definition of fragmented care. The study was under-powered to observe statistically significant differences across groups, but we found concerning, non-significant trends: patients with fragmented care were more likely to be Medicaid recipients (65.9 vs. 58.8 %) and to experience a complication (23.8 vs. 18.1 %) compared to those with non-fragmented care. Most patients (n = 37) received no identifiable treatment prior to transfer and arrived to the study hospital with no communication to the receiving hospital from the outside provider (n = 34). Nine patients (21 %) presented with ruptured ectopic pregnancies. The fragmentation we observed in our study may contribute to previously identified socio-economic disparities in ectopic pregnancy outcomes. Conclusion If future research confirms these findings, health information exchanges and regional coordination of care may be important strategies for reducing maternal mortality. [ABSTRACT FROM AUTHOR]

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Background: Health systems aim to narrow inequality in access to health care across socioeconomic groups and area of residency. However, in low-income countries, studies are lacking that systematically monitor and evaluate health programs with regard to their effect on specific inequalities. We aimed to measure changes in inequality in access to maternal and child health (MCH) interventions and the effect of Primary Health Care (PHC) facilities expansion on the inequality in access to care in Ethiopia.Methods: The Demographic and Health Survey datasets from Ethiopia (2005 and 2011) were used. We calculated changes in utilization of MCH interventions and child morbidity. Concentration and horizontal inequity indices were estimated. Decomposition analysis was used to calculate the contribution of each determinant to the concentration index.Results: Between 2005 and 2011, improvements in aggregate coverage have been observed for MCH interventions in Ethiopia. Wealth-related inequality has remained persistently high in all surveys. Socioeconomic factors were the main predictors of differences in maternal and child health services utilization and child health outcome. Utilization of primary care facilities for selected maternal and child health interventions have shown marked pro-poor improvement over the period 2005-2011.Conclusions: Our findings suggest that expansion of PHC facilities in Ethiopia might have an important role in narrowing the urban-rural and rich-poor gaps in health service utilization for selected MCH interventions. [ABSTRACT FROM AUTHOR]

Objectives: To examine socioeconomic and health system determinants of wealth-related inequalities in neonatal mortality rates (NMR) across 48 low- and middle-income countries. Methods: We used data from Demographic and Health Surveys conducted between 2006 and 2012. Absolute and relative inequalities for NMR and coverage of antenatal care, facility-based delivery, and Caesarean delivery were measured using the Slope Index of Inequality and Relative Index of Inequality, respectively. Meta-regression was used to assess whether variation in the magnitude of NMR inequalities was associated with inequalities in coverage of maternal health services, and whether country-level economic and health system factors were associated with mean NMR and socioeconomic inequality in NMR. Results: Of the three maternal health service indicators examined, the magnitude of socioeconomic inequality in NMR was most strongly related to inequalities in antenatal care. NMR inequality was greatest in countries with higher out-of-pocket health expenditures, more doctors per capita, and a higher adolescent fertility rate. Determinants of lower mean NMR (e.g., higher government health expenditures and a greater number of nurses/midwives per capita) differed from factors associated with lower NMR inequality. Conclusions: Reducing the financial burden of maternal health services and achieving universal coverage of antenatal care may contribute to a reduction in socioeconomic differences in NMR. Further investigation of the mechanisms contributing to these cross-national associations seems warranted. [ABSTRACT FROM AUTHOR]

Background: Discussions of maternity care in developing countries tend to emphasise service uptake and overlook choice of provider. Understanding how families choose among health providers is essential to addressing inequitable access to care. Our objectives were to quantify the determinants and choice of maternity care provider in Mumbai's informal urban settlements, and to explore the reasons underlying their choices.Methods: The study was conducted in informal urban communities in eastern Mumbai. We developed regression models using data from a census of married women aged 15-49 to test for associations between maternal characteristics and uptake of care and choice of provider. We then conducted seven focus group discussions and 16 in-depth interviews with purposively selected participants, and used grounded theory methods to examine the reasons for their choices.Results: Three thousand eight hundred forty-eight women who had given birth in the preceding 2 years were interviewed in the census. The odds of institutional prenatal and delivery care increased with education, economic status, and duration of residence in Mumbai, and decreased with parity. Tertiary public hospitals were the commonest site of care, but there was a preference for private hospitals with increasing socio-economic status. Women were more likely to use tertiary public hospitals for delivery if they had fewer children and were Hindu. The odds of delivery in the private sector increased with maternal education, wealth, age, recent arrival in Mumbai, and Muslim faith. Four processes were identified in choosing a health care provider: exploring the options, defining a sphere of access, negotiating autonomy, and protective reasoning. Women seeking a positive health experience and outcome adopted strategies to select the best or most suitable, accessible provider.Conclusions: In Mumbai's informal settlements, institutional maternity care is the norm, except among recent migrants. Poor perceptions of primary public health facilities often cause residents to bypass them in favour of tertiary hospitals or private sector facilities. Families follow a complex selection process, mediated by their ability to mobilise economic and social resources, and a concern for positive experiences of health care and outcomes. Health managers must ensure quality services, a functioning regulatory mechanism, and monitoring of provider behaviour. [ABSTRACT FROM AUTHOR]

We examine progress towards the 1994 International Conference on Population and Development (ICPD) commitment to provide universal access to sexual and reproductive health (SRH) services by 2014, with an emphasis on changes for those living in poor and emerging economies. Accomplishments include a 45% decline in the maternal mortality ratio (MMR) between 1990 and 2013; 11.5% decline in global unmet need for modern contraception; ~21% increase in skilled birth attendance; and declines in both the case fatality rate and rate of abortion. Yet aggregate gains mask stark inequalities, with low coverage of services for the poorest women. Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 80 developing countries highlight persistent disparities in skilled birth attendance by household wealth: in 70 of 80 countries (88%), ≥80% of women in the highest quintile were attended by a skilled provider at last birth; in only 23 of the same countries (29%) was this the case for women in the lowest wealth quintile. While there have been notable declines in HIV incidence and prevalence, women affected by HIV are too often bereft of other SRH services, including family planning. Achieving universal access to SRH will require substantially greater investment in comprehensive and integrated services that reach the poor. [ABSTRACT FROM AUTHOR]

Women from minority populations, such as Mexican-American women, face unique social and cultural Stressors that are different from men and women in the majority population. These differences have important consequences for the physical and mental health of pregnant mothers and contribute to perinatal health inequalities. As the population in the U.S. continues to diversify, the health care community is becoming more aware of how Stressors affect demographic populations differently. Particularly for Mexican-American women, acculturation to mainstream culture poses risks for the mother and child that may be driven by acculturative stress. Protective cultural practices need to be identified in research and practice to promote healthier maternal outcomes for vulnerable populations. INSET: ACCULTURATION HAS CONSEQUENCES FOR INFANTS. [ABSTRACT FROM AUTHOR]

Background Poor outcomes after childbirth are associated with physical ill health and with an absence of a positive sense of well-being. Postnatally poor physical health is thought to be influenced by the care received, the nature of the birth, and associated complications. The aim of this study was to estimate the effects of a range of clinical and other factors on positive outcome and well-being 3 months after childbirth. Methods This study used data on more than 5,000 women from a 2010 National Maternity Survey about their experiences of maternity care, and health and well-being 3 months after childbirth. Positive outcome was defined as women reporting no problems and feeling 'very well' at the time of the survey. Results In the univariate analysis, several variables were significantly associated with positive outcome, including sociodemographic, antenatal, intrapartum, and postnatal factors. In the final logistic regression model, young mothers, those without physical disability and those with no or few antenatal or early postnatal problems, were most likely to have positive outcomes. Other significant factors included a positive initial reaction to the pregnancy, not reporting antenatal depression, fewer worries about the labor and birth, and access to information about choices for care. Conclusions This study shows how positive outcomes for women after childbirth may be influenced by health, social, and care factors. It is important for caregivers to bear these factors in mind so that extra support may be made available to those women who are likely to be susceptible to poor outcome. ( BIRTH 40:1 March 2013) [ABSTRACT FROM AUTHOR]

Background: China has made impressive progress towards the Millennium Development Goal (MDG) for maternal and reproductive health, but ensuring that progress reaches all segments of the population remains a challenge for policy makers. The aim of this review is to map disadvantaged populations in terms of maternal health in China, and to explain the causes of these inequities to promote policy action. Methods: We searched PUBMED, Popline, Proquest and WanFang and included primary studies conducted in mainland China. Experts were also contacted to identify additional studies. Disadvantaged populations in terms of MDG 5 and the reasons for this disadvantage explored by authors were identified and coded based on the conceptual framework developed by the WHO Commission on the Social Determinants of Health. Results: In China, differences in maternal health service utilization and the maternal mortality ratio among different income groups, and among regions with different socio-economic development still exist, although these differences are narrowing. Groups with low levels of education and ethnic minorities utilize maternal health care less frequently and experience higher maternal mortality, although we could not determine whether these differences have changed in the last decade. Rural-to-urban migrants use maternal health care and contraception to a lower extent than permanent residents of cities, and differential maternal mortality shows a widening trend among these groups. Gender inequity also contributes to the disadvantaged position of women. Intermediary factors that explain these inequities include material circumstances such as long distances to health facilities for women living in remote areas, behavioral factors such as traditional beliefs that result in reduced care seeking among ethnic minorities, and health system determinants such as out-of-pocket payments posing financial barriers for the poor. Conclusions: Inequity in maternal health continues to be an issue worthy of greater programmatic and monitoring efforts in China. [ABSTRACT FROM AUTHOR]

Introduction: Skilled birth attendance (SBA) and measles immunization reflect two aspects of a health system. In Kenya, their national coverage gaps are substantial but could be largely improved if the total population had the same coverage as the wealthiest quintile. A decomposition analysis allows identifying the factors that influence these wealth-related inequalities in order to develop appropriate policy responses. The main objective of the study was to decompose wealth-related inequalities in SBA and measles immunization into their contributing factors. Methods: Data from the Kenyan Demographic and Health Survey 2008/09 were used. The study investigated the effects of socio-economic determinants on [1] coverage and [2] wealth-related inequalities of SBA utilization and measles immunization. Techniques used were multivariate logistic regression and decomposition of the concentration index (C). Results: SBA utilization and measles immunization coverage differed according to household wealth, parent's education, skilled antenatal care visits, birth order and father's occupation. SBA utilization further differed across provinces and ethnic groups. The overall C for SBA was 0.14 and was mostly explained by wealth (40%), parent's education (28%), antenatal care (9%), and province (6%). The overall C for measles immunization was 0.08 and was mostly explained by wealth (60%), birth order (33%), and parent's education (28%). Rural residence (-19%) reduced this inequality. Conclusion: Both health care indicators require a broad strengthening of health systems with a special focus on disadvantaged sub-groups. [ABSTRACT FROM AUTHOR]

This study examined differences in health status, rates of postpartum depression, perceptions of health services, unmet service needs, and barriers to service use among women born in and outside of Canada at 6 weeks following postpartum discharge from hospital. A secondary analysis of data gathered for a longitudinal cross-sectional survey of postpartum health and service use was conducted. Data from participants recruited from two urban hospitals were used for this analysis (n = 1,045). Analyses examined differences between women born in and outside of Canada. Immigrant women were significantly more likely to experience fair/poor postpartum health status and risk for postpartum depression. Immigrant women were also more likely to rate community health services as fair/poor, and were less likely to be able to get care for emotional health problems. Postpartum health services need to be responsive and accessible in order to meet the needs of immigrant women. [ABSTRACT FROM AUTHOR]