Inequalities in the coverage of place of delivery and skilled birth attendance: analyses of cross-sectional surveys in 80 low and middle-income countries

Abstract

BackgroundHaving a health worker with midwifery skills present at delivery is one of the key interventions to reduce maternal and newborn mortality. We sought to estimate the frequencies of (a) skilled birth attendant coverage, (b) institutional delivery, and (c) the combination of place of delivery and type of attendant, in LMICs.MethodsNational surveys (DHS and MICS) performed in 80 LMICs since 2005 were analyzed to estimate these four categories of delivery care. Results were stratified by wealth quintile based on asset indices, and by urban/rural residence. The combination of place of delivery and type of attendant were also calculated for seven world regions.ResultsThe proportion of institutional SBA deliveries was above 90 % in 25 of the 80 countries, and below 40 % in 11 countries. A strong positive correlation between SBA and institutional delivery coverage (rho: 0.97, p <0,001) was observed. Eight countries had over 10 % of home SBA deliveries, and two countries had over 10 % of institutional non-SBA deliveries. Except for South Asia, all regions had over 80 % of urban deliveries in the institutional SBA category, but in rural areas, only two regions (CEE & CIS, Middle East & North Africa) presented average coverage above 80 %. In all regions, institutional SBA deliveries were over 80 % in the richest quintile. Home SBA deliveries were more common in rural than in urban areas, and in the poorest quintiles in all regions. Facility non-SBA deliveries also tended to be more common in rural areas and among the poorest.ConclusionFour different categories of delivery assistance were identified worldwide. Pro-urban and pro-rich inequalities were observed for coverage of institutional SBA deliveries.Electronic supplementary materialThe online version of this article (doi:10.1186/s12978-016-0192-2) contains supplementary material, which is available to authorized users.

The Inverse Equity Hypothesis: Analyses of Institutional Deliveries in 286 National Surveys

“…26,27 This is confirmed by our finding of an average difference greater than 50 percentage points between the 2 extremes of the wealth distribution in all surveys. We point out that similar magnitudes of absolute gaps may represent very different inequality patterns.…”

“…Information on skilled birth attendants was available in a smaller number of surveys, and results were virtually identical to those for coverage with institutional deliveries as expected because of the high correlation between the 2 indicators (Pearson's r = 0.956; P < .001). 27 These results are available upon request.…”

“…An analysis of 75 countries with high maternal and child mortality showed that coverage with skilled birth attendance increased by less than 1 percentage point a year from 41% in 1990 to 65% in 2015. 50 In light of the strong association between skilled attendance and institutional deliveries, 27 the rates of improvement for the latter must have also been small.…”

“…24 Growing availability of data from low-and middle-income countries allowed us to test the hypothesis in national surveys that provided information on socioeconomic position and on the proportion of births occurring in a health facility (institutional delivery coverage). We chose this outcome because it is measured in many surveys with high validity, 25 usually presenting marked socioeconomic gradients, 26,27 and because delivery by a skilled attendant in a health facility is a key intervention to reduce maternal and newborn mortality.…”

Safe Childbirth and Motherhood in African Great Lakes Region: External Pelvimetry in Nulliparae and Scheduled Caesarean Section

“…The situation is even worse when it comes to pregnant women in developing countries where deliveries are not most of times attended by skilled health professionals with obvious poor-rich inequalities [3]. Cross-sectional surveys in 80 low and middleincome countries have shown inequalities in the coverage of place of delivery and skilled birth attendance (SBA): SBA deliveries at home and facility non-SBA deliveries were more common in rural than in urban areas and among the poorest in all concerned regions including Sub-Saharan Africa [4]. Another multi-country study showed that only 17.7% of the poorest women versus 54.1% of the richest women used public facilities in Sub-Saharan Africa; and among home births in the poorest, 56% were unattended whereas 41% were attended by a traditional birth attendant [5].…”