The purpose of this paper is to give a global picture of poor-rich differences in the utili-sation of delivery care and other maternal health services. Results published in acces-sible literature are reviewed and complemented with recent data based on the Demo-graphic and Health Survey (DHS) program.
The results of descriptive and comparative studies are summarised in five points:
In most countries, poor-rich differences in the utilisation of delivery care are huge. Wealth and delivery care use are associated across the entire wealth hierarchy. Inequalities in delivery care use are much larger in some countries than in others. Inequalities tend to be smaller in countries with high female literacy rates. Large inequalities are observed with respect to most maternal health services. Results that are relevant to the explanation of inequalities are summarised in four points:
A minor part of poor-rich disparities are due to confounders such as rural vs. urban residence. Lower use of delivery care by poor mothers is partly due to their lower education. A wide array of factors mediate the effect of income or education on the use of deliv-ery care. Poor-rich disparities are strongly sensitive to the national and local context. The final section of the paper discusses implications for maternal health policies.
Introduction
More than one decade after the Safe Motherhood Initiative was launched (Mahler 1987), maternal mortality still takes a heavy toll in most parts of the developing world (Donnay 2000). There is little doubt that the burden of maternal mortality and morbidity falls disproportionately on poor and low educated women. Underutilisation of maternal health services is likely to be
a main factor contributing to maternal mortality among socio-economically disadvantaged women.
The purpose of this paper is to give a global picture of poor-rich inequalities in the utilisation of maternal health services. The overview consists of two parts, the first one being descriptive and the second explanatory. The descriptive part provides basic information on poor-rich disparities in the utilisation of maternal health services and in particular of delivery care. We will address the question whether similar patterns of inequalities are observed throughout the developing world. Without doubt, lower utilisation by poor educated mothers is a common theme to all developing countries, but is this a theme with major variations? The explanatory part will assess possible explanations of the link between poverty and maternal health services. We will discuss the role of poverty as compared to other forms of socio-economic disadvantage, especially having no or little education. In addition, we will give a brief overview of the factors
have been suggested to mediate the effect of socio-economic disadvantage on the utilisation of delivery care. This overview is based in part on results of studies that are reported on
in accessible publications such as international journals. Unfortunately, this evidence appeared to be fragmentary. The evidence comes from a few countries and-within these Countries-often from specific regions, cities or villages. Uncertain is to what extent this evidence can be extrapolated to other areas or countries of the developing world. In order to create a global picture, we therefore relied heavily on data available from recent analyses and reports that were made on the basis of data from the international Demographic and Health Survey (DHS) program. All illustrative figures and tables presented in this paper are based on these DHS analyses. For further illustrative materials, the reader is referred to the publications listed at the end of this paper (available upon request from the second author). The focus of this paper is on the utilisation of delivery care instead of maternal mortality. The main reason for this is that, to our knowledge, there is hardly any empirical evidence on poor-rich differences in maternal mortality and morbidity. A few studies produce valid estimates (eg Kestler
1995) but often estimates of poor-rich differences are notably biased (eg Jagdish & Cleland 1996). This dearth of information underlines the'hidden' nature of maternal health problems (Graham & Campbell 1992, Sadana 2000). Another reason to focus on delivery care is that there is a close link between delivery care and maternal mortality.