Poor rural women have less access to skilled birth attendance in low- and middle-income countries

The poorest women living in rural areas have less access to skilled care during childbirth in low- and middle-income countries (LMICs), according to a study by the Federal University of Pelotas. The socioeconomic level and the place of residence are key factors for assessing inequalities in the coverage of skilled birth attendance (SBA) in these countries.

Such conclusions are part of a doctoral thesis developed in the Postgraduate Program in Epidemiology of the Federal University of Pelotas (PPGE-UFPEL) by the Haitian physician Gary Joseph, supervised by the professors Cesar Victora and Inácio Crochemore da Silva.

The study assessed the coverage level of SBA, institutional deliveries and its relation to the wealth assets index, household income and place of residence of women in approximately 300 nationally representative surveys conducted in more than 300 LMICs from 1991 to 2015. The World Health Organization (WHO) established a target of SBA coverage for all countries of a least 90% by 2030.

The results showed that one in five women gave birth without the assistance of a skilled health personnel during delivery. Overall, mean SBA coverage was 73.8%, ranging from 11.8% in Ethiopia in 2011 to 100% in Belarus in 2012; while, mean institutional delivery coverage was 70.5%, for countries with surveys available since 2005.

Pro-urban and pro-rich inequalities were evident in access to SBA and institutional deliveries in these countries. The richest women in urban areas had approximately 40 percentage points higher in SBA coverage compared to the poorest women in rural areas.  Mean coverage for urban and rural richest women was 93.4% and 86.7% respectively, while, among the poorest urban and rural women, this was only 66.7% and 55.5%, respectively.

According to WHO, ensuring the assistance of a skilled health professional during delivery is one of the main interventions to reduce maternal and neonatal mortality.

Approximately half of the poorest women in rural areas are delivering without SBA in LMICs. They are exposed to the risk of dying from causes that can be prevented, "says the author of the thesis.

Based on the analysis of household income and SBA coverage over time, the study identified groups of countries that have been most successful in increasing coverage through specific programs and policies adopted in the countries.

Five countries such as Egypt, Rwanda, Cambodia, Burkina Faso and Nepal had increased SBA coverage of 40 percentage points during a period of 10 years or more. “In these countries, the household income has increased, but coverage rose more rapidly than would be predicted from the change in income”, adds Joseph

In Nepal, by example, the combination of a vast network of facilities and use of community health volunteers contributed to strengthening health systems and provide public health services free of cost; cash incentives were provided to women who delivered with SBAs, and this program also covered the cost of transportation and incentives to SBAs for attending home deliveries.

Countries such as Ethiopia, Chad, Tanzania and Nigeria, on the other hand, presented increases of less than 10 percentage points in coverage, along with a modest increase in population income. Such changes in SBA coverage seem to have been due only to these slight increases in income, other than policies or programs adopted in these countries.

Overall, absolute income allows better prediction of SBA coverage across countries compared to models that are based solely on relative wealth quintiles. This result is particularly important for countries with national surveys as it improves the understanding of social inequalities in health by using estimated absolute income, to understand whether progress in health indicators may be attributed to improvements in income and to encourage countries to collected data on household income, concluded Joseph.