Evaluation of socio-economic inequalities in the use of maternal health services in rural western China

Highlights

• The evaluation of socio-economic inequalities in maternal health services utilisation is rare in rural western China.

• The socio-economic inequalities in maternal health services utilisation are systematically evaluated in this paper.

• Our findings have important policy implications for the Chinese government.

Abstract

Objectives

To describe the use of maternal health services according to the standards of the Chinese Ministry of Health, and assess socio-economic inequalities in usage in rural Shaanxi province, western China.

Study design

Cross-sectional survey.

Methods

Principal components analysis was used to measure the economic status of households. A concentration index (CI) approach was used as a measure of socio-economic inequalities in the use of maternal health services, and a decomposable CI was used to identify the factors that contributed to the socio-economic inequalities in usage.

Results

In total, 4760 women who had given birth in the preceding three years were selected at random to be interviewed in the five counties. Household wealth index was calculated by constructing a linear index from asset ownership indicators using principal components analysis to derive weights. The CI approach is a standard measure in the analysis of inequalities in health. If the CI for the use of maternal health services is positive, it is pro-rich; if it is negative, it is pro-poor. The decomposition method was used to estimate the contributions of individual factors to CI. The overall CI for five or more prenatal visits was 0.075. The household wealth index was found to make the greatest contribution to socio-economic inequalities for five or more prenatal visits (35.5%), followed by maternal education (28.8%), receipt of a health handbook during pregnancy (12.1%), age group (11.0%), distance from health facility (10.5%), family members (1.5%) and district of residence (0.6%).

Conclusions

Socio-economic inequalities in the use of prenatal health services were pro-rich in rural western China. Socio-economic inequalities in hospital delivery and postnatal health check-ups were not evident. Improving household economic status, providing prenatal health services for women with low income and low educational level, providing health handbooks and improving traffic conditions should be promoted as methods to eliminate socio-economic inequalities in the use of maternal health services.

Introduction

Recent global estimates of maternal mortality indicate that more than half a million women died due to pregnancy-related causes in 2005.¹ In developing countries, the maternal mortality rate (MMR) is estimated at 40–800 per 100,000 live-births, which is approximately 200 times higher than that in Western countries.² Key health care interventions can prevent deaths due to pregnancy-related causes. Adherence to prenatal care, delivery in a medical setting and having a skilled health worker at delivery could improve maternal health.2, 3, 4, 5 However, the use of these interventions is limited in developing countries.⁶

A previous study revealed that those in least need of health care (i.e. the healthy and wealthy) are more likely to receive care than the sick and the poor.⁷ If one ignores socio-economic inequalities in the use of maternal health services, underuse of available maternal health services occurs in areas where the need for such services is greatest amongst disadvantaged populations who are less healthy and in greater need of health services. Additionally, health intervention programmes are supply-oriented, and ignore the social factors that constrain the demand for, access to and effective use of health services.⁸

In China, the surveillance system recorded that the MMR decreased from 62.5 to 49.3 per 100,000 live births between 2001 and 2006. However, rural–urban disparities in maternal mortality have remained unchanged. The rural MMR was approximately four times higher than the urban MMR in 2001 and 2006.9, 10 Unchanged rural–urban disparities in maternal mortality are reflected by inequalities in access to maternal health care, such as prenatal care, skilled birth assistance and postnatal care.¹¹ Since the 1990s, China has improved its maternal health care through political and financial support. Community-based health care and a three-tier primary care network were established following the economic reforms in China. However, as the Government provided autonomy to hospitals without contributing public finance, the disparity between urban and rural areas, and between different regions, has increased, and health care expenditures have grown too high.¹²

Most areas of rural Shaanxi province are mountainous with underdeveloped economic conditions and poor health services. Information on the use of maternal health services in these areas is scarce. This paper aimed to describe the use of maternal health services in accordance with the standards of the Chinese Ministry of Health (MOH). The concentration index (CI) approach was used to estimate the degree of socio-economic inequalities in the use of maternal health services, and a decomposable CI was used to identify the factors that contributed to socio-economic inequalities in usage in rural Shaanxi province, western China.