Economic inequalities in maternal health care: prenatal care and skilled birth attendance in India, 1992-2006

Abstract

Background: The use of maternal health care is limited in India despite several programmatic efforts for its improvement since the late 1980's. The use of maternal health care is typically patterned on socioeconomic and cultural contours. However, there is no clear perspective about how socioeconomic differences over time have contributed towards the use of maternal health care in India.

Methodology/principal findings: Using data from three rounds of National Family Health Survey (NFHS) conducted during 1992-2006, we analyse the trends and patterns in utilization of prenatal care (PNC) in first trimester with four or more antenatal care visits and skilled birth attendance (SBA) among poor and nonpoor mothers, disaggregated by area of residence in India and three contrasting provinces, namely, Uttar Pradesh, Maharashtra and Tamil Nadu. In addition, we investigate the relative contribution of public and private health facilities in meeting the demand for SBA, especially among poor mothers. We also examine the role of salient socioeconomic, demographic and cultural factors in influencing aforementioned outcomes. Bivariate analyses, concentration curve and concentration index, logistic regression and multinomial logistic regression models are used to understand the trends, patterns and predictors of the two outcome variables. Results indicate sluggish progress in utilization of PNC and SBA in India and selected provinces during 1992-2006. Enormous inequalities in utilization of PNC and SBA were observed largely to the disadvantage of the poor. Multivariate analysis suggests growing inequalities in utilization of the two outcomes across different economic groups.

Conclusions: The use of PNC and SBA remains disproportionately lower among poor mothers in India irrespective of area of residence and province. Despite several governmental efforts to increase access and coverage of delivery services to poor, it is clear that the poor (a) do not use SBA and (b) even if they had SBA, they were more likely to use the private providers.

Figure 1. Association between maternal health care (prenatal care and skilled birth attendance) and maternal mortality ratio across 15 major states, India.

A. X axis = Prenatal care (%). Y axis = Maternal mortality ratio (MMR) per 1000 live births. B. X axis = Skilled birth attendance (%). Y axis = Maternal mortality ratio (MMR) per 1000 live births.

Figure 2. Concentration curves showing inequalities in prenatal care (PNC) by economic status of population across states, India, 1992–2006.

A [INDIA]. B [UTTAR PRADESH]. C [MAHARASHTRA]. D [TAMILNADU]. X axis = Cumulative proportion of births ranked by wealth status. Y axis = Cumulative proportion of births with prenatal care (PNC). Red square = Concentration curve for 1992–93. Pink triangle = Concentration curve for 1998–99. Green cross = Concentration curve for 2005–06.

Figure 3. Concentration curves showing inequalities in skilled birth attendance (SBA) by economic status of population across states, India, 1992–2006.

A [INDIA]. B [UTTAR PRADESH]. C [MAHARASHTRA]. D [TAMILNADU]. X axis = Cumulative proportion of births ranked by wealth status. Y axis = Cumulative proportion of births with prenatal care (PNC). Red square = Concentration curve for 1992–93. Pink triangle = Concentration curve for 1998–99. Green cross = Concentration curve for 2005–06.

Figure 4. Percent distribution of births delivered by source of providers among poor and non-poor mothers across states, India, 1992–2006.

X axis = Economic status [poor vs.non-poor] by survey year [1992–93; 1998–99; 2005–06]. Y axis = Type/place of birth attendance (in percent). Black bar = Unskilled delivery at home. Red bar = Skilled delivery at home. Green bar = Delivery at public health facilities. Purple bar = Delivery at private health facilities.