Economic Inequalities in Maternal Health Care: Prenatal Care and Skilled Birth Attendance in India, 1992–2006

S. V. Subramanian,Abhishek Singh,Abdisalan M. Noor,Praveen Kumar Pathak

doi:10.1371/journal.pone.0013593

S. V. Subramanian, Abhishek Singh + Show 2 more

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https://doi.org/10.1371/journal.pone.0013593

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Abstract

BackgroundThe 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 FindingsUsing 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.ConclusionsThe 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.

Highlights

Maternal mortality, a crisis essentially of the poor in 21st century [1], and a neglected tragedy of developing countries [2], reflects one of the shameful failures of human development [3]
The use of prenatal care (PNC) and skilled birth attendance (SBA) remains disproportionately lower among poor mothers in India irrespective of area of residence and province
Blocks were selected at the first stage, census enumeration blocks (CEB) containing approximately 150–200 households were selected at the second stage, and the required number of households were selected at the Populationa Density of populationa Urban population (%)a Sex Ratioa Decadal Growtha (%) Crude Birth Rateb Crude Death Rateb Life expectancy at birth, maled Life expectancy at birth, femaled Total Fertility Ratec Infant Mortality Rateb Maternal Mortality Ratiog Female Literacy Ratea (%) Per capita income (INR)e State Human Development Indexh Population below poverty linef (%)

Summary

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

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