Abstract
BackgroundThe fifth Millennium Development Goal (MDG5) aims at improving maternal health. Globally, the maternal mortality ratio (MMR) declined from 400 to 260 per 100000 live births between 1990 and 2008. During the same period, MMR in sub-Saharan Africa decreased from 870 to 640. The decreased in MMR has been attributed to increase in the proportion of deliveries attended by skilled health personnel. Global improvements maternal health and health service provision indicators mask inequalities both between and within countries. In Namibia, there are significant inequities in births attended by skilled providers that favour those that are economically better off. The objective of this study was to identify the drivers of wealth-related inequalities in child delivery by skilled health providers.MethodsNamibia Demographic and Health Survey data of 2006-07 are analysed for the causes of inequities in skilled birth attendance using a decomposable health concentration index and the framework of the Commission on Social Determinants of Health.ResultsAbout 80.3% of the deliveries were attended by skilled health providers. Skilled birth attendance in the richest quintile is about 70% more than that of the poorest quintile. The rate of skilled attendance among educated women is almost twice that of women with no education. Furthermore, women in urban areas access the services of trained birth attendant 30% more than those in rural areas. Use of skilled birth attendants is over 90% in Erongo, Hardap, Karas and Khomas Regions, while the lowest (about 60-70%) is seen in Kavango, Kunene and Ohangwena. The concentration curve and concentration index show statistically significant wealth-related inequalities in delivery by skilled providers that are to the advantage of women from economically better off households (C = 0.0979; P < 0.001).Delivery by skilled health provider by various maternal and household characteristics was 21 percentage points higher in urban than rural areas; 39 percentage points higher among those in richest wealth quintile than the poorest; 47 percentage points higher among mothers with higher level of education than those with no education; 5 percentage points higher among female headed households than those headed by men; 20 percentage points higher among people with health insurance cover than those without; and 31 percentage points higher in Karas region than Kavango region.ConclusionInequalities in wealth and education of the mother are seen to be the main drivers of inequities in the percentage of births attended by skilled health personnel. This clearly implies that addressing inequalities in access to child delivery services should not be confined to the health system and that a concerted multi-sectoral action is needed in line with the principles of the Primary health Care.
Highlights
The fifth Millennium Development Goal (MDG5) aims at improving maternal health
The situation in Namibia is much better compared to this average - about 81% of births attended by skilled health personnel
A negative value of the concentration index denotes inequity in skilled care at birth that is to the advantage of the lower wealth quintiles implying that women of lower socio-economic status are delivered by skilled health providers more than their counterparts who are wealthier
Summary
The maternal mortality ratio (MMR) declined from 400 to 260 per 100000 live births between 1990 and 2008. The decreased in MMR has been attributed to increase in the proportion of deliveries attended by skilled health personnel. Global improvements maternal health and health service provision indicators mask inequalities both between and within countries. The objective of this study was to identify the drivers of wealth-related inequalities in child delivery by skilled health providers. There is increasing evidence on the existence of pervasive inequalities in health and health care that are related to socio-economic position as may be measured by household income/expenditure/wealth, occupation, gender, area of residence etc. In Sub-Saharan Africa, the adjusted maternal mortality ratio in 2008 was 640 per 100,000 live births, as compared to 14 per 100,000 in the developed regions. While the life time risk of maternal death is 1 in 31 in Sub-Saharan Africa, the corresponding figure in the developed regions of the world is 1 in 4,300 [6]
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