Trends in equity in use of maternal health services in urban and rural Bangladesh

Bangladesh has experienced a rapid decline in maternal mortality, with the maternal mortality ratio (MMR) decreasing from 322 deaths per 100,000 live-births in 2001 to 194 deaths per 100,000 live-births in 2010. This decline has been largely facilitated by a government drive to scale up the national strategy for maternal health, including the upgrading of health facilities to provide Emergency Obstetric Care (EmOc) services and the introduction of the maternal health voucher scheme. The use of antenatal care (ANC) from medically trained providers has increased in both urban and rural areas between 2001 and 2010. However, the gap in use of ANC between the rich and the poor narrowed in urban areas but widened in rural areas. In contrast, the gap in use of facility deliveries widened in both urban and rural areas. The private sector has surpassed the public sector in providing maternal healthcare services in both domains, with the share of non-governmental organizations (NGOs) increasing in urban areas. The concentration index was calculated for urban and rural areas to measure equity in distribution of ANC and facility deliveries across wealth quintiles. The results showed that equity in utilization of health facilities for deliveries has improved at a faster rate in urban areas. The changing service environment in urban and rural areas is reflective of the faster pace of improvement in equity in maternal healthcare utilization in urban areas. The public health service delivery system in urban areas is not as extensive as in rural areas, and primary health care provision is largely under the jurisdiction of the Ministry of Local Government, Rural Development and Cooperatives. The private sector has filled the gap in primary health service provision in urban areas, charging fees for services. Urban trends in maternal health care use are of particular interest given the rapid urbanization of Bangladesh. The growth of the private sector has been fueled by demand side factors, particularly improvements in living standards. The very different nature of the healthcare infrastructure in urban and rural areas raises questions about the implications for equity in use of maternal health services in urban and rural domains. The objectives of this study were to examine whether equity in maternal health service use has narrowed or widened over time, and whether there are different patterns in urban and rural areas. A second objective was to examine changes in types of provider used over the last decade in urban and rural domains. The study used the 2001 and 2010 Bangladesh Maternal Mortality and Health Care Survey data to examine trends in use of ANC and facility deliveries. Separate wealth quintiles were constructed for urban and rural areas, and the concentration index was calculated to measure equity in distribution of ANC and facility deliveries across wealth quintiles. The results of this study have implications for policy and program implementation in Bangladesh. The findings suggest that equity in maternal healthcare utilization has improved at a faster rate in urban areas, but the gap in use of facility deliveries has widened in both urban and rural areas. The private sector has played a significant role in providing maternal healthcare services in both domains, and the share of NGOs has increased in urban areas. The study highlights the need for targeted interventions to improve equity in maternal healthcare utilization in rural areas and to address the barriers faced by the poor in accessing maternal healthcare services.