Levels of and changes in socioeconomic inequality in delivery care service: A decomposition analysis using Bangladesh Demographic Health Surveys

BACKGROUND: Socioeconomic inequality in maternity care is well-evident in many developing countries including Bangladesh, but there is a paucity of research to examine the determinants of inequality and the changes in the factors of inequality over time. This study examines the factors accounting for the levels of and changes in wealth-related inequality in three outcomes of delivery care service: health facility delivery, skilled birth attendance, and C-section delivery in Bangladesh. METHODS: This study uses from the Bangladesh Demographic and Health Survey of 2011 and 2014. We apply logistic regression models to examine the association between household wealth status and delivery care measures, controlling for a wide range of sociodemographic variables. The Erreygers normalised concentration index is used to measure the level of inequalities and decomposition method is applied to disentangle the determinants contributing to the levels of and changes in the observed inequalities. RESULTS: We find a substantial inequality in delivery care service utilisation favouring woman from wealthier households. The extent of inequality increased in health facility delivery and C-section delivery in 2014 while increase in skilled birth attendance was not statistically significant. Wealth and education were the main factors explaining both the extent of and the increase in the degree of inequality between 2011 and 2014. Four or more antenatal care (ANC4+) visits accounted for about 8% to 14% of the observed inequality, but the contribution of ANC4+ visits declined in 2014. CONCLUSION: This study reveals no progress in equity gain in the use of delivery care services in this decade compared to a declining trend in inequity in the last decade in Bangladesh. Policies need to focus on improving the provision of delivery care services among women from poorer socioeconomic groups. In addition, policy initiatives for promoting the completion of quality education are important to address the stalemate of equity gain in delivery care services in Bangladesh.