Inequalities in the coverage of place of delivery and skilled birth attendance: analyses of cross-sectional surveys in 80 low and middle-income countries.
BACKGROUND
Having a health worker with midwifery skills present at delivery is one of the key interventions to reduce maternal and newborn mortality. We sought to estimate the frequencies of (a) skilled birth attendant coverage, (b) institutional delivery, and (c) the combination of place of delivery and type of attendant, in LMICs.


METHODS
National surveys (DHS and MICS) performed in 80 LMICs since 2005 were analyzed to estimate these four categories of delivery care. Results were stratified by wealth quintile based on asset indices, and by urban/rural residence. The combination of place of delivery and type of attendant were also calculated for seven world regions.


RESULTS
The proportion of institutional SBA deliveries was above 90 % in 25 of the 80 countries, and below 40 % in 11 countries. A strong positive correlation between SBA and institutional delivery coverage (rho: 0.97, p <0,001) was observed. Eight countries had over 10 % of home SBA deliveries, and two countries had over 10 % of institutional non-SBA deliveries. Except for South Asia, all regions had over 80 % of urban deliveries in the institutional SBA category, but in rural areas, only two regions (CEE & CIS, Middle East & North Africa) presented average coverage above 80 %. In all regions, institutional SBA deliveries were over 80 % in the richest quintile. Home SBA deliveries were more common in rural than in urban areas, and in the poorest quintiles in all regions. Facility non-SBA deliveries also tended to be more common in rural areas and among the poorest.


CONCLUSIONS
Four different categories of delivery assistance were identified worldwide. Pro-urban and pro-rich inequalities were observed for coverage of institutional SBA deliveries.
International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3o andar, Pelotas, RS, 96020-220, Brazil. gjoseph@equidade.org.
Gary
http://orcid.org/0000-0002-9300-2069
G
Joseph
International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3o andar, Pelotas, RS, 96020-220, Brazil.
Inácio Crochemore Mohnsam
IC
da Silva
International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3o andar, Pelotas, RS, 96020-220, Brazil.
Fernando C
FC
Wehrmeister
International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3o andar, Pelotas, RS, 96020-220, Brazil.
Aluísio J D
AJ
Barros
International Center for Equity in Health, Post-Graduate Program in Epidemiology, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3o andar, Pelotas, RS, 96020-220, Brazil.
Cesar G
CG
Victora
D036861:Delivery, Obstetric / Q000379:methods / Q000706:statistics & numerical data*; D003906:Developing Countries; D005260:Female; D006268:Health Facilities; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006700:Home Childbirth; D006801:Humans; D007182:Income; D008880:Midwifery / Q000706:statistics & numerical data*; D011203:Poverty / Q000706:statistics & numerical data*; D011247:Pregnancy; D012959:Socioeconomic Factors
Birth attendance; Delivery assistance; Developing countries; Global health; Low and middle-income countries; Maternal health services; Skilled birth attendance; Skilled delivery