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Background: Despite improvement in the coverage of most maternal, newborn, and child health services, inequality in the uptake of services still remains the challenge of health systems in most developing countries. This study was conducted to examine the degree of inequities and potential predictors of inequity in reproductive and maternal health services utilization in the Oromia region, Ethiopia. Methods: The 2016 Ethiopian demographic and health survey data set was used. Utilization rate of four maternal health service categories (family planning, antenatal care, facility based delivery and postnatal care) was considered in the analysis. Equity in each of these indicators was assessed by residence (urban/rural), wealth index, and educational status. Inequality in service utilization was estimated using rate ratios, concentration curve, and concentration indices. Results: Overall data of 5701 women were used in this analysis. The concentration index to all of the maternal health service utilization indicators showed significance. The concentration index of family planning, antenatal care, facility based delivery, and postnatal care was 0.136 (95% CI=0.099-0.173), 0.106 (95% CI=0.035-0.177), 0.348 (95% CI=0.279-0.418), and 0.348 (95% CI=0.279-0.418), respectively. Maternal age and all of the three socio-demographic factors (residence, education, and wealth) showed inequitable distribution of maternal health service utilization in the Oromia region. The majority of women who were in the favored groups utilized the key reproductive and maternal health services. Conclusion: The utilization of maternal health services in the study area is grossly skewed to those who are well off, educated, and live in urban areas. Any action intended to improve utilization of maternal and child health services should aim to reduce the unnecessary and avoidable disparity demonstrated in our analysis. This of course demands multisectoral intervention to impact on the determinants.
Oromia was one of the ten regional states in Ethiopia with the largest population and surface area. Oromia is comprised of 21 zonal administrations and 19 town administrations. In the region there were a total of 317 rural districts and 7021 kebeles. According to 2007 population and housing census projections, the total population of the region was 36,839,051 in 2017 and 38,170,034 in 2020. In 2020, there were 107 hospitals (95 public and 12 private hospitals), 1404 health centers, and 7090 health posts. The 2016 Ethiopian demographic and health survey data set was used as a source of data to address the research questions.26 The survey was conducted from January 18 to June 27, 2016 and data were extracted from March 15 to April 2018. In the survey, all women in the reproductive age group (15–49) who were residing in the selected households were included.26 A sample of Enumeration areas (EA’s) was selected using a two stage stratified sampling strategy, where each region is stratified into urban and rural area. A census frame created during the 2007 population and housing census was used (comprising of a total of 84,915 EAs). In this study EA referred to a geographic area covering on average 181 households. In the first stage, 645 EA’s (202 in urban areas and 443 in rural areas) were selected with a probability proportional to each region’s size. In the second stage, 28 households per EA were selected with an equal probability systematic selection from the newly created household listing. A full description of the study method is available in the Ethiopian demographic and health survey (EDHS) 2016 full report.26 In this analysis, data of 5701 eligible women of the reproductive age group in the Oromia region were used. Data extracted for analysis included demographic variables (age), socioeconomic characteristics (residence, wealth index, educational status), and key indicators for reproductive and maternal health service uptake (family planning, antenatal care, delivery, postnatal care). These are key maternal services provided at the maternity unit of health facilities (health centers and hospitals) in Ethiopia. Furthermore, at the maternity unit screening and treatment of syphilis, hepatitis, HIV/AIDS, and acute malnutrition are undertaken by the health workers. At health posts maternal services including family planning, antenatal care (second and third visits), and postnatal care are provided. The health extension workers assigned at Ethiopian health posts link women to close health centers for antenatal care (first and fourth visits) and delivery services. Urban areas included all capitals of administrative zones and woredas. Areas with at least 1000 people primarily engaged in non-agricultural activities and/or localities were declared as urban areas by administrative officials. Rural areas were all areas which were not urban areas.26 The wealth index in the survey was computed using household assets ranging from a television to a bicycle or a car, in addition to housing characteristics such as the source of drinking water, toilet facilities, and flooring materials. It was determined using principal component analysis (PCA).26 The wealth index was used as an indicator of level of wealth that is in line with income and expenditure measures. The wealth index in the analysis was created in three steps. First, wealth scores were calculated using indicators common for both urban and rural areas. In the second step, using indicators specific to household’s in urban and rural areas separate factor scores were produced. Then in the third stage, separate area specific factor scores were combined to produce a nationally applicable wealth index by adjusting scores specific to the areas.26 In this analysis four categories of educational levels are utilized: no education, primary education, secondary education, and higher education. Women with no formal education were labeled as no education, while women with incomplete primary and complete primary education level were labeled as a primary education, and those with incomplete secondary and complete secondary were labeled as secondary education. Moreover, women who received more than secondary education were labeled as higher education.26 Skilled providers: skilled health service providers included doctors, nurses, midwives, health officers, and health extension workers. Institutional deliveries: referred to a delivery that occurs in a health facility (health center or hospital). Use of modern contraceptive methods: percentage of currently married women (15–49) who are currently utilizing a modern contraceptive method such as male and female sterilization, injectable, intrauterine devices (IUDs), contraceptive pills, implants, female and male condoms, standard days method, lactational amenorrhea method, and emergency contraception. Antenatal care by skilled provider: the proportion of women aged 15–49 who had a live birth in the 5 years preceding the survey that received antenatal care from skilled providers (physicians, nurses or midwives, health officers, and health extension workers) at least once. Birth at health facility: proportion of live births in the 5 years preceding the survey delivered in a health facility (private or public). Postnatal care: proportion of women aged 15–49, with a live birth in the 2 years preceding the survey, who received a postnatal checkup in the first 2 days after giving birth. Four different equity analysis techniques were used to address the research questions. The techniques were equity gap, equity ratio, concentration curve, and concentration index.13–16 Equity gap was used to show absolute percentage point difference in service coverage between the highest wealth quintile and the lowest, between the highest educational levels achieved and the lowest, and between urban and rural residents. The equity ratio was calculated by dividing service coverage in the top wealth quintile by that in the bottom, and service coverage among urban by that of rural dwellers. The concentration curve plots the cumulative percentage of the population, ranked by wealth, beginning with the poorest, and ending with the richest (x-axis) against the cumulative percentage of the health service utilization (y-axis). Concentration index (CI) was estimated to quantify the level of inequities in access and utilization for each maternal health service. The index takes a value between −1 and +1; 0 index indicates the presence of equality in utilization of the health variable. When the concentration index takes on a positive value, the line of concentration curve will be below the line of equity, implying a pro-rich uptake of the service and vice versa. The concentration index for t=1, …, T groups was computed in a spreadsheet program using the following formula. where is the cumulative percentage of the sample ranked by economic status in group t, and is the corresponding concentration curve ordinate.
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