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Background: Despite the pro-poor health policies in Ethiopia, the utilization of maternal, neonatal, and child health services remains a challenge for the country. Health equity became central in the post-2015 Sustainable Development Goals globally and is a priority for Ethiopia. The aim of this study was to assess equity in utilization of a range of maternal and child health services by applying absolute and relative equity indices. Methods: Data on maternal and child health utilization emanated from a baseline survey conducted for a large project ‘Optimizing the Health Extension Program from December 2016 to February 2017 in four regions of Ethiopia. The utilization of four or more antenatal care visits; skilled birth attendance; postnatal care within 2 days after childbirth; immunization with BCG, polio 3, pentavalent 3, measles and full immunization of children aged 12-23 months; and vitamin A supplementation for 6-23 months old children were stratified by wealth quintiles. The socioeconomic status of the household was assessed by household assets and measured by constructing a wealth index using principal component analysis. Equity was assessed by applying two absolute inequity indices (Wealth index [quintile 5-quintile 1] and slope index of inequality) and two relative inequity indices (Wealth index [quintile5: quintile1] and concentration index). Results: The maternal health services utilization was low and inequitably distributed favoring the better-off women. About 44, 71, and 18% of women from the better-off households had four or more antenatal visits, utilized skilled birth attendance and postnatal care within two days compared to 20, 29, and 8% of women from the poorest households, respectively. Skilled birth attendance was the most inequitably distributed maternal health service. All basic immunizations: BCG, polio 3, pentavalent 3, measles, and full immunization in children aged 12-23 months and vitamin A supplementation were equitably distributed. Conclusion: Utilization of maternal health services was low, inequitable, and skewed against women from the poorest households. In contrast, preventive child health services were equitably distributed. Efforts to increase utilization and reinforcement of pro-poor and pro-rural strategies for maternal, newborn and immunization services in Ethiopia should be strengthened.
The study was conducted in ten zones of four regions in Ethiopia, namely Amhara, Oromia, Southern Nations, Nationalities and Peoples (SNNP), and Tigray. These regions cover more than 85% of the total population of the country. Agriculture is the predominant source of economy in these regions. Ethiopia has one of the lowest income per capita but is one of the fastest-growing economies in Africa with an increment in Gross Domestic Product of 7% since 2014 [19]. The health care system is three-tiered: primary, secondary, and tertiary-level of care. The present study was part of an evaluation of the large project entitled “Optimizing the Health Extension Program” (OHEP) that aimed at improving services utilization of the integrated community case management of childhood illnesses (ICCM) and the community-based newborn care (CBNC). The beneficiaries of the intervention are the caretakers and their children under five years, who are the study subjects of this survey. The evaluation of the intervention has been registered in the trial registration Current Controlled Trials ISRCTN12040912. The data were collected from December 2016 to February 2017. A two-stage stratified cluster sampling technique was used to select the study subjects. First, 200 Enumeration Areas (EAs) were selected in the study areas. Each enumeration area formed one cluster that was the primary sampling unit. Second, all households, as secondary sampling units, within a cluster were listed as a sampling frame. Of the listed households, 30 were selected using systematic random sampling. Overall, a total of 6000 households were sampled but data were collected from 5714 households. Data from six EAs in the SNNP region were not collected for security reasons. Nine indicators were used to assess equity in the utilization of MNCH services. The first three were maternal indicators: four or more antenatal care visits (ANC4+), skilled birth attendance (SBA), and postnatal care visits within two days (PNC). These maternal indicators were based on interviews with women who had a live birth in the past 12 months before the survey. Skilled birth attendance was defined as a dichotomous variable where mothers were coded as having delivered by a skilled birth attendant if they received delivery care by skilled health attendant [20]. Child immunization indicators included BCG, three polio immunizations, three pentavalent immunizations, measles and full immunization of children 12–23 months of age. Information on vitamin A supplementation included children aged 6–23 months [7, 12]. Utilization for all immunization types was based on the combined information recorded on the child’s vaccination card with responses from the caretaker in case of missing immunization card information. Full immunization coverage was defined as the percentage of children aged 12–23 months, who had received one dose of BCG vaccine, three doses of the polio vaccine, three doses of pentavalent vaccine, and one dose of measles vaccine [21]. Utilization of vitamin A supplementation was defined as children aged 6–23 months who had received vitamin A supplementation in the six months preceding the survey. These variables were coded as 1 when the respondent or child had received the service and 0 when the respondent had not received the service. The socioeconomic status of each household was constructed using principal component analysis (PCA) of household assets followed by stratification of the households into wealth quintiles [22]. The analysis was done by aggregating the ownership of durable assets; access to utilities and infrastructure; and housing characteristics; ownership of a house and ownership of livestock variables into a single proxy variable of household wealth. All asset variables were coded into binary variables. Asset variables with zero standard deviations were excluded from the PCA as they did not contribute to the analysis. The first component of the PCA was used to construct the wealth quintiles [22]. Based on the PCA weights for each asset variable, an aggregated score was calculated for each of the surveyed households, which was grouped into quintiles with quintile 1 (Q1) representing the poorest 20% of households in the sample and quintile 5 (Q5) representing 20% of the better-off. The study subjects were thereafter grouped into quintiles based on their household wealth scores. Two absolute and two relative equity measures were used to assess equity in the utilization of maternal, neonatal and child health services based on household wealth quintiles. For a given health indicator, the absolute inequity reflects the magnitude of absolute difference in health services utilization between the two subgroups (Q5-Q1) and the slope index of inequity (SII) across the entire distribution of socioeconomic status. The relative inequity measures the ratio (Q5: Q1) and the concentration index (CIX) in health services utilization. The CIX and SII, including standard errors [12] and p-values, were assessed using commands downloaded from the International Center for Equity in Health [17, 23]. The utilization of the services by the wealth quintiles and the distance between the wealth quintiles were graphically depicted using equiplot [12, 24]. STATA 14.1 (StataCorp, Texas, USA) was used to analyze the data. During the analysis, all the commands were preceded with svy to account for the clustering.
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