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Skip to 0 minutes and 12 seconds[DR LENKA BENOVA]:: In this lecture, we will take a closer look at the reasons for inequalities in maternal health outcomes, globally and locally. Understanding and tackling inequalities in maternal health is important and embedded in the Sustainable Development Goals, which refer to leaving no one behind. Achieving a maternal mortality ratio of maximum 70 per 100,000 live births by 2030 might mask countries or subgroups with much higher levels. So there's actually a stipulation for no single country to exceed 140 maternal deaths per 100,000 live births. In the step on the global profile of maternal mortality and morbidity earlier this week, we heard about the increasing diversity in maternal health both within, and across, countries and regions.

Skip to 1 minute and 3 secondsThis is not just an issue in low- and middle-income countries. For example, a US study published in 2015 showed that the maternal mortality ratio for white women was 12 per 100,000 live births. This is about the average of high income countries. However, black women's mortality ratio was more than three times as high. And at nearly 40 deaths per 100,000 live births, it was higher than in Egypt and about the level recorded in Turkmenistan, or Jamaica. In this lecture, we will focus on the drivers of the divergence in maternal health, particularly focusing on inequalities in access to health care and the impact this has had on the women left behind.

Skip to 1 minute and 47 secondsConceptually, where can we begin to trace and address inequalities in health outcomes? We can consider this simplified flowchart. In order to improve health outcomes, women need to have access to care. This includes a range of dimensions, such as seeking care-- for example, attending antenatal care appointments or having a skilled birth attendant (SBA) present at delivery-- and having health services available. Secondly, once women are with a health care provider, is the quality of care they receive optimal? As we already heard, women's risk profiles also play an important role in health outcomes on a population level.

Skip to 2 minutes and 31 secondsIn this presentation, I will focus on the first element on this pathway to inequalities-- access to care-- and show how access links to quality of care. What do we mean by inequality and access? Over the period that the Millennium Development Goals were tracked, there was an increase in the proportion of women receiving some of the core maternal health services. For example, the proportion of women receiving a skilled birth attendant at delivery increased from 57% to 74%. And the proportion of women who received four or more antenatal care visits rose from 37% to 64%. However, inequalities still exist.

Skip to 3 minutes and 15 secondsThis graph is from a study that looked at inequalities in the use of a skilled birth attendant at delivery in 46 low- and middle-income countries by women's wealth deciles. The wider the horizontal bar, the greater the extent of inequality in a given country. Here, I have selected countries with the lowest-- shown above the blue line-- and the highest-- below the blue line-- levels of skilled attendance. The black marker shows country level percentages of births attended by a skilled person. The light pink, for the poorest 10th of women, and dark pink for the richest 10th, and the remaining 10ths in between.

Skip to 4 minutes and 0 secondsWhat we can see immediately, is the wide gap between richest and poorest women in the countries with low coverage of skilled birth attendants. This gap was more than 80 percentage points in four of the countries analysed. Nigeria is a good example of how inequalities operate. With each decile of women of increasing wealth, the coverage of skilled birth attendants rises. We can also see that in many countries, regardless of national SBA coverage, use of care by the most privileged groups of women is near universal. From a policy perspective, it would be tempting to focus on the groups just below the average in an effort to improve the national coverage.

Skip to 4 minutes and 43 secondsBut significant improvements in overall coverage rely on reaching the poorest, the most left behind. The last point I would like to make here is that even in the countries with high skilled birth attendant coverage-- below the blue line-- there are substantial gaps between women from different levels of wealth. And as we can see in the case of Gabon, Congo, and Colombia, for example, it is largely the poorest 10th of women who are left behind the rest of the country. Let's now look at the concept of access in more detail. The word access is often used as a synonym for utilisation of care, such as the example of coverage with skilled birth attendants we have just seen.

Skip to 5 minutes and 28 secondsHowever, for a person to use health care, several aspects have to fall in place. The right time, the right place, the right price, and the right person. In simplified terms, access consists-- first and foremost-- of physical accessibility. By which we mean the availability of health services within reasonable reach, whether this means a local health centre with family planning services, or a hospital delivery ward. Secondly, women's ability to pay for services without financial hardship is an important dimension of access. Last but not least, acceptability is a large issue and entails issues such as people's willingness to seek services and cultural expectations of the medical process.

Skip to 6 minutes and 18 secondsThe wide gaps in coverage of skilled birth attendants we saw in some countries on the previous slide are a product of these three dimensions of access. For example, poorer women might live in rural communities farther away from facilities providing maternal care. They might not be able to afford the fees and indirect costs of care, such as childcare and transport. And they might have previous experience being discriminated against based on their ethnic or religious background, resulting in deciding to deliver at home, rather than in a health facility. These dimensions co-exist and interact in different ways to shape health care use and health outcomes among women in different countries, based on the health system and patterns of marginalisation.

Skip to 7 minutes and 5 secondsLet's look at each of these three dimensions in turn, with an example. A study in the Pwani Region of Tanzania can serve as a good example of the importance of physical accessibility of health facilities. On the map on the right hand side, we can see in blue, the various levels of health facilities available. The circles show sub-village home delivery rates. Yellow for low levels of home deliveries, and red for high levels. As we move away from the hospitals, which are concentrated on the eastern side of the region, we see an increase in the concentration of red, particularly in the most remote locations. This study concluded that the further away women lived from hospitals, the higher their likelihood of home delivery.

Skip to 7 minutes and 55 secondsFor every kilometre increase in distance, the odds of delivering at home increased more than twofold. However, physical distance does not have to be the primary driver of this relationship. Other issues that are related to accessibility are time needed to reach the facility, road conditions-- including seasonal variations-- availability of transport options, safety, or unpredictable opening hours. Another phenomenon we see on this map is that-- perhaps counter-intuitively-- there are some sub-villages where home delivery rates are high, despite being located very close to facilities. One of the reasons for this could be that the care provided at those facilities is not acceptable or not affordable. We look at financial affordability next.

Skip to 8 minutes and 49 secondsThis graph shows regional averages of places where women delivered in four low- and middle-income country regions, according to women's wealth quintile. We can see that the red, top portion, women who delivered in home locations without a skilled birth attendant, is largest for poorest women, and in each region it gradually declines as women's wealth increases. At the same time, the use of facilities for delivery-- shown in shades of blue-- increases with wealth. And a large part of wealthier women's deliveries occur in facilities outside of public governmental provision, in the so-called private sector, which is shown in dark blue.

Skip to 9 minutes and 36 secondsWhat are the financial implications of seeking delivery care on women and their families in low- and middle-income countries, where the vast majority of health spending is out-of-pocket? A study in India calculated that the average maternal expenditure for delivery in 2004 varied from about $10 for a birth at home, to $25 for a public facility, to over a hundred dollars for a private facility. The researchers found that for half of the studied households, the amounts paid exceeded their capacity to pay, and constituted so-called catastrophic health expenditure defined as more than 40% of the household expenditure above the poverty line. All poor women in the sample experienced catastrophic health expenditure, despite the majority delivering at home.

Skip to 10 minutes and 31 secondsThis shows that even the relatively small amount needed for a home delivery can be beyond the financial means of women living in poverty. Financial affordability, of course, is not only about the fees paid for care. There are indirect costs, such as laboratory tests, medications, informal payments, travel, childcare, lost income. And all of these contribute to the decision-making about whether, and where, to seek care. Countries can implement policies to reduce the financial burden of accessing care through various programmes, such as vouchers, reimbursements, or user-fee removals. However, such programmes should be monitored rigorously and specifically targeted toward the poorest and most vulnerable women.

Skip to 11 minutes and 23 secondsFor example, in Egypt, a study found that women who used free public care for antenatal and delivery care were not poorer than the average user of public care. In fact, the poorest women were much more likely not to use any antenatal care and facility delivery care than to receive subsidised free public care. This might be due to their inability to obtain information about the provision of subsidised or free care, but it might also be linked to acceptability of health care services, to which we turn next.

Skip to 12 minutes and 2 secondsThe third element of access, acceptability of care, entails numerous dimensions, including those related to the health service and modalities of its provision such as health care worker attitudes, gender of provider, perception of quality of care, or previous, poor experience with care. Acceptability of receiving care for pregnancy and childbirth can vary across cultures and populations. For example, women of high parity might have low perceived need for pregnancy and delivery care if they consider their pregnancy to be normal, or they might be discouraged from seeking care by others.

Skip to 12 minutes and 44 secondsSocial norms and expectations also affect patterns in their use of care, such as desire to appear modern, ability to seek care-- which is linked to empowerment and autonomy-- embarrassment and fear of being shamed. For example, not having clean clothes for oneself or one's baby, but also issues such as seeking private care being a reflection of social status and reputation. What kind of women and populations tend to be affected by inequalities in use of maternal care? Countries experiencing war, breakdown of governance, and other health system shocks, such as Ebola, are particularly prone to lack of investment in health care and progress on maternal care. Secondly, within countries, women living in rural and remote areas have difficulties with access to facilities.

Skip to 13 minutes and 38 secondsHowever, recent research has shown that in urban areas, the gap between the rich and the poor in using maternal care can be higher than in rural areas despite availability of providers. This finding highlights reasons other than geographic proximity

Skip to 13 minutes and 57 secondsthat can be barriers to accessing good quality care: mainly financial, but also discrimination and disrespect. Such issues affect other vulnerable groups, including ethnic minorities, illegal and legal migrants-- who might face additional language and administrative barriers-- or adolescents and unmarried women, who could encounter stigmatisation. One of the five calls for action in the maternal health series refers to quality of care, and another, to equity of care. But these are not two separate issues. Rather, they overlap and interact in a way that must be understood contextually in order to be addressed effectively. Access is a major determinant of quality of care. The most basic example is a woman delivering at home.

Skip to 14 minutes and 49 secondsShe might be able to summon a skilled birth attendant to assist with the delivery, but the environment and the equipment available will fall far below that available in a well equipped maternity ward. Yet, even when women seek care in the formal health care system, we must also consider the quality of care they're receiving. We can begin to understand the access quality connection by delving beyond the coverage indicators, to ask what types of providers or facilities are different groups of women accessing. What quality of care are these different providers able to give women? For example, in Senegal, 78% of births occur in health facilities.

Skip to 15 minutes and 37 secondsBut when we look in more detail, we see that most of these facility-based deliveries occur in primary and secondary level facilities, rather than in hospitals. While we know little about the quality of care of women receive in these facilities, we can see that a much greater proportion of women delivering in lower level facilities-- which are represented by the inner circle-- reported not having a skilled birth attendant at delivery, compared to women delivering in hospitals, which are shown in the outer circle. It is of great concern that more than a quarter of women who deliver in lower level facilities did not have a skilled birth attendant.

Skip to 16 minutes and 18 secondsAnd the type of women delivering in these lower level facilities might be more geographically remote and poorer. Despite appearing as having access to delivery care, the quality of care such women receive in lower level facilities might be far below that of urban, wealthier women who deliver in hospitals.

Skip to 16 minutes and 44 secondsThe second example is from Jordan. It appeared in one of the previous slides with near universal coverage with skilled birth attendants. In 2012, 99% of births were happening in health facilities, and there were very small differences in the coverage by wealth. 100% of the richest, versus 97% of the poorest women delivered in a health facility. However, taking a closer look, we find that the vast majority of the richest women-- 75%-- delivered in the private sector. And the opposite is true of the poorest women, where 80% delivered in the public sector. This extreme stratification raises questions about the quality and acceptability of care in the public sector, and the impact of financial expenditure from using the private sector.

Skip to 17 minutes and 40 secondsTo conclude, there have been improvements in maternal health overall. But these improvements have not been experienced equally, with widening disparities in maternal health between, and within, countries. The overall coverage of care has improved in the past decades, but important issues of inequalities in access and poor quality of care remain. The three main concluding messages of this session are, that first, an in-depth, contextual understanding should underpin any efforts to remedy inequalities in access. Second, that focusing on the most marginalised and vulnerable women is the strategy with the highest population level impact.

Skip to 18 minutes and 25 secondsAnd third, that while striving for universal access to care, we must not forget that such care needs to be of high quality and delivered in a respectful way in order to improve maternal and newborn health.

What is the impact of widening inequalities in maternal health care?

What are the pathways to inequalities in maternal health, and what are the impacts on women’s lives?

In this step Dr Lenka Benova (LSHTM) describes what drives divergence including inequalities in access to health care. Access to care is examined in terms of physical proximity, financial affordability and acceptability of care. The step identifies who are the vulnerable women left behind and what the impacts are on their lives.

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This video is from the free online course:

The Lancet Maternal Health Series: Global Research and Evidence

London School of Hygiene & Tropical Medicine

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