Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries

Summary

Background

Countdown to 2015 tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5, with particular emphasis on within-country inequalities. We assessed how inequalities in maternal, newborn, and child health interventions vary by intervention and country.

Methods

We reanalysed data for 12 maternal, newborn, and child health interventions from national surveys done in 54 Countdown countries between Jan 1, 2000, and Dec 31, 2008. We calculated coverage indicators for interventions according to standard definitions, and stratified them by wealth quintiles on the basis of asset indices. We assessed inequalities with two summary indices for absolute inequality and two for relative inequality.

Findings

Skilled birth attendant coverage was the least equitable intervention, according to all four summary indices, followed by four or more antenatal care visits. The most equitable intervention was early initation of breastfeeding. Chad, Nigeria, Somalia, Ethiopia, Laos, and Niger were the most inequitable countries for the interventions examined, followed by Madagascar, Pakistan, and India. The most equitable countries were Uzbekistan and Kyrgyzstan. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest than for the richest individuals.

Interpretation

We noted substantial variations in coverage levels between interventions and countries. The most inequitable interventions should receive attention to ensure that all social groups are reached. Interventions delivered in health facilities need specific strategies to enable the countries' poorest individuals to be reached. The most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent.

Funding

Bill & Melinda Gates Foundation, Norad, The World Bank.

Introduction

Countdown to 2015 for maternal, newborn, and child survival was conceived in 2003¹ to track country and global progress towards achievement of Millennium Development Goals (MDGs) 4 (reduce child mortality) and 5 (improve maternal health).² Countdown monitors population-based estimates of coverage for effective interventions in 75 countries with high rates or numbers of maternal or child deaths. Data for coverage indicators are obtained from nationally-representative household surveys.³ Since its inception, Countdown has emphasised the need to address inequities in maternal and child health as a key strategy to improve health and survival.⁴ Stratified analyses of key coverage indicators by sex, wealth, maternal education, urban or rural residence, and region of the country have been an essential part of Countdown reports,3, 5, 6 country profiles, and publications.2, 7, 8, 9

We report analyses of nationally-representative surveys available for 54 of the 75 Countdown countries. We aimed to identify which of 12 key maternal, newborn, and child health interventions are most inequitably distributed within these countries and which were least likely to be equitable in the delivery of these interventions. Furthermore, we assessed whether intercountry variability in coverage is greater for poor than for richer individuals.