Measuring and decomposing the inequality of maternal health services utilization in Western Rural China
© Liu et al.; licensee BioMed Central Ltd. 2014
Received: 14 November 2013
Accepted: 20 February 2014
Published: 3 March 2014
To measure socioeconomic inequalities in maternal health services in rural western China and to analyze the determinants’ contributions of inequalities.
Study design: a cross-sectional study.
The data utilized in this study were obtained from a cross-sectional study from 10 provinces in rural Western China in 2005. Wealth index of household socioeconomic status was developed by using principle component analysis. Concentration index, concentration curve and decomposition of the concentration index were employed to measure socioeconomic inequality in maternal health services utilization.
For more than four times prenatal visits, the concentration index was 0.0605 (95% CI: 0.0603, 0.0607). The concentration index of hospital delivery was 0.0230 (95% CI: 0.0210, 0.0240) and the concentration index of more than 2 times postnatal visits was 0.0842 (95% CI: 0.0836, 0.0847). Han ethnicity woman, particularly in conjunction with high school education and rich wealth status, was the main contributor to inequality in maternal health services utilization.
There is a strong pro-rich inequality of maternal health services in rural western China. This study suggests that an effective way to reduce the inequality is not only to narrow the gap of income between the rich and poor, but focus education on ethnic minority woman in rural remote areas.
KeywordsMaternal health care utilization Rural Western China Socioeconomic inequality Decomposition
Health inequality is used to designate differences, variations, and disparities in the health achievements of individuals and groups . Researchers worldwide have focused on health inequality and population health. A study carried out among nine western industrialized countries exhibited a strong negative correlation existing between income inequality and life expectancy . Some studies found a positive association existing between income inequality and mortality [1, 3–5]. Meanwhile, some other studies also showed possible effects of income inequality on self rated health  and children’s malnutrition [7, 8]. These findings suggested that income inequality is bad for the health of the whole population . In contrast, access to health services is concentrated among those at the upper end of the socioeconomic spectrum, while socioeconomic status contributed to greater inequality of health services utilization [9–11].
China has achieved much in healthcare with its rapid economic development. But great inequality in population health exists due to its geographic and economic factors. For example, in 2005, the maternal mortality rate (MMR) was less than 20 per 100,000 live births in eastern coastal regions, which was approximately 4–5 times lower than that of in western regions. Meanwhile, the proportion of hospital delivery had reached nearly 100% at the county level of eastern coastal regions, but was 70% or less at the county level in western areas . The contrasts of medical services in quality and accessibility between China’s large cities and its less developed rural areas were obvious. According to the Ministry of Health, numbers of doctors, hospital beds, the types of health care and medical treatments in large cites are approaching levels in industrialized countries. However, the number of village doctors decreased from 1.8 million to 0.8 million, as well as the number of health workers decreased from 3.4 million to 0.8 million during the same period .
Our previous study has described the utilization of maternal healthcare services, and analyzed the associated factors and assessed their regional differences among 10 provinces in rural western China. The purpose of this present study was to analyze the degree of income-related inequality of maternal health services utilization and to decompose socioeconomic inequality into its determinants. These findings can be used to make implications for the Chinese government to promote maternal healthcare utilization for rural resident in rural western China.
The data utilized in this study were obtained from a cross-sectional study from 10 provinces in rural Western China in 2005. The background of this study and the selection of sites were described in our previous published paper .
Three outcomes were treated as maternal health services utilization index: (1) if a woman had more than four times prenatal visits; (2) if a woman had a hospital delivery; and (3) if a woman had more than two times postnatal visits. Determinants associated with maternal health services utilization were: woman’s age which are categorized into four levels (1: less than 20 years; 2: 20–29 years; 3: 30–39 years; 4: over 39 years), ethnicity (Han vs. minority), woman’s education (primary, secondary and high school), husband’s education (primary, secondary and high school), household wealth index (poor, middle, rich), and parity (1, 2, and more than 2).
The household wealth index is a commonly used measurement of socio-economic status of households. It was developed by using the first principle component analysis. The index combined information on a set of household asserts and living conditions: the resource of household income, the ownership of a television, bicycle and motorcycle, and the availability of clean water. The index was categorized into 3 socio-economic levels: poor, middle and rich households.
Where C is concentration index; y i is maternal health services utilization index; R i is the fractional rank of individual i in the distribution of socio-economic position; μ is the mean of the maternal health services utilization variable of the sample and cov denotes the covariance.
The concentration curve plots the cumulative percentage of the health variable (y-axis) against the cumulative percentage of the population, ranked by socio-economic status (x-axis). If, by contrast, the maternal health services utilization sector variable takes higher (lower) values among poorer people, the concentration curve will lie above (below) the line of equality. The farther the curve is under the line of equality, the more concentrated the maternal health services utilization variable is among the poor.
Equation 3 shows that the overall inequality in maternal health utilization has two components, a deterministic or “explained” component and an “unexplained” component. In the former component β k is the coefficient from a regression of maternal health services utilization variable on determinant k, is the mean of determinant k, μ is the mean of the maternal health service utilization index, and C k is the CI for determinant k. In the latter component, GC ϵ is the generalized CI for the error term.
The decomposition method was used with a linear, additively separable model. However, the maternal health service utilization variables in this study are non-linear. Probit regression models are employed to analyze the influences of determinants on the probability of maternal health services utilization. One possibility when deal with a discrete change from 0 to 1 is to use marginal or partial effects, which shows the change in an explanatory variable [11, 16, 17].
Data was analyzed using STATA 12 statistical software and MS Excel.
Socio-economic characteristics of the surveyed women
Women’s age (years)
Women education (years)
Husband education (years)
Decomposition of inequality in the maternal health services utilization
More than 4 times prenatal visits
More than 2 times postnatal visits
> = 3
From Table 2, it is clearly observed that most of the inequality in maternal health service utilization can be explained by inequalities in women’s age, ethnicity, women’s education, husband’s education, and wealth. The variable parity seems to have an inequality reducing effect. Among these contributions, ethnicity, education and wealth made the greatest contribution to the inequality of maternal health service utilization. All of the contributions were positive, indicating that most of the pro-rich inequalities are affected by ethnicity, education and wealth. Therefore, woman with Han ethnicity and high school education had an above average probability of maternal health services utilization, were disproportionately concentrated in rich socioeconomic status groups.
This study focused on income-related inequality of maternal health services utilization and decomposed socioeconomic inequality into its determinants in western rural China. Most areas of rural western China are mountainous with underdeveloped economic conditions and poor health services, our previous study showed that the maternal healthcare were underutilized till 2005, and a great disparity existed in western rural China . This study showed that the inequality existed in maternal health services utilization and socio-economic factor was the major factor accounted for the inequality. The three concentration index of maternal health services utilization were positive showed that obvious pro-rich inequalities of maternal health services utilization existed, that is, woman with a lower socioeconomic status are less likely to use maternal healthcare services, which indicates that a disproportionate share of maternal health services resources is utilized by richer people in spite of lower need. The results were similar to many others in health services studies in different parts of the world [10, 18–20].
Compared to more than four times prenatal visits and more than two times postnatal visits, inequality in hospital delivery was lower. Since 2000, the China government and Ministry of Health have made continuous efforts and have issued a series of legislation to promote maternal health services and improve the inequality in maternal health services utilization in less-developed western rural areas. The comprehensive strategies included restrict on hospital delivery costs, provide appropriate subsidies for poor pregnant women, and strengthen the maternal health service quality in township hospital to improve the hospital delivery in rural western China . These measurements could increase the rate of hospital delivery in poor women.
After decomposing the inequality of maternal health services utilization, this study showed that Han ethnicity woman, particularly in conjunction with high school education and rich wealth status, was the main contributor to inequality in maternal health services utilization. The result was consistent with previous studies that better wealth status was associated with increased maternal health services utilization. Better wealth status directly affects whether a woman can actually reach a facility for maternal health service and afford transportation costs [22, 23]. Ethnicity and religion are often considered as markers of cultural background and are expected to influence beliefs, norms and values in relation to childbirth, service use and women’s status. Some studies showed that levels of maternal health services utilization were very low among ethnic minority women in rural China because of their traditional customs, such as a preference for home delivery [24–26]. Maternal education is consistently and strongly associated with all types of health behaviors. Education can increase knowledge of the benefits of preventive health care and awareness of health services, improve the ability of individuals to produce health by influencing their life style, and increase the use of health care services through improved knowledge, attitude and practice [23, 27]. Some studies also found that education of woman is the major determinant of inequalities in maternal health services utilization [10, 18]. In some African areas, women with higher education and lower socioeconomic status used more maternal health services than that of lower education and higher socioeconomic status .
At present, China’s strategy has largely focused on supply-side interventions through insured and subsidized delivery of care, and the improved quality of that care. It is necessary to explore a practical, sustainable development and low-cost maternal and children’s health model for western rural areas. Hence, bridging inequalities in the maternal levels of education is an important undertaking to narrow inequalities in the use of maternal health services. The government should focus education on rural woman, especially ethnic minority woman in rural remote areas in western China.
Beyond that, these three major contributors interact in different ways to determine use of health services. Low wealth status is indicated by low education and low income. In many societies, ethnicity and religion are closely linked to socioeconomic position and place of residence. Income and education are definitely linked to access, experiences and benefits from health care, which itself is a social determinant of health [29, 30]. Furthermore, the results also show that residual variable contributed a lot to the inequality, suggesting that there remains a good deal of unexplained variation in inequality besides the variables examined in this analysis. It is important to note that redressing wealth inequalities alone can not be an effective intervention to inequalities in access to maternity care in the absence of intervention that also tackle the other social determinants such as education.
There are limitations to the study. First, fewer variables were used to compose the wealth index, which is used to measure the woman’s socioeconomic status, making it might be a poor representation of the woman’s actual economic situation. Second, there was likely to be recall bias because the subjects were interviewed with events that occurred a few years ago.
There is a strong pro-rich inequality of maternal health services in rural western China. The inequality of hospital delivery was lower than that of more than four times prenatal visits and more than two times postnatal visits. As ethnicity, education and wealth index were the main factors contributing to the pro-rich inequality of maternal health services utilization. This study suggests that an effective way to reduce the inequality is not only to narrow the gap of income between the rich and poor, but focus education on ethnic minority woman in rural remote areas as well.
We thank the Ministry of Health, People’s Republic of China, and United Nations Children’s Fund for supporting and cooperation; Health Department of each project province and local health bureau and MCH stations for cooperation and organization in the field data collection; and staff from Xi’an Jiaotong University for participation in the data collection.
- Kawachi I, Subramanian SV, Almeida FN: A glossary for health inequalities. J Epidemiol Community Health. 2002, 56: 647-652. 10.1136/jech.56.9.647.View ArticlePubMedPubMed CentralGoogle Scholar
- Editorials: Income inequality and population health. Br Med J. 2002, 324: 1-2. 10.1136/bmj.324.7328.1.
- Enrico M, Laura C, Giulio B, Cesaroni G, Davoli M, Mirale MP, Vergine L, Baglio G, Simeone G, Perucci CA: Income inequality and mortality in Italy. Eur J Public Health. 2005, 15: 411-417. 10.1093/eurpub/cki007.View ArticleGoogle Scholar
- Ahmad Reza Hosseinpoor EVD, Speybroeck N, Nahavi M: Decomposing socioeconomic inequality in infant mortality in Iran. Int J Epidemiol. 2006, 35: 1211-1219. 10.1093/ije/dyl164.View ArticlePubMedGoogle Scholar
- Feng XL, Zhu J, Zhang L, Song L, Hipgrave D, Guo S, Ronsmans C, Guo Y, Yang Q: Socio-economic disparities in maternal mortality in China between 1996 and 2006. BJOG: An International Journal of Obstetrics and Gynaecology. 2010, 117: 1527-1536. 10.1111/j.1471-0528.2010.02707.x.View ArticleGoogle Scholar
- Vasoontara Y, Lynette LL, Gordon CA, Alexander S, Adrian SC: Measuring and decomposing inequity in self-reported morbidity and self-assessed health in Thailand. Int J Equity Health. 2007, 6: 23-10.1186/1475-9276-6-23.View ArticleGoogle Scholar
- Ellen VP, Ahmad RH, Caroline J-A, Jeanette V, Niko S: Malnutrition and the disproportional burden on the poor: the case of Ghana. Int J Equity Health. 2007, 6: 21-10.1186/1475-9276-6-21.View ArticleGoogle Scholar
- Uthman OA: Decomposing socio-economic inequality in childhood malnutrition in Nigeria. Matern Child Nutr. 2009, 5: 358-367. 10.1111/j.1740-8709.2009.00183.x.View ArticleGoogle Scholar
- Khadr Z: Monitoring socioeconomic inequity in maternal health indicators in Egypt: 1995–2005. Int J Equity Health. 2009, 8: 38-10.1186/1475-9276-8-38.View ArticlePubMedPubMed CentralGoogle Scholar
- Eyob Z, Doyin O, Joses MK, Mwikisa CN: Inequities in skilled attendance at birth in Namibia: a decomposition analysis. BMC Pregnancy & Childbirth. 2011, 11: 34-10.1186/1471-2393-11-34.View ArticleGoogle Scholar
- Wagstaff AVDE, Watanabe N: On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam. J Econometrics. 2003, 112: 207-223. 10.1016/S0304-4076(02)00161-6.View ArticleGoogle Scholar
- MOH C: Report on maternal health care. National Surveillance Report on Health. 2006, Beijing: Peking Union Medical College Press, 195-1Google Scholar
- Zhao ZW: Income inequality, unequal health care access, and mortality in China. Popul Dev Rev. 2006, 32: 461-483. 10.1111/j.1728-4457.2006.00133.x.View ArticleGoogle Scholar
- Xiaoning L, Xiaoyan Z, Hong Y, Duolao W: Use of maternal healthcare services in 10 provinces of rural western China. Int J Gynecol Obstet. 2011, 144: 260-264.Google Scholar
- Wagstaff ADAE: Measuring and testing for inequity in the delivery of health care. J Hum Resour. 2000, 35: 716-733. 10.2307/146369.View ArticleGoogle Scholar
- Van Doorslaer EKX, Jones AM: Explain income-related inequalities in doctor utilization in Europe. Health Econ. 2004, 13: 629-647. 10.1002/hec.919.View ArticlePubMedGoogle Scholar
- Van Doorslaer EKX: Explain the differences in income-related health inqualities accross European countries. Health Econ. 2004, 13: 609-628. 10.1002/hec.918.View ArticlePubMedGoogle Scholar
- Limwattananon S, Tangcharoensathien V, Prakongsaib P: Equity in maternal and child health in Thailand. Bull World Health Organ. 2010, 88: 420-427. 10.2471/BLT.09.068791.View ArticlePubMedGoogle Scholar
- Daniel F, Chunhuei C: Health care utilization in Ecuador: a multilevel analysis of socio-economic determinants and inequality issues. Health Pol Plann. 2010, 25: 209-218. 10.1093/heapol/czp052.View ArticleGoogle Scholar
- Houweling TA, Kunst AE, Huisman M, Mackenbach JP: Using relative and absolute measures for monitoring health inequalities: experiences from cross-national analyses on maternal and child health. Int J Equity Health. 2007, 6: 15-10.1186/1475-9276-6-15.View ArticlePubMedPubMed CentralGoogle Scholar
- Xiaoning L, Duolao W, Hong Y: The evaluation of “Safe Motherhood” program on maternal care utilization in rural western China: a difference in difference approach. BMC Publ Health. 2010, 10: 566-10.1186/1471-2458-10-566.View ArticleGoogle Scholar
- Say L, Raine R: A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bull World Health Organ. 2007, 85: 812-819. 10.2471/BLT.06.035659.View ArticlePubMedPubMed CentralGoogle Scholar
- Ahmed S, Creanga AA, Gillespie DG, Tsui AO: Economic status, education and empowerment: implications for maternal health service utilization in developing countries. Plos One. 2010, 5: 1-6.Google Scholar
- Long QA, Zhang TH, Xu L, Tang SL, Hemminki E: Utilisation of maternal health care in western rural China under a new rural health insurance system (New Co-operative Medical System). Trop Med Int Health. 2010, 15: 1210-1217. 10.1111/j.1365-3156.2010.02602.x.View ArticlePubMedGoogle Scholar
- Li J, Luo C, Deng R, Jacoby P, Klerka ND: Maternal mortality in Yunnan, China: recent trends and associated factors. Int J Obstet Gynaecol. 2007, 114: 865-874. 10.1111/j.1471-0528.2007.01362.x.View ArticleGoogle Scholar
- Harris A, Zhou Y, Liao H, Barclay L, Zeng WY, Gao Y: Challenges to maternal health care utilization among ethnic minority women in a resource-poor region of Sichuan Province China. Health Pol Plann. 2010, 25: 311-318. 10.1093/heapol/czp062.View ArticleGoogle Scholar
- Simkhada B, van Teijlingen ER, Porter M, Simkhada P: Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. J Adv Nurs. 2008, 61: 244-260. 10.1111/j.1365-2648.2007.04532.x.View ArticlePubMedGoogle Scholar
- McTavish S, Moore S, Harper S, Lynch J: National female literacy, individual socio-economic status, and maternal health care use in sub-Saharan Africa. Soc Sci Med. 2010, 71: 1958-1963. 10.1016/j.socscimed.2010.09.007.View ArticlePubMedGoogle Scholar
- Gyimah S, Takyi B, Addai I: Challenges to the reproductive-health needs of African women: on religion and maternal health utilization in Ghana. Soc Sci Med. 2006, 62: 2930-2944. 10.1016/j.socscimed.2005.11.034.View ArticlePubMedGoogle Scholar
- Gabrysch S, Campbell OM: Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009, 9: 1-18. 10.1186/1471-2393-9-1.View ArticleGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/14/102/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.