Inequity in uptake of maternal health care services in developing countries: a systematic review and meta-analysis

Background Maternal health service uptake remains an important predictor of maternal outcomes including maternal mortality. This systematic review and meta-analysis aimed to summarize the available evidence on the uptake of maternal health care services in developing countries and to assess the impact of place of residence, education status, and wealth index on the uptake of these services. Methods We examined the databases MEDLINE, Web of Science, Global Index Medicus, and Scopus until June 14, 2022. Cross-sectional studies done between 2015 and 2022 were considered. Mothers of reproductive age and all states of health were included in the study. Independently, two authors determined the eligibility of studies, extracted data, evaluated the risk of bias, and ranked the evidence’s degree of certainty. To combine the data, we performed a random-effects meta-analysis. The PROSPERO registration ID is CRD42022304094. Results We included 51 studies. Mothers living in urban areas were three times more likely to receive antenatal care (OR 2.95; 95% CI 2.23 to 3.89; 15 studies; 340,390 participants) than rural mothers. Compared with no education, those with primary education were twice as likely to utilize antenatal care (OR 2.36; 95% CI 1.80 to 3.09; 9 studies; 154,398 participants) and those with secondary and higher education were six and fourteen times more likely to utilize antenatal care, respectively. Mothers in the second wealth index were twice as likely as mothers in the lowest wealth index to utilize antenatal care (OR 1.62; 95% CI 1.36 to 1.91; 10 studies; 224,530 participants) and antenatal care utilization increased further among mothers in the higher wealth index. We observed similar relative inequalities in skilled delivery care and postnatal care utilization based on the pace of residence, education, and wealth index. Conclusion In developing countries, the problem of inequity in utilizing maternal health care services persists and needs considerable attention.


Introduction
Health inequality refers to a measurable aspect of difference in health that can be observed across individuals or social groups (1).These differences might exist in health conditions or might be related to access to health prevention, therapy, or rehabilitation (2).The term 'health inequity' involves the moral social perception of existing health inequalities and refers to inequalities that are considered unjust by society or that stem from some kind of injustice, mainly affecting groups with less wealth, prestige, and power (3,4).
Maternal mortality, defined as death during pregnancy or within 42 days after childbirth, is an important indicator of socioeconomic inequalities, as it is influenced by the availability of health care and obstetric care (5).Antenatal care contacts and births attended by skilled health professionals, early routine postnatal care, and timely management and treatment of complications are important aspects of reducing preventable maternal mortality (6,7).
As part of the Sustainable Development Goals (SDGs), the member states of the United Nations expressed their commitment to reducing maternal mortality to less than 70 maternal deaths per 100,000 live births by 2030 (8).Based on recent data, we are far from reaching these goals, as since 2016 maternal mortality has been reported to decrease in only a part of the world, including Central and South Asia, Australia, and New Zealand, while in Sub-Saharan Africa, Oceania, East and Southeast Asia, and north Africa stagnation in maternal mortality is observed (9).In the same period, maternal mortality increased in Europe, North America, Latin America, and the Caribbean (9).Infectious diseases, adolescent pregnancies, cesarean section, availability of health workforce, coverage of births by health facilities and hospitals, and inequalities in service coverage might play the most important role in maternal mortality (10).Underutilization of maternal and child health care services can put women and their offspring at risk of dying (11).
Worldwide, governments have started to place increasing emphasis on addressing inequities in maternal and child health services and these efforts improved relative equity of the coverage of reproductive and maternal health services across countries over the last decades (12).However, among low and middle-income countries there are still differences in the extent to which equity is reached, and inequity in coverage of health services persists in some of the countries more than in others (13).For the current 2024 fiscal year, low-income economies are defined as those with a Gross National Income (GNI) per capita, calculated using the World Bank Atlas method, of $1,135 or less in 2022; lower middle-income economies are those with a GNI per capita between $1,136 and $4,465; upper middle-income economies are those with a GNI per capita between $4,466 and $13,845; high-income economies are those with a GNI per capita of $13,846 or more.And low-or middle-income countries are referred to as developing countries (14,15).
Even across different regions of a country, significant differences might be present in the utilization of maternal health services (16).The most important factors indicated in studies to have an important impact on the utilization of maternal health services were education, region of residence, maternal age, and distance to health facilities (17).For example, if a woman lives in an impoverished rural area, like Sub-Saharan Africa and South Asia, where the number of available skilled health professionals is limited, the probability of not receiving sufficient healthcare is extremely high.In high-and upper-middle-income countries more than 90% of all births are attended by a trained midwife, doctor, or nurse.In contrast, in low-income and lower-middle-income countries less than half of all births are assisted by such skilled health personnel (18).According to World Health Organization (WHO), childbearing or reproductive age for women is from 15 to 49 years (19).
A previous systematic review carried out on equity in maternal health care service utilization in developing countries identified 36 studies published between 2005 and 2015, out of which 33 reported severe inequities in maternal health care utilization (20).This systematic review included only studies published in English, and maternal health care services were limited to antenatal care.Data were summarized narratively but not quantitatively.Besides, new studies have been published since then, which might show a more up-todate picture.
For the present systematic review and meta-analysis, maternal health care services considered based on the literature (21) are antenatal care, skilled delivery care, and postnatal care, while inequity for the services is assessed based on three variables including residence, wealth index, and educational status.
This systematic review and meta-analysis aimed to summarize available evidence related to the uptake of maternal healthcare services in developing countries in the period of 2015 to 2022 and to assess differences across groups with different places of residence, education status, and wealth index.

Methods
The methodology and the results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) reporting guideline (22).This study is registered on PROSPERO with the registration ID: CRD42022304094.

Searches
For this systematic review and meta-analysis, we searched the following electronic databases until 14th June 2022 without restrictions to the language of publications: Ovid MEDLINE (09/06/2022), Web of Science (comprising Science Citation Index and Emerging Citation Index) (14/06/2022), Global Index Medicus comprising African Index Medicus (AIM), Index Medicus for the Eastern Mediterranean Region (IMEMR), Index Medicus for the South-east Asia Region (IMSEAR), Latin America and the Caribbean Literature on Health Science (LILACS) and Western Pacific Region Index Medicus (WPRO) (16/06/2022) and Scopus (14/06/2022).Details of our search strategies are available in the Supplementary material.
We used a snowball search method to identify other potentially eligible studies or supplementary publications by searching the reference lists of included studies.All 51 studies included were published in English.

Study inclusion and exclusion criteria
We included cross-sectional (observational) studies investigating maternal health care services (including antenatal care, skilled delivery care, and postnatal care) utilization either separately or all services together from 2015 to 2022 in developing countries.The participants of the studies were mothers of reproductive age (15-49 years) (19) with all health statuses, residing in and having utilized maternal health care services in developing (low and middleincome) countries.Health status refers to medical conditions (both physical and mental health), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability (23).
A country's development status was determined using the World Bank Classifications of countries (14).
Using Covidence™ software, two review authors (GA and EM) separately screened the titles and abstracts of each retrieved record.In a subsequent step, all possibly relevant full texts were evaluated for eligibility.Any differences of opinion were settled by consensus or by consulting a third author (SL).

Potential effect modifiers and reasons for heterogeneity
We assessed methodological heterogeneity through the assessment of risk of bias, and clinical heterogeneity through the assessment of similarities and differences between studies in terms of types of participants and outcomes.We considered the size and direction of the effect and used a standard χ 2 test with a significance level of α = 0.1 and the I 2 statistic, which quantifies inconsistency across studies, to assess the effect of heterogeneity on the meta analysis.In almost all socioeconomic sub-groups we observed high heterogeneity among studies.
We used funnel plots to assess reporting bias and investigate small-study effects when at least ten studies were included in a meta analysis.

Study quality assessment
Each included study's risk of bias was evaluated separately by two review authors (GA and EM), and any discrepancies were settled by consensus.The risk of bias was evaluated with the Joanna Briggs Institute (JBI) critical appraisal checklist for analytical cross-sectional studies (24).Based on the checklist, studies were rated on an 8-point scale (Table 1).Those studies achieving a score exceeding half of the total points were eligible for inclusion in the systematic review and meta-analysis.

Data extraction strategy
We retrieved information on study methods, participants, maternal health care services, outcomes, funding sources, and potential conflict of interest statements from full-text publications.One reviewer (GA or EM) extracted the data, while a second reviewer (GA or EM) verified its accuracy, consistency, and completeness.
The outcome of interest for this systematic review was inequity in utilization or uptake of maternal health care services (antenatal care, skilled delivery care, and postnatal care), reported as frequency or percentage by mothers' residence, educational status, and wealth index.

Data synthesis and presentation
We conducted a meta analysis for every outcome for which we judged the participants and outcomes to be similar enough to provide meaningful results.We conducted meta-analyses for the following three comparisons: Antenatal care utilization versus non-utilization, skilled delivery care utilization versus non-utilization, and post-natal care utilization versus non-utilization.To assess inequity, we investigated the following three factors in association with maternal health care utilization: place of residence (urban and rural), educational status (no education, primary, secondary, and higher), and wealth index (lowest, second, middle, fourth and highest).
We presented the results as odds ratios (ORs) with 95% confidence intervals because our data were dichotomous.We did statistical analyses using RevMan (version 5.4.1).As we expected differences between studies like differences in sample size, we decided to combine the data using a random effects model.We used Mantel-Haenszel weighting because the outcomes are dichotomous.
Results of eligible studies that do not provide data in an appropriate format for meta-analysis are summarized in a narrative format.The result is presented using PRISMA 2020 checklist (Supplementary material).

Results
We retrieved 2,109 studies through database searching.We removed duplicates and screened 2,045 studies based on their titles and abstracts.After removing irrelevant studies, we assessed 221 full-text studies for eligibility to be included in this systematic review.Finally, 51 studies met our inclusion criteria.Of these, we were able to include 34 studies in the quantitative syntheses (meta-analysis) (Figure 1).
All studies were conducted in low-income and lower-middleincome countries.The age of the participants in the included studies ranged from 15-49 years.The types of maternal health care services were antenatal care in 14 studies, skilled delivery care in 14 studies, postnatal care in 3 studies, and in another 20 studies, the services were at least two of maternal health care services mentioned above (Table 2).
The number of women investigated in the included studies ranged from 200 (45) to 699,686 (61).Funnel plots were used to assess reporting bias and investigate small-study effects.The findings from funnel plots indicated symmetrical funnel plots which in turn shows the absences of publication bias (Supplementary material).

Antenatal care utilization Utilization of antenatal care by place of residence
For the place of residence, utilization of antenatal care favors mothers living in urban places than those living in rural places.So, when compared to mothers living in rural areas, mothers living in urban areas utilize antenatal care three times more likely (OR 2.95; 95% CI 2.23, to 3.89; 15 studies; 340,390 participants; p < 0.00001) (Figure 2).

Utilization of antenatal care by the educational status of mothers
For the utilization of antenatal care in relation to the educational status of the mothers, we found that compared to no education, those with primary education utilize antenatal care two times more likely (OR 2.36; 95% CI 1.80 to 3.09; 9 studies; 154,398 participants p < 0.00001).Similarly, compared to mothers with no education, those with secondary and higher education utilized antenatal care six times (OR 6.00; 95% CI 4.13 to 8.73; 9 studies, 154,398 participants, p < 0.00001) and fourteen times (OR 14.27; 95% CI 7.93, 25.67; 9 studies, 154,398 participants, p < 0.00001) more likely, respectively, p < 0.00001 (Figure 3).

Utilization of antenatal care by wealth index
When we investigated the utilization of antenatal care by wealth index of mothers, we found that compared to mothers with the lowest wealth index, those with the second wealth index utilize antenatal care

Skilled delivery care utilization Utilization of skilled delivery care by place of residence
When we investigated the uptake of skilled delivery care by place of residence, the results indicated that mothers living in urban areas utilize skilled delivery care six times more likely than those mothers living in rural areas (OR 6.33; 95% CI 4.95 to 8.09; 16 studies, 166,085 participants; p < 0.00001) (Figure 5).

Utilization of skilled delivery care by the educational status of mothers
As to the utilization of skilled delivery care by the educational status of mothers, we found that compared to those with no education, those with primary education utilized skilled delivery care three times more likely (OR 2.49; 95% CI 1.89 to 3.29; 9 studies; 53,182 participants, p < 0.00001).Those with secondary and higher education utilized skilled delivery care seven times (OR 6.59; 95% CI 4.24 to 10.26; 9 studies, 53,726 participants, p < 0.00001) and twenty-seven times (OR = 26.53;95% CI = 16.44,42.83; 9 studies; 45,880 participants, p < 0.00001) more likely than mothers with no education, respectively (Figure 6).

Utilization of skilled delivery care by wealth index
Concerning utilization of skilled delivery care by wealth index of mothers, we found that compared to mothers with the lowest wealth index, those with the second wealth index utilize skilled delivery care two times more likely (OR 1.89; 95% CI 1.66 to 2.15; 14 studies; 151,578 participants; p < 0.00001).Those mothers in the middle, fourth, and highest wealth index utilized skilled delivery care three times.

Postnatal care utilization Utilization of postnatal care by place of residence
As to utilization of postnatal care by place of residence, we found that urban mothers are three times more likely to utilize postnatal care than rural mothers (OR 2.74; 95% CI 1.98 to 3.78; 4 studies; 14,347; p < 0.00001) (Figure 8).

Utilization of postnatal care by educational status of mothers
Concerning the utilization of postnatal care by the educational status of mothers, we found that compared to no education, those with primary education utilize postnatal care two times more likely (OR 1.99; 95% CI 0.78 to 5.04; 2 studies; 4,642 participants; p = 0.15).Those with secondary education utilize postnatal care five times (OR 5.27; 95% CI 1.78 to 15.60; 2 studies; 4,828 participants; p = 0.003) and those with higher education ten times (OR 9.66; 95% CI 7.39 to 12.63, 2 studies; 3,289 participants; p < 0.00001) more likely than mothers with no education (Figure 9).

Utilization of postnatal care by wealth index
For the utilization of postnatal care by wealth index of mothers, we found that compared to mothers with the lowest wealth index, those with second wealth index utilize postnatal care two times more likely (OR 1.46; 95% CI 1.10, 1.96; 4 studies; 96,432 participants; p = 0.01).In the same way, compared to mothers in lowest wealth index, those in middle, fourth and highest wealth index utilize postnatal care two times (OR 2.01; 95% CI 1.39, 2.91; 4 studies; 90,962 participants; p = 0.0002), three times (OR 2.62; 95% CI 1.55, 4.44; 4 studies; 85,894 participants; p = 0.0003) and five times (OR 5.06; 95% CI 2.45, 10.45; 4 studies; 81,335 participants; p < 0.0001) more likely, respectively (Figure 10).

Additional results from studies not included in meta-analyses
A total of 17 studies were not included in the meta-analysis, but their findings were summarized for the qualitative synthesis only.In these studies, the outcomes were not reported as frequencies or percentages.However, the result agrees with the result from a meta-analysis.Utilization of antenatal care and skilled delivery care by the educational status of mothers Among the 17 studies examined, 6 studies have indicated that education has a direct effect on antenatal care and skilled delivery care utilization.Notably, in Ghana, women with secondary school education or higher were more inclined to receive prenatal and skilled delivery care compared to those without formal education (59).Similarly, in Northern Ghana, the educational attainment of mothers significantly correlated with the utilization of skilled delivery services (62).
In Indonesia, evidence indicates that education plays a crucial role in influencing women to undergo more than four antenatal care visits (67).Moreover, in Congo, a higher level of education was associated with increased utilization of antenatal care (73).
A comprehensive study across five African countries demonstrated a positive link between women's education and various aspects of maternal health care, including the type of antenatal care provider, timing and frequency of antenatal care visits, delivery location, and presence of a skilled birth attendant (74).In Nigeria, the research suggested a consistently higher concentration of maternal healthcare usage among well-educated and wealthier mothers throughout the study period (71).

Utilization of antenatal care and skilled delivery care by wealth index
Out of 17 studies, 10 studies have highlighted the correlation between the wealth index and the utilization of antenatal care and skilled delivery care.Research conducted in Nepal revealed an escalating trend in the utilization of skilled delivery care and antenatal care as the wealth index of mothers transitions from the poorest to the least poor (60).The ratio of utilization for four ANC visits and institutional delivery between the richest and the poorest quintile mothers were 5.08 and 9.00, respectively, (64).Additionally, women from low socioeconomic backgrounds were six times more likely to deliver without skilled assistance compared to those from high socioeconomic backgrounds (68).
In India, the probability of having at least four ANC visits is nearly four times higher for women in the richest households than for those in the poorest households (61).In the Philippines, facility-based delivery coverage was higher for non-poor households compared to poor households (63).A study across three different Asian countries revealed a pro-rich inequality in the use of facility delivery services (65).
For skilled birth attendance and four or more antenatal care visits in Kenya, the absolute difference in coverage between the wealthiest quintile (quintile 5) and poorest quintile (quintile 1) was 61.6 and 31.0%,respectively (66).
In Zimbabwe, women from middle-income and richest households were more likely to utilize antenatal care services than women from the poorest households.Maternal service utilization in Zimbabwe exhibited a pro-rich pattern, indicating a preference for maternal health care utilization among women from wealthy households (58).In Nigeria, the concentration of at least four ANC visits and a higher number of ANC visits were disproportionately higher among the rich (70).Similarly, in Myanmar, the utilization of skilled birth attendants (SBAs) among women was disproportionately concentrated among the affluent, irrespective of maternal characteristics (72).

Discussion
In the present systematic review, we summarized up-to-date evidence about the utilization of maternal health care services, including antenatal care, skilled delivery care, and postnatal care in developing countries.In all three areas of maternal health care  services, we have seen that place of residence, education, and wealth index are still important determinants, that is those living in urban areas, having a higher education level, or a higher wealth index utilize maternal health services more often.The greater the difference in education or wealth between the two groups, the greater the difference in the use of maternal health care services between them.The results

FIGURE 10
Forest plot showing postnatal care utilization by wealth index of mothers in developing countries, 2015 to 2022.To our knowledge, this is the first systematic review summarizing available evidence on inequity in the uptake of maternal health care services in developing countries not only in a narrative way but also quantitatively, by including meta-analyses.As compared to previous systematic reviews the present systematic review does not only focus on a specific maternal health care service but includes antenatal care, skilled delivery care, as well as postnatal care.Other strengths include a comprehensive search strategy, conducted in electronic databases without imposing language restrictions.This way we think, the likelihood of overlooking published studies was minimal, although there was a potential for missing unpublished ones.We aimed to reduce bias wherever possible by having at least two review authors work independently on study selection, data extraction, and risk of bias assessments.
A previous systematic review carried out on equity in maternal healthcare service utilization in developing countries investigated studies published between 2005 and 2015 (20).The present systematic review summarizes evidence for the period 2015 to 2022.Although the results of these two systematic reviews are only partially comparable due to the more limited questioning and lack of quantitative analysis in the previous review, it can be concluded that inequity in the uptake of maternal health care services described earlier persists in developing countries.
Several interventions might be potentially effective in reducing inequalities in maternal and child health in low-and middle-income settings.Besides immunization campaigns, nutrition supplement programs, and demand-side interventions, healthcare provision improvement interventions are tested in different countries, including different health programs, which aim to improve the uptake of maternal and child healthcare services (75).In Tanzania, simple guidelines, and messages for use in primary health facilities and communities were developed (76).In Brazil, the family health program was introduced, where multi-professional teams were working under the principles of comprehensive care and provided permanent and systematic follow-up of high-risk families residing in a pre-specified area with high infant mortality rates (77).In Bangladesh, voluntary community health workers provide intensive home-based maternal and newborn care.This program aimed to increase the utilization of antenatal care and to train attendants for home delivery (78).Another program addressing both the demand side (education about the benefits of ANC and PNC visits, pathologic signs related to pregnancy and delivery) and supply side interventions (strengthening health facilities, providing trained personnel and equipment) was able to successfully improve the utilization of maternal health services and reduce inequalities (79).In Indonesia, midwives were trained and posted in every village with specific responsibility for pregnancy, delivery, and postpartum care.This way this program focused on inequities in antenatal care check-ups and birth attendance by trained professionals (80).Although the evidence level is generally low, all these programs seemed to be effective in achieving results in the field of equity of maternal and child health care services.
When designing and implementing interventions to reduce inequalities in access to maternal and newborn care, the 5As framework of access developed by Penchansky and Thomas should be borne in mind.They argue that access to care is simultaneously dependent on affordability, availability, accessibility, accommodation, and acceptability (81).These five aspects of access form a chain that is no stronger than its weakest link, so interventions that target only one or two of them may not reduce inequality at all (82,83).In general, Changes in social determinants of health at the societal level can only be brought about by systemic, complex interventions.The obstacles to decisions leading to such measures are a lack of recognition of the problems, short-term political interests, and limited resources (84,85).
Further research should be conducted to delve deeper into the effectiveness of the above-mentioned and additional interventions to improve the uptake of maternal health care services.The effectiveness of these interventions should be investigated separately for the different sociodemographic groups.These studies and sub-group analyses might facilitate targeted interventions in the most vulnerable groups.Governments should use the results of research activities to plan the implementation of programs.Progress in equity should be monitored, and recommendations should be forwarded to concerned bodies periodically.In most developing countries, there are demographic and health surveillance sites where demographic and health data are collected, analyzed, and reported regularly.Therefore, monitoring health inequity should be incorporated in these sites as one theme.In summary, this systematic review and meta-analysis synthesized data from 51 cross-sectional studies analyzing the uptake of maternal health care services in developing countries.The findings revealed a consistent and statistically significant effect of place of residence, education, and wealth index of mothers on the uptake of maternal health care services indicating persistence of relative inequity in utilization in developing countries.Currently, the services are mostly utilized by mothers who reside in urban areas, are more educated, and have the highest wealth index.Based on the conclusions of the literature synthesis, recommendations can be formulated for health policy that could increase the uptake of maternity services and reduce inequalities.The article may draw the attention of health policy makers to the fact that the low uptake and inequalities in maternal health care cannot be improved by interventions in the health sector alone, i.e., intersectoral action is needed.
Include *Y, yes; N, no; U, unclear; Q, question.The score is calculated by summing up Y in each row.

FIGURE 1 PRISMA
FIGURE 1 PRISMA flow diagram indicating study selection.

FIGURE 2
FIGURE 2Forest plot showing antenatal care utilization by place of residence in developing countries, 2015 to 2022.

FIGURE 3 Forest
FIGURE 3Forest plot showing antenatal care utilization by educational status of mothers in developing countries, 2015 to 2022.

FIGURE 4 Forest
FIGURE 4Forest plot showing antenatal care utilization by wealth index of mothers in developing countries, 2015 to 2022.

FIGURE 5 Forest
FIGURE 5Forest plot showing skilled delivery care utilization by place of residence in developing countries, 2015 to 2022.

FIGURE 6 Forest
FIGURE 6Forest plot showing skilled delivery care utilization by educational status of mothers in developing countries, 2015 to 2022.

FIGURE 7 Forest
FIGURE 7Forest plot showing skilled delivery care utilization by wealth index of mothers in developing countries, 2015 to 2022.

FIGURE 8 Forest
FIGURE 8 Forest plot showing postnatal care utilization by place of residence in developing countries, 2015 to 2022.

FIGURE 9 Forest
FIGURE 9Forest plot showing postnatal care utilization by educational status of mothers in developing countries, 2015 to 2022.

TABLE 1
Study quality assessment using the Joanna Briggs Institute critical appraisal checklist for analytical cross-sectional studies.

TABLE 2 (
Continued) *Economic classification of countries according to World Bank Classification 2022.10.3389/fpubh.2024.1415092Frontiers in Public Health 08 frontiersin.org this systematic review and meta-analysis clearly indicate that there is a relative inequity in the utilization of antenatal care, skilled delivery care, and postnatal care for mothers in developing countries. of