Decomposing socioeconomic inequality in skilled birth attendant utilization in Ethiopia: A secondary data analysis

Inequalities in access to and utilization of skilled birth attendants (SBA) present a substantial challenge in low- and middle-income countries, hindering progress towards achieving universal health coverage in maternal health. Countries should regularly monitor inequality in access to SBA at both national and subnational levels. Therefore, this study aimed to measure socioeconomic inequalities and the contributing factors to the utilization of SBA among postpartum women in Ethiopia.

We used secondary data from the second cohort's 6-week postpartum survey in combination with the baseline data of the Performance Monitoring for Action Ethiopia longitudinal study, conducted between November 2021 and October 2022. The study employed a multistage stratified cluster sampling technique to select 1,966 postpartum women. Socioeconomic inequality in the utilization of SBA was measured using the Erreygers Normalized Concentration Index (ECI) and visualized by a concentration curve. A concentration index decomposition analysis was conducted to identify the factors that contribute to the socioeconomic related health inequality in the utilization of SBA.

Utilization of SBA was 61.6% (95% CI: 59.0-64.0) in Ethiopia. The concentration curve in the utilization of SBA lay below the line of equality, and the ECI was 0.5308, with a standard error of 0.0398 and a p value < 0.001, demonstrating that the utilization of SBA was disproportionally concentrated among women belonging to the highest socioeconomic status. The concentration index decomposition analysis showed that household wealth index (40.3%), educational level (16.5%), place of residence (16.5%), antenatal care visits (15.7%), administrative regions (5.3%), and use of maternal waiting homes (2.9%) were the contributing factors to the socioeconomic inequality in the utilization of SBA in Ethiopia.

We found a strong pro-rich socioeconomic related health inequality in the utilization of SBA in Ethiopia. Therefore, the government and responsible stakeholders need to implement targeted interventions such as improving health literacy, improving the coverage of antenatal care four visits, promoting the utilization of maternal waiting homes, and establishing financial support mechanisms for economically disadvantaged women to reduce the observed socioeconomic related health inequality in utilizing SBA.