Socioeconomic equity in maternal health services use in Bangladesh: The role of service readiness in health facilities during the period 2001–2016

Abstract

Background Equity in health service utilization refers to equal treatment for equal health needs, regardless of socioeconomic status. In low- and middle-income countries, inequity in maternal health service use remains a pressing issue in the pursuit of universal health coverage by 2030. This study examines whether socioeconomic equity in the use of key maternal health services—antenatal care (ANC) from a medically trained provider, facility delivery, and management of complications—improved faster in districts with high facility readiness than elsewhere in Bangladesh between 2001 and 2016. Methods and findings We analyzed data from three rounds of the Bangladesh Maternal Mortality and Health Care Survey and corresponding Bangladesh Health Facility Survey rounds. These datasets were linked at the district level and pooled for the years 2001, 2010, and 2016. Using an adaptation of the Difference-in-Differences (DID) model based on linear probability models, we estimated whether poor-nonpoor gaps in maternal health service utilization changed differently over time in districts with high facility readiness than in districts with lower readiness. Bangladesh achieved substantial improvements in overall maternal health service use during the study period. However, these gains were not equitably distributed. Socioeconomic equity improved modestly for ANC and complication management but worsened significantly for facility deliveries. The gap between nonpoor and poor women widened more in high facility readiness districts than in low readiness districts (p < 0.05). Additionally, equity in ANC use improved among women living within one hour of a private facility (p < 0.05). Conclusions This is the first systematic investigation of the role of facility readiness in maternal health equity in Bangladesh using nationally representative data. Despite overall progress, persistent and, in some cases, widening socioeconomic inequities were observed—especially in facility-based delivery. These findings highlight the need for targeted policy action to ensure that improvements in service readiness translate into more equitable maternal healthcare access and outcomes.