UNFPAState of World Population 2002
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HOME: STATE OF WORLD POPULATION 2002: Health and Poverty
State of World Population
Characterizing Poverty
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Health and Poverty

Reproductive Health and Poverty
Measuring Health Differentials between Rich and Poor
Supporting More Equitable Health Care

Measuring Health Differentials between Rich and Poor

Health gaps between rich and poor are generally wider in poorer countries than richer ones, but this does not have to be so. Countries that design their health systems to promote equality can show a narrow range of difference, regardless of income. Viet Nam has reduced the differences between richest and poorest on most health measures (including those related to reproductive health) to less than two to one (15).

This applies to rich countries as well as poor ones. In the United States, the country that spends the most on health care per capita in the world, inequalities in access to health care are higher than in other industrialized states. These disparities mean that overall health performance is worse; for example, infant and child mortality in the United States is higher than in most European Union countries.

INFANT MORTALITY AND WEALTH A study of infant mortality and reproductive health indicators in 44 developing countries (16) reveals very wide differences between regions, and between rich and poor within countries. National averages tell only part of the story: child survival and reproductive health are matters of internal equity as well as overall wealth or poverty. Child survival and child health are tied to income levels, between and within nations. Child mortality levels in some poor communities in the United States, for example, rival those in Panama (17).

Poor infants and children are more likely to die than children in better-off families. In some countries, for example, the under-5 mortality rate of the poorest 20 per cent of the population is more than four times that of the richest 20 per cent (18). Comparing 44 developing countries, the average infant mortality rate in the poorest families is twice as high as in the richest families. The goal of halving infant mortality could be reached in several regions by bringing national averages down to the levels of the richest 20 per cent.

But in some regions it will be more difficult. In sub-Saharan Africa and South Asia, which have the highest infant mortality, the gap between the richest and the poorest is smaller, and even among the richest 20 per cent infant deaths are higher than the average in other regions.

Health risks to infants and children are worse in poor families with many children. Larger families are more common among the poor and the children in them are less likely to receive even basic preventive health care (19). If the children become ill, they are less likely to be treated. If the sick child is a girl, her risks can be even higher.

Figure 4: Infant mortality differentials
Average deaths per 1,000 live births, richest fifth to poorest fifth of population, by region

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SAFE MOTHERHOOD In any country, poor women are far more likely than rich women to die in childbirth. Rates of maternal mortality show a greater disparity between rich and poor nations than any of the other commonly used public health indicators, including infant mortality rates. Maternal mortality is a function of access to resources and access to care: women who become pregnant in developing countries face a risk of maternal death 80 to 600 times higher than women in developed counties (20).

A woman's lifetime risk of dying due to maternal causes (pregnancy, delivery and related complication) is:

  • in Africa, one in 19;
  • in Asia, one in 132;
  • in Latin America, one in 188;
  • in more-developed countries, only one in 2,976 (21).

A mother's death is more than a personal tragedy. It can have severe consequences, not only for her family, but also for the community and the economy. When mothers die, their young children are also more likely to die (22).

Approximately 500,000 women die each year from maternal causes, and many times that number suffer illnesses and injuries associated with pregnancy and childbirth.

Ninety-nine per cent of these deaths occur in developing countries (23). These maternal mortality differences reflect both higher risk and the larger number of births in developing countries.

Unwanted fertility, leading to the birth of unplanned and unwanted children, is higher in poorer settings and among the poorest of the poor. There is less information on maternal morbidity (24) but the differentials are likely to be similar, since the causes-lack of information, access, community and family support, finance, transport and provider quality (25) -are broadly the same as those that produce unwanted children.

There are also wide differences within countries. The outcomes of pregnancy depend on the health and age of the mother, her nutritional status, her prior pregnancy history and the spacing between her previous births, as well as her available resources, her education and her access to information and services.

Protecting the health of mother and baby requires:

  • good antenatal care;
  • skilled attendants;
  • a safe place to give birth;
  • access to emergency obstetric care.

Most maternal deaths could be prevented. Complications of pregnancy and childbirth are a leading cause of death and disability for women aged 15-49 in most developing countries. Better care in childbirth and more access to it would substantially reduce maternal mortality.

Poorer women do not have access to the more costly services before or during delivery. Access to and use of maternal services still tend to be more affected by wealth than either contraceptive use or completed fertility (see figures below), perhaps because of the relatively high fees for attendants or hospitals.

GOOD ANTENATAL CARE The lower a woman's income, the less likely she is to seek antenatal care, but restrictions on women also reduce access. In 44 countries studied, more than three quarters of pregnant women visit a doctor, nurse or midwife at some point in their pregnancy. In South Asia and North Africa, where women's mobility is more restricted, the figure is nearer one third.

The gap between rich and poor families is greatest when national averages are lowest. In South Asia the gap between the richest and poorest groups results from particularly high levels of care among the richest-even in relation to the next 20 per cent. In North Africa, where the rich/poor gap is even greater, differences between the wealth groups are more evenly distributed.

SKILLED BIRTH ATTENDANTS Poorer women are even less likely to have skilled assistance at delivery than to seek antenatal care. In Asian countries and sub-Saharan Africa they are half as likely. In North Africa, however, women are more likely to give birth with skilled assistance than to seek care during pregnancy.

Increases in antenatal care and attended delivery as wealth increases are sharper than for other basic health care services, such as oral rehydration therapy or medical treatment for diarrhoea, medical treatment for acute respiratory infections or immunization. Attendance by a doctor is the most sensitive to income (26).

A SAFE PLACE TO GIVE BIRTH Childbirth at home or in a health facility is also strongly related to wealth. In the 44 countries studied, nearly 80 per cent of the poorest quintile have their children at home. Nearly 80 per cent of births in the richest families are at a health facility, as are most births in the two richest quintiles. At each lower wealth group, the proportion of home births increases.

Figure 5: Antenatal care differentials
Per cent of pregnant women served by a doctor, nurse or midwife, poorest fifth to richest fifth of population, by region

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Figure 6: Trained delivery differentials
Per cent of births attended by a skilled attendant, poorest fifth to richest fifth of population, by region

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FERTILITY AND CONTRACEPTIVE USE There is little difference in fertility between income groups in countries with fertility rates above six children per woman (for example, Nigeria, Mali, Madagascar, Malawi, Niger, Zambia, Burkina Faso, Benin and Uganda). The wealthiest tend to have fewer children than the poorer, but total fertility is never as low as four.

In Latin American countries, where fertility ranges from about 3.5 to 5.1 children per woman, the differences by wealth group are among the largest in the world. In six countries, the wealthiest quintile has fertility rates below replacement (less than 2.1 children), while the poorest have 2.5 to 3.5 more children per woman.

In intermediate-level fertility countries in Europe and Asia, the wealthiest families are at or below replacement level fertility and the poorest have more than twice as many children (4.6 in Kyrgyz Republic). In the Asian countries reviewed (national fertility between 2.3 and 4.9) not all the wealthy groups have reached low fertility levels. In five, the wealthiest have reached fertility levels at or below replacement while the poorest are higher (between 3.1 in Viet Nam, and 6.5 in the Philippines). Other countries are earlier in the transition. In Nepal only the wealthiest had fewer than four children (2.9). In Pakistan only the wealthiest had as few as four children, and all groups of poorer women had between 4.9 and 5.1.

FAMILY PLANNING USE Differences in access, acceptance and use of family planning accounts for most of the difference in the fertility of rich and poor.

The higher the overall level of women's contraceptive use, the lower the differential between women in the richest and poorest groups. Once family planning use exceeds 40-45 per cent overall, the differences between wealth groups narrows considerably, and family planning becomes accepted as the norm.

In sub-Saharan African countries, where contraceptive prevalence is only around 10 per cent, the richest use family planning more than five times as often as the poorest (27). In Pakistan, the country with the lowest overall prevalence in South Asia (9 per cent) the difference is 20 times. In Nepal, with a prevalence of 26 per cent, the difference is less than three times. Differences are large in the Philippines, where contraceptive use is low; but in Indonesia and Viet Nam, where contraceptive prevalence is high, wealth differentials are relatively low. Several European and Central Asian countries have reached overall prevalence levels of family planning close to 50 per cent, with lower differences between richer and poorer.

In Latin America, overall contraceptive prevalence rates are high. In the lower-prevalence countries, internal wealth differentials are greater. In high-prevalence countries, family planning is widely accepted, and other factors contribute to a varied relationship between wealth levels and prevalence. In North Africa, the rich are twice as likely as the poor to use contraception.

Figure 7: Fertility differentials
Births per woman, richest fifth to poorest fifth of population, by region

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Figure 8: : Family planning differentials
Contraceptive prevalence, poorest fifth to richest fifth of population, by region

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ADOLESCENT CHILDBEARING The poorest women start their childbearing earliest. In many developing countries, poor women start bearing children between ages 15 and 19. Their higher levels of pregnancy reflect early marriage, less ability to negotiate delays in sex and reproduction, and less access to family planning.

Countries with low adolescent fertility overall have larger differences in fertility between poorer and richer young people. The exception is Latin America, with a relatively high overall level of adolescent fertility and wide differences between the wealthiest and poorest. The poorest families have extremely high rates of childbearing among the young.

In Indonesia, the Philippines and Viet Nam, the poorest adolescents are nearly seven times as likely to have children as their better-off counterparts. In the Philippines, poor young women are nearly 11 times as likely to have a child. In all three countries, reductions in youthful fertility are systematically related to increases in wealth.

In Egypt, adolescent fertility differences reflect wealth levels in a regular way. In Morocco, adolescent fertility is much lower in wealthier than in poorer families.

Countries in Europe and Central Asia do not show a regular relation between wealth and adolescent fertility, indicating a complex interaction among service access, ethnic variation and regional differentials. The wealthiest subgroups still have the lowest adolescent fertility, however.

Latin American countries show a large gap between the poorest group (ranging from 105 to 234 births per thousand adolescent women) and the three middle quintiles, and another large gap between these intermediate groups and the wealthiest (ranging from 18 to 58). Only in Haiti, the poorest country in the region, does a single large gap occur between the richest quintile and the four poorest.

In some of the 22 countries reviewed in sub-Saharan Africa, adolescent fertility decreases with higher wealth (28). Many others show a large difference between the wealthiest group and the others but there are no systematic differences among the poorer groups, probably because these are all least-developed countries, and the wealthier are well-to-do only in comparison with the poorest. Compared to other regions, nearly everyone is very poor (29).

Figure 9: : Adolescent fertility differentials
Births per thousand women aged 15-19, richest fifth to poorest fifth of population, by region

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Figure 10: Relative disadvantage of successive wealth groups on elements of reproductive health

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OVERVIEW OF DIFFERENCES BY WEALTH There are glaring differences in infant mortality between poorer families and the better off. The "reproductive health gap" between wealthier and poorer is often at least as wide. The largest overall difference between the poorest and wealthiest groups is in assisted delivery (an expensive service), but the measure that most clearly sets one income group off from the next is adolescent fertility. The teenage pregnancy gap between richer and poorer is wider than the gap in both trained birth attendance and infant mortality.

The use of family planning services depends less on cost than on personal motivation and institutional commitment to providing the service, so older age groups show smaller gaps between richer and poorer. For the young, early marriage, social pressure and reluctance to spend public money on protecting their reproductive health increase the dangers of being both young and poor.

NON-WEALTH-BASED HEALTH DIFFERENTIALS Well-being and wealth depend on more than income and bank balances. Physical and social infrastructure, opportunities, resources, skills and information all add or subtract, reinforced by complex social processes of inclusion and exclusion. Geographical location is important: rural areas provide lower levels of services, information and opportunities than urban areas.

Some of the reproductive health differentials reflect rural poverty, but differences can be seen within both urban and rural areas (30). Fewer rural residents reach the income levels seen in cities, but the poorest have the worst services in both. In India, for example, total and adolescent fertility levels, contraceptive usage and immunization levels are very similar across the wealth spectrum in rural and urban areas. The poorest in rural areas are more disadvantaged than their counterparts in cities-rural families have less access to safe delivery services, particularly if they involve highly trained personnel or specialized facilities. In the richest groups, the differences are minor (31).

Urban areas are growing rapidly, and the majority of the world's poor will soon be urban (32). In theory, economies of scale and ease of access could increase coverage, but there are already large inequities in access to basic services within cities. On the other hand, smaller cities, while better served than rural areas, compare poorly to larger cities (33).

The relative disadvantage of medium-sized cities in providing health quality and service is a growing problem as a larger proportion of urban dwellers comes to live in them (34). Municipal and other local authorities have more responsibility under the decentralization of public health administration, an aspect of health reform, without the corresponding resources or revenueraising authority. Local governments will find it increasingly difficult to fill the gaps in services.

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