Equity of skilled birth attendant utilization in developing countries: financing and policy determinants.

OBJECTIVES Developing countries with higher health care spending have greater overall utilization of maternal health services than do countries with lower spending. However, the rich tend to disproportionately use these services. We assessed whether redistributive government policies in the context of higher levels of health spending were associated with more-equitable use of skilled birth attendants (doctors, nurses, or midwives) between rich and poor. METHODS We used data from Demographic and Health Surveys of 45 developing countries and disaggregated by wealth quintile. Multivariable regression analyses were used to assess the joint effect of higher health care expenditures, the wealth distribution of women's fifth-grade education (a proxy for redistributive policy environment within the central government) and the overall proportion of women with fifth-grade education (a proxy for female literacy and an indicator of governments' commitment to girls' education). RESULTS We found that utilization of skilled birth attendants was more equitable when higher health expenditures were accompanied by redistributive education policies. CONCLUSIONS Higher health care expenditures should be accompanied by redistributive policies to reduce the gap in utilization of skilled birth attendants between poorer and richer women in developing countries.