Call to address ethnic inequalities in access to RMNCH services
Authors: Yuan Huang
Journal: The Lancet Global Health (2018)

In The Lancet Global Health, Marilia Mesenburg and colleagues present analyses of the ethnic gaps in coverage of reproductive, maternal, and child health (RMNCH) services across 16 Latin American and Caribbean countries.1Mesenburg MA Restrepo-Mendez MC Amigo H et al.Ethnic group inequalities in coverage with reproductive, maternal and child health interventions: cross-sectional analyses of national surveys in 16 Latin American and Caribbean countries.Lancet Glob Health. 2018; 6: e902-e913Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar This important study could help to address health equity problems for ethnic minority populations in these regions. The authors considered four outcomes of RMNCH services: coverage with modern contraception, antenatal care coverage, skilled birth attendants at birth, and coverage with three doses of diphtheria-pertussis-tetanus vaccine among children aged 12–23 months. In most of the countries studied, coverage with modern contraception (median coverage ratio 0·82, IQR 0·66–0·92), antenatal care (0·86, 0·75–0·94), and skilled birth attendants (0·75, 0·68–0·92) was lower among indigenous women than in the reference group. Vaccine coverage among children only showed significant gaps in three countries. The lower uptake of services for indigenous women compared with their non-indigenous counterparts persisted after adjustment for household wealth, women's education, and urban-rural residence. However, the reasons why indigenous populations are lagging behind have not yet been fully explored. The international literature suggests that two types of factors—intrinsic or personal factors including particular socioeconomic status, cultural norms, and competence in language; and extrinsic or organisational factors focusing on geographical location, service provision, and health policies—play a part in differential access to health services and worse health outcomes among ethnic minorities.2Szczepura A Access to health care for ethnic minority populations.Postgrad Med J. 2005; 81: 141-147Crossref PubMed Scopus (182) Google Scholar, 3Stephens C Nettleton C Porter J Willis R Clark S Indigenous peoples' health—why are they behind everyone, everywhere?.Lancet. 2005; 366: 10-13Summary Full Text Full Text PDF PubMed Scopus (128) Google Scholar As the authors conclude, the differences in wealth, education, and residence considered in their work cannot completely explain the gaps in RMNCH service coverage between indigenous and non-indigenous populations. Factors such as cultural beliefs or institutional barriers are not easily measured or are rarely considered in national surveys.4Gabrysch S Campbell O Still too far to walk: Literature review of the determinants of delivery service use.BMC Pregnancy Childbirth. 2009; 9: 34Crossref PubMed Scopus (666) Google Scholar Without considering these factors, it might be difficult to fully understand the underlying causes for ethnic disadvantage in RMNCH use. Qualitative research can explore this phenomenon more deeply and provide more information on the barriers faced by indigenous populations in accessing health services One important finding from Mesenburg and colleagues' work is that although people of African descent were considerably poorer than the reference groups (which were composed mainly of people of European descent), they had similar levels of RMNCH service coverage to the reference groups. The authors suggest that this might be partly because people of African descent—unlike indigenous populations—are predominantly urban in most of the countries considered in the study. Urban residence could facilitate access to health services in at least three ways. First, geographical location could be a main concern when deciding to seek care and reaching care after a decision has been made. Previous studies in both African and Asian settings have shown that women who live in remote villages are less likely to access health-care services.5Griffiths P Stephenson R Understanding users' perspectives of barriers to maternal health care use in Maharashtra, India.J Biosoc Sci. 2001; 33: 339-359Crossref PubMed Scopus (128) Google Scholar, 6Duong DV Binns CW Lee AH Utilization of delivery services at the primary health care level in rural Vietnam.Soc Sci Med. 2004; 59: 2585-2595Crossref PubMed Scopus (83) Google Scholar, 7D'Ambruoso L Abbey M Hussein J Please understand when I cry out in pain: women's accounts of maternity services during labour and delivery in Ghana.BMC Public Health. 2005; 5: 140Crossref PubMed Scopus (150) Google Scholar Second, some rural health facilities might be underused owing to the poor quality of their services; a negative reputation of inadequate capacity and poor service attitude could prevent people from going to a health facility, even if its location is convenient.4Gabrysch S Campbell O Still too far to walk: Literature review of the determinants of delivery service use.BMC Pregnancy Childbirth. 2009; 9: 34Crossref PubMed Scopus (666) Google Scholar, 8Thaddeus S Maine D Too far to walk: maternal mortality in context.Soc Sci Med. 1994; 38: 1091-1110Crossref PubMed Scopus (1511) Google Scholar Third, rural populations might have more traditional beliefs that makes their receptivity to modern medical practice less than that of urban residents.4Gabrysch S Campbell O Still too far to walk: Literature review of the determinants of delivery service use.BMC Pregnancy Childbirth. 2009; 9: 34Crossref PubMed Scopus (666) Google Scholar The misunderstanding caused by the conflicts between clinical practices and local norms could prevent people from seeking care.9Adams V Miller S Chertow J et al.Having a “safe delivery”: conflicting views from Tibet.Health Care Women Int. 2005; 26: 821-851Crossref PubMed Scopus (50) Google Scholar, 10Harris A Zhou Y Liao H et al.Challenges to maternal health care utilization among ethnic minority women in a resource-poor region of Sichuan Province, China.Health Policy Plan. 2010; 25: 311-318Crossref PubMed Scopus (38) Google Scholar These three considerations seem fundamental to understand the ethnic disparities in health-care use between indigenous and non-indigenous populations. However, the authors were unable to explore them in the present study because of data limitation. Future studies focusing on service provision are needed that could benefit national or community health planning. Another crucial finding from Mesenburg and colleagues' work is that the services delivered at community level through campaigns such as immunisation and antenatal care are less inequitable than are services that require access to health facilities (eg, contraceptives or skilled attendant at birth). Therefore, community-based health interventions including health education campaigns conducted by community health workers who understand the local culture and language could be possible ways to increase health awareness and further change care-seeking behaviours. The authors suggest that another potential reason for the ethnic inequalities in RMNCH coverage between indigenous and non-indigenous populations is that services requiring access to health facilities might incur additional costs in user fees and transportation. The provision of small financial support such as a transportation subsidy might encourage use of health-care facilities among poorer populations. We hope that the messages from this study will not only raise awareness of the ethnic inequalities that exist in RMNCH service coverage and use, but will also motivate the conception and delivery of health-care interventions for ethnic minorities living in remote and poor communities. The Countdown to 2030 continues to improve maternal and child health globally. Ethnic minorities who shoulder a disproportionate share of the overall burden of adverse health outcomes are the target of policies and interventions aiming to achieve country-level progress by increasing the coverage of essential RMNCH interventions. A comprehensive understanding of the reasons underlying the ethnic variation in needs and access to RMNCH services is fundamental. Mesenburg and colleagues' Article should not be seen as a final product showing the severity of ethnic inequalities, but a launch pad for future studies. We call for more works to improve the information base about ethnic minorities over the world to guide future implementation of policy initiatives. I declare no competing interests. Ethnic group inequalities in coverage with reproductive, maternal and child health interventions: cross-sectional analyses of national surveys in 16 Latin American and Caribbean countriesThe lower coverage levels for indigenous women are pervasive, and cannot be explained solely by differences in wealth, education, or residence. Interventions delivered at community level—such as vaccines—show less inequality than those requiring access to services, such as birth attendance. Regular monitoring of ethnic inequalities is essential to evaluate existing initiatives aimed at the inclusion of minorities and to plan effective multisectoral policies and programmes. Full-Text PDF Open Access