{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,2]],"date-time":"2026-10-02T20:40:55Z","timestamp":1790973655426,"version":"4.1.0"},"reference-count":23,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2020,1,16]],"date-time":"2020-01-16T00:00:00Z","timestamp":1579132800000},"content-version":"unspecified","delay-in-days":15,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["OPP1148933"],"award-info":[{"award-number":["OPP1148933"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100010269","name":"Wellcome","doi-asserted-by":"publisher","award":["101815\/Z\/13\/Z"],"award-info":[{"award-number":["101815\/Z\/13\/Z"]}],"id":[{"id":"10.13039\/100010269","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Glob Health"],"accepted":{"date-parts":[[2019,12,18]]},"published-print":{"date-parts":[[2020,1]]},"abstract":"<jats:sec>\n                  <jats:title>Introduction<\/jats:title>\n                  <jats:p>Wealth-related inequalities in reproductive, maternal, neonatal and child health have been widely studied by dividing the population into quintiles. We present a comprehensive analysis of wealth inequalities for the composite coverage index (CCI) using national health surveys carried out since 2010, using wealth deciles and absolute income estimates as stratification variables, and show how these new approaches expand on traditional equity analyses.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>83 low-income and middle-income countries were studied. The CCI is a combined measure of coverage with eight key reproductive, maternal, newborn and child health interventions. It was disaggregated by wealth deciles for visual inspection of inequalities, and the slope index of inequality (SII) was estimated. The correlation between coverage in the extreme deciles and SII was assessed. Finally, we used multilevel models to examine how the CCI varies according to the estimated absolute income for each wealth quintile in the surveys.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>The analyses of coverage by wealth deciles and by absolute income show that inequality is mostly driven by coverage among the poor, which is much more variable than coverage among the rich across countries. Regardless of national coverage, in 61 of the countries, the wealthiest decile achieved 70% or higher CCI coverage. Well-performing countries were particularly effective in achieving high coverage among the poor. In contrast, underperforming countries failed to reach the poorest, despite reaching the better-off.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>There are huge inequalities between the richest and the poorest women and children in most countries. These inequalities are strongly driven by low coverage among the poorest given the wealthiest groups achieve high coverage irrespective of where they live, overcoming any barriers that are an impediment to others. Countries that \u2018punched above their weight\u2019 in coverage, given their level of absolute wealth, were those that best managed to reach their poorest women and children.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjgh-2019-002229","type":"journal-article","created":{"date-parts":[[2020,1,27]],"date-time":"2020-01-27T00:25:14Z","timestamp":1580084714000},"page":"e002229","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":41,"title":["Are the poorest poor being left behind? Estimating global inequalities in reproductive, maternal, newborn and child health"],"prefix":"10.1136","volume":"5","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2022-8729","authenticated-orcid":false,"given":"Aluisio J D","family":"Barros","sequence":"first","affiliation":[{"name":"Department of Data and Analytics, WHO, Geneve, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7137-1747","authenticated-orcid":false,"given":"Fernando C","family":"Wehrmeister","sequence":"additional","affiliation":[{"name":"International Center for Equity in Health, Universidade Federal de Pelotas, Pelotas, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7843-9345","authenticated-orcid":false,"given":"Leonardo Zanini","family":"Ferreira","sequence":"additional","affiliation":[{"name":"Department of Data and Analytics, WHO, Geneve, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2840-6841","authenticated-orcid":false,"given":"Luis Paulo","family":"Vidaletti","sequence":"additional","affiliation":[{"name":"Department of Data and Analytics, WHO, Geneve, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7322-672X","authenticated-orcid":false,"given":"Ahmad Reza","family":"Hosseinpoor","sequence":"additional","affiliation":[{"name":"Post-Graduate Programme in Epidemiology, Universidade Federal de Pelotas, Pelotas, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2465-2180","authenticated-orcid":false,"given":"Cesar G","family":"Victora","sequence":"additional","affiliation":[{"name":"Department of Data and Analytics, WHO, Geneve, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2020,1,26]]},"reference":[{"key":"2025072913475226000_5.1.e002229.1","unstructured":"Gwatkin DR , Rutstein S , Johnson K , et al . Socio-economic differences in health, nutrition, and population within developing countries : an overview. Washington, DC: World Bank, 2007. http:\/\/documents.worldbank.org\/curated\/en\/962091468332070548\/pdf\/483610WP0Socio10Box338901B01PUBLIC1.pdf"},{"key":"2025072913475226000_5.1.e002229.2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(03)13917-7"},{"key":"2025072913475226000_5.1.e002229.3","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0174823","article-title":"Socioeconomic inequalities in skilled birth attendance and child stunting in selected low and middle income countries: wealth Quintiles or deciles?","volume":"12","author":"Wong","year":"2017","journal-title":"PLoS One"},{"key":"2025072913475226000_5.1.e002229.4","doi-asserted-by":"crossref","first-page":"550","DOI":"10.2105\/AJPH.2017.303657","article-title":"Measuring socioeconomic inequalities with predicted absolute incomes rather than wealth Quintiles: a comparative assessment using child stunting data from national surveys","volume":"107","author":"Fink","year":"2017","journal-title":"Am J Public Health"},{"key":"2025072913475226000_5.1.e002229.5","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(08)60560-7"},{"key":"2025072913475226000_5.1.e002229.6","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001390","article-title":"Measuring coverage in MNCH: determining and interpreting inequalities in coverage of maternal, newborn, and child health interventions","volume":"10","author":"Barros","year":"2013","journal-title":"PLoS Med"},{"key":"2025072913475226000_5.1.e002229.7","doi-asserted-by":"publisher","DOI":"10.2471\/BLT.16.173138"},{"key":"2025072913475226000_5.1.e002229.8","doi-asserted-by":"crossref","unstructured":"Akseer N , Bhatti Z , Rizvi A , et al . Coverage and inequalities in maternal and child health interventions in Afghanistan. BMC Public Health 2016;16.doi:10.1186\/s12889-016-3406-1","DOI":"10.1186\/s12889-016-3406-1"},{"key":"2025072913475226000_5.1.e002229.9","doi-asserted-by":"crossref","DOI":"10.3402\/gha.v6i0.22217","article-title":"Equity in maternal, newborn, and child health care coverage in India","volume":"6","author":"Singh","year":"2013","journal-title":"Glob Health Action"},{"key":"2025072913475226000_5.1.e002229.10","doi-asserted-by":"crossref","first-page":"1297","DOI":"10.1001\/jamainternmed.2017.3133","article-title":"Progress toward universal health coverage: a comparative analysis in 5 South Asian countries","volume":"177","author":"Rahman","year":"2017","journal-title":"JAMA Intern Med"},{"key":"2025072913475226000_5.1.e002229.11","doi-asserted-by":"crossref","DOI":"10.3402\/gha.v7.24765","article-title":"Association between coverage of maternal and child health interventions, and under-5 mortality: a repeated cross-sectional analysis of 35 sub-Saharan African countries","volume":"7","author":"Corsi","year":"2014","journal-title":"Glob Heal Action"},{"key":"2025072913475226000_5.1.e002229.12","article-title":"Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India","volume":"38","author":"Filmer","year":"2001","journal-title":"Demography"},{"key":"2025072913475226000_5.1.e002229.13","unstructured":"Rutstein SO , Johnson K . The DHS wealth index. DHS comparative reports No. 6. Calverton (MD): ORC Macro, 2004."},{"key":"2025072913475226000_5.1.e002229.14","unstructured":"Rutstein SO . The DHS wealth index: approaches for rural and urban areas. DHS work. Pap. No. 60, 2008. Available: http:\/\/dhsprogram.com\/pubs\/pdf\/WP60\/WP60.pdf"},{"key":"2025072913475226000_5.1.e002229.15","doi-asserted-by":"crossref","unstructured":"Lopez JH , Serven L . A Normal Relationship? Poverty, Growth, and Inequality. In: World bank policy research working papers, 2006: 1\u201331.","DOI":"10.1596\/1813-9450-3814"},{"key":"2025072913475226000_5.1.e002229.16","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1016\/j.econlet.2013.08.014","article-title":"Using an asset index to simulate household income","volume":"121","author":"Harttgen","year":"2013","journal-title":"Econ Lett"},{"key":"2025072913475226000_5.1.e002229.17","doi-asserted-by":"crossref","first-page":"464","DOI":"10.2105\/AJPH.2017.304277","article-title":"The inverse equity hypothesis: analyses of institutional deliveries in 286 national surveys","volume":"108","author":"Victora","year":"2018","journal-title":"Am J Public Health"},{"key":"2025072913475226000_5.1.e002229.18","doi-asserted-by":"publisher","DOI":"10.1093\/heapol\/czr038"},{"key":"2025072913475226000_5.1.e002229.19","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(04)17145-6"},{"key":"2025072913475226000_5.1.e002229.20","unstructured":"Pan American Health Organization . Strategic plan of the Championing health: sustainable development and equity. official document 345. Washington, DC: PAHO, 2013. https:\/\/www.paho.org\/hq\/dmdocuments\/2017\/paho-strategic-plan-eng-2014-2019.pdf"},{"key":"2025072913475226000_5.1.e002229.21","doi-asserted-by":"publisher","DOI":"10.1136\/jech.2009.088021"},{"key":"2025072913475226000_5.1.e002229.22","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2017-000437","article-title":"Is governance, gross domestic product, inequality, population size or country surface area associated with coverage and equity of health interventions? ecological analyses of cross-sectional surveys from 80 countries","volume":"2","author":"Wehrmeister","year":"2017","journal-title":"BMJ Glob Heal"},{"key":"2025072913475226000_5.1.e002229.23","doi-asserted-by":"crossref","DOI":"10.1186\/s12884-018-1734-0","article-title":"Absolute income is a better predictor of coverage by skilled birth attendance than relative wealth Quintiles in a multicountry analysis: comparison of 100 low- and middle-income countries","volume":"18","author":"Joseph","year":"2018","journal-title":"BMC Pregnancy Childbirth"}],"container-title":["BMJ Global Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjgh-2019-002229","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,7,29]],"date-time":"2025-07-29T20:47:59Z","timestamp":1753822079000},"score":1,"resource":{"primary":{"URL":"https:\/\/gh.bmj.com\/lookup\/doi\/10.1136\/bmjgh-2019-002229"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,1]]},"references-count":23,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2020,1,26]]},"published-print":{"date-parts":[[2020,1]]}},"alternative-id":["10.1136\/bmjgh-2019-002229"],"URL":"https:\/\/doi.org\/10.1136\/bmjgh-2019-002229","relation":{},"ISSN":["2059-7908"],"issn-type":[{"value":"2059-7908","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,1]]}}}