{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T12:11:32Z","timestamp":1790856692958,"version":"4.1.0"},"reference-count":60,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2024,4,12]],"date-time":"2024-04-12T00:00:00Z","timestamp":1712880000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec><jats:title>Introduction<\/jats:title><jats:p>Aggregate statistics of maternal health care services have improved in Ethiopia. Nevertheless, the country has one of the lowest Universal Health Coverage (UHC) service coverage indices, with slight improvement between 2000 and 2019. There are disparity studies that focus on a single dimension of inequality. However, studies that combine multiple dimensions of inequality simultaneously may have important policy implications for closing inequalities. In this study, we investigated education inequalities in the receipt of maternal health care services in rural and urban areas separately, and we examined whether these inequalities decreased, increased, or remained unchanged.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>The data for the study came from the 2011 and 2016 Ethiopia Demographic and Health Surveys. Using women's education as a dimension of inequality, we separately analyzed inequalities in maternal health care services in urban and rural settings. Inequalities were measured through the Erreygers concentration index, second differences, and Relative Index of Inequality (RII). Whether inequalities changed over time was analyzed by relative and absolute measures. An Oaxaca-type decomposition approach was applied to explain changes in absolute disparities over time.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>There were glaring educational disparities in maternal health care services in urban and rural areas, where the services were more concentrated among women with better schooling. The disparities were more severe in urban than in rural areas. In urban areas, skilled birth service was the most unequal in both periods. Disparities in rural places were roughly similar for all services except that in 2011, postnatal care was the least unequal, and in 2016, skilled birth was the most unequal services. Trend analyses revealed that disparities significantly dropped in urban by absolute and relative measures. Conversely, in rural regions, the disparities grew by the concentration index measure for most services. The RII and second differences presented conflicting results regarding whether the gaps were increasing, shrinking, or remaining the same.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Substantial disparities in maternal health care services remained and even increased, as in rural areas. Different and targeted strategies are needed for urban and rural places to close the observed educational inequalities in these areas.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fpubh.2024.1332801","type":"journal-article","created":{"date-parts":[[2024,4,12]],"date-time":"2024-04-12T04:21:25Z","timestamp":1712895685000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":6,"title":["Explaining changes in educational disparities in competent maternal health care services in urban and rural areas in Ethiopia"],"prefix":"10.3389","volume":"12","author":[{"given":"Gebretsadik","family":"Shibre","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wubegzier","family":"Mekonnen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Damen","family":"Haile Mariam","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2024,4,12]]},"reference":[{"key":"B1","unstructured":"The Global Health Observatory. Explore a World of Health Data. SDG Target 3.8: Achieve Universal Health Coverage (UHC)."},{"key":"B2","unstructured":"GenevaWorld Health Organization.Tracking Universal Health Coverage: (2017). Global Monitoring Report2017"},{"key":"B3","unstructured":"GenevaWorld Health Organization.Health Equity Assessment Toolkit (HEAT): Software for exploring and comparing health inequalities in countries. Built-in database edition. Version 5.02023"},{"key":"B4","doi-asserted-by":"publisher","first-page":"e017142","DOI":"10.1136\/bmjopen-2017-017142","article-title":"Women's decision-making autonomy and utilisation of maternal healthcare services: results from the Bangladesh Demographic and Health Survey","volume":"7","author":"Ghose","year":"2017","journal-title":"BMJ Open."},{"key":"B5","doi-asserted-by":"publisher","first-page":"e065674","DOI":"10.1136\/bmjopen-2022-065674","article-title":"Trends and patterns of inequalities in using facility delivery among reproductive-age women in Bangladesh: a decomposition analysis of 2007\u20132017 Demographic and Health Survey data","volume":"12","author":"Rahman","year":"2022","journal-title":"BMJ Open"},{"key":"B6","doi-asserted-by":"publisher","first-page":"e040450","DOI":"10.1136\/bmjopen-2020-040450","article-title":"Twelve-year persistence of inequalities in antenatal care utilisation among women in Tanzania: a decomposition analysis of population-based cross-sectional surveys","volume":"11","author":"Bintabara","year":"2021","journal-title":"BMJ Open"},{"key":"B7","doi-asserted-by":"publisher","first-page":"e057681","DOI":"10.1136\/bmjopen-2021-057681","article-title":"Individual and contextual factors associated with maternal healthcare utilisation in Mali: a cross-sectional study using Demographic and Health Survey data","volume":"12","author":"Bain","year":"2022","journal-title":"BMJ Open"},{"key":"B8","unstructured":"Determinants of antenatal care use in nine sub-Saharan African countries: a statistical analysis of cross-sectional data from Demographic and Health Surveys\n            AndegiorgishAK\n            ElhoumedM\n            QiQ\n            ZhuZ\n            ZengL\n          10.1136\/bmjopen-2021-05167535149562BMJ Open.2022"},{"key":"B9","doi-asserted-by":"publisher","first-page":"e063426","DOI":"10.1136\/bmjopen-2022-063426","article-title":"Multilevel analysis of quality of antenatal care and associated factors among pregnant women in Ethiopia: a community based cross-sectional study","volume":"12","author":"Negash","year":"2022","journal-title":"BMJ Open"},{"key":"B10","doi-asserted-by":"publisher","first-page":"239","DOI":"10.1186\/s12884-022-04571-9","article-title":"Decomposing maternal socioeconomic inequalities in Zimbabwe; leaving no woman behind","volume":"22","author":"Lukwa","year":"2022","journal-title":"BMC Preg Childbirth"},{"key":"B11","unstructured":"Tracking Universal Health Coverage: 2021 global monitoring report. Geneva: World Health Organization and International Bank for Reconstruction and Development\/The World Bank2021"},{"key":"B12","doi-asserted-by":"publisher","first-page":"152","DOI":"10.1186\/s12939-017-0648-1","article-title":"Examining changes in maternal and child health inequalities in Ethiopia","volume":"16","author":"Ambel","year":"2017","journal-title":"Int J Equity Health"},{"key":"B13","doi-asserted-by":"publisher","first-page":"5421","DOI":"10.3390\/ijerph19095421","article-title":"Wealth and education inequities in maternal and child health services utilization in rural Ethiopia","volume":"19","author":"Wuneh","year":"2022","journal-title":"Int J Environm Res Public Health"},{"key":"B14","doi-asserted-by":"publisher","first-page":"367","DOI":"10.1186\/s12913-017-2298-9","article-title":"Socioeconomic inequalities in the uptake of maternal healthcare services in Ethiopia","volume":"17","author":"Mezmur","year":"2017","journal-title":"BMC Health Serv Res"},{"key":"B15","unstructured":"Addis AbabaMinistry of Health-EthiopiaMinistry of Health. National Health Equity Strategic Plan 2020\/21-2024\/25.2020"},{"key":"B16","doi-asserted-by":"publisher","DOI":"10.1186\/s12939-022-01680-x","article-title":"A policy analysis of policies and strategic plans on Maternal, Newborn and Child Health in Ethiopia","author":"Rono","year":"2022","journal-title":"Int J Equity Health"},{"key":"B17","volume-title":"Ethiopia National Heath Accounts Report, 2019\/20.","year":"2022"},{"key":"B18","doi-asserted-by":"publisher","first-page":"100771","DOI":"10.1016\/j.cegh.2021.100771","article-title":"Trends, regional inequalities and determinants in the utilization of prenatal care and skilled birth attendant in Ethiopia: A multilevel analysis","volume":"11","author":"Woldeamanuel","year":"2021","journal-title":"Clin Epidemiol Glob Health."},{"key":"B19","doi-asserted-by":"publisher","first-page":"S64","DOI":"10.2105\/AJPH.2018.304922","article-title":"Advancing health services research to eliminate health care disparities","volume":"109","author":"Wasserman","year":"2019","journal-title":"Am J Public Health"},{"key":"B20","doi-asserted-by":"publisher","DOI":"10.1093\/heapol\/czt045","article-title":"Determinants of prenatal care use: evidence from 32 low-income countries across Asia, Sub-Saharan Africa and Latin America","author":"Guliani","year":"2014","journal-title":"Health Policy Plan."},{"key":"B21","volume-title":"Handbook on Health Inequality Monitoring with a Special Focus on Low- and Middle-Income Countries","year":"2013"},{"key":"B22","volume-title":"Guide to DHS Statistics","author":"Croft","year":"2018"},{"key":"B23","unstructured":"Central StatisticalAgency\/Ethiopia\n            ICFInternational\n          Addis Ababa, EthiopiaCentral Statistical Agency\/Ethiopia and ICF International;Ethiopia Demographic and Health Survey 20112012"},{"key":"B24","volume-title":"Ethiopia Demographic and Health Survey 2016.","author":"Central Statistical","year":"2017"},{"key":"B25","unstructured":"Births Attended by Skilled Health Personnel"},{"key":"B26","unstructured":"Equity Stratifiers2022"},{"key":"B27","doi-asserted-by":"publisher","DOI":"10.1186\/s12978-022-01432-8","article-title":"Female education and maternal health care utilization: evidence from Uganda","author":"Amwonya","year":"2022","journal-title":"Reprod Health"},{"key":"B28","doi-asserted-by":"publisher","first-page":"231","DOI":"10.4103\/ijabmr.ijabmr_121_21","article-title":"Effect of women's and partners' education on maternal health-care services utilization in five empowered action group States of India: an analysis of 13,443 women of reproductive age","volume":"11","author":"Yadav","year":"2021","journal-title":"Int J Appl Basic Med Res"},{"key":"B29","unstructured":"UnitedNations Girls' Education Initiative\n          Why Educating Girls is the Answer to Sustainable Development."},{"key":"B30","doi-asserted-by":"publisher","DOI":"10.1186\/s12884-017-1246-3","article-title":"Factors influencing utilisation of maternal health services by adolescent mothers in Low-and middle-income countries: a systematic review","author":"Banke-Thomas","year":"2017","journal-title":"BMC Preg Childbirth"},{"key":"B31","doi-asserted-by":"publisher","DOI":"10.1186\/s12884-017-1499-x","article-title":"Examining the mechanisms by which women's status and empowerment affect skilled birth attendant use in Senegal: a structural equation modeling approach","author":"Shimamoto","year":"2017","journal-title":"BMC Preg Childbirth"},{"key":"B32","doi-asserted-by":"publisher","first-page":"2","DOI":"10.7189\/jogh.10.020434","article-title":"SWPER Global: A survey-based women's empowerment index expanded from Africa to all low- and middle-income countries","volume":"10","author":"Ewerling","year":"2020","journal-title":"J Glob Health"},{"key":"B33","volume-title":"The DHS Wealth Index","author":"Rutsein","year":"2004"},{"key":"B34","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph19126969","article-title":"Summary measures of health inequality: a review of existing measures and their application","author":"Schlotheuber","year":"2022","journal-title":"Int J Environ Res Public Health"},{"key":"B35","doi-asserted-by":"publisher","first-page":"702","DOI":"10.1093\/aje\/kwh090","article-title":"A modified poisson regression approach to prospective studies with binary data","volume":"159","author":"Zou","year":"2004","journal-title":"Am J Epidemiol"},{"key":"B36","doi-asserted-by":"crossref","first-page":"1245","DOI":"10.1214\/aos\/1176344010","article-title":"On a characterization of Ridits","volume":"5","author":"Brockett","year":"1977","journal-title":"Ann Statis"},{"key":"B37","unstructured":"NewsonR\n          WRIDIT: Stata module to generate weighted ridits.2021"},{"key":"B38","unstructured":"GenevaWorld Health Organization.Health Equity Assessment Toolkit Plus (HEAT Plus): Software for exploring and comparing health inequalities in countries. Upload database edition. Version 1.02017"},{"key":"B39","doi-asserted-by":"publisher","first-page":"81","DOI":"10.15195\/v6.a4","article-title":"Best practices for estimating, interpreting, and presenting nonlinear interaction effects","volume":"6","author":"Mize","year":"2019","journal-title":"Sociol Sci"},{"key":"B40","doi-asserted-by":"publisher","first-page":"015","DOI":"10.1177\/1536867X19893644","article-title":"Stata tip 134: multiplicative and marginal interaction effects in nonlinear models","volume":"19","year":"2019","journal-title":"Stata J"},{"key":"B41","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1177\/1536867X1601600112","article-title":"conindex: estimation of concentration indices","volume":"16","author":"O'Donnell","year":"2016","journal-title":"Stata J."},{"key":"B42","doi-asserted-by":"publisher","first-page":"659","DOI":"10.1016\/j.jhealeco.2012.10.012","article-title":"On correcting the concentration index for binary variables","volume":"32","author":"Kjellsson","year":"2013","journal-title":"J Health Econ."},{"key":"B43","volume-title":"Analyzing Health Equity Using Household Survey Data. A Guide to Techniques and Their Implementation","author":"O'Donnell","year":"2008"},{"key":"B44","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-021-06854-x","article-title":"Maternal education level and maternal healthcare utilization in the Democratic Republic of the Congo: an analysis of the multiple indicator cluster survey 2017\/18","author":"Wang","year":"2021","journal-title":"BMC Health Serv Res"},{"key":"B45","unstructured":"Learning and Development! | UNICEF Ethiopia"},{"key":"B46","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0254281","article-title":"Women empowerment and skilled birth attendance in sub-Saharan Africa: a multi-country analysis","author":"Dickson","year":"2021","journal-title":"PLoS ONE"},{"key":"B47","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh-2020-002430","article-title":"The impact of a health facility construction campaign on health service utilisation and outcomes: analysis of spatially linked survey and facility location data in Ethiopia","author":"Croke","year":"2020","journal-title":"BMJ Glob Health"},{"key":"B48","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph17124292","article-title":"Barriers to accessing maternal care in low income countries in africa: a systematic review","author":"Dahab","year":"2020","journal-title":"Int J Environ Res Public Health"},{"key":"B49","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1007\/s11205-019-02187-9","article-title":"Approaches and alternatives to the wealth index to measure socioeconomic status using survey data: a critical interpretive synthesis","volume":"148","author":"Poirier","year":"2020","journal-title":"Soc Indic Res"},{"key":"B50","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-020-08480-4","article-title":"Inequalities in the utilisation of maternal health care in rural India: evidences from national family health survey III & IV","author":"Ali","year":"2020","journal-title":"BMC Public Health"},{"key":"B51","unstructured":"Why addressing women's income and time poverty matters for sustainable development\n            UNWomen\n          World Survey on the Role of Women in Development2019"},{"key":"B52","doi-asserted-by":"publisher","first-page":"1845","DOI":"10.2105\/AJPH.2009.179689","article-title":"Innovative approaches to reducing financial barriers to obstetric care in low-income countries","volume":"100","author":"Richard","year":"2010","journal-title":"Am J Public Health"},{"key":"B53","doi-asserted-by":"publisher","first-page":"564","DOI":"10.34172\/ijhpm.2020.104","article-title":"Cost of utilising maternal health services in low- and middle-income countries: a systematic review","volume":"10","author":"Banke-Thomas","year":"2020","journal-title":"Int J Health Policy Manag"},{"key":"B54","unstructured":"Fee exemption for maternal care in Sub-Saharan Africa: a review of 11 countries and lessons for the region\n            RichardF\n            AntonyM\n            WitterS\n            KelleyA\n            SieleunouI\n            Meessen B etal\n          Global Health Govern2013"},{"key":"B55","article-title":"Ethiopia health sector development programme","author":"Ethiopia","year":"2008","journal-title":"HSDP iii. 2005\/06 \u2013 2010\/11 (GC) (1998 \u2013 2003). EFY)."},{"key":"B56","year":"2017","journal-title":"ETHIOPIAN Emergency Obstetric and Newborn Care (EmONC) Assessment 2016)"},{"key":"B57","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1000327","article-title":"Examining the \u201curban advantage\u201d in maternal health care in developing countries","author":"Matthews","year":"2010","journal-title":"PLoS Med"},{"key":"B58","doi-asserted-by":"publisher","DOI":"10.1080\/27707571.2022.2046908","article-title":"Socio-cultural beliefs and practices during pregnancy, child birth, and postnatal period: a qualitative study in Southern Ghana","author":"Ansong","year":"2022","journal-title":"Cogent Public Health"},{"key":"B59","doi-asserted-by":"publisher","DOI":"10.1186\/s12884-018-1721-5","article-title":"Exploring barriers to the use of formal maternal health services and priority areas for action in Sidama zone, southern Ethiopia","author":"Kea","year":"2018","journal-title":"BMC Preg Childbirth"},{"key":"B60","volume-title":"Potential Bias and Selectivity in Analyses of Children Born in the Past Five Years Using DHS Data","author":"Rutstein","year":"2014"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2024.1332801\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,4,12]],"date-time":"2024-04-12T04:21:35Z","timestamp":1712895695000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2024.1332801\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,4,12]]},"references-count":60,"alternative-id":["10.3389\/fpubh.2024.1332801"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2024.1332801","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,4,12]]},"article-number":"1332801"}}