BackgroundRelative to the attention given to improving the quality of and access to maternal health services, the influence of women's socio-economic situation on maternal health care use has received scant attention. The objective of this paper is to examine the relationship between women's economic, educational and empowerment status, introduced as the 3Es, and maternal health service utilization in developing countries.Methods/Principal FindingsThe analysis uses data from the most recent Demographic and Health Surveys conducted in 31 countries for which data on all the 3Es are available. Separate logistic regression models are fitted for modern contraceptive use, antenatal care and skilled birth attendance in relation to the three covariates of interest: economic, education and empowerment status, additionally controlling for women's age and residence. We use meta-analysis techniques to combine and summarize results from multiple countries. The 3Es are significantly associated with utilization of maternal health services. The odds of having a skilled attendant at delivery for women in the poorest wealth quintile are 94% lower than that for women in the highest wealth quintile and almost 5 times higher for women with complete primary education relative to those less educated. The likelihood of using modern contraception and attending four or more antenatal care visits are 2.01 and 2.89 times, respectively, higher for women with complete primary education than for those less educated. Women with the highest empowerment score are between 1.31 and 1.82 times more likely than those with a null empowerment score to use modern contraception, attend four or more antenatal care visits and have a skilled attendant at birth.Conclusions/SignificanceEfforts to expand maternal health service utilization can be accelerated by parallel investments in programs aimed at poverty eradication (MDG 1), universal primary education (MDG 2), and women's empowerment (MDG 3).

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Objective To determine if higher fertility and lower contraceptive use among the poorer segments of society should be considered an inequality, reflecting a higher desire for large families among the poor, or an inequity, a product of the poor being prevented from achieving their desired fertility to the same degree as wealthier segments of society. Methods Using the most recent Demographic and Health Surveys from 41 countries, we analysed the differences in fertility in light of modern contraceptive use, unwanted fertility (defined as actual fertility in excess of desired fertility) and the availability of family planning services found among poorer and wealthier segments of society. The asset index in each survey was used to construct wealth quintiles and the concentration index (CI) of income inequality was found in health variables. Findings The relationship between the CI found in the total fertility rate and the use of contraceptives was linear, R-square of 0.289. Unwanted births in the poorest quintile were more than twice that found in the wealthiest quintile, respectively 1.2 and 0.5, although there was wide variation among the 41 countries. The CI in our measure of family planning availability (radio messages, knowledge of services and contact with field workers) was largely positively associated with the CI in modern contraceptive prevalence, respectively R-squares of 0.392, 0.692 and 0.526. Conclusion In many countries the higher fertility and lower contraceptive use found among poorer relative to wealthier populations should be considered an inequity.Bulletin of the World Health Organization 2007;85:100-107. IntroductionIn 2000, the United Nations Millennium Declaration created the Millennium Development Goals (MDGs).1,2 These goals established the elimination of poverty and the attainment of equity as a core organizing theme for development activities, including health.3-5 A large literature on inequities in health exists, although this knowledge has not consistently translated into programmes designed to fill inequity gaps. 6,7 In contrast, there has been very little research on possible inequities in fertility, the number of children people have. We think an important reason why fertility inequities have not received much attention is that they do not easily fit into the concept of inequity.Although there is not a consensual definition of inequity, most economists and ethicists agree with Whitehead in distinguishing between a difference that has no moral implications, an inequality, and a difference that does have moral implications and is considered unjust, an inequity. Scandinavian-Americans are quite often blond is an inequality with no moral implications. Yet the fact that poor children's mortality rate from preventable diseases is much higher than that found among children from wealthier families raises many moral issues and is considered an inequity.10 A difference labelled an inequity is likely to have a societal response quite different from a difference designated as an inequality. Indee...