Investigating Health Inequality Using Trend, Decomposition and Spatial Analyses: A Study of Maternal Health Service Use in Nepal

Shehzad Ali*, Amardeep Thind, Saverio Stranges, M Karen Campbell, Ishor Sharma

*Corresponding author for this work

Research output: Contribution to journalArticleResearchpeer-review


Objectives: (a) To quantify the level and changes in socioeconomic inequality in the utilization of antenatal care (ANC), institutional delivery (ID) and postnatal care (PNC) in Nepal over a 20-year period; (b) identify key drivers of inequality using decomposition analysis; and (c) identify geographical clusters with low service utilization to inform policy. Methods: Data from the most recent five waves of the Demographic Health Survey were used. All outcomes were defined as binary variables: ANC (=1 if ≥4 visits), ID (=1 if place of delivery was a public or private healthcare facility), and PNC (=1 if ≥1 visits). Indices of inequality were computed at national and provincial-level. Inequality was decomposed into explanatory components using Fairile decomposition. Spatial maps identified clusters of low service utilization. Results: During 1996-2016, socioeconomic inequality in ANC and ID reduced by 10 and 23 percentage points, respectively. For PND, the gap remained unchanged at 40 percentage points. Parity, maternal education, and travel time to health facility were the key drivers of inequality. Clusters of low utilization were displayed on spatial maps, alongside deprivation and travel time to health facility. Conclusion: Inequalities in the utilization of ANC, ID and PNC are significant and persistent. Interventions targeting maternal education and distance to health facilities can significantly reduce the gap.

Original languageEnglish
Article number1605457
JournalInternational Journal of Public Health
Publication statusPublished - 2 Jun 2023


  • Female
  • Pregnancy
  • Humans
  • Maternal Health Services
  • Nepal
  • Health Status Disparities
  • Socioeconomic Factors
  • Prenatal Care


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