Socioeconomic inequalities in access to skilled birth attendance among urban and rural women in low-income and middle-income countries.

Introduction: Rapid urbanisation is one of the greatest challenges for Sustainable Development Goals. We compared socioeconomic inequalities in urban and rural women's access to skilled birth attendance (SBA) and to assess whether the poorest urban women have an advantage over the poorest rural women.

Methods: The latest available surveys (DemographicHealth Survey, Multiple Indicators Cluster Surveys) of 88 countries since 2010 were analysed. SBA coverage was calculated for 10 subgroups of women according to wealth quintile and urban-rural residence. Poisson regression was used to test interactions between wealth quintile index and urban-rural residence on coverage. The slope index of inequality (SII) and concentration index were calculated for urban and rural women.

Results: 37 countries had surveys with at least 25 women in each of the 10 cells. Average rural average coverage was 72.8 % (ranging from 17.2% % in South Sudan to 99.9 % in Jordan) and average urban coverage was 80.0% (from 23.6% in South Sudan to 99.7% in Guyana. In 33 countries, rural coverage was lower than urban coverage; the difference was significant (p<0.05) in 15 countries. The widest urban/rural coverage gap was in the Central African Republic (32.8% points; p<0.001). Most countries showed narrower socioeconomic inequalities in urban than in rural areas. The largest difference was observed in Panama, where the rural SII was 77.1% points larger than the urban SII (p<0.001). In 31 countries, the poorest rural women had lower coverage than the poorest urban women; in 20 countries, these differences were statistically significant (p<0.05).

Conclusion: In most countries studied, urban areas present a double advantage of higher SBA coverage and narrower wealth-related inequalities when compared with rural areas. Studies of the intersectionality of wealth and residence can support policy decisions about which subgroups require special efforts to reach universal coverage.