Comparison of urban-rural inequality in quality antenatal care among women in Bangladesh and Pakistan: a multivariable decomposition analysis

TL;DR

The study compares urban-rural gaps in quality antenatal care for women in Bangladesh and Pakistan, finding wealth and education as key contributors.

Contribution

The novel contribution is the multivariable decomposition analysis revealing country-specific factors driving urban-rural inequality in antenatal care.

Findings

Urban women in Bangladesh and Pakistan are 20%-25% more likely to receive quality ANC than rural women.

Wealth status explains nearly 58% of inequality in Bangladesh and 46% in Pakistan.

Education and media exposure are significant contributors to inequality in both countries.

Abstract

Urban-rural inequality in accessing quality antenatal care (ANC) is a well-documented challenge in low- and middle-income countries like Bangladesh and Pakistan, hindering maternal healthcare utilization and progress towards the Sustainable Development Goals. This study explores the key factors contributing to this inequality in Bangladesh and Pakistan and highlights inter-country differences.

We analyzed data from Demographic Health Surveys (2017–2018) of Bangladesh and Pakistan for women aged 15–49 who had at least one live birth in the three years preceding the survey. To identify the extent and sources of inequality, we decomposed urban-rural differences in quality ANC utilization into explained (attributable to variations in socioeconomic and demographic characteristics) and unexplained (reflecting differences in the effects of these characteristics) components using Blinder-Oaxaca type models adapted for nonlinear response variables.

Urban women were significantly more likely to receive quality ANC than rural women in both Bangladesh and Pakistan, with disparities of about 20%-25% points. Most of the inequality was explained by differences in socioeconomic and educational characteristics rather than behavioral factors. Wealth status was the dominant contributor, explaining nearly 58% of the inequality in Bangladesh and 46% in Pakistan, followed by women’s and husbands’ education, media exposure, and women’s autonomy. The pattern of predictors was broadly consistent across both countries, though education contributed more in Pakistan, while media exposure and husband’s education played a larger role in Bangladesh.

Significant urban-rural inequality exists in Bangladesh and Pakistan, which is more pronounced in Pakistan. Among the common significant predictors for both countries, wealth disparity has the highest contribution percentage. In Pakistan, women’s education is the second largest contributor to inequality, whereas in Bangladesh, both media exposure and husband’s education played notable roles. Reducing urban-rural inequality in quality ANC requires targeted policies addressing wealth and educational disparities, along with interventions that promote media access and women’s autonomy to ensure equitable maternal healthcare utilization.

The online version contains supplementary material available at 10.1186/s12978-026-02266-4.

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