Socio-Economic Inequalities in Maternity Care under Political Instability: Evidence from Egypt, Jordan, and Yemen

By Mesbah Fathy Sharaf (Assistant Professor, Department of Economics, University of Alberta, Canada) and Ahmed Shoukry Rashad (Visiting Assistant Professor, Department of Economics, Frankfurt School of Finance and Management, Germany).

Medical care during pregnancy is crucial for protecting women from health risks during and after pregnancy and has been consistently linked to better child health outcomes. As part of the global efforts to curb maternal mortality, the United Nations included the reduction in maternal mortality by two-third, between 1990 and 2015, as one of the Millennium Development Goals (MDGs). While the trend in maternal health has been over-studied, little attention has been given in the literature to the disparities in maternal health among socio-economic classes in the Arab countries, especially after the Arab Spring era.

In an earlier study, Lozano et al., (2011) tracked the progress toward the MDGs for health across the world and reported that the Arab countries had made an accelerated progress in curbing maternal mortality. In fact, the steady progress in national averages may mask socio-economic disparities underneath it, since the MDGs for health call for improvement in national averages. The growth in national averages could be attained either by improvement in the health of the poor or the better-off. Consequently, the improvement in national averages may result from the improvement in the health of the better-off, while the poor are lagging behind.

To study the economic-related inequality in maternity care utilization under political instability, we use the most recent rounds of the Demographic and Health Survey (DHS) for Egypt, Jordan, and Yemen. Concentration curves and concentration indices are used to examine the demographic and socio-economic correlates of maternity care utilization, and to assess the situation under the political instability that followed the Arab Spring. Also, we investigate the underlying factors that generate the socio-economic inequalities in maternity care utilization by decomposing the concentration index into its determinants.

We find that the degree of the socio-economic inequalities in maternity care utilization varies largely within the Arab world. The level of inequality is severe and alarming in Yemen, moderate in Egypt, and minor in Jordan. Results of the decomposition analysis show that socio- economic disparities in maternity care utilization are mainly due to the lack of economic resources and its correlates among the poor. While it might be expected that the political instability in the region would adversely affect the progress toward the MDGs for health, the progress in Egypt toward achieving health equity has not been reversed and instead, continued to improve as compared to the DHS round in 2008. However, in Yemen, the available data does not permit such comparison. Though the concentration index for Jordan did not show dramatic change, in particular between 2007 and 2012, yet this still conveys an important message that Jordan was able to maintain its progress toward achieving health equity, despite the recent political upheaval in the region.

Reducing the socio-economic disparity in maternity healthcare requires health and social policy reforms that incorporate demand-side financing programs such as health vouchers scheme and conditional cash transfers to the marginalized women and those living in deprived regions. These programs should be supplemented by supply-side interventions such as mobile clinics to deprived and remote areas, training traditional birth attendant, and upgrading health facility infrastructure and equipment for health care, which requires additional investments in the health sector. In the long run, increasing education, especially among the poor, and poverty reduction measures that focus on rural communities could help narrow the inequalities in maternity healthcare, and hence improves population health outcomes.


Lozano, R., et al. (2011). “Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis.” The lancet 378(9797): 1139-1165.

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