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Margaret E. Kruk, MD, MPH, Marta R. Prescott, MPH and Sandro Galea, MD, DrPH

Margaret E. Kruk is with the Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, and the Averting Maternal Death and Disability Program, Columbia University, New York, NY. Marta Prescott and Sandro Galea are with the Department of Epidemiology, School of Public Health, University of Michigan. Ann Arbor.

Correspondence: Requests for reprints should be sent to Margaret E. Kruk, University of Michigan School of Public Health, Department of Health Management and Policy, 109 Observatory Rd, SPH II M3166, Ann Arbor, MI, 48109 (e-mail: mkruk{at}umich.edu).

Objectives. Developing countries with higher health care spending have greater overall utilization of maternal health services than do countries with lower spending. However, the rich tend to disproportionately use these services. We assessed whether redistributive government policies in the context of higher levels of health spending were associated with more-equitable use of skilled birth attendants (doctors, nurses, or midwives) between rich and poor.

Methods. We used data from Demographic and Health Surveys of 45 developing countries and disaggregated by wealth quintile. Multivariable regression analyses were used to assess the joint effect of higher health care expenditures, the wealth distribution of women’s fifth-grade education (a proxy for redistributive policy environment within the central government) and the overall proportion of women with fifth-grade education (a proxy for female literacy and an indicator of governments’ commitment to girls’ education).

Results. We found that utilization of skilled birth attendants was more equitable when higher health expenditures were accompanied by redistributive education policies.

Conclusions. Higher health care expenditures should be accompanied by redistributive policies to reduce the gap in utilization of skilled birth attendants between poorer and richer women in developing countries.