Trends, determinants and inequality of utilization of maternal healthcare services in Bangladesh: an analysis of demographic and health surveys from 2004 to 2022

BACKGROUND: Bangladesh, like many low- and middle-income countries, is lagging behind the Sustainable Development Goal (SDG) target related to reducing maternal mortality by 2030. Maternal healthcare services (MHS) utilization remains low and inequitable, contributing to poor maternal outcomes. This study analyzed trends, determinants, and inequalities in MHS utilization in Bangladesh from 2004 to 2022. METHODS: We analyzed six rounds of the Bangladesh Demographic and Health Survey (2004-2022) with sample sizes of 5,206, 4,773, 6,176, 4,390, 4,928, and 4,921, focusing on women aged 15-49 with the most recent birth who had given birth within five years preceding the surveys. We considered four important maternal health service indicators, including attending at least four antenatal care (ANC) visits with medically trained providers, skilled birth attendance (SBA), institutional delivery (ID), and postnatal care (PNC) for the mother by medically trained providers within two days of childbirth. Survey-adjusted logistic regression and dominance analysis identified key MHS utilization predictors, while concentration curves and absolute and relative measures assessed inequality across equity strata (categories/stratifiers used to compare differences in MHS utilization across population subgroups, such as urban vs. rural, poorest to richest, no education to higher education, etc.). RESULTS: Between 2004 and 2022, access to ANC, SBA, and ID increased by 21.6%, 53.1%, and 52.2%, respectively, whereas for PNC, the increase was 32.4% between 2007 and 2022. Key predictors of MHS utilization included residence, education, wealth, media exposure, parity, and pregnancy termination. For instance, in 2022, rural women were 29% less likely to use ANC (AOR = 0.71; 95% CI: 0.59-0.86) compared to 54% in 2004 (AOR = 0.46; 95% CI: 0.35-0.60). Wealthier women were significantly more likely to utilize SBA, with the richest quintile being 4.3 times more likely in 2004 and 3.8 times more likely in 2022. Wealth, and the respondent's and their husband's education levels were the strongest predictors of MHS utilization. While inequalities across difference places of residence, wealth, and education levels have declined, disparities persist. Wealth-related inequality in ANC, SBA, and ID was lowest in 2022 but highest in 2004, with substantial reductions in relative and absolute disparities over time. CONCLUSIONS: Despite increased maternal healthcare utilization in Bangladesh from 2004 to 2022, disparities persist across wealth, respondent and husbands' education, and place of residence. Targeted interventions are needed to reduce inequality and align with SDG targets by 2030.