The healthcare services and health outcomes are inequitably distributed between and within countries (1). The inequity persists in many low and middle-income countries (2), despite efforts to foster equal access and utilization to healthcare (3, 4). Wealth-based inequities in the utilization of maternal, neonatal, and child health services exist in low-income countries (5). Shreds of evidence suggest inequities in mortality and morbidity continue to grow among the poor and marginalized socially excluded populations in low and middle-income countries (6–8). Furthermore, studies in the South Asian region have indicated that improving equitable access to child and maternal healthcare services leads to a decreased child and maternal mortality (9, 10).
Equity is defined as the equal utilization of services for equal needs (1, 11). Evidence suggests the social excluded groups are multidimensionally weaker section of the population, particularly the children and women are more likely to get suboptimal healthcare services than the advantageous one (12, 13, 14). Thereby, the morbidity and mortality rates are concentrated on the weaker side than the population on the better-off side, where the services' utilization is higher with lesser needs (15, 16). The inequities in health outcomes and services utilization raise concerns with social and economic implications among population of diverse cultural spheres based on the group identity (14, 17). As a result, equity in healthcare is set on a vital priority in the Sustainable Development Goals (SDGs) alongside Universal Health Coverage (UHC) (18). Thus, India's government has emphasized on National Health Mission (NHM) for the improvement of maternal health, which is an essential aspect of increasing equity through reaching almost to every corner of the country.
In India, considerable improvement has been observed in Maternal Mortality Rate (MMR) that is decreased by 51.96 percent, from 254 deaths per 100,000 live births in 2004-06 (19) to 122 deaths per 100,000 in 2015-17 (20). Similarly, the Infant Mortality Rate (IMR) has witnessed a sharp decline from 53 deaths per 1000 live births in 2008 to 33 deaths per 1000 live births in 2017 (21). But the demographic indicators are substantially poor among the population who are resident of a fragile ecosystem such as Indo-Bangladesh border. The resident face disclamations in the lines of regional identity. The areas have seen huge influx of cross border migration since decades which makes certain sections excluded. Studies have shown that decreasing mortality rate not necessarily assure equity in the utilization of healthcare services (22, 23, 24). A high level of inequity in health outcomes is evident within and between the states. The state-wise MMR in India revealed a wide-ranging inequity between states like Assam at 237 deaths per 100,000 live births, Uttar Pradesh at 201, and different scenarios from states like Kerala and Tamil Nadu at 46 and 66 deaths per 100,000 live births, respectively. Further, inequity in health outcomes exists within states favoring the better-off population subgroups (25).
Likewise, studies have shown that healthcare services' utilization is considerably higher among the better-off population (26, 27). Marginalized sections of the population in a disadvantaged region often have less access to healthcare services, resulting in under-utilization of services rather than the population in a less disadvantageous region (25, 28). Areas where there exists prolonged history of cross border international migration.
The under-utilization of maternal healthcare services in India largely contributes to higher mortality and morbidity (15, 29). The morbidity and mortality can be prevented with regular antenatal care, institutional delivery, and postnatal care after the delivery (30). Previous studies revealed that other than the clinical reason for maternal deaths such as hemorrhage, sepsis, obstructed labor, and anemia, socioeconomic and demographic factors play a significant role in a higher mortality rate (31). Studies have demonstrated that socioeconomic and demographic factors play a significant role in utilizing healthcare services (3, 32). Numerous studies in India documented the range of structural and contextual factors determining the utilization of healthcare services. Factors such as wealth status, education qualification, socio-cultural, socioeconomic, and accessibility-related factors have a significant association with maternal healthcare (29). Against this backdrop, geographical location further contributes to the inequity in the utilization of healthcare services (33, 34). Saprii et al., (2015) further added that the healthcare workforce's availability influences the parameters of the utilization of services in any steep terrain.
Thus, this paper attempts to assess the effect of households' wealth and socio-demographic characteristics on the utilization of maternal healthcare services along Indo-Bangladesh border districts of Assam, through a primary cross-sectional dataset among Indian women aged 15–49 years. The study assessed the wealth of household and housing conditions for three critical indicators of maternal health service utilization: Antenatal Care, Institutional Delivery, and Postnatal Care after the delivery.