Socioeconomic inequalities and determinants of institutional delivery among women in Ethiopia: a cross-sectional analysis of the 2024-2025 Ethiopia Demographic and Health Survey
Based on the 2024–2025 Ethiopia Demographic and Health Survey, this study reveals that while 61.3% of women delivered in health facilities, institutional delivery remains significantly concentrated among socioeconomically advantaged women, with wealth, education, and urban residence being key determinants that necessitate targeted equity-focused policies.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Giving birth is one of the most universal human experiences, yet the safety of that moment depends heavily on where a woman lives and how much money her family has. In many parts of the world, the difference between a safe delivery in a hospital and a risky one at home often comes down to access to skilled doctors, clean equipment, and emergency care. When a mother gives birth in a health facility, she is more likely to survive complications like severe bleeding or infection, and her baby has a better chance of starting life healthy. However, even when hospitals exist, not everyone can reach them. Some women face long walks, lack of transport, or simply cannot afford the indirect costs of leaving their homes. Understanding who gets to use these life-saving services and who does not is crucial for fixing the gaps in global health.
A new study looks closely at this problem in Ethiopia, a country that has worked hard to build more clinics and train more health workers over the last few decades. Researchers wanted to know if these improvements have reached everyone equally, or if the benefits are still flowing mostly to the wealthy and educated. They turned to a massive, nationally representative survey conducted in 2024 and 2025, which asked thousands of women about their most recent births. By looking at the data, the team could map out exactly how wealth, education, and location shape a mother's choice of where to give birth.
The study focused on nearly 7,000 women who had given birth in the five years before the survey. The researchers found that while about 61 percent of these women delivered in a health facility, the situation was far from equal. The data revealed a stark divide: women who were poor, lived in rural areas, or had little to no formal education were much less likely to give birth in a hospital than their wealthier, urban, and educated counterparts. In fact, the gap was so wide that the researchers described the distribution of hospital births as heavily skewed toward the rich. If you were to line up all the women from poorest to richest, the poorest would be clustered at the bottom with very few hospital births, while the richest would be at the top with almost all of them.
To measure this inequality, the team used several tools that act like a ruler for fairness. One measure showed that the difference in hospital delivery rates between the very poorest and the very richest women was nearly 78 percentage points. Another measure indicated that a woman at the top of the wealth ladder was almost six times more likely to deliver in a facility than a woman at the bottom. These numbers held true even after the researchers accounted for other factors like age, religion, or how many children a woman already had. The most powerful predictors of where a woman gave birth were her education level and her household wealth. A woman with a higher education was four times more likely to use a health facility than a woman with no schooling, and a woman from the richest families was nearly nine times more likely to do so than a woman from the poorest families.
Where a woman lived also played a massive role. Women in cities were almost three times more likely to deliver in a hospital than those in the countryside. This is likely because cities have more clinics, better roads, and easier access to emergency transport. The study also found that the number of children a woman already had mattered. Women who were having their fourth child or more were less likely to go to a hospital than those having their first baby. The researchers suggest this might be because women with many children feel more confident in their ability to handle birth at home, or because they find it harder to leave their other children behind to go to a clinic.
Interestingly, the study found that some factors people often assume are important did not matter once wealth and education were taken into account. For example, while women who listened to the radio or watched television were more likely to use hospitals, this was mostly because those activities are common among wealthier, educated people. When the researchers looked at the data carefully, the media exposure itself did not independently push a woman to a hospital if she was poor or uneducated. Similarly, a woman's age or her specific religious group did not change the outcome once her economic situation was considered. The data suggested that money and schooling are the primary gates that open or close the door to safe delivery.
The researchers were careful to note that their work shows a snapshot of a situation, not the cause of it. Because they asked women about births that happened up to five years ago, they could not prove that a lack of money caused a home birth, only that the two things happened together. They also pointed out that the survey measured where the birth happened, not how good the care was inside the hospital. Despite these limits, the findings are clear: Ethiopia has made progress, but the benefits of that progress are not shared equally. The study concludes that simply building more hospitals is not enough. To truly fix the problem, policies must target the specific barriers faced by poor, rural, and less-educated women, such as providing transport, financial support, and education that helps them understand the value of skilled care. Without these targeted efforts, the gap between the rich and the poor in maternal health will likely remain wide.
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