Maternal health care in vietnam, demand for antenatal care and choice of delivery care services

UNIVERSITY OF ECONOMICS ERAMUS UNIVERSITY ROTTERDAMVIETNAM - NETHERLANDS PROGRAMME FOR M.A IN DEVELOPMENT ECONOMICS MATERNAL HEALTH CARE IN VIETNAM: DEMAND FOR ANTENATAL CARE AND CHOICE

UNIVERSITY OF ECONOMICS ERAMUS UNIVERSITY ROTTERDAM

VIETNAM - NETHERLANDS PROGRAMME FOR M.A IN DEVELOPMENT ECONOMICS

MATERNAL HEALTH CARE IN VIETNAM: DEMAND FOR

ANTENATAL CARE AND CHOICE OF DELIVERY CARE

SERVICES

By Nguyen Thi Hoai Trang

A Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of

Master of Art in Development Economics

Academic Supervisor: Dr Truong Dang Thuy

HO CHI MINH CITY, June 2016

“This is to certify that this thesis entitled “MATERNAL HEALTH CARE IN VIETNAM:

DEMAND FOR ANTENATAL CARE AND CHOICE OF DELIVERY CARE SERVICES”, which is submitted by me in fulfillment of the requirements for the degree of

Master of Art in Development Economics to the Vietnam – The Netherlands Programme (VNP).The thesis constitutes only my original work and due supervision and acknowledgement havebeen made in the text to all materials used

HCMC, June 06th, 2016

Nguyen Thi Hoai Trang

I would like to acknowledge my supervisor, Dr Truong Dang Thuy for his great

contribution to my thesis Without his support, my thesis would be not possible By his largeknowledge and experiences, he gave me the informative comments and enabled me to understand mywork better I would like to express my sincere gratitude to his guidance and encouragement, whichmake me stronger to overcome the challenges and fulfill my work completely

By this chance, I would like to express my appreciation toward all lecturers of the Vietnam– Netherlands Program who have provided with valuable economic knowledge during my study

in this program Next, I wish to thank to all my friends here at VNP- MDE 19, who shareunforgettable memories in studying together

Finally, I would like to express my deep gratitude to my family for their support and endurance when I pursue my postgraduate studies

This thesis research aims to analyze the impact of individual characteristics, householdcharacteristic and communities in utilization of maternal health care services in Vietnam Usingthe latest data of Vietnam’s Multiple Indicator Cluster Survey 2013-2014, it employs theNegative Nominal Model for demand of prenatal care visits and Multinomial Logistic Model forthe choice of delivery facility With respect to the demand of prenatal care visits, the resultshows that higher education, higher age, exposure to mass media and no religion increase thenumber of prenatal care visits while higher birth order, unmarried or separated status, ethnicitygroup and lower household wealth index decrease the number of prenatal care Moreover, living

in rural, disadvantaged areas and the community with higher illiteracy rate decrease the demand

of prenatal care visits while living in the community with higher proportion of women givingbirth at health facilities increase the demand Concerning the choice of delivery facility, moreprenatal care visits and exposure to mass media are positively associated with the choice ofgiving birth at public hospital In contrast, suffering the burden of taking care more children,lower household wealth index, living in rural and the community with higher illiteracy ratioadversely affect the choice of public hospital delivery The results suggest the improvement ofmaternal health program in rural and underdeveloped areas as well as universal education overthe country, especially for the ethnic minority group

Keywords: prenatal care visits, the place of childbirth, individual characteristics, household

characteristics, community characteristics, Vietnam

DECLARATION i

ACKNOWLEDGEMENT ii

ABSTRACT iii

LIST of TABLES and FIGURES vii

ABBREVIATION viii

CHAPTER I 1

INTRODUCTION 1

1.1 Problem statement 1

1.2 Research objectives 3

1.3 Research questions 4

1.4 Structure 4

CHAPTER II 5

LITERATURE REVIEW 5

2.1 The role of maternity health care 5

2.2 Overview of maternal health and health care in Vietnam 6

2.2.1 The culture 6

2.2.2 The two-child policy 6

2.2.3 Maternal mortality ratio and maternal health care in Vietnam 7

2.3 The demand for health care 11

2.3.1 Theoretical background 11

2.3.2 Empirical Literature Review 13

2.4 The choice of health care provider 19

2.4.1 Theoretical background: 19

2.4.2 Empirical literature review 20

CHAPTER III 23

METHODOLOGY AND DATA DESCRIPTION 23

3.1 Conceptual framework 24

3.2 Empirical framework 25

3.2.1 Demand for Prenatal care 26

3.2.2 Choice of birth delivery facility 27

3.3 Data 28

3.4 Variables definition 28

3.4.1 Dependent variables 28

3.4.2 Independent variables 29

RESULTS AND DISCUSSIONS 31

4.1 Descriptive Results 32

4.2 Analysis of Demand for prenatal care 34

4.2.1 Bivariate analysis 34

4.2.2 Analysis of Negative Binomial Model 37

4.3 Analysis of Choice in the delivery care providers 41

4.3.1 Bivariate analysis 41

4.3.2 Analysis of Multinomial Logistic Model 44

CHAPTER V 47

CONCLUSION, RECOMMENDATION and LIMITATION 48

5.1 Main findings 48

5.2 Policy Recommendation 49

5.3 Limitation and Further Research 50

REFERENCE 51 APPENDIX 56 STATA RESULTS 71

LIST of TABLES and FIGURES List of Tables

Table 1: Description of Variables 30

Table 2:Descriptive Results – Numeric Variables 33

Table 3 : Descriptive Results - Dummy Variables 33

Table 4: Bivariate analysis in the demand of prenatal care visits 35

Table 5: Negative binomial regression for the demand of prenatal care visits 40

Table 6 : Bivariate analysis in the choice of delivery care providers - numeric independent variables 41

Table 7:Bivariate analysis in the choice of delivery care provider – dummy independent variables 43 Table 8: Multinomial Logistic Regression for the choice of delivery care provider 46

Table 9: Marginal effects for the choice of delivery care provider 47

List of Figures Figure 1: MMR in Vietnam in the period of 2000 – 2015 8

Figure 2: MMR of the Asian countries in the period of 2000 – 2015 8

Figure 3: Percentage of women having at least 1 visit and at least 4 visits during pregnancy 9

Figure 4: The percentage of the women taking antenatal care visits by residence in 2011 and 2014 10 Figure 5: The percentage of the women taking antenatal care visits by ethnicity in 2011 and 2014 10 Figure 6 The association between individual level, household level and community level characteristics with the utilization of maternal health care services 25

Figure 7: The association between the demand of maternal care visits and numerical independent variables 37

ABBREVIATION

CHAPTER I INTRODUCTION

1.1 Problem statement

There is a growing concern about the maternal health care globally, especially in lowincome countries World Health Organization (WHO 2014) reported that the global maternalmortality ratio (MMR) in 2013 was 210 maternal deaths per 100 000 live births, decreasingfrom 380 maternal deaths per 100 000 live births in 1990 However, the ratio in developingregions was 14 times higher than in developed regions Even though maternal death isgenerally decreasing worldwide, it has yet to achieve the target of Millennium DevelopmentGoal 5 by reducing the MMR by three quarters between 1990 and 2015 (WHO 2014)

The maternal death has direct causes and indirect causes The direct cause resultsfrom arising complications during pregnancy, delivery and postpartum, or improper treatmentsuch as hemorrhage, infection, obstructed labor, unsafe abortion, ectopic pregnancy andanesthesia-related deaths while the indirect cause results from the disease which previouslyexists or be not due to indirect obstetric causes like hepatitis anemia, malaria, heart diseaseand tetanus (WHO 2005) It was reported that direct causes made up the higher number ofmaternal death than indirect causes with 80% of the total MMR (WHO 2005)

These complications could be preventable thanks to the intervention of health care such asantenatal care and delivery care, which was introduced by WHO in the safe motherhood package

in 1994 (Tran 2012) Antenatal cares provide the opportunities to pregnancy women and theirfamily to be informed of their health and the growth status of unborn baby Low birth weightscould be prevented if the pregnant women are well acknowledged about their unborn baby’sweight and height during the antenatal care and then improve their diet In addition, antenatalcheck-ups detect the danger signs and risks of pregnancy and delivery and make timelyinterventions For example, tetanus immunization in the antenatal care period is vital to save thelife of the women and their baby The management of high blood pressure during pregnancyensures the maternal health and increase the infant survival (WHO and UNICEF 2003).Furthermore, delivery care also plays an important role in reducing maternal deaths WHOrecommended the child birth at health facility or attended by skilled health staffs to ensure to thesafe delivery and give birth to healthy baby With good hygiene and adequate medical equipment,the delivery at facility could decrease the complications arising from the

labor such as hemorrhage, obstructed labor In addition, skill health professionals are available inthe facilities ensure safe delivery and provide proper emergency management (Tran 2012)

In pursuit of Millennium Development Goal 5 “Improving maternal health”, Vietnam also

is making progress in improving the maternal health with the drop of maternal mortality ratio.The World Bank shows that MMR in Vietnam has remarkable improvements in last 15 years indecrease from 81 deaths per 100,000 live births in 2000 to 54 per 100,000 in 2015 The access toantenatal care, an important period for health of pregnant women and their baby and deliveryservice has also increased Multiple indicator cluster survey in 2014 (MICS 5) shows that thepercentage of women aged 15-49 with a live birth in the last two years who received antenatalcare at least once is 95.8 per cent nationwide However, there are considerable disparity inmaternal mortality ratio and utilization of maternal health care among ethnicity group, place ofresidence and the regions where the pregnant women are living MPI 2015 reported that maternalmortality in mountainous areas is more than three times higher than in lowland areas.Furthermore, MICS5 indicates that the times of prenatal care visits differs among the womenliving rural and urban area, especially regarding having more than 4 visits In addition, the ethnicminority groups get more disadvantage of access to maternal health care with 79% of thosehaving 1 visit and 32.7% of those having at least 4 visits compared to 99.2% and 82.1 % of theKinh group as shown Therefore, growing disparities in health outcomes and health careutilization have posed a great challenging in recent years

The above challenges lead to several studies in the utilization of maternal health care inVietnam Most of them focused on the influence of demographic and socioeconomic factors

(Sepheri et al 2008, Tran et al 2011, Goland et al 2012, Malqvist et al 2012, Malqvist et al.

2013) Demographic factors which were shown to increase the probability of the health servicesare younger age, low birth order while the factors reported to decrease the probability areseparated or unmarried status, unintended pregnancy In addition, socio-economic factors makegreater influence on the use of the maternal health care services Higher education level of a

woman is the most important determinant reported in the previous studies (Sepheri et al 2008, Tran et al 2011, Goland et al 2012, Malqvist et al 2012, Malqvist et al 2013, Wakabayashi

2014) Lower household income is also shown to be a strong factor in the likelihood of using

maternal health care (Sepheri et al 2008, Goland et al 2012) Some studies emphasized the

disparity in the maternal health care utilization among ethnic majority and minority groups

(Malqvist et al 2012, Malqvist et al 2013) On the other hand, major equity in rural and urban

areas also was identified by Tran et al (2011) and Sepheri et al (2008) pointed out the

regional disparity in the availability and accessibility to the maternal health care in Vietnam

However, most of them overlooked the community factors, except Sepheri et al.

(2008) estimating the impacts of poverty rate The omission of the factor may bias theinfluence on maternity health care utilization, especially for the disadvantaged women The

omission of community effects may result in biased estimates of the roles of factors (Singh et

al 2014) Community beliefs and norms encourage or prevent health care seeking behaviors

of the women In addition, community economic development may influence the access tohealth services and indirectly increase decision making power of women and positive

attitudes toward health service use (Stephenson et al 2006) The community level factors

reported to be strong indicators could be the poverty rate, the proportion of women in thecommunity with higher education and the proportion of women delivering their child inhealth facility The poverty rate was negatively associated with the probability of taking

antenatal care (Gage & Calixte 2006, Sepehri et al 2008, Ononokpono et al 2013, Singh et

al 2014,) and facility delivery (Gage & Calixte 2006, Sepehri et al 2008) whereas the high

proportion of women with higher education and higher proportion of women choosing facilityfor delivery were positively associated with the utilization of maternal health care

(Stephenson et al 2006, Gage 2007, Ononokpono et al 2013, Singh et al 2014).

Therefore, there is a need to properly investigate the determinants on health careservice utilization including individual level, household level and community levelcharacteristics Using the latest dataset from Vietnam Multiple indicator cluster survey in

2014 (MICS 5), this study applies the Poisson Model to estimate the impact of socialdeterminants on the demand for prenatal care visits, and the Multinomial Logistic Model tomeasure the association between social factors and choice on delivery care providers

1.2 Research objectives

The overall objective of this thesis research is twofold First, we analyze the demand ofprenatal health care Particularly, we examine the determinants of the number of antenatalcare visits of women taking during the last two years using data from MICS 5 Second, weinvestigate the choice on service facility for delivery of pregnant women in Vietnam

1.3 Research questions

To investigate the above objectives, the following questions need to be answered thoroughly:

Question 1: What are the determinants of the demand for antenatal care visits?

Question 2: What are the determinants of the choice on delivery care provider?

1.4 Structure

The paper is organized as follows In Chapter 2, the general theories related to thedemand of health care and the choice of health care provider are discussed and the previousstudies on the impact of social determinants on utilization of maternal health care are reviewed.Chapter 2 presents the conceptual framework and the methodology with two applied methodsusing the dataset namely Multiple Indicator Cluster Survey 2013-2014 (MICS5) In the samechapter, methods investigating the determinants of the demand of prenatal health care and thechoice of service facility for delivery will be presented The results and discussion are presentedChapter 4 Chapter 5 concludes the paper and discusses policy implications

CHAPTER II LITERATURE REVIEW

This chapter presents the theoretical review and empirical review regarding the demandfor prenatal care visits and the choice of facility for delivery The first part is to provide the role

of maternal health care and the overview of maternal health care in Vietnam The next part is topresent the theoretical background for the demand for health care services, and the choice ofhealth care facility and their determinants The final section reviews the determinants affectingthe demand of prenatal care visits and the choice of delivery care providers reported in theprevious studies in developed countries and developing countries, especially in Vietnam

2.1 The role of maternity health care

Motherhood is a positive experience which a women encounters; however, there aresome health problems happening during pregnancy, childbirth, and the postpartum period.The consequences impact seriously not only on the women’s health but also on the babies.Three quarter of maternal deaths is reported to occur during childbirth and the postpartumperiod However, antenatal care and delivery care can prevent these complications

The introduction of antenatal care (ANC) began in the early 1900s with the aim ofhelping pregnant women and the unborn healthy and detecting adverse conditions in order totake timely interventions For example, the antenatal care will enable the women to enhancethe understanding of the fetal growth and her health status Adverse outcome such as lowbirth weights can be avoidable by improving the women’s nutritional status In addition, thewomen will be informed about the risks during pregnancy and delivery The World HealthOrganization (WHO) recommended at least one visits to skilled health providers or at leastfour ANC visits to any providers According to the guidelines of WHO, the ANC programincludes assessment of mother and fetus like body weight and height measurement, bloodpressure, urine and blood tests; medical provisions like tetanus vaccination and supplement ofiron and foliate and health consulting and education

The delivery at health facilities also plays an important role to ensure women to gothrough childbirth safely and deliver healthy infants In fact, proper medical technology andhygienic conditions during delivery can prevent complications and infections leading tomorbidity and mortality of mother and her child In addition, skilled birth attendants areavailable in most health facilities According to WHO, a skilled birth attendant is defined as amidwife, doctor or nurse, who is well skilled to ensure normal childbirth and the postnatal

mediation, and who can detect complications and provide necessary emergency management.WHO recommended that in countries with very high MMR, at least 60% of child deliveriesshould be assisted by skilled birth attendants by 2015 During 2005-2010, it was reported that69% of women giving birth were attended by skilled birth staffs (Tran, 2012)

2.2 Overview of maternal health and health care in Vietnam

2.2.1 The culture

Vietnam culture is highly influenced by Confucianism, especially in the north region

of the country According to the tradition of Confucianism, the son of the family will inheritthe family resources and worship the ancestors In addition, he has responsibility for takingcare of the family members and maintains the continuity of the family line Therefore, givingbirth to a son brings a proud to the family and improves the status of the women in thefamily However, it will put high pressure of having a son on the women in the family,especially for the women with daughters The strong preference for sons is the main reasonfor increasing sex ratio at birth

Moreover, male members are considered as the breadwinners and main incomeearners in the family and have strong decisions on the family affairs whereas femalemembers are considered as vulnerable members when their life is determined by her parents.After getting married, they will usually live with their husband family and the income willprobably be controlled by the parent-in-law and their husband The strong Confucianism andexisting hierarchism limits their autonomy and their independent decisions for their lives,especially their health For example, the childbirth experience from the mother and themother-in-law highly influence on the maternity care of young women and could prevent thewomen to seek essential maternal health care

2.2.2 The two-child policy

The two-child policy in Vietnam was issued in late 1980s with restriction of themaximum number of children per household Vietnam government practiced some familyplanning measures to reach the goal such as providing the free birth control devices as well asprosing the facilities for those who was allowed for abortions In addition, the family who did notcomply with the two-child policy, they would be penalized in different ways like paying high fee.For the government staffs who broke the policy, they would be prolonged the salary raise orreducing to lower position Therefore, due to fear of penalization and discredit, some womenconceal their pregnancy and do not take adequacy of maternal health cares In addition,

more children put heavy burden on shoulders of women and create time and financialconstraints to utilization of maternal health care services After many revision of the policy,the revised 2009 Population Ordinance is the effective prevailing policy in Vietnam.According to the Ordinance, couples have right to decide the time of having children and thebirth spacing but are allowed to have one or two children Thanks to the population policy,the total fertility rate dropped from 2.55 in 2001 to 1.99 in 2011 (GSO 2013) suggesting thetwo-child policy was successful to ensure the steady population growth However, there aresome challenges for the government to take account for The contraceptive methods had beennot conducted effectively IUD is the most popular method applied in most families;however, it comes with the side effects so many women hesitate to use it In addition,Vietnam has faced the high abortion rate, especially among the young age It could be mainlyattributed to lack of knowledge about the contraceptive methods and son preferences besideother reasons such as financial problems or health status.

2.2.3 Maternal mortality ratio and maternal health care in Vietnam

In Vietnam, the government recommends pregnant women should have at least threeprenatal visits during the pregnancy to detect and prevent the risks negatively affecting thehealth of mother and baby The content of prenatal care includes blood pressuremeasurement, urine testing, blood testing and measure of weight and height In addition, thenational guidelines suggest that pregnant women should deliver the baby at health facilities.Proper medical attention and hygienic condition at health facilities reduce the complicationsoccurring in and after the childbirth In addition, for the complications, Caesarean section isrequired but should be performed by the skilled obstetric doctors to ensure safe childbirth.During the postpartum period the guidelines recommend at least two health checkups for bothmother and child

The maternal mortality ratio is the ratio of women who die from causes related topregnancy and childbirth in the period from pregnancy until 42 days after delivery, per 100,000children born during the study period The data from the World Bank shows that MMR inVietnam has remarkable improvements in last 15 years in decrease from 81 /100,000 in 2000 to54/100,000 in 2015 The target of Millennium Development Goal 5 with MMR of 58.3 per100,000 live births by 2015 has been achieved completely However, when comparing to otherAsian countries, Vietnam still left behind the developed countries such as Singapore, Malaysia

and Thailand Therefore, Vietnam should make greater effort to reduce the MMR and ensure

the persistent population growth

Maternal mortality ratio (per 100,000 live

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Figure 1: MMR in Vietnam in the period of 2000 – 2015

Source: The World Bank

Philippines Vietnam 0

8

Source: The World Bank

In order to reduce MMR and IMR, WHO recommends each pregnant woman should

have at least four prenatal care visits or at least one prenatal care attended by professional

health staffs It is widely agreed that antenatal care is vital to provide the information to

women and her families about potential risks during pregnancy and childbirth Vietnam has

made significant improvements in antenatal care coverage over the last years The figure 3

shows that 95.8 % of pregnant women have at least 1 prenatal care visits in 2014, which is

higher than the ratio in 19997 However, the percentage of those receiving more than 4 visits

is still low at 73.7% This is a challenge against which the country should take more

measures In addition, there are considerable disparity in utilization of maternal health care

among ethnicity group, place of residence and the region where the pregnant women are

living Figure 4 indicates that there is greater difference in the times of prenatal care visits

among the women living rural and urban area, especially regarding having more than 4 visits

In addition, the ethnic minority group get more disadvantage of access to maternal health care

with 79% of those having 1 visit and 32.7% of those having at least 4 visits compared to

99.2% and 82.1 % of the Kinh group as shown in Figure 5

At least 4 times by any providers At least 1 visit by skilled health worker

9

Antenatal care visits by residence

Figure 4: The percentage of the women taking antenatal care visits by residence in 2011

and 2014

Sources: MICS3 and MICS4

Antenatal care visits by ethinicity

Figure 5: The percentage of the women taking antenatal care visits by ethnicity in 2011

and 2014

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2.3 The demand for health care

2.3.1 Theoretical background

Economists became interested in the health seeking behavior in the late 1960s and

investigating the factors influencing the behavior The major contributions were by Grossman

(1972), Rosenstock (1974), Thaddeus and Maine (1994) and Andersen (1995)

Grossman (1972) argued that what individual demand when purchasing health care is not

health care but good health Firstly, he set up the model of demand for health, in which the individual

has positive utility of consumption goods and negative utility of sick time ( ) (Zweifel et al 2009)

In addition, the health stock H changes overtime Therefore, the health capital

decrease at the rate However, the individual can increase health capital by investing in I In

a two-period model, the current health could be specified as

Where, U is utility, H is stock of health capital, is the rate of the depreciation of the

heath stock, w is wage rate, X is consumption goods, M is the consumed amount of medical

services, I is investment in health, is sick time and is time invested in favor of health

Grossman (1972) argued that the individual demand for health for two reasons: first, as

investment commodity and second, consumption commodity

Basing on the function ( , ) and ( 1 ) from (1.1) and (1.2), Grossman constructed the demand function for medical services in investment model:

ln = − (1 + ( − 1)) + (1 + ( − 1)) − (1 − ) (1.3)

Where, is the production elasticity of medical services and is the effectiveness of education E; is the marginal efficiency of health capital 1

From the utility function (1.1) including sick time and consumption good, he

constructed the demand function for medical services in consumption model:

ln = − (1 + ( − 1)) + (1 − )(1 − ) − (1 − ) −

(1.4)

11

From the investment model (1.3) and consumption model (1.4), the demand of health services depends

on the price of medical services, the wage rate, education and wealth It could be seen that the price of medical services decrease the optimum quantity of 1 whereas the wage rate increase the quantity of 1 In the multiple period model, both of demand functions also are added the age because the depreciation rate is positively

correlated with age (Zweifel et al 2009)

In addition to the Grossman Model, some researches brought out some model toexplain the individual’s health seeking behavior Rosenstock (1974) introduced health beliefmodel to explain the health-related behavior The model suggested that individual’s beliefabout health problem, perception regarding benefit and barrier and cues to action combinetogether to explain the health-promoting behavior The modifying variables such asdemographic and psychosocial characteristics made the indirect effect on the perceptions Inthe model, the perception regarding serious consequences and risks from developing a healthproblem most highly increase the likelihood of engaging in health-promoting behaviors Thenext step was the perception of benefits received from taking action and barriers to takingaction such as inconvenience, side effect If the perceived benefits outweigh the barrier, itleads to health-promoting behavior or otherwise The following is cues to action includinginternal and external cues Internal cues are pain, symptoms while external cues areinformation obtained from friends, mass media The model was applied to developintervention to change health-related behavior by targeting the parts in the model

Thaddeus and Maine (1994) developed the three delay theory to identify the barriers

to the timely and adequately utilization of maternal health care They viewed that the firstphase was delay in seeking care The factors effecting the phase included decisions ofindividual and family, the status of women, previous experience regarding health caresystem, financial and opportunity cost The next phase was delay in getting access to thehealth facility due to the availability of facilities, distance to facilities, transportation cost andtransportation infrastructure The last phase was delay in taking adequate care The relevantcauses were lack of equipment and skilled health staffs, qualification of health staffs

The behavioral Model of Health Services Utilization by Andersen (1995) has been used

in the studies on utilization of health services in both developed and developing countries (Thind

et al 2008) In the Andersen’s Model, one individual getting access to and using health care

services was a function of three factors, namely predisposing, enabling and need factors Thepredisposing factors were classified into three groups such as demographic characteristics,

12

social structure and health beliefs Demographic characteristics represent the tendency ofindividuals to use services, including age, gender, marital status while social structure reflectthe ability of individuals to seek health care services, including education, occupation andethnicity Health beliefs were perception and attitudes regarding the health care systems thatinfluence the utilization of the services The next was enabling factors, both personal andorganizational, which measure the actual ability to obtain health services Personal enablingfactors included income, health insurance, travel and waiting times while organizationalenabling factors were the availability of health facilities The last one is need factors, thedirect causes to utilization of health services The need was the self-assessment of healthstatus and evaluation from health staffs.

2.3.2 Empirical Literature Review

Theoretically, prenatal care is considered a vital factor in maternal and infantmortality Measuring and counseling during prenatal care help women understanding healthstatus of herself and her baby, detecting risks in order to ensure safe pregnancy, childbirth aswell as decrease post-partum problems While some researches were conducted to estimatethe association between maternal health care and health outcome, some studies focus ondeterminants effecting utilization of maternal health care The below is to present the factorsinfluencing the demand of prenatal care visits and the choice of delivery location from theprevious studies

The determinants are categorized into three characteristics including individual level,household level and community level The individual variables include education attainment,maternal age, marital status, religion, ethnicity while household characteristics are householdsize and household wealth Further, community level consists of place of residence, regiondummies, poverty rate and illiteracy rate

Individual level characteristics

Mother’s education

Most studies highlighted the importance of mother education on the use of maternalhealth care The higher level of education women has, the more likely to use adequate ANC.(Arthur 2012, Bbaale 2011, Navaneetham & Dharmalingam 2002) It was explained thateducated women had more decision-making power on health-related matters and seek the betterhealth care outside their home (Navaneetham & Dharmalingam 2002) However, there was no

significant difference in the utilization of maternal health care among educated women bylevel of education, especially between primary level and second level (Navaneetham &Dharmalingam 2002) In addition, when measuring the effect of the introduction of National

Health Insurance (NHI) in Taiwan, Chen et al (2003) found that education attainment did not

have insignificant impact on antenatal care before NHI but was significantly positive afterNHI The reason for this difference was ambiguous In general, educated women are wellinformed of the importance of maternal care and will increase more frequencies of antenatalcare visits than less-educated mothers

Marital status

Marital status also is a key determinant of the use of maternal health care Sepehri et

al (2008) suggested that the marital status impacted the use of any prenatal care greater than

the number of visits but has no significant influence on decision of delivery place It could beexplained that single mothers unwillingly get access to the health care due to face ofstigmatization because the childbirth is widely considered the responsibility of mother as well

as her husband in Vietnam (Sepehri et al 2008) Researches in other countries were consistent with the study of Sepehri et al (2008) In the study in Taiwan, Chen et al (2003)

found that thanks to the support from their husband, married women more likely to get access

to maternal care visits than unmarried women

Mother’s age

The age of expectant mother is other factor in the utilization of maternal healthservices The higher age the mothers get, the lower the probability they will seek health care(Arthur 2012) It could be explained that experience and knowledge related maternal health

may influence on the maternal health seeking behavior (Chen et al 2003) Tsawe & Susuman

(2014) showed that the women in the age of 15-39 more likely to take health check-upsfrequently than those in the age of above 40 However, there were some researches showingthat women’s age was insignificantly associated with the attendance of ANC for example, inTurkey (Celik & Hotchkiss 2000)

Birth order

As the same as the age of expectant mother, most studies found that the increasingnumber of children ever born had the same negative effect on the use of maternal health careservices The higher order births will decrease the likelihood of using the services for somereasons It may be due to time and resource constraints for women having larger families.(Navaneetham & Dharmalingam 2002) In contract, those who have the first pregnancy willmore likely to use the antennal care due to lack of experience Arthur (2012) argued thatthose who underwent the child birth may undertake ANC visits less because she had badexperience with the service Similarly, Tsawe & Susuman (2014) agreed with Arthur (2012)that the use of maternal health care was influenced by the experience over the providedservice If a woman is provided the better service, she willingly utilizes the service morefrequently On the other hand, due to the two-child policy and fear of penalties, those with

more two children may undertake less maternal health care (Sepehri et al 2008).

Unintended pregnancies

Studying in the maternal health service in Southwestern Ethiopia, Wado et al (2013)

found that pregnancy intention was significantly related to the utilization of antenatal care butinsignificantly to the delivery care The reason why the unwanted pregnant women less likely

to receive antenatal care adequately is ambiguous Wado et al (2013) hypothesized that

women with unwanted pregnancies did not prepare well in the respect of emotion and financefor childbirth and childbearing so they less take care of their health and their unborn One ofthe argument is the women with unintended pregnancies recognized their pregnancy late so

they miss the first timing antenatal care visits Wado et al (2013) observed that women with

unwanted pregnancy detect the pregnancy around one month later compared with ones withpregnancy intention In general, the study implied that the pregnancy intention was highlyassociated with the utilization of maternal care; however, its association with the deliverycare was still unclear

Media exposure

Some studies resulted that frequencies of using mass media positively related to theutilization of ANC The higher is the level of exposure to mass media like radio and television thehigher is the likelihood of using ANC Navaneetham & Dharmalingam (2002) found that womenwatching television and listening radio regularly increased the opportunities of her seeking ANC

It can be explained that the mass media will provide the information regarding

to the maternal health and enhance the awareness of the available maternal health services.Tsawe & Susuman (2014) reported that those who had more knowledge of the maternalhealth service more likely to receive the service timely and adequately In fact, lack ofinformation poses the challenges to the utilization of maternal health.

Working status

The importance of working status in maternal health care utilization also is welldocumented in some previous studies Navaneetham & Dharmalingam (2002) found thatnon-working women more likely seek maternal health care services than earning women Itcould be explained that non-working women were relatively richer in comparison with thoseworking In addition, women’s work in the developing countries does not come with well-paid salary, which leads lower likelihood of using maternal health care services Anotherstudy by Bbaale (2011) pointed out that the type of job which pregnancy women related toimpacts the utilization of antennal care in different way It could be attributed to conditions ofjobs and income they earn, which has great effect on the affordability of health care service.Women who working in farm or factory have more tendency to use antenatal care thanhousewives as well as women who working in government more likely seek antenatal care

after being covered by national health insurance (Chen et al 2003).

Household-level characteristics

Ethnicity

The significant impact of ethnicity in the utilization of maternal health services is

found in some studies Sepehri et al (2008) showed that women belonging to ethnic majority

more likely give birth at health facilities than those in ethnic minority in Vietnam It could beexplained that ethnic group find difficulties to communicate with health provider due tolanguage barrier In addition, lower attainment of maternal health care among ethnic group

women is attributed to lower level of education and poor socio-economic condition (Singh et

al 2014) In other countries, the results are consistent with this study Navaneetham &

Dharmalingam (2002) pointed out that women in “Schedules” castes and tribes had lowerANC check-up in India Similarly, Kudish women were less likely to take ANC service inTurkey (Celik & Hotchkiss 2000)

Similar to Ethnicity, religious difference is one of the most important determinants ofhealth service utilization because religion affects the way people live and behave as well as theirbelief (Bbaale 2011) If women believing in the traditional birth attendants more likely give birth

at home rather than going to hospital or clinic (Tsawe & Susuman 2014) Studying in India,

Singh et al (2013) found that practices in Muslim restrict women among this religion to enjoy

health care benefits Similarly, Muslim women in Kerala tend to give birth at home and refuse to

be assisted by skilled health providers; however, the probability of antennal care visits in the firsttrimester is higher among them (Navaneetham & Dharmalingam 2002)

Household wealth status

Previous researches show that household wealth status has positive impact on the use

of ANC (Bbaale 2011; Tsawe & Susuman 2014) There are many indicators regardinghousehold income index showed in the previous studies For example, Navaneetham &Dharmalingam (2002) showed that the women enjoy higher living standard three times morelikely to get adequate prenatal care visits rather than those with lower living standard Owing

a car found to be positive associated with utilization of maternal health care (Celik &Hotchkiss 2000) Even though some countries provided the service freely, the matterremained unchanged It is implied that the health care services may come with another costsdirectly and indirectly such as transportation cost (Arthur 2012) Women who find difficult toafford traveling fee to the hospital is less likely to undertake checkup of ANC than those who

do not find difficult to get money to go to hospital (Tsawe & Susuman 2014) Generally,financial problems were also major hindrance on the utilization of maternal health care

Community-level characteristics

Place of residence

Place of residence is key concern in ANC utilization The previous studies resulted thatwomen in rural areas less likely use maternal health services than urban women due to longdistance to the health facilities In addition, financial problems also were a barrier for them tocomplete use of maternal health care because they could not afford the transportation cost as well

as ANC cost (Tsawe & Susuman 2014) The shortage of skilled attendant also is the reason whyrural women less frequently undertake antenatal care than urban area In fact, there is lack ofqualified health provider in rural area in comparison with the cities (WHO, 2006)

Understanding these matters, some countries applied the program to minimize the problems.For example, when studying four states in the south Indian in 2002, Navaneetham &Dharmalingam (2002) found that there is no significant difference between rural and urbanarea in terms of the demand for antenatal care The underlying reason was that multipurposehealth workers provide antenatal care to pregnant women by visiting their home In contrast,Celik & Hotchkiss (2000) found that urban and rural difference did not significantly impactthe prenatal care after holding the constant regional status and other variables in the study inTurkey.

Regional differences

The difference in utilization of maternal health care is due to the implementation ofhealth care program, the availability and accessibility of the health care service among the

regions Studying in Vietnam, Sepehri et al (2008) pointed out that women living in the

disadvantaged regions like Central Highlands less likely undertake any maternal health carethan those living in Red River Delta However, there was no significant regional difference in

the frequency of prenatal visits (Sepehri et al., 2008) Similarly, in Turkey, Celik &

Hotchkiss (2000) also found that living in developed regions of the country had significantlypositive association with attendance of prenatal care service

Poverty rate, illiteracy rate and ratio of facility delivery

Beside individual level and household level characteristics, community levelcharacteristics have been paid greater attention in the previous studies in recent years (Gage

2007, Sepheri et al 2008, Ononokpono et al 2013 and Singh et al 2014) Stephenson et al.

(2006) argued that community could influence health outcomes through several ways Forexample, community beliefs and norms may have great effect on positive or negative attitudes onhealth care services, which in turn lead to health care seeking behavior In addition, economicdevelopment of a community will attract the investment of health care infrastructure, socialsupport as well as improvement of knowledge in benefits of health care services Studying inrural Mali, Gage (2007) suggested that community with higher portion of well-educated womenwas highly associated to likelihood of getting access to maternal health care In Vietnam, Sepehri

et al (2008) pointed out that women living in community with higher poverty rate have fewer

tendency to deliver their baby in health facilities in comparison with those living in communitywith lower poverty rate One of the community level characteristics,

which were also found to be positively associated with the demand of prenatal care visits is

the proportion of women in same community giving birth at health facility (Ononokpono et

al 2013) The research showed that the women living in the community with the high

proportion more likely 5.8 times to take adequate prenatal check-up compared to those in thelower community level proportion

2.4 The choice of health care provider

2.4.1 Theoretical background:

In the late 1980s, Gertler, Locay and Sanderson (1987) firstly developed the healthseeking behavior in the choice of health care providers They argued that at the first stage, theindividual decides whether to seek health care and at the second stage, he or she selects thehealth care providers with the maximum utility The utility function of individual i receivinghealth care from provider j is presented as follows:

In which, is the utility of the individual i after receiving health care from provider j, ℎ is expected health status of the individual after receiving health care from provider j and is other consumption expenditure after paying provider j.

The health status after receiving health care from provider j for an individual idepends on the quality of provider j’s health care

ℎ =ℎ

Where ℎ0 is the health status before receiving health care from provider j

The quality of health care differs among health care providers and individuals.Therefore, the quality of health care depends on the characteristics of health care providersand characteristics of individual as follows:

The other consumption expenditure after receiving the health care is the remaining ofthe income after paying health care provider j The price of the alternative j is the paymentfor the health care including direct cost such as consultation cost, medicine cost and indirectcost such as transportation cost and waiting time

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= −

(2.4)Assuming that the individual has j alternatives and would like to maximize the utility

so the utility maximization is expressed as:

∗

= max ( 1 , … , )

Where ∗ is the maximum utility and

alternative of health care provider 1, …., j

1 ,… ,

is the individual utility with

Combining (2.1), (2.2), (2.3) and (2.4) we get

(2.5)Researchers could not measure the utility of the individual but investigate thecharacteristics of the alternatives and the characteristics of the individual (Train, 2009).Therefore, the utility function of the individual is expressed as follows:

= +

(2.6)

In which, is observed characteristics and is unobserved characteristics

Combining (2.5) and (2.6) we get

The observed characteristics of the individual are gender, age, education, income,insurance whereas the unobserved characteristics are perception of quality of the health careprovider, the preferential medical administration The observed characteristics of the healthcare provider are the price, the distance from house of the patient to the health care providerwhereas the unobserved characteristics are the fame, prestige of the health care provider

2.4.2 Empirical literature review

It is widely acknowledged that childbirth at health facilities is associated with lowerrate of maternal mortality and morbidity However, there are still women choosing the childbirth at home, especially in developing countries Therefore, some previous studies havefurther conducted to investigate the determinants of the choice of delivery care provider.They have focused the characteristics of individual of the women, household and communitywhere they are living

Individual level characteristics

Most studies highlighted the important role of prenatal care visits in the decision to

seek health care Stephenson et al (2006) argued that the prenatal care during pregnancy was

highly associated with the choice of delivery at health facilities by informing the benefit of

institutional delivery and appropriate services Sepehri et al (2008) agreed this point that

timing and adequate prenatal care visits could raise the awareness of the need of care fordelivery

Education attainment also is found to play the important role in the choice of child

birth place (Sepehri et al 2008) For example, Celik & Hotchkiss (2000) pointed out that the

women with higher education more likely to choose facility delivery rather than traditionalhome delivery It is likely that the highly educated women have the stronger and independentdecisions to the best health care services Furthermore, the educated women have much morechance to be well informed of the benefit of facility-based delivery

With respect to the birth order, the previous studies reported that it has strongassociation with the choice of delivery at health facilities Navaneetham & Dharmalingam(2002) found that the women with first birth order more likely to give birth at health careinstitutions rather than those with second birth order There are some arguments regarding thematter Some researchers pointed out that the women with higher parity faced time andresource constraints to utilize the facilities services due to large families On the other hand, itcould be the bad experiences from previous childbirth, which make them to underestimate thedemand for facility-based delivery

Concerning the age of the pregnancy women, there are mixed result regarding itseffect in the choice of birth delivery alternatives Celik & Hotchkiss (2000) reported that theage of women at last child birth was not significantly associated with the choice of delivery

location On contrary, Stephenson et al (2006) argued that the age of the interviewed women

had significant association with the choice of facility delivery in the study of six Africacountries He found that the women with age of 40-49 and 30-39 more likely to deliver theirbaby at health facilities than women aged 20-29 However, the effect was not significant insome countries such as Burkina Faso, Ivory Coast or Ghana

In addition, marital status showed mixed result in the decision in the birth delivery

location Stephenson et al (2006) pointed that the women in polygamous marriage or those

who was separated less likely to have their last childbirth at health institutions in all of six

Africa countries However, Sepehri et al (2008) found that marital status had no significant

impact in the choice of delivery location

Household level characteristics

The choice of the place of delivery is also highly influenced by the household levelcharacteristics, namely household wealth index, ethnicity and religion With respect to the

household wealth index, Stephenson et al (2006) found that women with higher household

income index more likely to choose the delivery at health institution rather than those withlower income index The reason is that the cost related birth delivery care as well astransportation restricts the poor women from utilizing the health services Some previousstudies identified that ethnicity has great influence in the choice of the facility delivery Celik

& Hotchkiss (2000) agreed that the effect is true in urban women and rural women He saidthat it could be due to the cultural and economic barriers or the poor of health care service.Similar to the ethnicity, religion also is considered as the key determinant in the women’s

decision in the place of childbirth When studying six Africa countries, Stephenson et al.

(2006) found that Muslim women in Ghana are less likely to deliver their baby in healthfacility compared to Catholic women, while Protestant women more likely to utilize theservice than Catholic women

Community level characteristics

There are also remarkable regional differences in the choice of delivery location Celik

& Hotchkiss (2000) found that urban women were more likely to seek the facility deliveryrather than rural women Furthermore, Celik & Hotchkiss (2000) said that the Eastern regions

in Turkey is less advantaged than Western and Northern regions, which caused moredifficulties for the women in Eastern regions to choose facility delivery compared to thoseliving in other regions Gage (2007) argued that the regional differences partly indicate theunequal accessibility and availability of health care facilities

In addition, some previous studies investigated the impact of community levelcharacteristics in the decision to delivery at health facilities There are several ways though which

the community affect the delivery facility choice of women Stephenson et al (2006) reported

that the community of higher concentration ratio of women with higher education improve thegreater autonomy level and provide more opportunity for the women to seek health

care during pregnancy and delivery Furthermore, he also found that higher concentration ratio ofwomen in the community delivering their baby at health facilities had a significantly positiveimpact on the decision in the delivery location It suggests that the practices of others in thecommunity could affect the health seeking behavior of the individual in the same community.

One of the important community level factors as reported in the study of Sepehri et al (2008) in

Vietnam is community level poverty rate He pointed that the community poverty rate affectednegatively the probability of giving birth at health facilities Women in the community withhigher poverty rate above 50% less likely to deliver their baby at health institutions incomparison to those in the community with poverty rate of equal and less than 10%

CHAPTER III METHODOLOGY AND DATA DESCRIPTION

This chapter presents the methodology and data description used to investigate thedeterminants of the utilization of maternal health care The first part is to introduce conceptual

framework describing the associations between the determinants and the demand of prenatal

care visits and the choice of delivery care providers respectively Next, two methods related

to the objective of the study, namely the Negative Binomial model and the Multinomial

Logistics model will be discussed to analyze the associations as mentioned in the previous

part The final section presents the data used in the study

3.1 Conceptual framework

Based on the theoretical reviews and empirical reviews, the demand of prenatal care visits

and the choice of delivery care provider are influenced by the individual, the household level and

the community level characteristics Individual characteristics include the education level, the

frequency of getting access to mass media, working status, marital status, pregnancy intention

and the birth order while the household characteristics include household wealth index,

household size, ethnicity and the religion of the household head Besides, the study supplements

the community level characteristics, which also affects the individual maternal health seeking

behavior through the residence place, poverty rate, illiteracy rate and the ratio of women giving

birth in health facilities The conceptual framework is expressed in Figure 6

Illiteracy rate

Figure 6 The association between individual level, household level and community level characteristics with the utilization of maternal health care services

3.2 Empirical framework

The objective of the study is to measure the social determinants on two types of maternalhealth care services such as number of prenatal care visits and the choice of delivery facility.The Negative Binomial Model is applied to analyzed the number of prenatal check-ups andthe Multinomial Logit Model for the decision on the delivery facility

3.2.1 Demand for Prenatal care

Poisson Model is applied for dependent variables which are non-negative integer Inthe model, Poisson distribution is used to describe the likelihood of events occurring k times

in a given period of time The distribution function is

model the over-dispersion The command nbreg in Stata is implemented to estimate the

Negative Binomial regression and provide the test of over-dispersion

In the study, the dependent variable is number of maternal check-ups that a pregnantwoman takes The independent variables are divided into three groups: individual level,household level and community level characteristics Different from the theory background,the prices of health care and the income are not included due to limitation of the data Thedetail will be introduced in next section

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3.2.2 Choice of birth delivery facility

Multinomial Logit Model is applied to measure the relationship between categorical variables and other explanatory variables Mothers are assumed to choose the facility that maxime utility And the choice of facility j of individual i coded as is 1, 2 ,3 … J The probability for choosing each alternative is 1 , 2 , … , The logit function is described as

of the demand of prenatal care visits, the independent variables are divided by three groups:individual, household and community

The command mlogit in Stata is employed to estimate the multinomial logistic model.

The independent variables are divided into three groups: individual level, household level andcommunity level characteristics The details will be introduced in next section

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