Is There a Causal Relationship Between Maternal Health Care Utilization and Subsequent Contraceptive Use?: Evidence from K...
Background <ul><li>Service integration receiving increased attention from governments and donors as way of improving effic...
Research questions <ul><li>Is post-partum modern FP method use related to the use of ANC and PNC relating to the index chi...
Data <ul><li>Most recent DHS: 2008-09 in Kenya and 2007 in Zambia </li></ul><ul><li>Selected Kenya and Zambia because: </l...
Methods (1) <ul><li>Statistical method: Cox proportional hazard model  </li></ul><ul><li>Dependent variable: duration (mon...
Methods (2) <ul><li>Independent variable: ANC and PNC service intensity score, constructed from 6 questions </li></ul><ul>...
Methods (3) <ul><li>Main control variables </li></ul><ul><ul><li>Knowledge of contraceptive methods </li></ul></ul><ul><ul...
Country findings: Kenya 46% adopted modern FP post-partum * p<.05; ** p<.01; *** p<.001 Controls for: socio-demographic ch...
Kenya: Influences of ANC and PNC services on post-partum modern FP use * p<.05; ** p<.01; *** p<.001 Controls for all wome...
Country findings: Zambia 45.9% adopted modern FP post-partum * p<.05; ** p<.01; *** p<.001 Controls for: socio-demographic...
Zambia: Influences of ANC and PNC services on post-partum modern FP use * p<.05; ** p<.01; *** p<.001 Controls for all wom...
Conclusions <ul><li>Evidence of MCH service use as mediator for individual characteristics to influence post-partum modern...
Limitations <ul><li>Not generalizable to all women of childbearing age </li></ul><ul><ul><li>Only married, cohabiting wome...
<ul><li>MEASURE Evaluation PRH is a MEASURE project funded by  </li></ul><ul><li>the United States Agency for Internationa...
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Maternal Health Care Utilization and Subsequent Contraceptive Use

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Findings from research conducted using secondary data from Kenya and Zambia to determine if there is a causal relationship between maternal health care utlization and susequent contraceptive use.

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  • This research was supported by the US Government through the MEASURE Evaluation Population and Reproductive Health Associates Award, which is led by the University of North Carolina at Chapel Hill. My colleague at Tulane University, Mai Do, is the lead author of this study.
  • It is often assumed that women who use maternal health care are more likely than those who do not to use modern contraceptives. The association between the two types of services can be expected for several reasons. First, family planning (FP) services are often provided within the context of maternal and child health care; therefore women who access these services may likely be exposed to FP counseling and promotion efforts. This mechanism may be particular relevant for women with a high risk pregnancy as health care providers may emphasize post-partum contraception to avoid subsequent pregnancy and health risks. Second, as a woman obtains maternal and child health care, she may develop a trust with the health care system. This trust can help remove social barriers to accessing FP services and provide motivations for her to use multiple services from the health care system. Such an effect is independent of whether FP services are included in maternal health care packages. Third, a woman’s early contact with the health care system may also reduce cognitive, psychosocial, and indirect financial barriers - in the forms of time and opportunity costs - to subsequent FP service use. Finally, the use of maternal and child health care likely contributes to improved infant and child survival, motivating mothers to seek and use FP methods. A surprisingly limited number of research studies have examined linkages between the use of maternal health care, namely antenatal care (ANC), delivery, and postnatal care (PNC), with contraceptive use after a child birth. Results of these studies are mixed. Zerai and Tsui ( 2001 ) reported a strong influence of prior use of ANC on subsequent use of modern contraception in Bolivia, Egypt, and Thailand. More recently, Hotchkiss et al. ( 2005 ) examined this topic in five countries: Bolivia, Guatemala, Indonesia, Morocco, and Tanzania. Unlike in Zerai and Tsui ( 2001 ), where a dichotomous indicator of ANC usage was used, a continuous index of the intensity of maternal and child health (MCH) service use was constructed based on a series of questions related to ANC, delivery care, and child vaccination in Hotchkiss et al. ( 2005 ). In Morocco, Guatemala, and Indonesia, the evidence suggested that the use of MCH services might have served as a “gateway” to FP use. In the other two countries, however, the authors found that positive associations between MCH service use and FP practice that were best explained by observed and unobserved factors that might have predisposed women to both types of services.
  • This current study aims to add to the body of evidence on the associations between maternal health care and FP practice. It seeks to answer the following research questions: 1) is the use of modern FP methods after a childbirth related to the use of antenatal (ANC) and postnatal care (PNC) relating to that index childbirth? and 2) if so, what can be said about the linkages between the use of these services?
  • We used DHS surveys in Kenya and Zambia. Both are based on nationally representative samples of households, men, and women of reproductive age and collected up-to-date information on a number of demographic and health indicators, including: fertility, mortality, FP, maternal and child health, etc. and HIV/AIDS. Kenya and Zambia were selected for the study for the following reasons: 1) each country has a Demographic and Health Survey (DHS) conducted within the last three years (i.e. in 2007 or later); 2) the DHS included a birth and contraceptive calendar; and 3) there was substantial contraceptive use among married and cohabiting women (prevalence of 20% or more). The criteria are to ensure that the study samples will include sufficiently large numbers of contraceptive users after the most recent childbirth to allow meaningful analyses.
  • Cox proportional hazard model was employed to examine the time duration from the last childbirth to a woman’s adoption of a modern contraceptive, as well as factors influencing this interval. The dependent variable of interest is the use of modern contraceptive methods after the last childbirth. Information comes from the birth and contraceptive use calendar, included in the DHS Women’s Questionnaire, which records month-by-month all events related to pregnancy, pregnancy outcomes, childbirth, breastfeeding, and contraceptive use for 60 months before the survey. The outcome is measured by duration (in months) from the time of the last childbirth to the time that a woman started using a modern method of contraception. At the time of the survey, if a woman had not adopted any modern contraceptive method, she is considered a censor.
  • Because there is a possibility that ANC and PNC service utilization is endogenous to post-partum modern FP use, i.e. they are determined by the same observed and unobserved women’s characteristics, test of exogeneity was performed. We followed the procedure laid out by Bollen, Guilkey and Mroz ( 1995 ), which involved estimating two equations: the first equation is an ordinary least square estimation of ANC and PNC service intensity score; the second equation is a proportional hazard model, in which the error term obtained from the first equation was included with the actual service intensity score. As an instrumental variable in the first equation, we used the age of the woman’s first birth, which was assumed to influence maternal health care use but not contraceptive use. Using Hausman and log likelihood ratio tests, we did not reject that the null hypothesis that maternal health care service intensity is exogenous in the contraceptive use equations. Therefore, the intensity of ANC/PNC service use can be employed as a predictor in the proportional hazard model for post-partum modern FP use. If the hazard ratio associated with the error term is not significantly different from zero, one would accept the null hypothesis that the ANC/PNC service intensity is exogenous in the contraceptive use equation. On the other hand, if the hazard ratio of the error term was statistically significant from zero, there is evidence of endogeneity and a two-step equation system should be used. This two-equation procedure also requires ANC/PNC service intensity and post-partum modern FP use to be identified by distinct variables or sets of variables, although some of the determinants may overlap ( Bollen, et al., 1995 ). These are instrumental variables that are theoretically related to one of the dependent variables and not related to the other. In this study, age of women’s at first birth was hypothesized to present pregnancy risks and to be related to ANC/PNC services only. Several factors, including the desire for more children, previous use of any modern contraceptives, knowledge of modern contraceptives, and visits by a FP field worker as well as to a health facility were hypothesized to be directly associated with only post-partum modern FP use. Hausman specification and log-likelihood ratio tests were used to examine whether the exclusion of these variables from the respective equations was appropriate. In both countries, the test of exogeneity showed no statistically significant association between post-partum modern FP use and the error term of ANC/PNC service intensity (results not shown). Specification tests also confirmed that the exclusion of the instrumental variables did not make a difference to the respective equations.
  • Now for the results This first table is on Kenya. We found that 46 percent of the sample adopted modern family planning after the birth, and we also found from the bivariate results that women who ever used a modern method of contraception before the conception of the index child used ANC/PNC services more intensively than did others (p&lt;.001). The last column presents results of the proportional hazard model, ANC/PNC service intensity was significantly related to the contraceptive use outcome. After controlling for other factors that may influence FP use, an increased ANC/PNC intensity score was positively and significantly associated with an increase in the likelihood of modern FP use after a woman’s last birth (hazard ratio=1.11; p&lt;.01).
  • In Kenya and Zambia, we also examined the relative importance of the intensity of ANC and PNC services separately to post-partum FP use. This table shows partial results of the multivariate proportional hazard model where two separate intensity scores were used for ANC and PNC services instead of the composite intensity score. These results indicate a strongly significant, positive association between ANC service intensity and post-partum modern contraceptive use (p&lt;.01). PNC service intensity was not found significantly related to post-partum modern contraceptive use. The associations between controlling factors and the contraceptive use behavior remained the same as in the earlier model.
  • The next two slides show the results from Zambia. 46 percent of the sample adopted a modern method post partum, and again, a significant, positive association was observed between women’s prior use of modern contraceptives and ANC/PNC service use intensity (coef=.10; p&lt;.01). The last column presents results of the multivariate proportional hazard model. ANC/PNC service intensity score is shown to have a significant, positive association with post-partum modern FP use. The result indicates that after the confounders were controlled for, an increase of one point in the service intensity score was associated with a 8 percentage point increase in the likelihood of post-partum modern FP use (p&lt;.05).
  • When ANC and PNC services were separated in the multivariate model, as shown in this table, we found a similar significant, positive association between the ANC service intensity and post-partum modern contraceptive use (hazard ratio=1.08; p&lt;.05). The PNC service intensity score was not shown to have a significant association with post-partum modern FP practice.
  • Maternal Health Care Utilization and Subsequent Contraceptive Use

    1. 1. Is There a Causal Relationship Between Maternal Health Care Utilization and Subsequent Contraceptive Use?: Evidence from Kenya and Zambia Mai Do and David Hotchkiss Tulane University
    2. 2. Background <ul><li>Service integration receiving increased attention from governments and donors as way of improving efficiency and access to services </li></ul><ul><li>Several reasons why use of maternal health services might influence post-partum contraceptive use </li></ul><ul><li>Few studies have examined family planning (FP) within the context of reproductive health service delivery </li></ul><ul><ul><li>Mixed evidence on linkages between maternal health care (ANC, delivery, and PNC) and post-partum FP </li></ul></ul>
    3. 3. Research questions <ul><li>Is post-partum modern FP method use related to the use of ANC and PNC relating to the index childbirth? </li></ul><ul><li>If so, what can be said about the linkages between these services? </li></ul>
    4. 4. Data <ul><li>Most recent DHS: 2008-09 in Kenya and 2007 in Zambia </li></ul><ul><li>Selected Kenya and Zambia because: </li></ul><ul><ul><li>DHS within the last three years </li></ul></ul><ul><ul><li>DHS included a birth and contraceptive calendar </li></ul></ul><ul><ul><li>Substantial contraceptive use among married and cohabiting women </li></ul></ul><ul><li>Study sample: married and cohabiting women who had a live birth within five years of the survey </li></ul><ul><ul><li>Kenya: 3,667 women </li></ul></ul><ul><ul><li>Zambia: 3,587 women </li></ul></ul>
    5. 5. Methods (1) <ul><li>Statistical method: Cox proportional hazard model </li></ul><ul><li>Dependent variable: duration (months) from childbirth to modern contraceptive adoption </li></ul>
    6. 6. Methods (2) <ul><li>Independent variable: ANC and PNC service intensity score, constructed from 6 questions </li></ul><ul><ul><li>Timing of first ANC visit, if any </li></ul></ul><ul><ul><li>Number of ANC visits (4 or more) </li></ul></ul><ul><ul><li>Received tetanus vaccination </li></ul></ul><ul><ul><li>Received ANC from trained provider </li></ul></ul><ul><ul><li>Whether specified procedures were carried out during ANC visit (measuring weight and height, blood pressure, taking urine and blood sample, breastfeeding counseling, being told about signs of complications) </li></ul></ul><ul><ul><li>Received PNC from trained provider </li></ul></ul>
    7. 7. Methods (3) <ul><li>Main control variables </li></ul><ul><ul><li>Knowledge of contraceptive methods </li></ul></ul><ul><ul><li>Woman visited and talked about FP with a field worker last 12 months </li></ul></ul><ul><ul><li>Woman visited and talked about FP at a health facility last 12 months </li></ul></ul><ul><ul><li>Desire for more children </li></ul></ul><ul><ul><li>Prior use of modern contraceptive methods </li></ul></ul><ul><ul><li>Recall of FP messages in the mass media </li></ul></ul><ul><li>Tests performed of exogeneity of ANC and PNC service intensity score </li></ul>
    8. 8. Country findings: Kenya 46% adopted modern FP post-partum * p<.05; ** p<.01; *** p<.001 Controls for: socio-demographic characteristics, durations of breasfeeding and amenorrrhea Characteristic Distribution ANC/PNC service intensity Post-partum modern FP use % or mean (s.e.) Coef. (s.e.) Hazard ratio (s.e.) ANC/PNC service intensity (range: -2.75; .90) 0 (1) 1.11 (.04)* Age at first birth 19.2 (3.4) .02 (.00)** - Desire for more children (ref=No) 49.7 - .88 (.05)* Number of modern methods known (knowledge) 6.7 (2.6) - 1.07 (.01)*** Visited and talked about FP at health facility last 12 months (ref=No) 20.9 - 1.21 (.07)** Heard FP messages on the radio last few months (ref=No) 71.6 - 1.15 (.08)*
    9. 9. Kenya: Influences of ANC and PNC services on post-partum modern FP use * p<.05; ** p<.01; *** p<.001 Controls for all women ’s characteristics mentioned before. Characteristic Distribution Post-partum modern FP use % or mean (s.e.) Hazard ratio (s.e.) ANC service intensity (range: -2.72; .88) .1 (.9) 1.10 (.04)** PNC service intensity (range: 0; 2.00) .6 (.6) 1.03 (.05)
    10. 10. Country findings: Zambia 45.9% adopted modern FP post-partum * p<.05; ** p<.01; *** p<.001 Controls for: socio-demographic characteristics, durations of breasfeeding and amenorrrhea Characteristic Distribution ANC/PNC service intensity Post-partum modern FP use % or mean (s.e.) Coef. (s.e.) Hazard ratio (s.e.) ANC/PNC service intensity (range: -4.07; 1.27) 0 (1) 1.08 (.03)* Age at first birth 18.6 (3.0) .04 (.01)* - Desire for more children (ref=No) 66.4 - .95 (.06) Number of modern methods known (knowledge) 6.8 (2.1) - 1.04 (.01)** Visited and talked about FP by a field worker last 12 months (ref=No) 7.8 - 1.20 (.10)* Visited and talked about FP at health facility last 12 months (ref=No) 32.4 - 1.23 (.07)***
    11. 11. Zambia: Influences of ANC and PNC services on post-partum modern FP use * p<.05; ** p<.01; *** p<.001 Controls for all women ’s characteristics mentioned before. Characteristic Distribution Post-partum modern FP use % or mean (s.e.) Hazard ratio (s.e.) ANC service intensity (range: -4.06; 1.26) .0 (.99) 1.08 (.03)* PNC service intensity (range: 0; 2.00) .6 (.7) .95 (.04)
    12. 12. Conclusions <ul><li>Evidence of MCH service use as mediator for individual characteristics to influence post-partum modern FP use </li></ul><ul><ul><li>Results suggest that maternal health care use and FP use are not influenced by common unobserved factors </li></ul></ul><ul><ul><li>Several observed individual factors influence maternal health care use, which then influence FP use </li></ul></ul><ul><li>Evidence that ANC, not PNC, service intensity related to post-partum modern FP use </li></ul><ul><ul><li>Need for service integration, esp. in public sector </li></ul></ul><ul><ul><li>PNC may be among the weakest aspects of RH program </li></ul></ul>
    13. 13. Limitations <ul><li>Not generalizable to all women of childbearing age </li></ul><ul><ul><li>Only married, cohabiting women included in the sample </li></ul></ul><ul><li>Possible endogeneity between FP use and exposure to FP messages in the media and visit by FP a field worker </li></ul><ul><li>No data on community-level and programmatic factors </li></ul>
    14. 14. <ul><li>MEASURE Evaluation PRH is a MEASURE project funded by </li></ul><ul><li>the United States Agency for International Development </li></ul><ul><li>(USAID) through Cooperative Agreement GHA-A-00-08-00003- </li></ul><ul><li>00 and is implemented by the Carolina Population Center at </li></ul><ul><li>the University of North Carolina at Chapel Hill in partnership </li></ul><ul><li>with Futures Group International, Management Sciences for </li></ul><ul><li>Health, and Tulane University. Views expressed in this </li></ul><ul><li>presentation do not necessarily reflect the views of USAID or </li></ul><ul><li>the U.S. Government. MEASURE Evaluation PRH supports </li></ul><ul><li>improvements in monitoring and evaluation in population, </li></ul><ul><li>health and nutrition worldwide. </li></ul>

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