Healthy Mothers, Healthy Children: Does Maternal Demand for Antenatal

Care Matter for Child Health in Nepal?

Nafisa HalimAlok K. BoharaXiaomin Ruan

University of New Mexico

Introduction

High maternal mortality and chronic child malnutrition despite impressive child mortality reduction in Nepal

High maternal mortality rate (540/100,000 live births in 1996)

1 in every 2 children, lighter for age and height; 1 in every 10 children, shorter for age

Context

5.3% of GNP in health expenditures

Safe Motherhood Program in Nepal

GO-NGO Collaboration in health

Still, 80% of deliveries take place at home

Research Questions

(1) Why isn’t antenatal care universal in Nepal?

(2) Does antenatal care matter for child health?

Prior Literature

Maternal Education

Learning about secular organizations

Empowered and autonomous to go beyond tradition

Paternal education is NOT as important

Problems with Prior Studies: Context-Insensitive?

Patriarchal social and economic institutions

Traditional pregnancy governing institutions favor mother-in-laws

Pregnancy is “shameful”

Event of childbirth “polluted”

Problems with Prior Studies: Methodological Constraints Maternal education correlated with parental and

spousal education

Maternal education: A correlation or a cause ofantenatal care?

Husbands’ role in pregnancy-related decision making

His education helps to “approve” of maternal careutilization

HypothesesH 1. Educated mothers are more likely to use professional

antenatal care than their non-educated counterparts. H 2. Mothers are more likely to use maternal care if their

husbands are educated.H 3. Mothers who have access to the media and, presumably,

health-related information are more likely to use professional antenatal care than mothers who lack such access.

H 4. Educated mothers tend to visit professional Antenatal care providers more frequently than their less-educated counterparts.

H 5. Mothers will tend to visit professional antenatal care providers more frequently if their husbands are educated.

H 6. Mothers who have access to the media and, presumably, health-related information tend to visit professional antenatal care providers more frequently than those who lack such access.

H 7. Children whose mothers have sought routine professional antenatal care during pregnancy are healthier in their infant and toddler years than the children of mothers who have not sought such care.

Data The Nepal Family and Health Survey

(NFHS), 1996 and 2001

A stratified cluster-sampling design

A nationally representative sample of 8,429 women, 15 – 49

As many as 3,549 mothers and 2,460 children, 0-36 months

MeasurementsAntenatal care: Type of antenatal care they sought

(modern vs. traditional/none) Frequency in antenatal care utilization

Child health (z-score): Standardized weights conditional on the median weight of a well-nourished child of the same age and sex in the US population.

Estimation Strategy: Two Staged

1st stageAntenatal care=f(maternal and paternal education, controls—age, exposure to media, employment, religion, caste, urbanity, and regional controls)Estimation technique: Binomial Logit Model

Antenatal Visits= f(maternal and paternal education, controls—age, exposure to media, employment, religion, caste, urbanity, and regional controls)Estimation technique: Negative Binomial (count) Model

2nd stageChild health=f(predicted antenatal care, controls—maternal height, weight, age, age at marriage; child’s sex, age, age-sq, parity, illness and immunization history; households’ water-supply and sanitation conditions; religion, caste)Estimation technique: Ordinary Least Squares

Child Health (by education)

0

0.5

1

1.5

2

2.5

Maternal Paternal

Hea

lth in

dica

tor

No education At least some education

Assortative Matching?

0

20

40

60

80

100

None Primary Secondary Higher

Maternal Education

pater

nal E

duca

tion

None Primary Secondary Higher

Results (Part I): Why isn’t antenatal care universal

in Nepal?

Maternal education Matters 15%, 34%, and 57% higher likelihood if

amother has five, ten, or at least twelve years of schooling than none

Paternal education matters 7%, 17%, 12% higher likelihood if her

husband has five, ten, or at least twelve years of schooling than none

Results (Part II): Does antenatal care utilization matter for child health?

Yes and significantly Z-score increases by 0.1 if a

mother utilizes antenatal care Z-score increases by 0.8 if she

pays 1 more antenatal visit

Discussion and Policy Implications Results robust to variations in sample

and estimation techniques Maternal Education matters Paternal education, more important than

the conventional wisdom suggests Raising awareness about importance of

antenatal care Raising awareness about maternal

health for child health Dissemination of health information