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BRIEF RESEARCH ARTICLE
Year : 2015  |  Volume : 59  |  Issue : 3  |  Page : 217-219  

Wealth index and maternal health care: Revisiting NFHS-3


1 Associate Professor, Lady Hardinge Medical College, New Delhi, India
2 Resident, Lady Hardinge Medical College, New Delhi, India
3 Director Professor, Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India
4 Research Scholar, Department of Economic Studies and Planning, Jawaharlal Nehru University (JNU), New Delhi, India
5 Epidemiologist-cum-Assistant Professor, Department of Community Medicine, SHKM Government Medical College, Nalhar, Haryana, India

Date of Web Publication7-Sep-2015

Correspondence Address:
Pritam Roy
Department of Community Medicine, Lady Hardinge Medical College, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.164665

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   Abstract 

The third National Family Health Survey (NFHS-3) is a large dataset on indicators of family welfare, maternal and child health, and nutrition in India. This article using NFHS-3 data is an attempt to bring out the impact of economic status, i.e., the wealth index on maternal health. The study was based on an analysis of the NFHS-3 data. Independent variables taken were the wealth index, literacy, and age at first child birth. Effects of these variables on the maternal health care services were investigated. Out of the total 124,385 women aged 15-49 years included in the NFHS-3 dataset, 36,850 (29.6%) had one or more childbirth during the past 5 years. The number of antenatal care (ANC) visits increased as the wealth index increased and there was a pattern for choice of place of delivery (for all deliveries during the last 5 years) according to the wealth index. Logistic regression analysis of the abovementioned variables were sought to find out the independent role of key determinants of the different aspects of maternal health care. It showed that the wealth index is the leading key independent determinant for three or more ANC received: Tetanus toxoid (TT) received before delivery, iron tablet/syrup taken for more than 100 days, and institutional delivery. Mother's literacy was the leading independent key determinant for early antenatal registration. The study suggested that along with the mother's literacy, the wealth index that is an important predictor of maternal health care can be added for categorization of the districts for providing differential approach for maternal health care services.

Keywords: India, literacy, maternal health care, third National Family Health Survey (NFHS-3), wealth index


How to cite this article:
Goel MK, Roy P, Rasania SK, Roy S, Kumar Y, Kumar A. Wealth index and maternal health care: Revisiting NFHS-3. Indian J Public Health 2015;59:217-9

How to cite this URL:
Goel MK, Roy P, Rasania SK, Roy S, Kumar Y, Kumar A. Wealth index and maternal health care: Revisiting NFHS-3. Indian J Public Health [serial online] 2015 [cited 2020 Sep 29];59:217-9. Available from: http://www.ijph.in/text.asp?2015/59/3/217/164665

Care of the expectant mother has always been a priority area in any nation's public health agenda. The outcome of a pregnancy is often related to the sum total of the quantity and quality an expectant mother receives during pregnancy. India too has witnessed an impressive improvement in maternal health-related indicators. But the "impressive" decline in maternal mortality at the national level is somewhat misleading because it does not reflect disparities among the states and across socioeconomic strata. Maternal death rates have been consistently higher in states like Assam, Uttar Pradesh, Uttarakhand, Rajasthan, Odisha, Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand (averaging 257/100,000 live births). The southern states (Kerala, Tamil Nadu, Andhra Pradesh, Karnataka) have comparatively lower maternal deaths (averaging 105/100,000 live births). [1] Addressing maternity care needs may have considerable ramifications for achieving the Millennium Development Goal 5 (MDG 5). Keeping in view the wide disparity in mortality rates and the ever so present financial constraints, the Reproductive and Child Health (RCH) program under the National Rural Health Mission (NRHM) was based on differential approach on the basis of crude birth rates and female literacy. However, several studies conducted in low-income countries have demonstrated socioeconomic status as an important determinant of maternal health care service utilization. [2],[3],[4],[5],[6],[7] With the improvement in literacy rates and the ever increasing health care costs especially in view of social provisioning of health financing, economic constraint are increasingly cited as an important prohibitive factor for the utilization of health care services. This article using the third National Family Health Survey (NFHS-3) data is an attempt to bring out the impact of economic status, i.e., the wealth index on maternal health. The wealth index has been developed and tested in a large number of countries in relation to inequalities in household income, use of health services, and health outcomes. [8],[9]

The study was based on the analysis of data collected during the NFHS-3, a large dataset on indicators of family welfare, maternal and child health, and nutrition in India. This survey, conducted in 2005-2006, covered a representative sample of 1,09,041 households including 124,385 women aged 15-49 years and 74,369 men aged 15-54 years. It captured data on all births occurring among these women over the preceding 5 years and on several individual-level, household-level, and community-level variables. The dataset was downloaded from the Demographic and Health Surveys online archive (http://www.measuredhs.com [Last accessed on 2014 Mar 15]) after obtaining due permission. Secondary data analysis of NFHS-3 was done using SPSS (Version 12.0, Chicago, Il, USA).th

The wealth index is an indicator of the level of wealth that is consistent with expenditure and income measures. It uses information on 33 household assets and housing characteristics. Each household asset is assigned a weight (factor score) generated through principal component analysis and the resulting asset scores are standardized in relation to a normal distribution. Each household is then assigned a score for each asset, and ranked accordingly to the score of household in which they reside. The sample is then divided into quintiles. In NFHS-3, one wealth index has been developed for the whole sample and for the country as a whole. [10]th

Independent variables taken were the wealth index, literacy, and age at first child birth. Effects of these variables [number of times antenatal care (ANC) received, time of first visit, tetanus toxoid (TT) received before delivery, iron tablet/syrup taken for more than 100 days, place of delivery] on the maternal health care services were investigated. As these dependent variables were qualitative in nature and logistic regression analysis was done with a model adjusted for factors at the individual level.

The NFHS-3 was conducted under the scientific and administrative supervision of the International Institute for Population Sciences (IIPS), Mumbai, Maharashtra, India. This institute conducted an independent ethics review of the NFHS protocol. Data collection procedures were also approved by the Institutional Review Board at the ORC Macro. This study is based on the NFHS data, which are available in the public domain to use with no identifiable information on the survey participants; therefore, this work is exempted from any ethical review.

Out of the total of 1,24,385 women (aged 15-49 years) included in the NFHS-3 dataset, 36,850 (29.6%) had one or more childbirth during the past 5 years and showed a number of ANC visits by females only during the most recent childbirth. Out of them, nearly 18% of did not receive any ANC and the proportion was highest among those belonging to the poorest quintile according to the wealth index. The number of ANC visits increased as the wealth index increased [Table 1].
Table 1: Distribution of number of ANCs according to the wealth index

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The dataset also showed that there was a pattern for choice of place of delivery (for all deliveries during the last 5 years) according to the wealth index. The poorest of the groups were having the highest proportion of home deliveries and as the wealth index improved, the proportion of the institutional deliveries also showed improvement. Strikingly, more than 40% and 15% of the women belonging to the richer and richest groups, respectively, also had home deliveries [Table 2].
Table 2: Coefficient of determination for multiple logistic regression analysis

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The dataset also had information on the different aspects of ANC focused at determining the quality. Moreover, the dataset also had information on other parameters that might also be the determinants of maternal health care indicators, e.g., literacy status and the age of the mother at the time of first child birth. Multiple logistic regression analysis of the abovementioned variables had been applied on to find out the independent role of the key determinants of different aspects of maternal health care as per the NFHS-3 data. Independent variables like the wealth index, mother's literacy, and age of the mother at the time of first child birth can explain 4.5% change for three or more ANC visits, of which the wealth index alone explains 4.1% changes. Similarly, 7.3% of changes can be explained by independent variables for TT received before delivery, of which 6.3% is explained by the wealth index alone. The wealth index also explains 7% change out of 8.3% of the changes for iron tablet/syrup taken for more than 100 days. Most importantly, 25.9% of institutional delivery can be explained by the three independent variables of which the wealth index alone explains 23.1%. The analysis showed that the wealth index is a leading independent key determinant for three or more ANC received, TT received before delivery, iron tablet/syrup taken for more than 100 days, and institutional delivery. Mother's literacy was the leading independent key determinant for early antenatal registration. Thus, the wealth index plays an important role in achieving various maternal health care indices.

Maternal mortality in India is either avoidable or easily manageable, provided timely care is sought and received. Adequate and quality ANC is the key if we were to achieve a safe motherhood. It requires early registration of the expectant mother, provision and utilization of services like timely and regular health checkups, immunization against tetanus, intake of iron-folic acid supplements, and finally an institutional delivery where any untoward event can be suitably taken care of.

Our study suggested that along with the female literacy, the wealth index that is an important predictor of maternal health care can be added for categorization of districts for providing differential approach for maternal health care services. As this was the leading independent key determinant, giving weightage to this important predictor will not only help provide cost-effective delivery of maternal care services, but also enable the policy makers and program managers to micromanage the service delivery packages according to community needs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Government of India, Ministry of Home Affairs. Maternal Mortality in India 2010-12: Special Bulletin. New Delhi, India: Sample Registration System. New Delhi: Office of the Registrar General; 2013.  Back to cited text no. 1
    
2.
Birmeta K, Dibaba Y, Woldeyohannes D. Determinants of maternal health care utilization in Holeta town, central Ethiopia. BMC Health Serv Res 2013;13:256.  Back to cited text no. 2
    
3.
Chakraborty N, Islam MA, Chowdhury RI, Bari W, Akhter HH. Determinants of the use of maternal health services in rural Bangladesh. Health Promot Int 2003;18:327-37.   Back to cited text no. 3
    
4.
Celik Y, Hotchkiss DR. The socio-economic determinants of maternal health care utilization in Turkey. Soc Sci Med 2000;50:1797-806.  Back to cited text no. 4
    
5.
Fatmi Z, Avan BI. Demographic, socio-economic and environmental determinants of utilisation of antenatal care in a rural setting of Sindh, Pakistan. J Pak Med Assoc 2002;52:138-42.  Back to cited text no. 5
    
6.
Ahmed S, Creanga AA, Gillespie DG, Tsui AO. Economic status, education and empowerment: Implications for maternal health service utilization in developing countries. PLoS One 2010;5:e11190.  Back to cited text no. 6
    
7.
Kesterton AJ, Cleland J, Sloggett A, Ronsmans C. Institutional delivery in rural India: The relative importance of accessibility and economic status. BMC Pregnancy Childbirth 2010;10:30.  Back to cited text no. 7
    
8.
Alam AY, Nishtar S, Amjad S, Bile KM. Impact of wealth status on health outcomes in Pakistan. East Mediterr Health J 2010;16(Suppl):S152-8.  Back to cited text no. 8
    
9.
Mishra US, Dilip TR. Reflections on wealth quintile distribution and health outcomes. Econ Polit Wkly 2008;43:77-82.  Back to cited text no. 9
    
10.
International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005. 06: India: Volume I. Mumbai: IIPS.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2]


This article has been cited by
1 How far is universal coverage of antenatal care (ANC) in India? An evaluation of coverage and expenditure from a national survey
Virendra Kumar,Pushpendra Singh
Clinical Epidemiology and Global Health. 2016;
[Pubmed] | [DOI]



 

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