John Serieux

What impact does contact with the prenatal care system have on women's use of facility delivery? Evidence from low-income countries

Prenatal and delivery care are critical both for maternal and newborn health. Using the Demographic and Health Surveys (DHS) data for thirty-two low-income countries across Asia, sub-Saharan Africa and Latin America, and employing a two-level random-intercept model, this paper empirically assesses the influence of prenatal attendance and a wide array of observed individual-, household- and community-level characteristics on a womans decision to give birth at a health facility or at home. The results show that prenatal attendance does appreciably influence the use of facility delivery in all three geographical regions, with women having four visits being 7.3 times more likely than those with no prenatal care to deliver at a health facility. These variations are more pronounced for Sub-Saharan Africa. The influence of the number of prenatal visits, maternal age and education, parity level, and economic status of the birthing women on the place of delivery is found to vary across the three geographical regions. The results also indicate that obstetrics care is geographically and economically more accessible to urban and rural women from the non-poor households than those from the poor households. The strong influence of number of visits, household wealth, education and regional poverty on the site of delivery setting suggests that policies aimed at increasing the use of obstetric care programs should be linked with the objectives of social development programs such as poverty reduction, enhancing the status of women, and increasing primary and secondary school enrollment rate among girls.

Determinants of prenatal care use: evidence from 32 low-income countries across Asia, Sub-Saharan Africa and Latin America

While much has been written on the determinants of prenatal care attendance in low-income countries, comparatively little is known about the determinants of the frequency of prenatal visits in general and whether there are separate processes generating the decisions to use prenatal care and the frequency of use. Using the Demographic and Health Surveys data for 32 low-income countries (across Asia, Sub-Saharan Africa and Latin America) and appropriate two-part and multilevel models, this article empirically assesses the influence of a wide array of observed individual-, household- and community-level characteristics on a womans decision to use prenatal care and the frequency of that use, while controlling for unobserved community level factors. The results suggest that, though both the decision to use care and the number of prenatal visits are influenced by a range of observed individual-, household- and community-level characteristics, the influence of these determinants vary in magnitude for prenatal care attendance and the frequency of prenatal visits. Despite remarkable consistency among regions in the association of individual, household and community indicators with prenatal care utilization, the estimated coefficients of the risk factors vary greatly across the three world regions. The strong influence of household wealth, education and regional poverty on the use of prenatal care suggests that safe motherhood programmes should be linked with the objectives of social development programmes such as poverty reduction, enhancing the status of women and increasing primary and secondary school enrolment rate among girls. Finally, the finding that teenage mothers and unmarried women and those with unintended pregnancies are less likely to use prenatal care and have fewer visits suggests that safe mother programmes need to pay particular attention to the disadvantaged and vulnerable subgroups of population whose reproductive health issues are often fraught with controversy.

Who is giving up the free lunch? The insured patients' decision to access health insurance benefits and its determinants: evidence from a low-income country.

OBJECTIVES This paper examines the determinants of the insureds decision to use their health insurance card when seeking outpatient and inpatient health care in Vietnam. METHODS Uses Vietnams latest Household Living Standard Survey data and random-intercept logistic regression to assess the influence of the observed individual, household and commune/ward factors on the insureds decision to access health insurance benefits while controlling for the unobserved commune/ward-specific factors. RESULTS Compared to the compulsory enrollees, the voluntary enrollees and the beneficiaries of the Health Care Fund for the Poor are less likely to use their card when seeking inpatient care. An individuals likelihood of accessing insurance benefits varies inversely with income and the level of education, suggesting that the outpatient care provided to the insured is of inferior quality. CONCLUSIONS Although health insurance has the potential of increasing access and reducing the financial burden of health care utilization, Vietnams experience clearly suggests that these benefits may not be fully realized as long as the quality of care remains low and the high opportunity costs of accessing insurance benefits deter the insured from accessing benefits.

Aid and Resource Mobilisation in Sub-Saharan Africa: the Role of Reverse Flows

Abstract This article seeks to ascertain the role of ‘reverse flows’ in explaining the observed limited impact of aid on resource mobilisation in Sub-Saharan Africa. It departs from the previous empirical literature on aid and resource mobilisation by abandoning the pervasive, but untenable, assumption that aid either displaces domestic saving (increases consumption) or increases investment. Some aid is, in fact, used to finance reverse flows (debt servicing, capital flight, and reserve accumulation). The evidence suggests that, for the period covering 1980 to 2006, nearly 50 per cent of aid to Sub-Saharan African countries was used to finance reverse flows.

Uptake of voluntary health insurance and its impact on health care utilization in Ghana

Ghana introduced a social health insurance scheme in 2003. One of its motivations was to protect consumers against adverse health shocks. Financing for the programme comes from a 2.5% goods and service tax, contributions by formal sector workers directly transferred from their social security savings and individual premiums from informal members. This arrangement makes formal workers compulsory members of the scheme while informal members voluntarily enroll. We view this as a natural experiment in which one section of the population automatically acquires insurance (with formal sector employment), and the remainder choose to obtain the same coverage (or not). Using data from the 2009/2010 Ghana Socioeconomic Panel Survey, we explore the determinants of the uptake of health insurance by informal members and test whether this voluntary health insurance uptake impacts the frequency of use of health care resources. We find robust evidence that older, wealthier and more educated individuals are more likely to buy (voluntary) health insurance. Moreover, using the method of propensity score matching, we find that voluntary health insurance uptake is strongly associated with higher health care utilization-implying that, with respect to the frequency of use, the mode of insurance acquisition matters.

The impact of the global economic crisis on HIV and AIDS programmes directed at women and children in Zambia

This investigation sought to ascertain the extent to which the global economic crisis of 2008–2009 affected the delivery of HIV/AIDS-related services directed at pregnant and lactating mothers, children living with HIV and children orphaned through HIV in Zambia. Using a combined macroeconomic analysis and a multiple case study approach, the authors found that from mid-2008 to mid-2009 the Zambian economy was indeed buffeted by the global economic crisis. During that period the case study subjects experienced challenges with respect to the funding, delivery and effectiveness of services that were clearly attributable, directly or indirectly, to the global economic crisis. The source of funding most often compromised was external private flows. The services most often compromised were non-medical services (such as the delivery of assistance to orphans and counselling to HIV-positive mothers) while the more strictly medical services (such as antiretroviral therapy) were protected from funding cuts and service interruptions. Impairments to service effectiveness were experienced relatively equally by (HIV-positive) pregnant women and lactating mothers and children orphaned through HIV. Children living with AIDS were least affected because of the primacy of ARV therapy in their care.

Does the Type of Provider and the Place of Residence Matter in the Utilization of Prenatal Ultrasonography? Evidence from Canada

BackgroundThere has been a proliferation of repeat prenatal ultrasound examinations per pregnancy in many developed countries over the past 20 years, yet few studies have examined the main determinants of the utilization of prenatal ultrasonography.ObjectiveThe objective of this study was to examine the influence of the type of provider, place of residence and a wide range of socioeconomic and demographic factors on the frequency of prenatal ultrasounds in Canada, while controlling for maternal risk profiles.MethodsThe study utilized the data set of the Maternity Experience Survey (MES) conducted by Statistics Canada in 2006. Using an appropriate count data regression model, the study assessed the influence of a wide range of socioeconomic, demographic, maternal risk factors and types of provider on the number of prenatal ultrasounds. The regression model was further extended by interacting providers with provinces to assess the differential influence of types of provider on the number of ultrasounds both across and within provinces.ResultsThe results suggested that, in addition to maternal risk factors, the number of ultrasounds was also influenced by the type of healthcare provider and geographic regions. Obstetricians/gynaecologists were likely to recommend more ultrasounds than family physicians, midwives and nurse practitioners. Similarly, birthing women who received their care in Ontario were likely to have more ultrasounds than women who received their prenatal care in other provinces/territories. Additional analysis involving interactions between providers and provinces suggested that the inter-provincial variations were particularly more pronounced for family physicians/general practitioners than for obstetricians/gynaecologists. Similarly, the results for intra-provincial variations suggested that compared with obstetricians/gynaecologists, family physicians/GPs ordered fewer ultrasound examinations in Prince Edward Island, British Columbia, Nova Scotia, Alberta and Newfoundland.ConclusionAfter controlling for a number of socioeconomic and demographic factors, as well as maternal risk factors, it was found that the type of provider and the province of prenatal care were statistically significant determinants of the frequency of use of ultrasounds. Additional analysis involving interactions between providers and provinces indicated wide intra- and inter-provincial variations in the use of prenatal ultrasounds. New policy measures are needed at the provincial and federal government levels to achieve more appropriate use of prenatal ultrasonography.

Measuring the Attributes of Poverty and its Persistence: A Case Study of Eritrea

This paper tries to identify the correlates of poverty in urban Eritrea using an estimation technique (the DOGEV model) that also allows for the inclusion of a measure of persistence- in poverty levels from cross-sectional estimation. The results suggest that 17 percent of the probability of being moderately poor and 22 percent of the probability of being extremely poor in Eritrea was attributable to this persistence - a predisposition toward poverty likely due to latent attributes related to past experience of poverty itself. The results also suggest that, in the post-war economy of the mid-1990s, those with vocational training fared best among all education groups. Being a war veteran also had a strong negative association with the poverty - reflecting successful attempts to support that group. The receipt of remittances also reduced the likelihood of poverty; though receipts from outside Eritrea had a much stronger effect than receipts from within Eritrea.