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Impact of education on the utilization of maternal health care services: An investigation from National Family Health Survey (2015–16) in India
Journal Pre-proofs Impact of education on the utilization of maternal health care services: An investigation from National Family Health Survey (2015-16) in India Bikash Barman, Jay Saha, Pradip Chouhan PII: DOI: Reference:
S0190-7409(19)30980-6 https://doi.org/10.1016/j.childyouth.2019.104642 CYSR 104642
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Children and Youth Services Review
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Please cite this article as: B. Barman, J. Saha, P. Chouhan, Impact of education on the utilization of maternal health care services: An investigation from National Family Health Survey (2015-16) in India, Children and Youth Services Review (2019), doi: https://doi.org/10.1016/j.childyouth.2019.104642
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Impact of education on the utilization of maternal health care services: An investigation from National Family Health Survey (2015-16) in India
Bikash Barman1 , Jay Saha2 & Prof. Pradip Chouhan3 1. Ph. D. Scholar, Dept. of Geography, University of Gour Banga, Malda, West Bengal, India, Email- [email protected] 2. ICSSR Project Assistant, Dept. of Geography, University of Gour Banga, Malda, West Bengal, India, Email- [email protected] 3. Professor, Dept. of Geography, University of Gour Banga, Malda, West Bengal, India, Email- [email protected]
Impact of education on the utilization of maternal health care services: An investigation from National Family Health Survey (2015-16) in India
Abstract Aim: The present study attempts to show the influence of women’s (15-49 yrs) education on the utilization of Maternal Health Care (MHC) services in India and also find out the other determinants for the utilization of MHC services. Data & Method: The entire study depends on secondary data collected from the National Family Health Survey (NFHS)-4 in the year of 2015-16 of India which was conducted on 189898 women having age group of 15-49 years. In the present study, the last birth women (189898) have been considered. For the proper depiction of the resulting binary logistic regression has been conducted. Variables: To show the level of utilization of MHC services in India, the highest educational level of the respondents have been considered as the explanatory variable and six outcome variables have been selected. Result: The unadjusted odds ratio (UOR) shows that women’s education positively and very significantly associated with the utilization of MHC services which indicates that the higher educated women are more likely to received at least 4 ANC visit [UOR 6.450, 95% CI (6.223 - 6.685) & p-value <0.01], taking 1st antenatal visit within first trimester [UOR 2.563, 95% CI (2.458 - 2.672) & p-value <0.01], ANC visit by skilled health professionals [UOR 9.139, 95% CI (8.624 - 9.684) & p-value <0.01], taking 2 or more than 2 TT doses [UOR 2.348, 95% CI (2.239 - 2.463) & p-value <0.01], delivered in health facility [UOR 14.64, 95% CI (13.63 - 15.73) & p-value <0.01 ] and received PNC within 42 days of delivery [UOR 1.361, 95% CI (1.024 - 1.808) & p-value <0.01] than the illiterate women. The adjusted odds ratio (AOR) was low compared to UOR which indicate that there were important effect of other variables (which have been controlled in the adjusted odds ratio) except education which also impact on the utilization of maternal health care services i.e. maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region. Key Words: Education, antenatal care (ANC), delivery care, postnatal care (PNC), India.
Introduction Improved maternal health care is a very important goal of Sustainable Development Goal (SDG) and Millennium Development Goal (MDG) which is the strong predictor to decline the pregnancy complication, maternal morbidity, maternal mortality and also, infant mortality (Adjiwanou & Legrand, 2013; Sahoo et. al., 2015; Neil, Naeve & Ved, 2017). Over the World different countries already introduced different programmes and policies for improve the availability and accessibility in the utilization of maternal health care services where India take many programmes and initiatives i.e. Janani Suraksha Yojana, Janani Shishu Suraksha Karyakaram, Matrima, Matrika and so on. Though there is a great variation by different determining factors (age, age at marriage, caste, religion, place of residence, economic condition, educational attainment, the educational level of the spouse, parental education and so on), education directly have a strong impact on the utilization of maternal health care services (Shariff & Singh, 2002; Chandhiok et. al., 2006; Jat, Ng & Sabestian, 2011; Chimankar & Sahoo, 2011; Joshi et. al., 2014). Education helps them to know about the human reproductive system; knowledge about the pregnancy, treatment-seeking behaviour at three phases i.e. antenatal, delivery and postnatal period, child spacing and newborn care (Govindaswami & Ramesh, 1997; Weitzman, 2017). In the global scenario, the World Fertility Survey and the Demographic and Health Surveys already gave the evidence of the very strong impact of the education mainly women’s education on the declining the maternal mortality, child morbidity and child mortality (Govindaswami & Ramesh, 1997; Joshi et. al., 2014). Education increases the women’s cognitive skills (Smith-Greenway, 2013) which benefit maternal health by increasing the ability to seek information about their own health as well as medical instruction to treatment and medication (Barber, 2001; SmithGreenway, 2013). On the other hand women’s education also triggering the improvement of economic opportunities, employment status and women autonomy which may help to take the better decision on the time of marriage, childbearing and money spent in the health section as they can effort easily (Raghupathy, 1996; Gunes, 2015). In India the most important barrier in the utilization of maternal health care services is the educational attainment and the economic condition which results in Kerala degree of utilization of maternal health care services are very high wherein Bihar, Chhattisgarh and Rajasthan the utilization is very far from the Indian average (Vora et. al., 2009; Singh et. al., 2012; Muzaffar, 2016; Jose et. al., 2018). All these changes occurred by education together affect the women’s fertility behaviour; if education increase then the child marriage will be
abolished, education increases the use of contraceptive which decreases the degree of high fertility and increases the child spacing which together decrease the pregnancy complication, stillbirth and unsafe abortion (Rose & Lawton, 2012; Behrman et. al., 2015; Thomas et. al., 2017). Except for these fertility changes education also may change the maternal health care behaviour by the receiving at least 4 antenatal visit within their first trimester of pregnancy, receiving 2 or more doses of TT injection, antenatal care by a health professional (Doctor, Auxiliary nurse midwives, nurses) by which easily can detect hypertension disorder, anaemia, brain haemorrhaging (Duley, 1992; Rush, 2000; Sibai et al., 2005); educated women deliver at an institution to decrease the risk of delivery complication and newborn death and received postnatal care within 2 days of delivery which lead to reducing the risk of postpartum infection and which give the healthy mother and children (Graham et. al., 2001; Chimankar & Sahoo, 2011; Vikram et. al., 2012; Sahoo et. al., 2015; Dimbuene et. al., 2017). Thus this study focuses on the degree of influence of education on the utilization of maternal health care services in two models i.e. in the first model where only educational effect has been shown and in second model educational impact including another influencing factor (maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region) have been introduced. Methods Data source The entire study has been done with the help of secondary data collected from National Family Health Survey-4 in India which has been conducted in 2015-16 over 601509 households, 699686 women aged 15–49 years with a response rate of 97%, and 112122 men aged 15–54 years with a response rate of 92% (Paul & Chouhan, 2019). In the present study, we have used the data on 190898 ever-married women aged 15-49 years who had at least one live birth in the past five years preceding the time of the survey. Measures Maternal health care utilization Utilization of maternal health care has been analyzed in three phases’ i.e. antenatal care (ANC), delivery care and postnatal care (PNC) wherein antenatal care four outcome variables have been selected i.e. adequate number of ANC visit i.e. at least 4 ANC visit as per recommendation of World Health Organization, proper timing of first ANC visit which has been considered as timing of first ANC within first trimester (WHO, 2016), skilled health
personnel for ANC where skilled health personnel has been considered as antenatal care by doctor/nurse/auxiliary nurse midwife and taking at least 2 or more tetanus toxoid injection as per WHOs recommendation. In case of delivery care, institutional delivery has been considered and in postnatal care, taking PNC within 42 days of delivery where all the outcome variables have been considered as binary i.e. if ‘yes’ then 1 and if ‘no’ then 0 for the proper depiction of the result. Education Educational attainment is the main explanatory variable in the present study which has been divided into four categories i.e. illiterate, primary, secondary and higher secondary and above. Study covariates Different socio-demographic and economic variables have been considered as covariates in the present study to show the determining effect on the utilization of maternal health care services except for education i.e. age of the respondents which has been categorized into three categories i.e. 15-24 years, 25-34 years and 35-49 years, age at marriage (<18years and 18 or >18 years), birth order (1, 2, 3 and 4 or 4+), caste (SC, ST, OBC & Others), religion (Hindu, Muslim, Christian and Others), place of residence (urban & rural), wealth index (poorest, poorer, middle, richer and richest), region (north, central, east, north-east, west & south) and mass media exposure (no exposure, partial exposure and full exposure) has been considered to show the adjusted odds ratio (controlled for maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region) between education and utilization of maternal health care services. Statistical analysis Bivariate and multivariate analysis was carried out to know the association between education and different maternal health care indicators in the present study. Binary logistic (0, 1) regression also has done to find the unadjusted odds ratio and adjusted odds ratio (where other independent variables were controlled) of educational impact on the utilization of maternal health care services. Results Table 1 depicts the respondent’s individuals (maternal age, age at marriage, birth order) and socio-cultural characteristics (education, caste, religion, wealth index, place of residence, region and mass media exposure) in India where most (46.9%) of the respondent's education
were secondary level and 27.6% were illiterate, 55.9% respondents have belonged from the age group 25-34 years and 37.6% were being married at <18 years old. Most of the respondents (45.3%) were from Other Backward Classes group and near about 45% of respondents belonged from a poor family who is inhabited in rural areas (70.2%). Table-1 be here Table 2 presents the individuals and socio-cultural characteristics of the respondents by their utilization of different maternal health care services in India which clearly stated that the higher secondary and above respondents were more advanced in terms of taking different maternal health care services i.e. at least 4 ANC (73.7%), ANC visit within first trimester (80.8%), skilled health personnel for ANC (93.8%), taking 2 or more TT injections (88.1%), institutional delivery (97.0%) and PNC within 42 days of delivery (99.0%) than the illiterate women. Legal age at marriage (18 or above) women were more advanced in the utilization of MHC services than the early marriage women and the women who had at least one live birth in the last 5 years preceding the survey, 62.2%, 73.9%, 87.0%, 87.3%, 91.1% and 98.8% had at least 4 ANC, ANC visit within first trimester, skilled health personnel for ANC, taking 2 or more TT injections, institutional delivery and PNC within 42 days of delivery respectively more than the higher birth order (4 or 4+). The weighted percentage of all the MHC indicators in India among the Muslim women was significantly lower than the Hindu women and also lower in rural areas than the urban areas. The poorest women were also very far from the proper utilization of all the MHC services than the richer and richest women (see table 2). Table-2 be here Table 3 shows the result of the binary logistic regression model for the association between maternal education and utilization of maternal health care services among the 15-49 aged women in India. The unadjusted odds ratio (UOR) represents the educational impact on the utilization of MHC services among the women aged 15-49 years where it was found that there was a significant variation in the likelihood of taking all the MHC services i.e. at least 4 ANC [UOR: 6.450, 95% CI: 6.223 - 6.685 & p<0.01], ANC visit within first trimester [UOR: 2.563, 95% CI: 2.458 - 2.672 & p<0.01], skilled health personnel for ANC [UOR:9.139, 95% CI: 8.624 - 9.684 & p<0.01], taking 2 or more TT injection [UOR:2.348, 95% CI: 2.239 2.463 & p<0.01], institutional delivery [UOR: 14.640, 95% CI: 13.63 - 15.73 & p<0.01] &
PNC within 42 days of delivery [UOR: 1.361, 95% CI: 1.024 - 1.808 & p<0.01] among the higher secondary and above educated women was higher than the illiterate (reference Table-3 be here category) women. After adjusting all the socio-economic variables (maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region) with the education, the adjusted odds ratio (AOR) was lower than the UOR which tells that not only education but also other many factors/variables which influence the utilization of MHC services among the ever-married women aged 15-49 years in India. The AOR among the higher secondary and above women was higher than the illiterate women in most of the MHC indicators (5 indicators) i.e. at least 4 ANC [AOR: 1.756, 95% CI: 1.674 - 1.841 & p<0.01], ANC visit within first trimester [AOR: 1.311, 95% CI: 1.244 - 1.383 & p<0.01], skilled health personnel for ANC [AOR: 2.137, 95% CI: 1.993 2.293 & p<0.01], taking 2 or more TT injection [AOR: 1.389, 95% CI: 1.305 - 1.478 & p<0.01] & institutional delivery [AOR: 2.899, 95% CI: 2.668 - 3.151 & p<0.01] which represents that there was a more likelihood of taking MHC services among the higher secondary and above women than the illiterate women but only in one indicator i.e. PNC within 42 days of delivery [AOR: 0.748, 95% CI: 0.521 - 1.073] the adjusted odds ration was lower among higher secondary and above women than the illiterate women which directly indicate that in case of taking PNC within 42 days of delivery effect of other variables was more than the effect of education. Discussion The present study reveals the association between the respondent’s (15-49 years aged evermarried women) education (illiterate, primary, secondary and higher secondary and above) and the utilization of maternal health care services (at least 4 ANC, ANC within first trimester, skilled health personnel for ANC, 2 or more doses TT injection, institutional delivery and PNC within 42 days of delivery) in India. Our study also provide the other associated factors (maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region) except education which also responsible for the utilization of maternal health care services (Bhatia & Cleland, 1995; Celik & Hotchkiss, 2000; Deo & Bhaskar, 2014; Sahoo et. al., 2015) though education was the strong predictor among the Indian women (Elo, 1992; Raghupathy, 1996; Govindaswamy & Ramesh, 1997; Dimbuene et. al., 2017; Weitzman, 2017). Our findings show the significant
association between the respondent’s education and the utilization of maternal health care services which also found in many previous studies i.e. in Bangladesh (Walton & Schbley, 2013), in Botswana (Letamo & Rakgoasi, 2003), in Indonesia (Titaley et. al., 2010), in Nepal (Deo & Bhaskar, 2014), in Mali (Gaje, A., 2007), in Uganda (Kalule Sabiti, 2014) and so on . The women who have acquired higher secondary and above education were more likely to received all the maternal health care services than the illiterate or low educated women (Chakraborty et. al., 2003; Mekonen & Mekonen, 2003; Jat et. al., 2011; Chimankar & Sahoo, 2011; Shahjahan et. al., 2012; Nair et. al., 2015;). The strong probable reason for the low use of maternal health care services among the low educated women were one hand the lack of proper knowledge about the availability, accessibility and utilization and other hands low educated women were not so frank to discuss about the different care at the time of pregnancy, delivery and post-delivery (Letamo & Rakgoasi, 2003; Gaje, 2007; Walton & Schbley, 2013; Joshi et. al., 2014; Thomas et. al., 2017; Navaneetham & Dharmalingam, 2017). Previous studies also shows that the lack of decision making power also the hindrance in the utilization of maternal health care services among the illiterate or low educated women in India (Bloom et. al., 2016) and also over the world i.e. Ethiopia (Tiruneh et. al., 2017; Wado, 2017) Nigeria (Dahiru & Oche, 2015; Babalola & Fatusi, 2009), Philippines (Yamashita et. al., 2017). Additionally a number of studies which also shows the effect of different socio-demographic factors over the utilization of maternal health care services which stated that exception of education there were also other factors which influences the utilization of maternal health care services (Celik & Hotchkiss, 2000; Arthur, 2012; Asundep et. al., 2013; Deo & Bhaskar, 2014; Pandey & Karky, 2014; Sabiti et. al., 2014; Hearld et. al., 2018). There were also many studies which stated that the low utilization of maternal health care services were found among the illiterate or low educated women which are very poor in terms of economic condition (Shahram et. al., 2015), who resided the very remote areas and among the Muslim community women who were not engaged with the any method (listening radio, watching television and reading newspaper) of mass media (Asp et. al., 2013; Acharya et. al., 2015; Odesanya et. al., 2015; Zamawe et. al., 2015; Gugsa et. al., 2016; Nwagbara, 2017). The improper utilization of maternal health care services leads to the high risk of maternal mortality and also a risk of newborn health (Paudel & Gautam, 2013; Joshi, Patil & Hegde, 2015; Shahram et. al., 2015; Thomas et. al., 2017; Ghumare & Padvi, 2018). For that reason governmental initiatives needs to improve the education among the women which may lead to the reduction of maternal and newborn mortality by increase the proper knowledge
about the accessibility, availability and proper use of the different health care services (Dixit, Dwivedi & Gupta, 2017; Paul & Chouhan, 2019; Paul, 2019). Limitation Though there is different merit of this study, there also some limitations i.e. in the National Family Health Survey data women’s occupation and spousal occupation data is very less which is the main demerits to run the logit model to show the association of employment status of the respondents and spouse on the utilization of maternal health care services and also the demerit in India there not only education perform to better utilization of maternal health care services but also the economic condition play a great role which is very nonuniform in nature. Conclusion Our study found that there was a significant association between education and the utilization of maternal health care services though other socio-demographic factors also play a significant role if education will increase then all the socio-economic backwardness will abolish. So education will be improved among the women mainly the younger or adolescent women so that they can avail or aware about the knowledge and practices of treatmentseeking behaviour which will create a new World where high fertility, pregnancy complication, maternal mortality as well as child mortality will be abolished. Compliance with Ethical Standards Conflicts of interest The authors declare that they have no conflicts of interest Ethical Approval This study is based on secondary data which is available in the public domain. Therefore, ethical approval is not required for conducting this study. Informed Consent Informed consent was obtained from all individual participants included in the study. Highlights: i) The unadjusted odds ratio (UOR) shows that women’s education positively and very significantly associated with the utilization of MHC services. ii) The adjusted odds ratio (AOR) was low compare to UOR which indicate that there were important effect of other variables (which have been controlled in the adjusted odds ratio) except education which also impact on the utilization of maternal health care services i.e.
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Table-1 Individual and socio-cultural characteristics of ever-married women aged 15– 49 years who had at least one live birth in the last 5 years preceding the survey, India, 2015–2016. Independent variables Women's education Illiterate Primary Secondary Higher Secondary Maternal age 15-24 years 25-34 years 35-49 years Age at marriage <18 years 18 or 18+ years Birth Order 1 2 3 4 or 4+ Caste SC ST OBC Others Religion Hindu Muslim Christian Others Wealth Index Poorest Poorer Middle Richer Richest Place of residence Urban
Weighted %
n
27.6 13.5 46.9 12.0
55165 26712 88871 20150
34.7 55.9 9.4
62082 107500 21316
37.3 62.7
66425 121205
33.6 34.5 16.6 15.3
61807 62484 33064 33543
21.99 10.7 45.3 22.0
35170 37889 74060 35888
79.4 16.2 2.1 2.3
138343 29309 15202 5650
23.4 21.2 19.9 19 16.6
46782 43739 38393 33312 28772
29.72
47833
Rural Region North Central East North-East West South Mass media exposure No exposure Partial exposure Full exposure
70.2
143065
13.2 25.7 25.4 3.9 13.1 18.7
36079 52952 39243 28825 13892 19907
24.6 67.7 7.7
49374 126910 14614
Table-2 Percentage (weighted) distribution of individuals and socio-cultural characteristics of women (15-49 years) by the different maternal health care indicators of India, 2015-16
Independent variables
ANC visit within 1st trimester
Skilled health personnel for ANC
Taking 2 or more tetanus toxoid injection
61.0 65.3 73.0
60.6 77.3 87.1
78.0 83.4 85.6
63.7 75.6 89.4
98.6 98.6 98.6
73.7
80.8
93.8
88.1
97.0
99.0
53.6 52.4 39.4
70.0 71.2 65.7
82.1 79.6 66.9
84.4 83.7 79.0
84.5 81.5 69.1
98.5 98.8 98.5
43.0 56.8
65.6 73.0
72.9 83.2
82.2 84.4
74.3 85.6
98.4 98.8
62.2 57.1 43.1 25.6
73.9 72.1 66.6 59.2
87.0 83.3 73.8 59.3
87.3 83.6 82.4 76.5
91.1 84.9 74.1 59.9
98.8 98.6 98.6 98.6
49.0 46.2
67.2 67.0
77.5 72.9
82.9 79.7
80.6 70.2
98.3 98.6
At least 4 ANC visit
Women's education Illiterate 28.2 Primary 45.7 Secondary 61.6 Higher Secondary Maternal age 15-24 years 25-34 years 35-49 years Age at marriage <18 years 18 or 18+ years Birth Order 1 2 3 4 or 4+ Caste SC ST
PNC Institutional within 42 Delivery days of delivery
OBC 48.6 Others 61.2 Religion Hindu 51.3 Muslim 49.3 Christian 63 Others 70.1 Wealth Index Poorest 25.2 Poorer 44.7 Middle 57.7 Richer 66.5 Richest 73.9 Place of residence Urban 67.1 Rural 45.1 Region North 50.53 Central 32.03 East 41.87 North-East 49.26 West 72.28 South 78.8 Mass media exposure No exposure 24.6 Partial exposure 60.1 Full exposure 64.5
71.2 74.0
78.2 85.5
83.4 86.0
82.4 85.8
99.1 98.2
70.2 70.0 74.6 77.0
79.3 77.0 84.2 92.8
83.7 82.6 80.5 87.3
83.1 72.1 81.4 92.7
98.7 98.1 98.8 98.2
58 64.2 71.3 76.0 81.6
57.1 76.2 85.6 90.4 94.1
78.7 82.8 84.4 85.3 88.2
61.3 77.1 86.9 91.9 96.2
98.3 98.0 98.6 99.0 99.5
76.3 67.5
89.1 75.1
85.1 82.9
90.5 77.5
98.9 98.6
74.8 63.9 63.0 64.7 77.5 78.8
84.7 73.2 67.9 81.8 87.4 93.0
84.0 83.0 86.4 82.3 82.3 81.0
85.6 73.6 72.6 71.3 91.2 96.2
99.5 99.3 97.3 97.7 99.2 98.9
58.6 73.0 74.5
57.6 86.1 88.6
78.2 85.6 82.3
62.8 86.8 93.1
98.5 98.7 99.1
Table-3 Result of binary logistic regression model for the association between maternal education and utilization of maternal health care services among the 15-49 aged women in India, 2015-16 Outcome variable Predictor variable
At least 4 ANC visit
ANC visit within 1st trimester
Skilled health personnel for ANC
2 or more tetanus toxoid injection
Instituti onal Delivery
OR (95%
OR (95%
OR (95%
OR (95%
OR
PNC within 42 days of delivery OR
CI)
CI)
1.00
1.00
1.803***
1.175***
1.990***
1.322***
(1.748 1.859)
(1.134 1.216)
(1.926 2.056)
(1.275 1.372)
3.468***
1.655***
3.837***
1.757***
(3.389 3.549)
(1.612 1.699)
(3.741 3.935)
(1.710 1.806)
Higher secondary & above
6.450***
2.563***
9.139***
2.348***
(2.458 2.672) -94067.913
Log Likelihood
(6.223 6.685) 122152.8 9 0.0658 189044
(8.624 9.684) 93663.383
(2.239 2.463) 86846.112
1.00
1.00
1.339***
1.044**
1.440***
1.218***
(1.292 1.387)
(1.005 1.085)
(1.389 1.494)
(1.170 1.268)
1.547***
1.151***
1.698***
1.365***
(1.500 1.594)
(1.113 1.190)
(1.643 1.755)
(1.317 1.416)
1.756***
1.311***
2.137***
1.389***
Education Illiterate_® Primary
Secondary
Pseudo R2 Observation Education Illiterate_® Primary
Secondary
Higher secondary & above
0.0143 156755
CI)
CI)
Unadjusted odds ratio 1.00 1.00
0.0757 0.0129 190898 189566 Adjusted odds ratio 1.00 1.00
(95% CI)
(95% CI)
1.00 1.561** * (1.512 1.611) 3.789** * (3.694 3.887)
1.00 0.908 (0.718 1.147) 1.072 (0.895 1.283)
14.64** *
1.361**
(13.63 15.73) 92173.3 34 0.0841 190337
(1.024 1.808) 3936.648 5 0.0010 66268
1.00 1.217** * (1.174 1.263) 1.720** * (1.662 1.779)
1.00
2.899** *
0.926 (0.718 1.196) 0.975 (0.777 1.224) 0.748
(1.674 (1.244 (1.993 (1.305 (2.668 (0.521 1.841) 1.383) 2.293) 1.478) 3.151) 1.073) -85778.189 -81014.95 Log Likelihood 102557.4 77757.743 76290.4 3542.164 3 91 Pseudo R2 0.1562 0.0331 0.1412 0.0468 0.1803 0.0295 Observation 175886 145765 177570 176381 177047 62416 95% Confidence interval in parentheses; *** p<0.01, ** p<0.05, * p<0.1 ®= Reference category, Adjusted model were controlled for maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region.
Highlights: iii)The unadjusted odd ratio (UOR) shows that women’s education positively and very significantly associated with the utilization of MHC services. iv) The adjusted odd ratio (AOR) was low compare to UOR which indicate that there were important effect of other variables (which have been controlled in the adjusted odd ratio) except education which also impact on the utilization of maternal health care services i.e. maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region.
Conflict of interest: None declared
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S0190-7409(19)30980-6 https://doi.org/10.1016/j.childyouth.2019.104642 CYSR 104642
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Received Date: Revised Date: Accepted Date:
6 September 2019 21 November 2019 21 November 2019
Please cite this article as: B. Barman, J. Saha, P. Chouhan, Impact of education on the utilization of maternal health care services: An investigation from National Family Health Survey (2015-16) in India, Children and Youth Services Review (2019), doi: https://doi.org/10.1016/j.childyouth.2019.104642
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Impact of education on the utilization of maternal health care services: An investigation from National Family Health Survey (2015-16) in India
Bikash Barman1 , Jay Saha2 & Prof. Pradip Chouhan3 1. Ph. D. Scholar, Dept. of Geography, University of Gour Banga, Malda, West Bengal, India, Email- [email protected] 2. ICSSR Project Assistant, Dept. of Geography, University of Gour Banga, Malda, West Bengal, India, Email- [email protected] 3. Professor, Dept. of Geography, University of Gour Banga, Malda, West Bengal, India, Email- [email protected]
Impact of education on the utilization of maternal health care services: An investigation from National Family Health Survey (2015-16) in India
Abstract Aim: The present study attempts to show the influence of women’s (15-49 yrs) education on the utilization of Maternal Health Care (MHC) services in India and also find out the other determinants for the utilization of MHC services. Data & Method: The entire study depends on secondary data collected from the National Family Health Survey (NFHS)-4 in the year of 2015-16 of India which was conducted on 189898 women having age group of 15-49 years. In the present study, the last birth women (189898) have been considered. For the proper depiction of the resulting binary logistic regression has been conducted. Variables: To show the level of utilization of MHC services in India, the highest educational level of the respondents have been considered as the explanatory variable and six outcome variables have been selected. Result: The unadjusted odds ratio (UOR) shows that women’s education positively and very significantly associated with the utilization of MHC services which indicates that the higher educated women are more likely to received at least 4 ANC visit [UOR 6.450, 95% CI (6.223 - 6.685) & p-value <0.01], taking 1st antenatal visit within first trimester [UOR 2.563, 95% CI (2.458 - 2.672) & p-value <0.01], ANC visit by skilled health professionals [UOR 9.139, 95% CI (8.624 - 9.684) & p-value <0.01], taking 2 or more than 2 TT doses [UOR 2.348, 95% CI (2.239 - 2.463) & p-value <0.01], delivered in health facility [UOR 14.64, 95% CI (13.63 - 15.73) & p-value <0.01 ] and received PNC within 42 days of delivery [UOR 1.361, 95% CI (1.024 - 1.808) & p-value <0.01] than the illiterate women. The adjusted odds ratio (AOR) was low compared to UOR which indicate that there were important effect of other variables (which have been controlled in the adjusted odds ratio) except education which also impact on the utilization of maternal health care services i.e. maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region. Key Words: Education, antenatal care (ANC), delivery care, postnatal care (PNC), India.
Introduction Improved maternal health care is a very important goal of Sustainable Development Goal (SDG) and Millennium Development Goal (MDG) which is the strong predictor to decline the pregnancy complication, maternal morbidity, maternal mortality and also, infant mortality (Adjiwanou & Legrand, 2013; Sahoo et. al., 2015; Neil, Naeve & Ved, 2017). Over the World different countries already introduced different programmes and policies for improve the availability and accessibility in the utilization of maternal health care services where India take many programmes and initiatives i.e. Janani Suraksha Yojana, Janani Shishu Suraksha Karyakaram, Matrima, Matrika and so on. Though there is a great variation by different determining factors (age, age at marriage, caste, religion, place of residence, economic condition, educational attainment, the educational level of the spouse, parental education and so on), education directly have a strong impact on the utilization of maternal health care services (Shariff & Singh, 2002; Chandhiok et. al., 2006; Jat, Ng & Sabestian, 2011; Chimankar & Sahoo, 2011; Joshi et. al., 2014). Education helps them to know about the human reproductive system; knowledge about the pregnancy, treatment-seeking behaviour at three phases i.e. antenatal, delivery and postnatal period, child spacing and newborn care (Govindaswami & Ramesh, 1997; Weitzman, 2017). In the global scenario, the World Fertility Survey and the Demographic and Health Surveys already gave the evidence of the very strong impact of the education mainly women’s education on the declining the maternal mortality, child morbidity and child mortality (Govindaswami & Ramesh, 1997; Joshi et. al., 2014). Education increases the women’s cognitive skills (Smith-Greenway, 2013) which benefit maternal health by increasing the ability to seek information about their own health as well as medical instruction to treatment and medication (Barber, 2001; SmithGreenway, 2013). On the other hand women’s education also triggering the improvement of economic opportunities, employment status and women autonomy which may help to take the better decision on the time of marriage, childbearing and money spent in the health section as they can effort easily (Raghupathy, 1996; Gunes, 2015). In India the most important barrier in the utilization of maternal health care services is the educational attainment and the economic condition which results in Kerala degree of utilization of maternal health care services are very high wherein Bihar, Chhattisgarh and Rajasthan the utilization is very far from the Indian average (Vora et. al., 2009; Singh et. al., 2012; Muzaffar, 2016; Jose et. al., 2018). All these changes occurred by education together affect the women’s fertility behaviour; if education increase then the child marriage will be
abolished, education increases the use of contraceptive which decreases the degree of high fertility and increases the child spacing which together decrease the pregnancy complication, stillbirth and unsafe abortion (Rose & Lawton, 2012; Behrman et. al., 2015; Thomas et. al., 2017). Except for these fertility changes education also may change the maternal health care behaviour by the receiving at least 4 antenatal visit within their first trimester of pregnancy, receiving 2 or more doses of TT injection, antenatal care by a health professional (Doctor, Auxiliary nurse midwives, nurses) by which easily can detect hypertension disorder, anaemia, brain haemorrhaging (Duley, 1992; Rush, 2000; Sibai et al., 2005); educated women deliver at an institution to decrease the risk of delivery complication and newborn death and received postnatal care within 2 days of delivery which lead to reducing the risk of postpartum infection and which give the healthy mother and children (Graham et. al., 2001; Chimankar & Sahoo, 2011; Vikram et. al., 2012; Sahoo et. al., 2015; Dimbuene et. al., 2017). Thus this study focuses on the degree of influence of education on the utilization of maternal health care services in two models i.e. in the first model where only educational effect has been shown and in second model educational impact including another influencing factor (maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region) have been introduced. Methods Data source The entire study has been done with the help of secondary data collected from National Family Health Survey-4 in India which has been conducted in 2015-16 over 601509 households, 699686 women aged 15–49 years with a response rate of 97%, and 112122 men aged 15–54 years with a response rate of 92% (Paul & Chouhan, 2019). In the present study, we have used the data on 190898 ever-married women aged 15-49 years who had at least one live birth in the past five years preceding the time of the survey. Measures Maternal health care utilization Utilization of maternal health care has been analyzed in three phases’ i.e. antenatal care (ANC), delivery care and postnatal care (PNC) wherein antenatal care four outcome variables have been selected i.e. adequate number of ANC visit i.e. at least 4 ANC visit as per recommendation of World Health Organization, proper timing of first ANC visit which has been considered as timing of first ANC within first trimester (WHO, 2016), skilled health
personnel for ANC where skilled health personnel has been considered as antenatal care by doctor/nurse/auxiliary nurse midwife and taking at least 2 or more tetanus toxoid injection as per WHOs recommendation. In case of delivery care, institutional delivery has been considered and in postnatal care, taking PNC within 42 days of delivery where all the outcome variables have been considered as binary i.e. if ‘yes’ then 1 and if ‘no’ then 0 for the proper depiction of the result. Education Educational attainment is the main explanatory variable in the present study which has been divided into four categories i.e. illiterate, primary, secondary and higher secondary and above. Study covariates Different socio-demographic and economic variables have been considered as covariates in the present study to show the determining effect on the utilization of maternal health care services except for education i.e. age of the respondents which has been categorized into three categories i.e. 15-24 years, 25-34 years and 35-49 years, age at marriage (<18years and 18 or >18 years), birth order (1, 2, 3 and 4 or 4+), caste (SC, ST, OBC & Others), religion (Hindu, Muslim, Christian and Others), place of residence (urban & rural), wealth index (poorest, poorer, middle, richer and richest), region (north, central, east, north-east, west & south) and mass media exposure (no exposure, partial exposure and full exposure) has been considered to show the adjusted odds ratio (controlled for maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region) between education and utilization of maternal health care services. Statistical analysis Bivariate and multivariate analysis was carried out to know the association between education and different maternal health care indicators in the present study. Binary logistic (0, 1) regression also has done to find the unadjusted odds ratio and adjusted odds ratio (where other independent variables were controlled) of educational impact on the utilization of maternal health care services. Results Table 1 depicts the respondent’s individuals (maternal age, age at marriage, birth order) and socio-cultural characteristics (education, caste, religion, wealth index, place of residence, region and mass media exposure) in India where most (46.9%) of the respondent's education
were secondary level and 27.6% were illiterate, 55.9% respondents have belonged from the age group 25-34 years and 37.6% were being married at <18 years old. Most of the respondents (45.3%) were from Other Backward Classes group and near about 45% of respondents belonged from a poor family who is inhabited in rural areas (70.2%). Table-1 be here Table 2 presents the individuals and socio-cultural characteristics of the respondents by their utilization of different maternal health care services in India which clearly stated that the higher secondary and above respondents were more advanced in terms of taking different maternal health care services i.e. at least 4 ANC (73.7%), ANC visit within first trimester (80.8%), skilled health personnel for ANC (93.8%), taking 2 or more TT injections (88.1%), institutional delivery (97.0%) and PNC within 42 days of delivery (99.0%) than the illiterate women. Legal age at marriage (18 or above) women were more advanced in the utilization of MHC services than the early marriage women and the women who had at least one live birth in the last 5 years preceding the survey, 62.2%, 73.9%, 87.0%, 87.3%, 91.1% and 98.8% had at least 4 ANC, ANC visit within first trimester, skilled health personnel for ANC, taking 2 or more TT injections, institutional delivery and PNC within 42 days of delivery respectively more than the higher birth order (4 or 4+). The weighted percentage of all the MHC indicators in India among the Muslim women was significantly lower than the Hindu women and also lower in rural areas than the urban areas. The poorest women were also very far from the proper utilization of all the MHC services than the richer and richest women (see table 2). Table-2 be here Table 3 shows the result of the binary logistic regression model for the association between maternal education and utilization of maternal health care services among the 15-49 aged women in India. The unadjusted odds ratio (UOR) represents the educational impact on the utilization of MHC services among the women aged 15-49 years where it was found that there was a significant variation in the likelihood of taking all the MHC services i.e. at least 4 ANC [UOR: 6.450, 95% CI: 6.223 - 6.685 & p<0.01], ANC visit within first trimester [UOR: 2.563, 95% CI: 2.458 - 2.672 & p<0.01], skilled health personnel for ANC [UOR:9.139, 95% CI: 8.624 - 9.684 & p<0.01], taking 2 or more TT injection [UOR:2.348, 95% CI: 2.239 2.463 & p<0.01], institutional delivery [UOR: 14.640, 95% CI: 13.63 - 15.73 & p<0.01] &
PNC within 42 days of delivery [UOR: 1.361, 95% CI: 1.024 - 1.808 & p<0.01] among the higher secondary and above educated women was higher than the illiterate (reference Table-3 be here category) women. After adjusting all the socio-economic variables (maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region) with the education, the adjusted odds ratio (AOR) was lower than the UOR which tells that not only education but also other many factors/variables which influence the utilization of MHC services among the ever-married women aged 15-49 years in India. The AOR among the higher secondary and above women was higher than the illiterate women in most of the MHC indicators (5 indicators) i.e. at least 4 ANC [AOR: 1.756, 95% CI: 1.674 - 1.841 & p<0.01], ANC visit within first trimester [AOR: 1.311, 95% CI: 1.244 - 1.383 & p<0.01], skilled health personnel for ANC [AOR: 2.137, 95% CI: 1.993 2.293 & p<0.01], taking 2 or more TT injection [AOR: 1.389, 95% CI: 1.305 - 1.478 & p<0.01] & institutional delivery [AOR: 2.899, 95% CI: 2.668 - 3.151 & p<0.01] which represents that there was a more likelihood of taking MHC services among the higher secondary and above women than the illiterate women but only in one indicator i.e. PNC within 42 days of delivery [AOR: 0.748, 95% CI: 0.521 - 1.073] the adjusted odds ration was lower among higher secondary and above women than the illiterate women which directly indicate that in case of taking PNC within 42 days of delivery effect of other variables was more than the effect of education. Discussion The present study reveals the association between the respondent’s (15-49 years aged evermarried women) education (illiterate, primary, secondary and higher secondary and above) and the utilization of maternal health care services (at least 4 ANC, ANC within first trimester, skilled health personnel for ANC, 2 or more doses TT injection, institutional delivery and PNC within 42 days of delivery) in India. Our study also provide the other associated factors (maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region) except education which also responsible for the utilization of maternal health care services (Bhatia & Cleland, 1995; Celik & Hotchkiss, 2000; Deo & Bhaskar, 2014; Sahoo et. al., 2015) though education was the strong predictor among the Indian women (Elo, 1992; Raghupathy, 1996; Govindaswamy & Ramesh, 1997; Dimbuene et. al., 2017; Weitzman, 2017). Our findings show the significant
association between the respondent’s education and the utilization of maternal health care services which also found in many previous studies i.e. in Bangladesh (Walton & Schbley, 2013), in Botswana (Letamo & Rakgoasi, 2003), in Indonesia (Titaley et. al., 2010), in Nepal (Deo & Bhaskar, 2014), in Mali (Gaje, A., 2007), in Uganda (Kalule Sabiti, 2014) and so on . The women who have acquired higher secondary and above education were more likely to received all the maternal health care services than the illiterate or low educated women (Chakraborty et. al., 2003; Mekonen & Mekonen, 2003; Jat et. al., 2011; Chimankar & Sahoo, 2011; Shahjahan et. al., 2012; Nair et. al., 2015;). The strong probable reason for the low use of maternal health care services among the low educated women were one hand the lack of proper knowledge about the availability, accessibility and utilization and other hands low educated women were not so frank to discuss about the different care at the time of pregnancy, delivery and post-delivery (Letamo & Rakgoasi, 2003; Gaje, 2007; Walton & Schbley, 2013; Joshi et. al., 2014; Thomas et. al., 2017; Navaneetham & Dharmalingam, 2017). Previous studies also shows that the lack of decision making power also the hindrance in the utilization of maternal health care services among the illiterate or low educated women in India (Bloom et. al., 2016) and also over the world i.e. Ethiopia (Tiruneh et. al., 2017; Wado, 2017) Nigeria (Dahiru & Oche, 2015; Babalola & Fatusi, 2009), Philippines (Yamashita et. al., 2017). Additionally a number of studies which also shows the effect of different socio-demographic factors over the utilization of maternal health care services which stated that exception of education there were also other factors which influences the utilization of maternal health care services (Celik & Hotchkiss, 2000; Arthur, 2012; Asundep et. al., 2013; Deo & Bhaskar, 2014; Pandey & Karky, 2014; Sabiti et. al., 2014; Hearld et. al., 2018). There were also many studies which stated that the low utilization of maternal health care services were found among the illiterate or low educated women which are very poor in terms of economic condition (Shahram et. al., 2015), who resided the very remote areas and among the Muslim community women who were not engaged with the any method (listening radio, watching television and reading newspaper) of mass media (Asp et. al., 2013; Acharya et. al., 2015; Odesanya et. al., 2015; Zamawe et. al., 2015; Gugsa et. al., 2016; Nwagbara, 2017). The improper utilization of maternal health care services leads to the high risk of maternal mortality and also a risk of newborn health (Paudel & Gautam, 2013; Joshi, Patil & Hegde, 2015; Shahram et. al., 2015; Thomas et. al., 2017; Ghumare & Padvi, 2018). For that reason governmental initiatives needs to improve the education among the women which may lead to the reduction of maternal and newborn mortality by increase the proper knowledge
about the accessibility, availability and proper use of the different health care services (Dixit, Dwivedi & Gupta, 2017; Paul & Chouhan, 2019; Paul, 2019). Limitation Though there is different merit of this study, there also some limitations i.e. in the National Family Health Survey data women’s occupation and spousal occupation data is very less which is the main demerits to run the logit model to show the association of employment status of the respondents and spouse on the utilization of maternal health care services and also the demerit in India there not only education perform to better utilization of maternal health care services but also the economic condition play a great role which is very nonuniform in nature. Conclusion Our study found that there was a significant association between education and the utilization of maternal health care services though other socio-demographic factors also play a significant role if education will increase then all the socio-economic backwardness will abolish. So education will be improved among the women mainly the younger or adolescent women so that they can avail or aware about the knowledge and practices of treatmentseeking behaviour which will create a new World where high fertility, pregnancy complication, maternal mortality as well as child mortality will be abolished. Compliance with Ethical Standards Conflicts of interest The authors declare that they have no conflicts of interest Ethical Approval This study is based on secondary data which is available in the public domain. Therefore, ethical approval is not required for conducting this study. Informed Consent Informed consent was obtained from all individual participants included in the study. Highlights: i) The unadjusted odds ratio (UOR) shows that women’s education positively and very significantly associated with the utilization of MHC services. ii) The adjusted odds ratio (AOR) was low compare to UOR which indicate that there were important effect of other variables (which have been controlled in the adjusted odds ratio) except education which also impact on the utilization of maternal health care services i.e.
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Table-1 Individual and socio-cultural characteristics of ever-married women aged 15– 49 years who had at least one live birth in the last 5 years preceding the survey, India, 2015–2016. Independent variables Women's education Illiterate Primary Secondary Higher Secondary Maternal age 15-24 years 25-34 years 35-49 years Age at marriage <18 years 18 or 18+ years Birth Order 1 2 3 4 or 4+ Caste SC ST OBC Others Religion Hindu Muslim Christian Others Wealth Index Poorest Poorer Middle Richer Richest Place of residence Urban
Weighted %
n
27.6 13.5 46.9 12.0
55165 26712 88871 20150
34.7 55.9 9.4
62082 107500 21316
37.3 62.7
66425 121205
33.6 34.5 16.6 15.3
61807 62484 33064 33543
21.99 10.7 45.3 22.0
35170 37889 74060 35888
79.4 16.2 2.1 2.3
138343 29309 15202 5650
23.4 21.2 19.9 19 16.6
46782 43739 38393 33312 28772
29.72
47833
Rural Region North Central East North-East West South Mass media exposure No exposure Partial exposure Full exposure
70.2
143065
13.2 25.7 25.4 3.9 13.1 18.7
36079 52952 39243 28825 13892 19907
24.6 67.7 7.7
49374 126910 14614
Table-2 Percentage (weighted) distribution of individuals and socio-cultural characteristics of women (15-49 years) by the different maternal health care indicators of India, 2015-16
Independent variables
ANC visit within 1st trimester
Skilled health personnel for ANC
Taking 2 or more tetanus toxoid injection
61.0 65.3 73.0
60.6 77.3 87.1
78.0 83.4 85.6
63.7 75.6 89.4
98.6 98.6 98.6
73.7
80.8
93.8
88.1
97.0
99.0
53.6 52.4 39.4
70.0 71.2 65.7
82.1 79.6 66.9
84.4 83.7 79.0
84.5 81.5 69.1
98.5 98.8 98.5
43.0 56.8
65.6 73.0
72.9 83.2
82.2 84.4
74.3 85.6
98.4 98.8
62.2 57.1 43.1 25.6
73.9 72.1 66.6 59.2
87.0 83.3 73.8 59.3
87.3 83.6 82.4 76.5
91.1 84.9 74.1 59.9
98.8 98.6 98.6 98.6
49.0 46.2
67.2 67.0
77.5 72.9
82.9 79.7
80.6 70.2
98.3 98.6
At least 4 ANC visit
Women's education Illiterate 28.2 Primary 45.7 Secondary 61.6 Higher Secondary Maternal age 15-24 years 25-34 years 35-49 years Age at marriage <18 years 18 or 18+ years Birth Order 1 2 3 4 or 4+ Caste SC ST
PNC Institutional within 42 Delivery days of delivery
OBC 48.6 Others 61.2 Religion Hindu 51.3 Muslim 49.3 Christian 63 Others 70.1 Wealth Index Poorest 25.2 Poorer 44.7 Middle 57.7 Richer 66.5 Richest 73.9 Place of residence Urban 67.1 Rural 45.1 Region North 50.53 Central 32.03 East 41.87 North-East 49.26 West 72.28 South 78.8 Mass media exposure No exposure 24.6 Partial exposure 60.1 Full exposure 64.5
71.2 74.0
78.2 85.5
83.4 86.0
82.4 85.8
99.1 98.2
70.2 70.0 74.6 77.0
79.3 77.0 84.2 92.8
83.7 82.6 80.5 87.3
83.1 72.1 81.4 92.7
98.7 98.1 98.8 98.2
58 64.2 71.3 76.0 81.6
57.1 76.2 85.6 90.4 94.1
78.7 82.8 84.4 85.3 88.2
61.3 77.1 86.9 91.9 96.2
98.3 98.0 98.6 99.0 99.5
76.3 67.5
89.1 75.1
85.1 82.9
90.5 77.5
98.9 98.6
74.8 63.9 63.0 64.7 77.5 78.8
84.7 73.2 67.9 81.8 87.4 93.0
84.0 83.0 86.4 82.3 82.3 81.0
85.6 73.6 72.6 71.3 91.2 96.2
99.5 99.3 97.3 97.7 99.2 98.9
58.6 73.0 74.5
57.6 86.1 88.6
78.2 85.6 82.3
62.8 86.8 93.1
98.5 98.7 99.1
Table-3 Result of binary logistic regression model for the association between maternal education and utilization of maternal health care services among the 15-49 aged women in India, 2015-16 Outcome variable Predictor variable
At least 4 ANC visit
ANC visit within 1st trimester
Skilled health personnel for ANC
2 or more tetanus toxoid injection
Instituti onal Delivery
OR (95%
OR (95%
OR (95%
OR (95%
OR
PNC within 42 days of delivery OR
CI)
CI)
1.00
1.00
1.803***
1.175***
1.990***
1.322***
(1.748 1.859)
(1.134 1.216)
(1.926 2.056)
(1.275 1.372)
3.468***
1.655***
3.837***
1.757***
(3.389 3.549)
(1.612 1.699)
(3.741 3.935)
(1.710 1.806)
Higher secondary & above
6.450***
2.563***
9.139***
2.348***
(2.458 2.672) -94067.913
Log Likelihood
(6.223 6.685) 122152.8 9 0.0658 189044
(8.624 9.684) 93663.383
(2.239 2.463) 86846.112
1.00
1.00
1.339***
1.044**
1.440***
1.218***
(1.292 1.387)
(1.005 1.085)
(1.389 1.494)
(1.170 1.268)
1.547***
1.151***
1.698***
1.365***
(1.500 1.594)
(1.113 1.190)
(1.643 1.755)
(1.317 1.416)
1.756***
1.311***
2.137***
1.389***
Education Illiterate_® Primary
Secondary
Pseudo R2 Observation Education Illiterate_® Primary
Secondary
Higher secondary & above
0.0143 156755
CI)
CI)
Unadjusted odds ratio 1.00 1.00
0.0757 0.0129 190898 189566 Adjusted odds ratio 1.00 1.00
(95% CI)
(95% CI)
1.00 1.561** * (1.512 1.611) 3.789** * (3.694 3.887)
1.00 0.908 (0.718 1.147) 1.072 (0.895 1.283)
14.64** *
1.361**
(13.63 15.73) 92173.3 34 0.0841 190337
(1.024 1.808) 3936.648 5 0.0010 66268
1.00 1.217** * (1.174 1.263) 1.720** * (1.662 1.779)
1.00
2.899** *
0.926 (0.718 1.196) 0.975 (0.777 1.224) 0.748
(1.674 (1.244 (1.993 (1.305 (2.668 (0.521 1.841) 1.383) 2.293) 1.478) 3.151) 1.073) -85778.189 -81014.95 Log Likelihood 102557.4 77757.743 76290.4 3542.164 3 91 Pseudo R2 0.1562 0.0331 0.1412 0.0468 0.1803 0.0295 Observation 175886 145765 177570 176381 177047 62416 95% Confidence interval in parentheses; *** p<0.01, ** p<0.05, * p<0.1 ®= Reference category, Adjusted model were controlled for maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region.
Highlights: iii)The unadjusted odd ratio (UOR) shows that women’s education positively and very significantly associated with the utilization of MHC services. iv) The adjusted odd ratio (AOR) was low compare to UOR which indicate that there were important effect of other variables (which have been controlled in the adjusted odd ratio) except education which also impact on the utilization of maternal health care services i.e. maternal age, age at marriage, birth order, caste, religion, wealth index, place of residence, exposure to mass media, and region.
Conflict of interest: None declared
Author’s statement: At first, I would like to thank you and the reviewer(s) for your observations and valuable comments on our manuscript and the opportunity to revise our paper. The suggestions offered by the reviewer(s) have been immensely helpful and will also appreciate your insightful on revising the manuscript. As the corresponding author, I have included the reviewer's comments immediately after this letter and respond to every comment, indicating exactly how we addressed each concern and problem and describing the changes, we have made. The revised manuscript has submitted in the submission link. We hope the revised manuscript will better suit the Children and Youth Services Review but are happy to consider a further revision, and we thank you for your continuing interest in our research.