Is There a Causal Relationship Between Maternal Health Care Utilization and

Subsequent Contraceptive Use?: Evidence from Kenya and Zambia

Mai Do and David HotchkissTulane University

Background

Service integration receiving increased attention from governments and donors as way of improving efficiency and access to services

Several reasons why use of maternal health services might influence post-partum contraceptive use

Few studies have examined family planning (FP) within the context of reproductive health service delivery Mixed evidence on linkages between maternal health care (ANC,

delivery, and PNC) and post-partum FP

Research questions

Is post-partum modern FP method use related to the use of ANC and PNC relating to the index childbirth?

If so, what can be said about the linkages between these services?

Data

Most recent DHS: 2008-09 in Kenya and 2007 in Zambia

Selected Kenya and Zambia because: DHS within the last three years

DHS included a birth and contraceptive calendar

Substantial contraceptive use among married and cohabiting women

Study sample: married and cohabiting women who had a live birth within five years of the survey Kenya: 3,667 women

Zambia: 3,587 women

Methods (1)

Statistical method: Cox proportional hazard model

Dependent variable: duration (months) from childbirth to modern contraceptive adoption

Methods (2)

Independent variable: ANC and PNC service intensity score, constructed from 6 questions Timing of first ANC visit, if any

Number of ANC visits (4 or more)

Received tetanus vaccination

Received ANC from trained provider

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)

Received PNC from trained provider

Methods (3)

Main control variables Knowledge of contraceptive methods

Woman visited and talked about FP with a field worker last 12 months

Woman visited and talked about FP at a health facility last 12 months

Desire for more children

Prior use of modern contraceptive methods

Recall of FP messages in the mass media

Tests performed of exogeneity of ANC and PNC service intensity score

Country findings: Kenya

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)*

46% adopted modern FP post-partum

* p<.05; ** p<.01; *** p<.001Controls for: socio-demographic characteristics, durations of breasfeeding and amenorrrhea

Kenya:Influences of ANC and PNC services on post-partum modern FP use

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)

* p<.05; ** p<.01; *** p<.001Controls for all women’s characteristics mentioned before.

Country findings: Zambia

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)***

45.9% adopted modern FP post-partum

* p<.05; ** p<.01; *** p<.001Controls for: socio-demographic characteristics, durations of breasfeeding and amenorrrhea

Zambia:Influences of ANC and PNC services on post-partum modern FP use

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)

* p<.05; ** p<.01; *** p<.001Controls for all women’s characteristics mentioned before.

Conclusions

Evidence of MCH service use as mediator for individual characteristics to influence post-partum modern FP use Results suggest that maternal health care use and FP use are not

influenced by common unobserved factors

Several observed individual factors influence maternal health care use, which then influence FP use

Evidence that ANC, not PNC, service intensity related to post-partum modern FP use Need for service integration, esp. in public sector

PNC may be among the weakest aspects of RH program

Limitations

Not generalizable to all women of childbearing age Only married, cohabiting women included in the sample

Possible endogeneity between FP use and exposure to FP messages in the media and visit by FP a field worker

No data on community-level and programmatic factors

MEASURE Evaluation PRH is a MEASURE project funded by

the United States Agency for International Development

(USAID) through Cooperative Agreement GHA-A-00-08-00003-

00 and is implemented by the Carolina Population Center at

the University of North Carolina at Chapel Hill in partnership

with Futures Group International, Management Sciences for

Health, and Tulane University. Views expressed in this

presentation do not necessarily reflect the views of USAID or

the U.S. Government. MEASURE Evaluation PRH supports

improvements in monitoring and evaluation in population,

health and nutrition worldwide.