UNIVERSITY OF ECONOMICS ERAMUS UNIVERSITY ROTTERDAM HO CHI MINH CITY INSTITUTE OF SOCIAL STUDIES THE NETHERLANDS VIETNAM VIETNAM - NETHERLANDS PROGRAMME FOR M.A IN DEVELOPMENT ECONOMICS MATERNAL HEALTH CARE IN VIETNAM: DEMAND FOR ANTENATAL CARE AND CHOICE OF DELIVERY CARE SERVICES By Nguyen Thi Hoai Trang A Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of Master of Art in Development Economics Academic Supervisor: Dr. Truong Dang Thuy HO CHI MINH CITY, June 2016 1 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com DECLARATION “This is to certify that this thesis entitled “MATERNAL HEALTH CARE IN VIETNAM: DEMAND FOR ANTENATAL CARE AND CHOICE OF DELIVERY CARE SERVICES”, which is submitted by me in fulfillment of the requirements for the degree of Master of Art in Development Economics to the Vietnam – The Netherlands Programme (VNP). The thesis constitutes only my original work and due supervision and acknowledgement have been made in the text to all materials used. HCMC, June 06th, 2016 Nguyen Thi Hoai Trang i LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com ACKNOWLEDGEMENT I would like to acknowledge my supervisor, Dr.
Truong Dang Thuy for his great contribution to my thesis. Without his support, my thesis would be not possible. By his large knowledge and experiences, he gave me the informative comments and enabled me to understand my work better. I would like to express my sincere gratitude to his guidance and encouragement, which make me stronger to overcome the challenges and fulfill my work completely.
By this chance, I would like to express my appreciation toward all lecturers of the Vietnam – Netherlands Program who have provided with valuable economic knowledge during my study in this program. Next, I wish to thank to all my friends here at VNP- MDE 19, who share unforgettable memories in studying together. Finally, I would like to express my deep gratitude to my family for their support and endurance when I pursue my postgraduate studies. ii LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com ABSTRACT This thesis research aims to analyze the impact of individual characteristics, household characteristic and communities in utilization of maternal health care services in Vietnam.
Using the latest data of Vietnam’s Multiple Indicator Cluster Survey 2013-2014, it employs the Negative Nominal Model for demand of prenatal care visits and Multinomial Logistic Model for the choice of delivery facility. With respect to the demand of prenatal care visits, the result shows that higher education, higher age, exposure to mass media and no religion increase the number of prenatal care visits while higher birth order, unmarried or separated status, ethnicity group and lower household wealth index decrease the number of prenatal care. Moreover, living in rural, disadvantaged areas and the community with higher illiteracy rate decrease the demand of prenatal care visits while living in the community with higher proportion of women giving birth at health facilities increase the demand. Concerning the choice of delivery facility, more prenatal care visits and exposure to mass media are positively associated with the choice of giving birth at public hospital.
In contrast, suffering the burden of taking care more children, lower household wealth index, living in rural and the community with higher illiteracy ratio adversely affect the choice of public hospital delivery. The results suggest the improvement of maternal health program in rural and underdeveloped areas as well as universal education over the country, especially for the ethnic minority group. Keywords: prenatal care visits, the place of childbirth, individual characteristics, household characteristics, community characteristics, Vietnam. iii LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com Contents DECLARATION.
iii LIST of TABLES and FIGURES .1 The role of maternity health care .2 Overview of maternal health and health care in Vietnam .2 The two-child policy .3 Maternal mortality ratio and maternal health care in Vietnam .3 The demand for health care .2 Empirical Literature Review .4 The choice of health care provider. 19 iv LUAN VAN CHAT LUONG download : add luanvanchat@agmail.2 Empirical literature review. 23 METHODOLOGY AND DATA DESCRIPTION .1 Demand for Prenatal care .2 Choice of birth delivery facility. 29 RESULTS AND DISCUSSIONS .2 Analysis of Demand for prenatal care .2 Analysis of Negative Binomial Model .3 Analysis of Choice in the delivery care providers .2 Analysis of Multinomial Logistic Model.
47 CONCLUSION, RECOMMENDATION and LIMITATION .3 Limitation and Further Research. 50 v LUAN VAN CHAT LUONG download : add luanvanchat@agmail. 71 vi LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com LIST of TABLES and FIGURES List of Tables Table 1: Description of Variables. 30 Table 2:Descriptive Results – Numeric Variables.
33 Table 3 : Descriptive Results - Dummy Variables. 33 Table 4: Bivariate analysis in the demand of prenatal care visits. 35 Table 5: Negative binomial regression for the demand of prenatal care visits. 40 Table 6 : Bivariate analysis in the choice of delivery care providers - numeric independent variables.
41 Table 7:Bivariate analysis in the choice of delivery care provider – dummy independent variables. 43 Table 8: Multinomial Logistic Regression for the choice of delivery care provider. 46 Table 9: Marginal effects for the choice of delivery care provider. 47 List of Figures Figure 1: MMR in Vietnam in the period of 2000 – 2015.
8 Figure 2: MMR of the Asian countries in the period of 2000 – 2015. 8 Figure 3: Percentage of women having at least 1 visit and at least 4 visits during pregnancy. 9 Figure 4: The percentage of the women taking antenatal care visits by residence in 2011 and 2014. 10 Figure 5: The percentage of the women taking antenatal care visits by ethnicity in 2011 and 2014.
10 Figure 6 The association between individual level, household level and community level characteristics with the utilization of maternal health care services. 25 Figure 7: The association between the demand of maternal care visits and numerical independent variables. 37 vii LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com ABBREVIATION ANC Antenatal Care CSDH Commission on Social Determinants on Heath GSO General Statistics Office IMR Infant Mortality Ratio MDGs Millennium Development Goals MICS Multiple indicator cluster survey MMR Maternal Mortality Ratio WHO World Health Organization viii LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com CHAPTER I INTRODUCTION 1.1 Problem statement There is a growing concern about the maternal health care globally, especially in low income countries. World Health Organization (WHO 2014) reported that the global maternal mortality ratio (MMR) in 2013 was 210 maternal deaths per 100 000 live births, decreasing from 380 maternal deaths per 100 000 live births in 1990.
However, the ratio in developing regions was 14 times higher than in developed regions. Even though maternal death is generally decreasing worldwide, it has yet to achieve the target of Millennium Development Goal 5 by reducing the MMR by three quarters between 1990 and 2015 (WHO 2014). The maternal death has direct causes and indirect causes. The direct cause results from arising complications during pregnancy, delivery and postpartum, or improper treatment such as hemorrhage, infection, obstructed labor, unsafe abortion, ectopic pregnancy and anesthesia- related deaths while the indirect cause results from the disease which previously exists or be not due to indirect obstetric causes like hepatitis anemia, malaria, heart disease and tetanus (WHO 2005).
It was reported that direct causes made up the higher number of maternal death than indirect causes with 80% of the total MMR (WHO 2005). These complications could be preventable thanks to the intervention of health care such as antenatal care and delivery care, which was introduced by WHO in the safe motherhood package in 1994 (Tran 2012). Antenatal cares provide the opportunities to pregnancy women and their family to be informed of their health and the growth status of unborn baby. Low birth weights could be prevented if the pregnant women are well acknowledged about their unborn baby’s weight and height during the antenatal care and then improve their diet.
In addition, antenatal check-ups detect the danger signs and risks of pregnancy and delivery and make timely interventions. For example, tetanus immunization in the antenatal care period is vital to save the life of the women and their baby. The management of high blood pressure during pregnancy ensures the maternal health and increase the infant survival (WHO and UNICEF 2003). Furthermore, delivery care also plays an important role in reducing maternal deaths.
WHO recommended the child birth at health facility or attended by skilled health staffs to ensure to the safe delivery and give birth to healthy baby. With good hygiene and adequate medical equipment, the delivery at facility could decrease the complications arising from the 1 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com labor such as hemorrhage, obstructed labor. In addition, skill health professionals are available in the facilities ensure safe delivery and provide proper emergency management. (Tran 2012) In pursuit of Millennium Development Goal 5 “Improving maternal health”, Vietnam also is making progress in improving the maternal health with the drop of maternal mortality ratio.
The World Bank shows that MMR in Vietnam has remarkable improvements in last 15 years in decrease from 81 deaths per 100,000 live births in 2000 to 54 per 100,000 in 2015. The access to antenatal care, an important period for health of pregnant women and their baby and delivery service has also increased. Multiple indicator cluster survey in 2014 (MICS 5) shows that the percentage of women aged 15-49 with a live birth in the last two years who received antenatal care at least once is 95.8 per cent nationwide. However, there are considerable disparity in maternal mortality ratio and utilization of maternal health care among ethnicity group, place of residence and the regions where the pregnant women are living.
MPI 2015 reported that maternal mortality in mountainous areas is more than three times higher than in lowland areas. Furthermore, MICS5 indicates that the times of prenatal care visits differs among the women living rural and urban area, especially regarding having more than 4 visits. In addition, the ethnic minority groups get more disadvantage of access to maternal health care with 79% of those having 1 visit and 32.7% of those having at least 4 visits compared to 99.1 % of the Kinh group as shown. Therefore, growing disparities in health outcomes and health care utilization have posed a great challenging in recent years.
The above challenges lead to several studies in the utilization of maternal health care in Vietnam. Most of them focused on the influence of demographic and socioeconomic factors (Sepheri et al. 2008, Tran et al. 2011, Goland et al.
2012, Malqvist et al. 2012, Malqvist et al. Demographic factors which were shown to increase the probability of the health services are younger age, low birth order while the factors reported to decrease the probability are separated or unmarried status, unintended pregnancy. In addition, socio-economic factors make greater influence on the use of the maternal health care services.
Higher education level of a woman is the most important determinant reported in the previous studies (Sepheri et al. 2008, Tran et al. 2011, Goland et al. 2012, Malqvist et al.
2012, Malqvist et al. Lower household income is also shown to be a strong factor in the likelihood of using maternal health care (Sepheri et al. 2008, Goland et al. Some studies emphasized the disparity in the maternal health care utilization among ethnic majority and minority groups (Malqvist et al.
2012, Malqvist et al. On the other hand, major equity in rural and urban 2 LUAN VAN CHAT LUONG download : add luanvanchat@agmail.com areas also was identified by Tran et al. (2011) and Sepheri et al. (2008) pointed out the regional disparity in the availability and accessibility to the maternal health care in Vietnam.
However, most of them overlooked the community factors, except Sepheri et al. (2008) estimating the impacts of poverty rate.