Healthy Mothers, Healthy Children:

1. Healthy Mothers, Healthy Children: Does Maternal Demand for Antenatal Care Matter for Child Health in Nepal? Nafisa Halim Alok K. Bohara Xiaomin Ruan University of New Mexico

2. Introduction • High maternal mortality and chronic child malnutrition despite impressive child mortality reduction in Nepal • High maternal mortality rate (540/100,000 live births in 1996) • 1 in every 2 children, lighter for age and height; 1 in every 10 children, shorter for age

4. Context • 5.3% of GNP in health expenditures • Safe Motherhood Program in Nepal • GO-NGO Collaboration in health • Still, 80% of deliveries take place at home

5. Research Questions (1) Why isn’t antenatal care universal in Nepal? (2) Does antenatal care matter for child health?

6. Prior Literature • Maternal Education • Learning about secular organizations • Empowered and autonomous to go beyond tradition • Paternal education is NOT as important

7. Problems with Prior Studies: Context-Insensitive? • Patriarchal social and economic institutions • Traditional pregnancy governing institutions favor mother-in-laws • Pregnancy is “shameful” • Event of childbirth “polluted”

8. Problems with Prior Studies: Methodological Constraints • Maternal education correlated with parental and spousal education • Maternal education: A correlation or a cause of antenatal care? • Husbands’ role in pregnancy-related decision making • His education helps to “approve” of maternal care utilization

9. Hypotheses H 1.Educated mothers are more likely to use professional antenatal care than their non-educated counterparts. H 2.Mothers are more likely to use maternal care if their husbands are educated. H 3.Mothers who have access to the media and, presumably, health-related information are more likely to use professional antenatal care than mothers who lack such access. H 4.Educated mothers tend to visit professional Antenatal care providers more frequently than their less-educated counterparts. H 5.Mothers will tend to visit professional antenatal care providers more frequently if their husbands are educated. H 6.Mothers who have access to the media and, presumably, health-related information tend to visit professional antenatal care providers more frequently than those who lack such access. H 7. Children whosemothers have sought routine professional antenatal care during pregnancy are healthier in their infant and toddler years than the children of mothers who have not sought such care.

10. Data • The Nepal Family and Health Survey (NFHS), 1996 and 2001 • A stratified cluster-sampling design • A nationally representative sample of 8,429 women, 15 – 49 • As many as 3,549 mothers and 2,460 children, 0-36 months

11. Measurements Antenatal care: • Type of antenatal care they sought (modern vs. traditional/none) • Frequency in antenatal care utilization Child health (z-score): Standardized weights conditional on the median weight of a well-nourished child of the same age and sex in the US population.

12. Estimation Strategy:Two Staged 1st stage Antenatal care=f(maternal and paternal education, controls—age, exposure to media, employment, religion, caste, urbanity, and regional controls) Estimation technique: Binomial Logit Model Antenatal Visits= f(maternal and paternal education, controls—age, exposure to media, employment, religion, caste, urbanity, and regional controls) Estimation technique: Negative Binomial (count) Model 2nd stage Child health=f(predicted antenatal care, controls—maternal height, weight, age, age at marriage; child’s sex, age, age-sq, parity, illness and immunization history; households’ water-supply and sanitation conditions; religion, caste) Estimation technique: Ordinary Least Squares

16. Results (Part I): Why isn’t antenatal care universal in Nepal? Maternal education Matters • 15%, 34%, and 57% higher likelihood if a mother has five, ten, or at least twelve years of schooling than none Paternal education matters • 7%, 17%, 12% higher likelihood if her husband has five, ten, or at least twelve years of schooling than none

18. Results (Part II): Does antenatal care utilization matter for child health? Yes and significantly • Z-score increases by 0.1 if a mother utilizes antenatal care • Z-score increases by 0.8 if she pays 1 more antenatal visit

19. Discussion and Policy Implications • Results robust to variations in sample and estimation techniques • Maternal Education matters • Paternal education, more important than the conventional wisdom suggests • Raising awareness about importance of antenatal care • Raising awareness about maternal health for child health • Dissemination of health information