Womens Education and Maternal Health Services: Findings from 2006 Demographic and Health Survey (DHS) in Papua

New Guinea

Sunhwa Lee Pacific Department 2 October 2012

Overview
1.

2.

3. 4. 5. 6.

PNG health status from a comparative perspective PNG maternal health from a development perspective Focus of research Data & methods of research Findings Policy & operation implications

Disclaimer: The views expressed in this paper/presentation are the views of the author and do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. Terminology used may not necessarily be consistent with ADB official terms.

Life Expectancy at Birth (years)

1990 2000 2008
80

60

40

20

0
Cambodia Fiji Islands Indonesia Lao PDR Philippines PNG TimorLeste Vanuatu

Source: ADB 2012. Papua New Guinea Critical Development Constraints. Based on data from ADB Key Indicators for Asia and the Pacific 2010.

Under-Five Mortality Rate (per 1,000 live births)

1990
200

2000

2008

150

100

50

0
Cambodia Fiji Islands Indonesia Lao PDR Philippines PNG TimorLeste Vanuatu

Source: ADB 2012. Papua New Guinea Critical Development Constraints. Based on data from ADB Key Indicators for Asia and the Pacific 2010.

Maternal Mortality Ratio (2005/2006 per 100,000 live births)

Fiji Islands Philippines Timor-Leste Indonesia Cambodia Lao PDR PNG* 0 100 200 300 400 500 600 700 800

Source: ADB 2012. Papua New Guinea Critical Development Constraints. Based on data from ADB Key Indicators for Asia and the Pacific 2010.

Percentage of Births Assisted by Skilled Health Staff (%)

Samoa (2004) Palau (2002) Fiji Islands (2002) Tonga (2004) FSM (2001) Marshall Islands (2007) Indonesia (2007) Vanuatu (2007) Kiribati (2005) Philippines (2008) PNG (2006) Lao PDR (2006) Timor-Leste (2003) 0 10 20 30 40 50 60 70 80 90 100

Source: ADB, Forthcoming, PNG: Critical Development Constraints. Based on data from World Development Indicators, World Bank, accessed on 14 October 2010.

Percentage of Women with At Least One Antenatal Care Visit During Pregnancy (1996 & 2006)
100 80 60 40 20 0

1996
PNG Urban Rural Southern Highlands

2006
Momase Islands No Grades Grades 6 Grades education 1-5 7+

Type of residence

Region

Mother's educational level

Source: ADB 2012. PNG: Critical Development Constraints. Based on 1996 and 2006 Demographic and Health Surveys, National Reports.

Percentage of Deliveries Assisted by Skilled Health Staff (1996 and 2006)

100 80 60 40 20 0 PNG Urban Rural Southern Highlands Momase Islands No Grades Grades 6 Grades education 1-5 7+ Mother's educational level

1996

2006

Place of residence

Region

Source: ADB 2012. PNG: Critical Development Constraints. Based on 1996 and 2006 Demographic and Health Surveys, National Reports.

Percentage of Fully Immunized Children (1996 and 2006, %)

80 60 40 20 0 PNG Urban Rural SouthernHighlandsMomase Islands No Grades Grades 6 Grades Male Female education 1-5 7+ Mother's educational level Child's sex

1996

2006

Place of residence

Region

Source: ADB 2012. PNG: Critical Development Constraints. Based on 1996 and 2006 Demographic and Health Surveys, National Reports.

Focus of Research: Utilization of maternal health services

Health care system (supply-side): - health expenditures - health care staff - functioning health facilities Social factors (demand-side): - economic status: household income/wealth - womens education - womens empowerment status (decision-making) Other geographic factors: - physical accessibility (urban vs. rural, basic infrastructure)

Health care system in PNG

Decentralized since 1995: - health services by provincial govt - churches operate half of rural services Declining health performance: - many facilities closed or not functioning (e.g., drug supplies, aid posts) - underfunding & inadequate staffing - significant variation across provinces ADB financing (& AusAID) for Rural Primary Health Services Delivery Project

Health Spending Performance by Province (2005-2008, %)

300 250 200 150 100 50 0 2005 2007 Average fiscal capacity 2006 2008 Cost of services estimate

New Ireland

Gulf

Morobe

Oro

Madang

Simbu

Enga

East New Britain

Sandaun

Central

Milne Bay

Southern Highlands

Higher funded

Medium funded

Western Highlands

Eastern Highlands

West New Britain

Lower funded

Source: National Economic and Fiscal Commission, 2009. Walking The Talk.

East Sepik

Western

Manus

Figure 4: Supervised delivery care and per capita health expenditure and health worker ratio per 10,000 population
100 90 80 70 60 50 40 30 20 10 0
New Ireland Northern(Oro) E New Britain W New Britain Bougainville Milne Bay Central Enga We Highlands Simbu So Highlands Ea Highlands Sandaum Madang Morobe Western E. Sepik Manus NCD Gulf

Per capita health exp Health worker ratio per 10,000 population Delivery care

Southern

Highlands

Northern

Islands

Source: ADB analysis based on data from 2006 DHS and NDoH.

Literature on Social, economic, demographic factors

Mothers education: strong impact on both maternal care & infant/child mortality (why?) Mothers employment: not straightforward (resources, awareness vs. risks, delayed care) HH economic status: consistently positive for maternal and children health (direct/indirect costs, living environments) Mothers age, birth order, birth interval - for 1st birth, more likely to seek care and give birth at a facility - young mothers: confounding factors ??

Data and Methods:

PNG 2006 DHS: - 8,000 rural & 2,000 urban HH - women in ages of 15-49 - children born during 5 yrs prior to the survey (unit of analysis): N =7,618 births Dependent variables for maternal health service utilization (a) at least one antenatal care (b) skilled health staff at delivery (c) place of delivery Estimation methods: - logistic regression (maximum likelihood) - multinomial logit for (c)

Descriptive statistics (Distribution %)

Variables Education None Grade 1-5 Grade 6 Grade 7 + Mos work None Work outside home Subsistence farming Asset None Radio TV Water Piped water Other Total (N=7,618) 31.9 19.1 26.6 22.4 35.9 23.0 41.2 63.2 26.7 10.1 25.0 75.0 Urban (N=1,854) 13.4 10.9 23.9 51.8 46.0 46.5 7.6 27.5 26.6 45.8 75.4 24.6 Rural (N=5,765) 34.7 20.4 27.0 18.0 34.3 19.4 46.3 68.7 26.7 4.6 17.4 82.6

Types of antenatal care, delivery, and place of birth

Figure 1: Antenatal and delivery care by types of providers and place of birth
Antenatal care (%)
Doctors, 10 Midwives, 1 No Care, 19 Relatives and other, 2 TBAs, 0

Delivery care (%)

Doctors, 8 TBAs, 4

Midwives, 9 Relatives and other, 29

Nurses, 40 No Care, 10

Place of birth (%)

Nurses, 67

Other health facilities, 22

Home environment, 49

Govt. hospitals, 29

Descriptive Statistics: Type of health services by urban vs. rural

Types of antenatal care Doctor Nurse Midwife Relative/traditional None Supervised delivery Yes (doctor/nurse/midwife) Place of delivery Hospitals/health centers Other facilities Home 28.8 22.0 49.3 76.4 11.0 12.6 21.5 23.6 54.9 51.9 87.7 46.5 Total (N=7,618) 10.3 66.9 1.2 3.1 18.5 Urban (N=1,854) 36.5 56.8 0.1 1.2 5.4 Rural (N=5,765) 6.3 68.4 1.4 3.4 20.5

(1)

Logistic regression models for utilization of antenatal care services (sel. vars.)
URBAN (n=1,210) coef. (SE) (0.41) -(0.40) (0.33) -(0.69) (0.21) -(0.25) (0.34) (0.36) (0.29) -(0.29) odd rat. 2.05 -2.30 2.96 -1.35 0.69 -1.48 2.92 1.47 1.92 -0.87 coef. -0.49*** -0.38** 0.90*** -0.11 0.52*** -0.25*** 0.49 0.35** 0.14 -0.41*** RURAL (n=5,764) (SE) (0.13) -(0.13) (0.18) -(0.12) (0.16) -(0.10) (0.36) (0.14) (0.11) -(0.14) odd rat. 0.61 -1.46 2.46 -1.12 1.68 -1.29 1.62 1.42 1.15 -1.50

Variables

Edu:

None Grade 1-5 Grade 6 Grade 7+

0.72 -0.83* 1.09** -0.30 -0.38^ -0.39 1.07*** 0.39 0.65* --0.14

Emp:

None Subsistence Outside emp

Asset:

None Radio TV

Order: 1st 2-3 4+ Water: Piped water

(2) Logistic regression models for assisted delivery (selected variables)

Variables URBAN (n=1,210) coef. Edu: None Grade 1-5 Grade 6 Grade 7+ Emp: None Subsistence Outside emp Asset: None Radio TV Order: 1st 2-3 4+ Water: Piped water 0.15 -0.08 0.92* -0.37 -0.21 -0.22 1.15** 0.89*** 0.31^ -0.23 (SE) (0.39) -(0.37) (0.41) -(0.38) (0.23) -(0.22) (0.31) (0.28) (0.18) -(0.23) odd rat. 1.17 -1.08 2.51 -1.44 0.81 -1.25 3.14 2.43 1.36 -1.25 coef. -0.48*** -0.38*** 0.84*** -0.00 0.33** -0.31*** 0.92*** 0.87*** 0.26*** -0.44*** RURAL (n=5,764) (SE) (0.11) -(0.11) (0.13) -(0.10) (0.12) -(0.09) (0.22) (0.12) (0.09) -(0.15) odd rat. 0.62 -1.46 2.33 -1.00 1.39 -1.37 2.50 2.38 1.30 -1.56

10

Table 1. Logistic Regression Models for Antenatal Care

URBAN Explanatory Variables Constant Education No education Grade 1-5 (reference) Grade 6 Grade 7+ Employment Not employed (reference) Subsistence farming Employed outside home Source of drinking water Other sources (reference) Piped or well water Assets None (reference) Radio only Radio &/or TV only Birth order First Births 2-3 4+ (reference) Mother's age 15-24 25-33 35-49 (reference) Region Highlands (reference) Southern Northern Islands Medical staff ratio Per capita health expenditure -2 log likelihood Sample size Coefficient 0.45 0.72 0.83 * 1.09 ** 0.30 -0.38 ^ -0.14 0.39 1.07 *** 0.39 0.65 * 0.10 -0.10 1.91 *** 0.97 * 1.20 * 0.94 -0.04 (0.03) (SE) (0.66) (0.41) (0.40) (0.33) 2.05 2.30 2.96 1.35 0.69 0.87 1.48 2.92 1.47 1.92 1.11 0.90 6.75 2.63 3.33 2.71 0.96 Odds Ratio Coefficient 1.08 *** -0.49 *** 0.38 ** 0.90 *** 0.11 0.52 *** 0.41 *** 0.25 *** 0.49 0.35 ** 0.14 -0.17 -0.04 0.13 -0.43 * 0.30 0.60 -0.04 * RURAL (SE) (0.32) (0.13) (0.13) (0.18) 0.61 1.46 2.46 1.12 1.68 1.50 1.29 1.62 1.42 1.15 0.84 0.96 1.14 0.65 1.34 1.83 0.96 Odds Ratio

(0.69) (0.21)

(0.12) (0.16)

(0.29)

(0.14)

(0.25) (0.34) (0.36) (0.29)

(0.10) (0.36) (0.14) (0.11)

(0.58) (0.40)

(0.16) (0.11)

(0.55) (0.40) (0.52)

(0.22) (0.20) (0.26) (0.38) (0.02)

N=1,210

N=5,764

Note: Standard errors are in parenthesis. *** p<.001, ** p<.01, *p<.05, ^p<.10 (two-tailed tests) Results are based on weighted data; standard errors are adjusted for survey design.

Table 2. Logistic Regregssion Models for Assisted Delivery URBAN Explanatory Variables Constant Education No education Grade 1-5 (reference) Grade 6 Grade 7+ Employment Not employed (Reference) Subsistence farming Employed outside home Source of drinking water Other sources (Reference) Piped or well water Assets None (Reference) Radio only Radio &/or TV only Birth order First Births 2-3 4+ (Reference) Mother's age 15-24 25-34 35-49 (Reference) Region Highlands (Reference) Southern Northern Islands Medical staff ratio average of 2004/2005 Per capita health expenditure -2 log likelihood Sample size Coefficient -0.23 0.15 0.08 0.92 * (SE) (0.67) (0.39) (0.37) (0.41) Odds Ratio -0.34 1.17 1.08 2.51 Coefficient -0.60 * -0.48 *** 0.38 *** 0.84 *** RURAL (SE) (0.31) (0.11) (0.11) (0.13) Odds Ratio 0.00 0.62 1.46 2.33

0.37 -0.21 0.23 0.22 1.15 ** 0.89 *** 0.31 ^ -0.69 -0.45 2.03 *** 1.03 *** 0.35 1.89 * -0.05 ^

(0.38) (0.23)

1.44 0.81 1.25 1.25 3.14 2.43 1.36 0.50 0.64 7.62 2.79 1.42 6.65 0.95

0.00 0.33 ** 0.44 *** 0.31 *** 0.92 *** 0.87 *** 0.26 *** -0.38 *** -0.24 ** -0.63 *** -0.84 *** 0.50 * 0.25 0.01

(0.10) (0.12)

1.00 1.39 1.56 1.37 2.50 2.38 1.30 0.68 0.79 0.53 0.43 1.66 1.29 1.01

(0.23)

(0.15)

(0.22) (0.31) (0.28) (0.18)

(0.09) (0.22) (0.12) (0.09)

(0.45) (0.32)

(0.13) (0.10)

(0.51) (0.35) (0.53) (0.90) (0.03)

(0.22) (0.18) (0.21) (0.35) (0.02)

N=1,210

N=5,764

Note: Standard errors are in parenthesis. *** p<.001, ** p<.01, *p<.05, ^p<.10 (two-tailed tests) Results are based on weighted data; standard errors are adjusted for survey design.

Table 3. Multinomial Logit Models for Places of Delivery in Rural Areas

(Reference outcome: delivery at home)

Rural Government Hospitals/ Health Centers Odds Ratio Coefficient (SE) -1.15 *** (0.33) Church Supported/ Other Health Centers Odds Ratio Coefficient (SE) -1.60 *** (0.38)

Explanatory Variables Constant Education No education Grade 1-5 (reference) Grade 1-6 Grade 7 or higher Employment Not employed (Reference) Subsistence farming Employed outside home Source of drinking water Other sources (Reference) Piped or well water Possession of a radio &/or TV None (Reference) Radio only Radio &/or TV only Birth order First Births 2-3 4+ (reference) Mother's age 15-24 25-34 35-49 (Reference) Region Highlands (Reference) Southern Northern Islands

-0.69 *** 0.21 0.81 *** -0.22 ^ 0.28 * 0.59 *** 0.44 *** 1.38 *** 0.96 *** 0.31 *** -0.49 ** -0.20 -0.80 *** -1.09 *** 0.13 -0.14 0.02

(0.15) (0.14) (0.16)

0.50 1.23 2.25 0.80 1.33 1.81 1.55 3.96 2.62 1.37 0.61 0.82 0.45 0.33 1.14 0.87 1.02

-0.24 0.40 ** 0.67 *** 0.21 ^ 0.41 ** 0.40 * 0.24 * 0.43 ^ 0.86 *** 0.23 * -0.37 ** -0.31 ** -0.56 * -0.82 *** 0.75 ** 0.27 0.02

(0.66) (0.13) (0.15)

0.79 1.49 1.95 1.23 1.51 1.50 1.27 1.53 2.37 1.26 0.69 0.73 0.57 0.44 2.13 1.31 1.02

(0.12) (0.15)

(0.13) (0.14)

(0.17)

(0.19)

(0.11) (0.23) (0.15) (0.12)

(0.11) (0.24) (0.13) (0.11)

(0.16) (0.13)

(0.15) (0.12)

(0.23) (0.22) (0.22) (0.38) (0.02)

(0.28) (0.23) (0.26) (0.45) (0.03)

Medical staff ratio average of 2004/2005 Per capital health expenditure -2 log likelihood Sample size

N=5,764

Note: Standard errors are in parenthesis. *** p<.001, ** p<.01, *p<.05, ^p<.10 (two-tailed tests) Results are based on weighted data; standard errors are adjusted for survey design.