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Background and objectives: Despite the benefits of maternal health services, these services are often underutilized, especially in the developing countries. The aim of the present study is to provide insight regarding factors affecting maternal health services use from the family perspective. Methods: We use data from the fourth National Health Services Survey in Jiangsu province of Eastern China to investigate the effect of family characteristics on the use of maternal health services. Family characteristics included whether or not living with parents, age of husband, husband’s education, and husband’s work status as well as family economic status. Demographic variables, social and environmental factors, and previous reproductive history were taken as potential confounders. Multiple logistic regression models were used to examine the independent effects of the family characteristic variables on maternal health service utilization. Results: The data indicate that the percentages of prenatal care, postnatal visits and hospital delivery were 85.44, 65.12 and 99.59 % respectively. Living with parents was associated with less use of prenatal care and husband’s age, education and employment status had no effect on the use of prenatal care after adjusting for potential confounding variables. Conclusions: Our findings suggest that maternal health education (especially the role of prenatal care) needs to be extended beyond the expectant mothers themselves to their parents and husbands. The difference of health care delivery as a result of traditional family culture may highlight the differences in factors influencing the use of postnatal visits and those influencing the use of prenatal care; which may be worthy of further study. Keywords: Maternal health care use, Pregnant women, Family characteristics, Prenatal care, Postnatal visits physical activity, and health insurance [4–9]. However, Background the use of health services is complex, and influenced by Maternal health services are important to ensure women many factors [10, 11]. The bio-psycho-social medical and children’s health, which is the base of human sus- model suggested that the factors affecting health need tainable development. Despite the benefits of maternal to be extended beyond the individual to society. Accord- health services, these services are often underutilized, ingly, this model must also be extended to the factors especially in the developing countries [1–3]. Previous influencing the use of maternal health services. Further - research on the factors that influence the use of mater - more, maternal health services are not only the responsi- nal health services has mainly focused on individual fac- bility of the pregnant woman and her doctor, but also the tors, such as economic status, education level, ethnicity responsibility of the family and the whole society. There - and race, religion, attitude and knowledge about health, fore, research on the use of maternal health services should extend beyond individual-level factors related to *Correspondence: firstname.lastname@example.org pregnant women, to include social-level factors . Public Health School, Tongji Medical College, Huazhong University of Science and Technology, Hangkong Road 13, Wuhan, Hubei, China Full list of author information is available at the end of the article © The Author(s) 2016. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Zhang et al. Asia Pac Fam Med (2016) 15:5 Page 2 of 8 As the basic social unit, the family has an important there are almost no population-based studies about the effect on health and health-related issues, including the effect of family characteristics on the use of maternal use of health services [13, 14]. Although many studies health care in China. have examined the importance of family-related factors In addition, two aspects of maternal health care in on health and the use of health services, those studies China should be noted. First, China’s maternal health mainly targeted children and adolescents [15–17]. A lim- care (usually including prenatal care, delivery, and post- ited number of studies have investigated the role of the partum hospital visits) has become an essential pub- husband in the use of maternal health services, with most lic health service, benefiting from national laws on of these from the Western countries [18–21]. However, population and family planning and on maternal and it is important to note that there are substantial cultural infant health care [31–33]. Pre- and postnatal visits differences in family characteristics between Eastern are almost free of charge, and hospital delivery charges and Western countries. These differences may influence enjoy preferential government policies (are inexpen- research results about family factors related to mater- sive) in maternal and child health institutions/hospitals. nal health care. In Western societies, the typical nuclear In China, these services are usually public. Second, in family structure comprises a husband, wife, and their China, prenatal care usually requires pregnant women to non-adult children. Children aged 18 and older often live actively go to maternal and child health institutions/hos- independently from their parents [22–24]. Family sys- pitals. However, postnatal care consists of at-home visits tems in Western societies can be redefined as married, by doctors, nurses, or midwives from maternal and child non-married partners, separated, divorced, and remar- health institutions/hospitals, as new mothers are tradi- ried [25, 26]. In an Eastern society such as China, adult tionally expected to rest indoors for 1 full month after children and their parents often live together, including giving birth (in Chinese “Zuo-Yue-Zi,” meaning 1-month adult children who are married. This tradition (adult confinement after childbirth). To a certain extent, post - children living with aging parents) is termed “filial piety” natal visits are passive services. Maternal health care in Chinese culture, and represents a core value of tradi- is not only related to physiological/medical issues, but tional Chinese society [23, 27, 28]. Typically in Chinese also to psychological/social issues, which should not be families, three or four generations (newly married young ignored. people, their parents, children born after marriage, and The present study offers preliminary evidence about even grandparents of the newly married young people) the influence of five family characteristics variables (liv - live under the same roof. This family structure serves ing with parents, husband’s age, husband’s education, many purposes, including caring for older adults, older husband’s employment status and family economic sta- family members sharing housework and caring for the tus) on the use of three different types of maternal health children of the young couple, and emotional interactions services (prenatal care, hospital delivery, and postnatal between younger and older family members. The reli - visits). Two questions are addressed: (1) What are the ance on family values based on traditional Chinese cul- family characteristics of pregnant women in China? (2) ture plays a much greater role than religious beliefs and What is the relationship between family characteristics activities, which is very different from Western societies and the use of maternal health care? [27–29]. These differences should not be ignored in stud - ies of the use of maternal health care in China. Methods Two aspects of Chinese family characteristics of preg- Data nant women are worth highlighting [30, 31]. First, there Data used in this analysis were drawn from the House- are few unmarried pregnant women in China, with hold Health Survey of the fourth China National Health almost all pregnant women being married with a hus- Services Survey (NHSS) in Jiangsu province, Eastern band. This is because being unmarried but preparing to China, from June 2008 to July 2008. The NHSS is organ - give birth is not acceptable in Chinese society accord- ized and directed by the Center of Health Statistics and ing to traditional ethics. Second, expecting the birth of a Information under the Ministry of Health, China, and new life is a happy occasion in China. Older adults are has been conducted every 5 years since 1993 [34, 35]. For pleased because they will soon “go up a grade” as grand- the fourth NHSS, the Ministry used a multi-stage, strati- parents, perhaps even becoming great-grandparents. It is fied cluster sampling method with systematic random generally accepted that prospective grandparents (older sampling at each stage. The fourth NHSS had four parts: adults) live with their adult children who are expecting the Household Health Survey, Health Institution Survey, a child, providing the pregnant woman (daughter-in-law Prescription Survey, and Medical Staff Survey, with 1 % or daughter) with daily life care, and sharing their experi- of the population included in each sampled province. ences of caring for a baby. However, to our knowledge, Quality control was implemented by supervisors charged Zhang et al. Asia Pac Fam Med (2016) 15:5 Page 3 of 8 with guiding and inspecting each survey step [36, 37]. For Measures the present study, there were 10,200 families represented Dependent variables in the sample, with the study population being women Three variables related to the use of preventive health aged 15–49 years who had given birth since 2003. The care by pregnant women during their last pregnancy number of respondents in each stage of the study sample were included in the dataset: prenatal care, hospital deliv- selection is displayed in Fig. 1. ery, and postnatal visits. Inquiries pertaining to three Jiangsu province is centrally located on the eastern variables began with the questions: How many times did coast of mainland China. The city of Shanghai and Zhe - you receive prenatal care? Did you give birth in a hospi- jiang and Jiangsu provinces constitute the Yangtze River tal? How many times did you receive postnatal visits? Delta city group. The eastern coast of mainland China is one of the most developed economic regions, and can Independent variables provide a social development and health service pro- We included five independent variables: whether or not vision model for poorer middle and west regions. The the woman are living with parents, husband’s age, hus- 2010 national census reported the resident population band’s education, husband’s employment status, and of Jiangsu province was 7865.99 million, accounting for family economic status. Family economic status was 5.87 % of the total population, with Jiangsu province measured with the per capita net income (family net ranked the fifth most populated in China . Accord - income/family size). In addition, given the differences ing to the China Development and Life Index published between urban and rural China, the classification of eco - by the China Statistical Society, in 2012, Jiangsu prov- nomic conditions of urban and rural residents were sepa- ince was ranked fourth of the 31 provinces in mainland rated . Urban areas with a cash receipts income and China with a Development and Life Index of 77.02 %. rural areas with a net income level of P25 and below were . Therefore, to some degree, Jiangsu province can be defined as bad; P25–75 as average; and P75 and above as considered as representative of developed coastal areas in good. Eastern China. Control variables We included variables that could influence the use of maternal health care as controls to statistically eliminate The number of households in the NHSS(2008) in their effects on the dependent variables. Pregnant wom - Jiangsu Province, China N=10,200 en’s demographics, social and environmental factors, and previous reproductive history (which are correlated with the use of maternal health care) were regarded as control The number of individuals in all variables. Demographic variables included the pregnant N=30,689 women’s age, education, and employment status of the pregnant women. Previous reproductive history includes The number of women in all responses to the questions: How many times have you N=15,672 been pregnant (including abortions)? How many times have you given birth? Inquiries about social and environ- mental factors include the questions: Do you have health The number of women aged 15-49 insurance? How long does it take to get to the nearest N=7,674 medical institution using the fastest way available? In addition, we add the types of place of residence, namely The number of women aged 15-49 who have given rural and urban with reference to existing studies [11, birth in the past 5 years 12]. N=1,203 Statistical analysis 1. Divorce: N=4 2. Widowed: N=4 We used three multiple logistic regression models to 3. Family structure data is not complete: examine the independent effect of the family character - N=207 istic variables on maternal health service utilization: (1) the effect of the family characteristic variables shown The number of women aged 15-49 who have given birth in the past 5 years and who have valid data alone, (2) with demographic, and previous reproductive N=988 history variables added, and (3) with social and environ- mental variables included. In addition, although some Fig. 1 Number of respondents in each stage of study sample selec- tion studies considered only one visit as use of prenatal care, Zhang et al. Asia Pac Fam Med (2016) 15:5 Page 4 of 8 four visits are recommended [40, 41]. The present study Table 1 Descriptive statistics for the primary variables (n = 988) uses a binary dependent variable (1 = four visits or more; 0 = three visits or less). Similarly, we use a binary vari- Variables N % able for postnatal visits (1 = one visit or more; 0 = zero Times of prenatal care visits), based on previous studies. As 99.59 % of women ≥4 844 85.44 had given birth in the hospital, we did not perform mul- 3 and less 144 14.56 tiple logistic analysis of hospital delivery. The coefficients Hospital delivery (missing = 4) from all regression models are reported as odds ratios Yes 980 99.59 (OR) with 95 % confidence intervals (CI). All analyses are No 4 0.41 performed using SPSS, version 12.0 (SPSS Inc, Chicago, Times of postnatal visits (missing = 16) IL, USA). ≥1 633 65.12 0 339 34.88 Results Whether or not living with parents Descriptive statistics for the primary variables Yes 675 68.32 The descriptive statistics for the primary variables are No 313 31.68 presented in Table 1. Of the three variables related to Husband’s age preventive health care use by pregnant women, the per- ≥35 year-old 305 30.87 centage of hospital delivery is the highest (99.59 %), and ≥30 year-old 426 43.12 that of postnatal visits is the lowest (65.12 %). The major - 18–29 year-old 257 26.02 ity of pregnant women lived with their parent (68.32 %), Husband’s education (missing = 1) reflecting China’s traditional family culture. In addition, College and above 244 24.72 it is interesting to note that family economic status did High school 301 30.50 not significantly differ between pregnant women who Junior high school 393 39.82 lived with their parents and those who did not (χ = 0.54; Primary school and below 49 4.96 p = 0.46). Husband’s employment status (missing = 2) Yes 940 95.33 Multivariate analysis of the association between family No 46 4.67 characteristics and prenatal care Pregnant women’s age Table 2 displays the ORs for the associations between ≥35 year-old 193 19.53 independent variables and prenatal care use. In model 1, living with parents, husband’s education, and family ≥30 year-old 373 37.75 economic status are significantly associated with prena - ≥25 year-old 370 37.45 tal care use. Specifically, respondents living with parents 18–24 year-old 52 5.26 are less likely to report prenatal care use compared with Pregnant women’s education (missing = 1) those not living with parents (OR 0.45, 95 % CI 0.30– College and above 205 20.77 0.67). Model 2 shows that living with parents was the High school 261 26.44 only variable that remained significant (OR 0.56, 95 % CI Junior high school 406 41.13 0.36–0.87) with the addition of the women’s demograph- Primary school and below 115 11.65 ics and previous reproductive history. Finally, living with Pregnant women’s employment status (missing = 2) parents and family economic status remained significant Yes 862 87.42 with the addition of social and environmental variables in No 124 12.58 model 3 (OR 0.48, 95 % CI 0.30–0.77; OR 2.20, 95 % CI Times of previous pregnancies of pregnant women 1.11–4.35, respectively). 2 and more 163 16.50 1 304 30.77 Multivariate analysis of the association between family 0 521 52.73 characteristics and postnatal visits Times of previous giving births of pregnant women Postnatal visits were associated with the family char- 1 and more 199 20.16 acteristic variables (Table 2), but there are some differ - 0 788 79.84 ences compared with prenatal care use. Model 1 shows Health insurance (missing = 6) that only the husband’s education was related to the use Yes 858 87.37 of postnatal visits. Furthermore, women whose husbands No 124 12.63 Zhang et al. Asia Pac Fam Med (2016) 15:5 Page 5 of 8 Table 1 continued synergy of both types of support will be more conducive to maternal and fetal health. In addition, maternal health Variables N % education (especially the role of prenatal care) needs to be The time to the nearest medical institution by the fastest way available extended from pregnant women to their parents. (missing = 2) This study shows that household income and the educa - ≥10 min or more 490 49.70 tion of pregnant women had a positive effect on mater - <10 min 496 50.30 nal health, which confirm the findings of previous studies Per capita income of family [1–3, 12, 29]. It is noteworthy that the husband’s age and Good 311 31.48 employment status were not significantly associated with General 433 43.83 the use of prenatal services. Pregnancy and the fetus are Bad 244 24.70 not only maternal responsibilities, but are also a husband’s Place of residence responsibility. The non-significant effects we found might Rural 577 58.40 indicate that husbands lack awareness of their responsi- Urban 411 41.60 bilities. In addition, although age is generally a risk factor for individual disease and the use of health services, this effect may be mainly confined to the individual, and can - had a higher education level, specifically college and not be extended to others. Another possible explanation above, were more likely to report postnatal visits com- for the lack of significance of employment status may be pared to those whose husbands had a primary school the conflict between time and income. For example, those education or lower (OR 2.55, 95 % CI 1.33–4.89). With with jobs may have more revenue, but less time to spend the addition of demographic factors and previous repro- with their wife; those without jobs, may have more time ductive history, model 2 showed that husband’s age and but less income. In other words, the conflict between time education have significant effects on postnatal visits. and income may confuse the impact on antenatal screen- Finally, only husband’s age remained significant, showing ing service use. The husband’s education was significantly a negative effect with the addition of social and environ - associated with the use of prenatal services in model 1. mental variables in model 3 (OR 0.53, 95 % CI 0.31–0.92). However, it was not significantly associated with the use of prenatal services in models 2 and 3, which is partly con- Discussion sistent with Short and Zhang’s report that the husbands’ Family characteristics and use of prenatal care education level was a protective factor for prenatal care The results of this study show that couples living with par - among married women in rural China . A likely expla- ents accounted for the majority of respondents, which is nation for this protective effect is that the higher the edu - consistent with China’s traditional culture of filial piety cation level, the higher the awareness of the importance of [27, 28]. However, it is noteworthy that living with par- health, which affects not only the individual, but also their ents was associated with less use of prenatal care. This family, including their wife and unborn child. This sug - may be explained by two reasons. First, pregnant women gests maternal health education also needs to be extended who live with parents may receive substantial help during to pregnant women’s husbands. The policy pathway of daily activities, such as grocery shopping, cooking, wash- taking husbands with higher education levels as entry ing clothes, and other housework, compared with those points, and using these smaller populations to guide other who do not live with parents. Therefore, they are likely to husbands’ participation in prenatal care may be an effec - have less stress and fatigue related to housework. Moreo- tive and sustainable development mechanism for the use ver, a pregnant woman’s husband is typically the main of prenatal care. wage earner, usually leaving home early and returning late. Therefore, pregnant women who live with parents may Family characteristics and use of postnatal visits have more of a sense of security, feel less lonely, and enjoy The present study shows that living with parents, the per a more comfortable life than those not living with their capita income of the family, and the husband’s employ- parents [27, 28]. Second, older parents, especially an older ment status have no significant influence on the use of mother-in-law or mother, can provide their adult children postnatal care. However, the husband’s age has a signifi - with general knowledge about pregnancy, such as nutrition, cant influence (the older the husband’s age, the lower fetal movement, and personal hygiene, as they have suc- the use of postnatal care). Factors influencing the use of cessfully experienced pregnancy. Therefore, the perceived postnatal visits also differed from those influencing the need for and the use of prenatal care may be reduced. How- use of prenatal care. Living with parents, the per capita ever, although the traditional family culture (living with income of the family and the numbers of previous births parents) may provide support for the daily life of pregnant had a significant influence on prenatal care, but not on women, professional prenatal care should not be ignored; Zhang et al. Asia Pac Fam Med (2016) 15:5 Page 6 of 8 Table 2 Estimated net effect of family characteristic variables and control variables on the use of prenatal care and post- natal visits (n = 988) Variables Prenatal care Postnatal visits Model 1 Model 2 Model 3 Model 1 Model 2 Model 3 Family characteristic variables Whether or not living with parents (ref = No) Yes 0.45 (0.30–0.67)** 0.56 (0.36–0.87)** 0.48 (0.30–0.77)** 1.12 (0.82–1.53) 1.06 (0.76–1.48) 0.97 (0.69–1.37) Husband’s age (ref = 18–29 year-old) ≥35 year-old 0.90 (0.55–1.48) 1.40 (0.64–3.04) 1.21 (0.55–2.66) 0.84 (0.57–1.23) 0.60 (0.35–1.03) 0.53 (0.31–0.92)* ≥30 year-old 1.36 (0.83–2.22) 1.56 (0.86–2.82) 1.49 (0.82–2.70) 0.72 (0.51–1.01) 0.63 (0.42–0.95)* 0.59 (0.39–0.90)* Husband’s education (ref = primary school and below) College and 10.19 (4.26–24.34)** 2.93 (0.92–9.33) 2.17 (0.65–7.23) 2.55 (1.33–4.89)** 2.52 (1.10–5.78)* 2.04 (0.87–4.77) above High school 3.54 (1.72–7.27)** 1.53 (0.66–3.55) 1.35 (0.57–3.18) 1.78 (0.95–3.35) 2.10 (1.00–4.40)* 1.80 (0.85–3.80) Junior high school 1.97 (1.02–3.78)* 1.56 (0.75–3.23) 1.49 (0.71–3.12) 1.48 (0.81–2.73) 1.90 (0.96–3.76) 1.76 (0.89–3.49) Husband’s employment status (ref = No) Yes 1.53 (0.57–4.11) 1.02 (0.35–3.00) 0.81 (0.27–2.43) 0.71 (0.38–1.34) 0.70 (0.35–1.38) 0.63 (0.31–1.28) Per capita income of family (ref = Bad) Good 2.19 (1.15–4.15)* 1.85 (0.95–3.59) 2.20 (1.11–4.35)* 0.92 (0.61–1.37) 0.90 (0.59–1.37) 1.09 (0.70–1.68) General 1.02 (0.67–1.55) 0.90 (0.58–1.40) 0.98 (0.62–1.53) 0.95 (0.68–1.32) 0.95 (0.68–1.34) 1.03 (0.73–1.46) Control variables Pregnant women’s age (ref = 18–24 year-old) ≥35 year-old 1.01 (0.32–3.18) 1.00 (0.31–3.17) 3.60 (1.51–8.59)** 3.52 (1.46–8.50)** ≥30 year-old 0.90 (0.34–2.37) 0.85 (0.32–2.24) 1.88 (0.91–3.89) 1.78 (0.85–3.73) ≥25 year-old 1.10 (0.47–2.57) 1.08 (0.46–2.52) 1.70 (0.89–3.25) 1.72 (0.89–3.32) Pregnant women’s education (ref = primary school and below) College and 2.90 (0.99–8.56) 1.74 (0.54–5.58) 0.72 (0.35–1.50) 0.44 (0.20–0.97)* above High school 3.22 (1.46–7.09)** 2.42 (1.05–5.56)* 0.54 (0.29–0.99)* 0.40 (0.21–0.75)** Junior high school 1.37 (0.78–2.40) 1.17 (0.66–2.08) 0.54 (0.32–0.91)* 0.46 (0.27–0.79)** Pregnant women’s employment status (ref = No) Yes 1.70 (0.85–3.40) 1.70 (0.80–3.58) 1.09 (0.69–1.71) 1.01 (0.63–1.64) Times of previous pregnancies of pregnant women (ref = 0) 2 and more 1.27 (0.66–2.46) 1.24 (0.64–2.42) 0.58 (0.37–0.89)* 0.54 (0.35–0.84)** 1 1.66 (0.93–2.96) 1.64 (0.92–2.94) 0.68 (0.48–0.95)* 0.66 (0.47–0.93)* Times of previous giving births of pregnant women (ref = 0) 1 and more 2.87 (1.45–5.66)** 2.54 (1.26–5.12)** 1.44 (0.89–2.35) 1.27 (0.77–2.09) Health insurance (ref = No) Yes 0.67 (0.37–1.23) 0.86 (0.56–1.33) The time to the nearest medical institution by the fastest way available (ref = <10 min) ≥10 min or more 1.00 (0.68–1.48) 1.26 (0.95–1.67) Place of residence (ref = Urban) Rural 0.43 (0.23–0.82)* 0.50 (0.33–0.75)** * P < 0.05 ** P < 0.01 (two-tailed test) postnatal visits. In contrast, the numbers of previous China, prenatal care is general active, whereas post-natal pregnancies had a significant influence on postnatal vis - visit are passive. Therefore, factors affecting the use of its but not on prenatal care. These differences may be postnatal visits may differ from those influencing the use attributable to the difference of service mode between of prenatal care. It may be inappropriate to analyze the prenatal care and postnatal visits. As mentioned, in factors influencing the use of postnatal visits with the Zhang et al. Asia Pac Fam Med (2016) 15:5 Page 7 of 8 2. Garg P, Williams JA, Satyavrat V. A pilot study to assess the utility and same model of those of prenatal care, which are rarely perceived effectiveness of a tool for diagnosing feeding difficulties in mentioned in existing studies. children. Asia Pac Fam Med. 2015;14(1):7. This study had several limitations. First, there was a 3. Cohen D, Coco A. 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Asia Pacific Family Medicine – Springer Journals
Published: Dec 1, 2016
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