1. Son preference, maternal health care utilization and infant death in rural China Jiajian Chen 1, Zhenming Xie 2, Hongyan Liu 2 1 East-West Center, USA, 2 China Population and Development Research Center

2. Background (1) Economic and health care system reform over the last two decades –Nation-wide privatization –Fee-for-service health care system –Increasing disparities in access to health care services

3. Background (2) Reorientation of family planning program –Service-orientated quality care –Safety of reproductive health services Adherence to one-child family policy –Control of illegal (“unapproved”) births –Disincentive measures

4. Importance of the issue Double burden on use of maternal health care, especially among women with illegal births in the context of recent reforms –Heavy fines –Fee-for-service health care services Detrimental impact of the disincentive measures on use of maternal health care is unintended but foreseeable This issue has become an important public health and reproductive health concern

5. Furthermore Existing study on use of maternal health care under China’s one-child policy failed to address how son preference culture interacts with birth control policy to affect the use of maternal health care (Li 2004) Little is known about the impact of maternal health care utilization on infant mortality in rural China in addition to the effects of other risk factors

6. Objective Assess the effects of socioeconomic conditions and interplay between son- preference and birth control policy on use of maternal health care and their effects on infant mortality in rural China

7. Data (1) National Family Planning and Reproductive Health Survey conducted in August and September 2001 Stratified multistage cluster random sample of 39,586 women (29,512 in rural areas) aged 15-49 from 31 provinces Community-level information was collected from 830 villages in rural areas only

8. Data (2) Information about use of maternal health care collected for live birth only Pooled live births born to married mothers between 1989 and July 2000 in rural China The study sample consists of 19,872 births born at least one year before the survey (Aug.-Sept. 2001) Limited by small sample size at village level, sampled villages within each of 307 counties were combined as county-level communities

9. Method Multilevel logistic regression random intercept models: log [p ij /(1 – p ij )] =  0 +  1 x ij +  2 w j +  0j where x ij : individual-level predictors w j : community-level predictors  0j: random effect at community level

10. Outcome variable Use of maternal health care –prenatal care –skilled assistance for birth delivery Infant death

11. Individual-level predictors Maternal age, maternal and paternal education, minority status Birth order: 1st birth, 2nd birth with no brother, 2nd birth with an older brother, 3 rd /4th birth with no brother, and 3 rd /4 th birth with brother Induced abortion of previous pregnancy prior to the index birth is included for maternal health care use analysis Birth sex, interaction between birth sex and birth order, status of prenatal care and skilled birth assistance are included for infant death analysis

12. Community-level predictors Prevalence of secondary maternal and paternal education, and minority ethnics Poor community (yes, no) Effectiveness of province’s family planning program (strong, moderate 1, moderate 2, and weak)

13. Strong Moderate 1 Moderate 2 Weak Regions of family planning program, China

14. Results

15. Selected sample characteristics Outcome variables Percent Prenatal care 58.8 Skilled assistance for birth delivery 45.9 Infant death 1.6 Total sample size: 19,872 births from 307 county-level communities

16. Selected sample characteristics Individual-level predictors Percent Year of births (1989-1992) 46.2 1993-1996 31.8 1997-2001 22.0 Maternal education (no school) 19.6 Primary 42.2 Secondary 38.2 Birth composition (order 1, no sibling) 52.1 order 2, no brother 19.7 order 2, with a brother 14.2 order 3/4, no brother 5.6 order 3/4 with a brother 8.4 Sex of birth (son) 55.1 Note: reference group is in parentheses.

17. Selected sample characteristics (contd.) Community-level predictors Percent Percent of women with secondary education 40.5 Percent of husband with secondary education 63.5 Poor 15.0 Effectiveness of province’s FP (strong) 36.0 Moderate 1 29.0 Moderate 2 27.0 Weak 8.0 Note: reference group is in parentheses.

18. Sex ratios at birth in rural China, data comparison

19. Sex ratios at birth by status of prenatal care utilization and birth order, rural China

20. Sex ratios at birth by status of induced abortion of previous pregnancy prior to the index birth and birth order, rural China

21. Infant mortality in rural China, data comparison

22. Infant mortality by birth year and maternal education in rural China

23. Adjusted odds for receiving maternal health care Skilled birth Characteristics Prenatal care assistance Individual-level effect Period of birth (1989-1992) 1993-19961.81*1.66* 1997-20003.52*3.33* Maternal education (no) Primary1.71*1.29* Secondary2.83*1.97* Induced abortion (no) Yes 1.11 1.27* Birth composition (order 1) Order 2, no brother0.49*0.45* Order 2, with a brother0.44*0.44* Order 3/4, no brother0.36*0.32* Order 3/4, with brother0.30*0.29* *: p<0.05, included all other selected variables

24. Adjusted odds for receiving maternal health care (contd.) Skilled birth Characteristics Prenatal care assistance Community-level effect Secondary maternal education1.01*1.00 Secondary paternal education1.02*1.03* Poor 0.62*0.53* Effectiveness of provincial FP (strong) Moderate 10.57*0.53* Moderate 2 0.54*0.47* Weak 0.52*0.40* Random effect Intercept only,  2  0.13*1.70* *: p<0.05, included all other selected variables

25. Adjusted odds for infant death Characteristics Odds ratio Individual-level effect Maternal education (no) Primary 0.83 Secondary 0.62* Used of prenatal care 0.67* Interaction Daughter X Order 2, no brother 2.00* Daughter X Order 2, with brother 0.65 Daughter X 3/4, no brother 4.37* Daughter X 3/4, with brother 1.28 Birth sex (ref=son) Daughter 0.94 Birth order (ref=order 1) Order 2, no brother 0.75 Order 2, with brother 0.93 Order 3/4, no brother 0.52 Order 3/4, with brother 1.02 *: p<0.05, included all other selected variables

26. Adjusted odds for infant death (contd.) Characteristics Odds ratio Community-level effect Maternal secondary education 1.00 Paternal secondary education 1.00 Poor 0.81 Effectiveness of province’s FP (strong) … Weak 2.64* Random effect Intercept only,  2  0.51* *: p<0.05, included all other selected variables

27. Summary While the use of maternal health care is improving over time, large disparities still exist in use of such services by maternal education, community income, and parity composition. Maternal education and prenatal care are associated with decreased infant mortality. Not all female infants, but only those of second and higher order with no brother are at high risk of excessive infant mortality.

28. Limitations Higher order birth as a proxy for unapproved birth Underreporting of higher order births and infant deaths: underestimated socioeconomic differentials in maternal care and infant mortality Community-level variables are not time dependent and do not fully explain the unobserved community variance

29. Policy implications China has done a good job in protecting the majority of women with officially approved births. The pressure to have a son within the limit of birth policy intensified a negative effect on use of maternal health care and infant survival. Further improvement in reproductive health of all women and infant survival needs effective reduction in obstacles to use of maternal health care among women who are less educated, poor, and at higher parity in rural China.

30. Infant mortality by sex and birth order, rural China

31. Infant mortality by sex and birth order (excluding twins), rural China