J Huazhong Univ Sci Technol[Med Sci] 34(6):869-874,2014 10.1007/s11596-014-1366-1 J DOI Huazhong Univ Sci Technol[Med Sci] 34(6):2014

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Factors Influencing the Utilization of Postpartum Visits among Rural Women in China* †



Yuan-xi XIANG (项远兮)1 , Ju-yang XIONG (熊巨洋)1 , Miao-miao TIAN (田淼淼)2, Fang YUAN (袁 芳)1, Zhan-chun FENG (冯占春)1# 1 School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China 2 Center for Policy and Health Management, Chinese Academy of Medical Sciences, Beijing 10020, China © Huazhong University of Science and Technology and Springer-Verlag Berlin Heidelberg 2014

Summary: Postpartum visits (PPVs) are still underutilized in rural China, and identification of factors that influence PPV use is important in ensuring the utilization of maternal health services and for wellbeing of women. A cross-section study was undertaken to collect related data from 347 rural women interviewed six weeks or more after delivery, and an ANOVA was performed to find whether there were significant differences in the number of PPVs among different rural areas in China. According to Andersen’s socio-behavioral model of health service use, factors were divided into equitable and inequitable ones. Chi-squared test, univariate and multiple analyses were used to determine the equity of PPV use by identifying factors that were most strongly associated with the use of a PPV. The results showed that 20.2% of the respondents (n=70) did not receive any PPVs, and 62.5% (n=173) of those who had PPVs (n=277) did not receive standard PPVs (referring to at least 3 visits). There was no significant difference among different rural areas in terms of the number of PPVs (F=1.514, P=0.211). Multiple regression analyses revealed that enabling factors such as compensation for delivery expense [OR (95% CI)=2.825 (1.331, 5.995)], village type [OR (95% CI)=1.802 (1.021, 3.182)] and service quality [OR (95% CI)=1.847 (1.074, 3.176)] were strongly associated with PPV use. Both enabling factors such as home visits [OR (95% CI)=1.855 (1.085, 3.174)], service quality [OR (95% CI)=1.993 (1.155, 3.439)] and need factors such as low birth weight [OR (95% CI)=4.424 (1.482, 13.203)] were significantly associated with standard PPV use. Our results suggested that the equitable access to PPVs has been considerably improved in rural areas in China. The associations between inequitable factors and PPV use warrant further exploration, and policies aimed at improving quality and patterns of service supply are needed in order to ensure a full equitable access to maternal health services. Key words: postpartum visit; utilization; maternal health; equitable access; essential public health services 

The postpartum period starts immediately after delivery and extends through the following six weeks[1, 2]. It is globally believed that postpartum care services are essential in reducing maternal and newborn deaths and improving their physical and psychological wellbeing[3, 4]. It was reported that 47% of women had at least one new health problem arising in the first 3 months after delivery and retained over time[5]. The cost-effectiveness of major interventions of postpartum care is particularly high in terms of the low cost covered and the high number of lives saved[3, 6]. Postpartum care can not only promote the healthy behaviors of mothers and infants, facilitate early detection and treatment of medical complications, provide extra visits for preterm infants but also prevent maternal-to-child transmission of diseases, such as HIV, and advocate breast feeding and family planning[7]. The Ministry of Health in China advocates that at                                                               Yuan-xi XIANG, E-mail: [email protected]; Ju-yang XIONG, E-mail: [email protected] † Both authors contributed equally to this work. # Corresponding author, E-mail: [email protected] * This project was supported by the National Natural Science Foundation of China (No. 71273097).

least 70% urban women and 60% rural women are supposed to have three postpartum home visits by health-care providers[8]. However, studies show that this is not happening in reality. According to the 4th National Health Service Survey (NHSS) in 2008, the rate of women having at least one PPV was 61.0% in urban areas, and 54.3% in rural areas[9]. The rate was only increased by 9.6% from 1993 to 2008 nationwide, and the increase was even less in rural areas (6.0%)[10]. As part of the Chinese Health System Reform (CHSR, initiated in 2009), maternal healthcare is a main component of essential public health services as well as the top priority of the policy agenda for the equalization of essential public health care and equity of health care[11]. However, limited research has been made to evaluate the equalization and equity of maternal health care, and to our knowledge, no published studies so far have analyzed how the new policies influence the equity and utilization of PPV in China. Hence, our study set out to explore factors associated with PPV services and analyze how the policies influence equalization and equity in maternal health care in rural China. This research addressed the following questions: (1) Is there any difference between provinces in the utilization of the PPVs? (2)

870 What are the potential factors associated with the PPVs? (3) How do the policies influence equalization and equity in maternal health care? A cross-sectional survey was carried out to perform the task. 1 MATERIALS AND METHODS 1.1 Sampling and Study Sites On basis of a multi-stage stratified random sampling framework, the data were collected using a cross-sectional survey conducted from July to November 2011. Human development indices were used to divide 31 first-level administrative regions (excluding Hong Kong, Macau and Taiwan) of China into four levels[12], and provinces of Zhejiang, Henan and Qinghai, and a municipality Chongqing were randomly selected from each level to represent 4 development levels in China. Three counties were randomly selected from each province and the municipality. According to the distance between each township and county town, townships fell into 3 categories, and one township was randomly selected from each category, with totally 36 townships obtained. Similarly, villages of the sample townships were divided into 3 categories according to their distance from township hospitals, and one village was randomly chosen from each category as the sample village, then 108 villages were obtained in total. Due to the fact that rural migrant women worked outside of their hometowns for more than 10 months every year, four participants were drawn from each village using the respondent-driven sampling method so as to prevent low respondent rate and responses that lack candor. At last, the response rate was 80.3% after check-control and reinvestigations, and a total of 347 participants were enrolled. 1.2 Data Collection A group of postgraduate students in School of Medicine and Health Management at Tongji Medical College and staff from local health care institutions had been trained as investigators by survey supervisors from Tongji Medical College. Ethical approval was obtained from the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (IRB No: FWA00007304). The protocol, informed consent document and questionnaire for participants were reviewed and approved. Written consents were obtained from the participants, and all of them were interviewed in person by investigators, and items and response choices were read and explained if necessary. 1.3 Questionnaire The questionnaire was delivered in Chinese and contained a series of closed-end questions (“yes or no” format). It consisted of two parts: socio-demographic information and the utilization of PPVs. Participants characteristics were assigned to categories in compliance with Andersen’s model[13], including predisposing factors (including variables such as age and ethnicity as demographic variables, and household size, education, employment as social variables), enabling factors (such as compensation for childbirth, household income, village type, number of home visits) and need factors (such as preterm delivery, delivery method, low birth weight and services quality).

J Huazhong Univ Sci Technol[Med Sci] 34(6):2014

1.4 Statistical Analysis In order to find the influencing factors associated with use of PPV, responses were dichotomized into non-use (n=0) or use of PPV (n≥1) among all participants. According to the National Essential Public Health Services Specification of China (2011)[14], no less than 3 postpartum visits should be given to women within 28 days following delivery. Then, among those who had PPVs, responses were dichotomized into standard use of PPV (n≥3) or non-standard use of PPV (1≤n≤3) so as to find which factors influences standard use of PPV (three or more visits were specified as standard use since minimum three visits at 7, 28, and 42 days after delivery are required by the national guideline.)[8]. It is anticipated that low education, low income and unemployment can increase non-use of PPV, and caesarean, preterm delivery, low birth weight, compensation for childbirth can increase the PPV use, and high education, employment, high income, preterm delivery, low birth weight, delivery method and compensation for childbirth can increase standard use of PPVs (n≥3). A one-way ANOVA was first conducted to compare the number of PPV use in four provinces. Then, univariate analyses were conducted using Chi-square tests to establish correlations between participant characteristics and use or standard use of PPV. Multiple logistic regressions were then used to analyze two dependent variables, use or non-use of PPV and standard use of PPV or not. Enter method was selected, and variables that were statistically significant predictors of use or standard use of PPV were retained in the final model. All reported P-values were two-sided, and P-value

Factors influencing the utilization of postpartum visits among rural women in China.

Postpartum visits (PPVs) are still underutilized in rural China, and identification of factors that influence PPV use is important in ensuring the uti...
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