Is breast-feeding a substitute for contraception in family planning?

Using data from the Cebu Longitudinal Health and Nutrition Survey, I disentangle the complex interrelationship between breast-feeding, postpartum amenorrhea, and choice of contraceptive method. I find evidence that women substitute breast-feeding for contraception. Further, endogeneity bias, if not controlled, would cause the relationship to be slightly overstated. In addition, the results suggest that although increased education and income result in decreased breast-feeding, any effect on fertility will be offset by changes in contraceptive use.

The effects of maternal-child health service utilization on subsequent contraceptive use in Morocco.

There are a number of reasons for anticipating that contact by women in developing country settings with modern maternal-child health (MCH) services will lead to increased use of family planning services. Indeed, the expectation of such a relationship underlies the integrated service delivery strategy that has been adopted on a more or less global basis. However, the available empirical evidence in support of this proposition is inconclusive. This study re-examines this issue in Morocco. Household survey data and data on the supply environment for health and family planning services gathered in 1992 are analysed in the study. A full-information maximum likelihood estimator is used to control for the possible endogeneity of health care and contraceptive choices. The findings indicate a substantial and apparently causal relationship between the intensity of MCH service use and subsequent contraceptive use. Policy simulations indicate that sizeable increases in contraceptive prevalence might be realized by increasing the coverage and intensity of use of MCH services.

PIP: This study examined the association between frequency of use of maternal and child health (MCH) services and subsequent contraceptive use (CU) in Morocco. Data were obtained from a 1992 Moroccan Health Survey among 3267 married women with at least 1 live birth and the 1992 Service Availability Module. Analysis was based on full information maximum likelihood estimates and nonparametric, discrete factor strategies. The analysis ignored the possibility that CU can lead to increase MCH use, because few women use contraception before a first birth. Findings indicate that intensity of MCH service use was a statistically significant determinant of subsequent CU. The magnitude of the effect was large. For example, an increase in MCH service use from 2 to 4 would result in an increase of over 71% in contraceptive prevalence, from 32% to 55%. Modern CU would increase from 55% to 65%. Traditional CU would increase from 7% to 19%. Increases were more likely despite controls for individual and household characteristics. Findings do not explain the role of integrated services. Since there are numerous sources of supply, it is likely that counseling and promotion by health facility staff were significant factors. Evidence supports the need to include community-level factors in the analysis, but key community factors remain unmeasured.

Household health expenditures in Nepal: implications for health care financing reform.

His Majesty's Government of Nepal has embarked on an ambitious social welfare programme of increasing the accessibility of primary education and health care services in rural communities. The implications on the financing of health care services are substantial, as the number of health posts has increased twelve-fold from 1992 to 1996, from 200 to 2597. To strengthen health care financing, government policy-makers are considering a number of financing strategies that are likely to have a substantial impact on household health care expenditures. However, more needs to be known about the role of households in the current structure of the health economy before the government designs and implements policies that affect household welfare. This paper uses the Nepal Living Standards Survey, a rich, nationally-representative sample of households from 1996, to investigate level and distribution of household out-of-pocket health expenditures. Utilization and expenditures for different types of providers are presented by urban/rural status and by socioeconomic status. In addition, the sources of health sector funds are analyzed by contrasting household out-of-pocket expenditures with expenditures by the government and donors. The results indicate that households spend about 5.5% of total household expenditures on health care and that households account for 74% of the total level of funds used to finance the health economy. In addition, rural households are found to spend more on health care than urban households, after controlling for income status. Distributing health care expenditures by type of care utilized indicates that the wealthy, as well as the poor, rely heavily on services provided by the public sector. The results of this analysis are used to discuss the feasibility of implementing alternative health care financing policies.

Effect of provider characteristics on choice of contraceptive provider: a two-equation full-information maximum-likelihood estimation.

We use surveys of households and health-care facilities conducted in the same area at the same time to determine which characteristics of providers attract users of contraceptives. By using the full-information maximum-likelihood technique to jointly estimate choice of contraceptive method and choice of provider, we avoid self-selection bias. Results support the need for modeling quality and for jointly estimating the choice of contraceptive method and the choice of provider to avoid biased estimates of coefficients. The results suggest that for the Cebu, Philippines region, small local clinics that focus on family planning tend to be most favored by clients.