Perspect Nurs Sci.  2018 Oct;15(2):49-69. 10.16952/pns.2018.15.2.49.

Service Quality beyond Access: A Multilevel Analysis of Neonatal, Infant, and Under-Five Child Mortality Using the Indian Demographic and Health Survey 2015~2016

• Kim R
• Choi N
• Subramanian SV
• Oh J

• KMID: 2424090
• DOI: http://doi.org/10.16952/pns.2018.15.2.49

Abstract

PURPOSE
The purpose of this study was to derive contextual indicators of medical provider quality and assess their relative importance along with the individual utilization of antenatal care (ANC) and institutional births with a skilled birth attendant (SBA) in India using a multilevel framework.
METHODS
The 2015~2016 Demographic and Health Survey (DHS) from India was used to assess the outcomes of neonatal, infant, and under-five child mortality. The final analytic sample included 182,980 children across 28,283 communities, 640 districts, and 36 states and union territories. The contextual indicators of medical provider quality for districts and states were derived from the individual-level number of ANC visits ( < 4 or≥4) and institutional delivery with SBA. A series of random effects logistic regression models were estimated with a stepwise addition of predictor variables.
RESULTS
About half of the mothers (47.3%) had attended≥4 ANC visits and 75.8% delivered in institutional settings with SBAs. Based on ANC visits, 276~281 districts (43.1~43.9%) and 13~16 states (36.5~44.4%) were classified as "low" quality areas, whereas 268~285 districts (41.9~44.5%) and 8~9 states (22.2~25.0%) were classified as "low" quality areas based on institutional delivery with SBAs. Conditional on a comprehensive set of covariates, the individual use of both ANC and SBA were significantly associated with all mortality outcomes (OR: 1.17, 95% CI: 1.08, 1.26, and OR: 1.10, 95% CI: 1.02, 1.19, respectively, for under-five child mortality) and remained robust even after adjusting for contextual indicators of medical provider quality. Districts and states with low quality were associated with 57~61% and 27~43% higher odds of under-five child mortality, respectively.
CONCLUSION
When simultaneously considered, district- and state-level provider quality mattered more than individual access to care for all mortality outcomes in India. Further investigations are needed to assess the importance of improving the quality of health service delivery at higher levels to prevent unnecessary child deaths in developing countries.

Keyword

Antenatal care; Provider quality; Child mortality; India; Multilevel analysis

MeSH Terms

Child
Child Mortality*
Child*
Developing Countries
Health Services
Health Surveys*
Humans
India
Infant*
Logistic Models
Mortality
Mothers
Multilevel Analysis*
Parturition

Figure

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  Figure 1 Four Level Data Structure of the Final Analytic Sample from India Demographic and Health Survey 2015~2016.

• 

  Figure 2 Constructing District- and State-Level Provider Quality Proxy Measures Based on % Mothers with≥4 Antenatal Care Visits and % Neonatal, Infant, and Under-Five Mortality, India Demographic and Health Survey 2015~2016.

• 

  Figure 3 Constructing District- and State-Level Provider Quality Proxy Measures Based on % Institutional Birth Delivery with Skilled Birth Attendant and % Neonatal, Infant, and Under-Five Mortality, India Demographic and Health Survey 2015~2016.

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