the socio-economic determinants of maternal health care utilization in turkey

The socio-economic determinants of maternal health careutilization in Turkey

Yusuf Celika, 1, David R. Hotchkissb,*aSchool of Health Administration, Hacettepe University, Ankara, Turkey

bDepartment of International Health and Development, School of Public Health and Tropical Medicine, Tulane University, 1440

Canal Street, Suite 2200, New Orleans, LA 70112, USA

Abstract

The purpose of this study is to investigate the individual-, household- and community-level factors that a�ect

women's use of maternal health care services in Turkey. The data used for the study come from the 1993 TurkeyDemographic and Health Survey (TDHS), a nationally representative survey of ever married women 15 to 49 yearsof age. In order to assess the impact of socio-economic factors on maternal health care utilization, we use logisticalregression techniques to estimate models of the prenatal care use and birth delivery assistance among women who

have had at least one birth in the three years prior to the survey. Separate models are also estimated for urban andrural women. The results indicate that educational attainment, parity level, health insurance coverage, ethnicity,household wealth and geographic region are statistically signi®cant factors that a�ect the use of health care services

thought essential to reduce infant and child mortality rates. The results of the model are used to provide insights forboth micro- and macro-level planning of maternal health service delivery. 7 2000 Elsevier Science Ltd. All rightsreserved.

Keywords: Maternal health services; Health care utilization; Turkey

Introduction

Over the past two decades, Turkey has maderemarkable progress in improving health outcomes

among its population, particularly among children andpregnant women. From 1983 to 1993, for example, theinfant mortality rate dropped by 35% and from 1974to 1995, the maternal mortality rate decreased by 53%

(Ministry of Health et al. 1994; Ministry of Health,

1997a). Although there have not been any careful stu-

dies of this mortality decline in Turkey, increased pur-

chasing power among households, improved

educational opportunities and improved health care

services may have been largely responsible.

While this health trend is encouraging, the current

levels of infant and maternal mortality remain unac-

ceptably high. In 1993, the infant mortality rate was

estimated to be 53 per 1000 live births and in 1995, the

maternal mortality rate was estimated to be 100 per

100,000 live births. Moreover, inequities by urban/

rural status, by geographic region and by ethnicity

remain large. For example, infant mortality among

Social Science & Medicine 50 (2000) 1797±1806

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1 Tel.: +90-312-311-5506; fax: +90-312-309-3625

* Corresponding author. Tel.: +1-504-585-6157; fax: +1-

504-584-3653.

E-mail addresses: [email protected] (Y. Celik), david.

[email protected] (D.R. Hotchkiss).

rural infants is estimated to be 1.5 times higher thanamong urban infants (Ministry of Health et al., 1994;

Ministry of Health, 1997a; Tuncbilek, 1988).One explanation for poor health outcomes among

women and children concerns the nonuse of modern

health care services by a sizable number of women.For example, in 1993, 37% of children in Turkey wereborn to mothers who did not use prenatal care and

24% of births were not assisted by medical pro-fessionals (Ministry of Health et al., 1994). Many stu-dies in both developed and developing countries

suggest that prenatal care is an important determinantof improved health outcomes among infants (Tuncbi-lek, 1988; Ahmad et al., 1991; Boerma and Bicego1992; Adetunji, 1994; Forste, 1994; Panis and Lillard,

1994; Panis and Lillard, 1995) and that birth deliveryassistance from a trained and well-equipped provider isnecessary to reduce maternal mortality (Maine and

Rosenfeld, 1999).Although improvements in maternal health care util-

ization are essential for further progress in this area,

there have not been any studies that identify the causalfactors that lead to the improved use of services bywomen in Turkey. This paper seeks to ®ll this gap.

Using the 1993 Turkey Demographic and Health Sur-vey (TDHS), a nationally representative sample ofwomen of childbearing age, we investigate the individ-ual-, household- and community-level factors that in-

¯uence women to use maternal services. The analysisuses a logistic regression model of the use of prenatalcare and a multinomial logistic regression model of the

use of birth delivery assistance. The rest of this paperis organized as follows: the next section provides abrief overview of the maternal health care supply en-

vironment; the third section discusses the logistic re-gression models used in the analysis; the fourth sectiondescribes the data; the ®fth section provides the multi-variate results; and the ®nal section uses the results to

provide insights for policy makers responsible for plan-ning the delivery of maternal services.

Maternal service delivery in Turkey

Maternal health care services in Turkey are mostlyprovided by the government-run referral system, com-

posed of health stations in rural areas, health posts inurban areas, health centers and hospitals. With thepassage of the socialization law in 1964, the govern-

ment began building village health stations and healthposts, which now total 11,877. Each facility employs atleast one midwife. Though midwifes have some respon-

sibilities in providing preventive health care services,their most important role is to monitor the women'spregnancies, to vaccinate children in their service areas

and to provide family planning services. Maternal andChild Health/Family Planning (MCH/FP) Centers,

administered by Department of Maternal and ChildHealth Services, are also common places where preg-nant women can access care. There are 274 MCH/FP

Centers in the country built for the primary purpose ofimproving maternal and child health status.An important characteristic of the public health care

sector is the discrepancy between the Western and theEastern regions with respect to the availability andquality of health care services (Ministry of Health,

1997b). Midwifes tend to be more concentrated in theWest, the region of Turkey which is the most devel-oped. For example, of the total number of midwives(39,551), 18.5% work in the three largest cities of Tur-

key Ð Istanbul, Izmir and Ankara Ð while only14.5% work in the 23 provinces of the East region,where the level of unmet need is higher. Health care fa-

cilities are also more concentrated in urban areas thanin rural areas. Because of the disparities in the distri-bution of health care personnel, the quality of service

delivery and also because of social unrest in the Eastregion, the utilization of services from village healthstations is frequently reported to be quite low.

Overall, the private sector plays a relatively minorrole in the delivery of maternal health care services.The sector consists mostly of public physicians whoare allowed to work in their private practices in the

afternoons and part-time practitioners. Of the totalnumber of hospital beds in Turkey, only 3.5% arewithin private facilities, although there are concerns

about the reliability of this estimate (Tatar and Tatar,1997). While relatively small on average, the privatesector is an important source of care in large urban

areas and in the Western part of the country. In ruralareas, traditional birth attendants are also importantsources of birth delivery care.

Statistical methods

In order to estimate the e�ects of socio-economic

factors on maternal health care utilization, two depen-dent variables were used in this study: the use of pre-natal services from a trained provider and the use oftrained birth delivery assistance. In the case of prenatal

care, a dichotomous dependent variable was con-structed to indicate whether or not the woman usedservices from a trained provider. Because the indicator

is dichotomous, a logistic regression model was esti-mated. Logistic regression models make it possible toestimate the probability of using health care, con-

ditional on the independent variables included in themodel. The speci®cation of the prenatal care model isthe following:

Y. Celik, D.R. Hotchkiss / Social Science & Medicine 50 (2000) 1797±18061798

log� pi2=pi1� � a0 � a1Xij � a2Yij � a3Zj � E1ij �1�The dependent variable is the log odds that individ-

ual i will chose alternative j relative to alternative 1,

where alternative 1 is no use of prenatal care from atrained provider and alternative 2 is a consultationwith trained provider, either in the woman's home or

in a health care facility. The independent variables areclassi®ed into three groups: individual-, household-and community-level factors, represented by the vec-

tors X, Y and Z, respectively and the as represent thenet e�ects of these variables on the probabilities ofusing health care. The term E1 represents unobserveddeterminants of prenatal care utilization and follows a

logistic distribution.To construct the indicator of birth delivery assist-

ance, women were classi®ed into three groups Ð those

who delivered at home without trained assistance,those who delivered at home with trained assistanceand those who delivered in a health care facility.

Because the variable is trichotomous, the followingmultinomial logistical regression model was estimated:

log� pij=pi1� � b0 � b1jXij � b2jYij � b3jZj � E2ij �2�

The dependent variable is the log odds that individ-ual i will chose delivery alternative j �j � 2, 3� relativeto alternative 1, where alternative 1 is a home deliverywithout the assistance of a trained provider, 2 is ahome delivery with the assistance of a trained provider

and 3 is a facility delivery with the assistance of atrained provider. Like the previous model, the indepen-dent variables consist of individual-, household- andcommunity-level factors, represented by the vectors X,

Y and Z, respectively. The bs vary by type of alterna-tive and represent the net e�ects of the independentvariables on the probabilities of choosing birth delivery

assistance. The term E2 represents unobserved determi-nants of birth delivery choice and is assumed to beindependently and identically distributed as a log Wei-

bull distribution.

Data

This data used in the study come from the 1993 Tur-key Demographic and Health Survey (TDHS), a

nationally representative survey of ever-marriedwomen 15 to 49 years of age. Data were collectedfrom 6519 ever-married women on their reproductive

histories, fertility, use of health care and family plan-ning services and the health of their children. The sur-vey also includes a wide variety of socio-economic and

demographic indicators at the individual-, household-and community-level. The sample used for this studywere those women who had at least one birth in the

three years prior to the survey interview. For those

who had more than one birth, only utilization behaviorassociated with the most recent pregnancy was con-sidered. The rationale for only including women who

gave birth during the three-year period is that mothersmay not be able to accurately answer questions askedabout births that occurred prior to this interval. As a

result of these inclusion restrictions, our sample con-sists of 2002 women.

Table 1 contains descriptive statistics for the twodependent variables used in the study. Of the totalsample of women who gave birth in the three years

prior to the survey, 69.2% received prenatal care byhealth care professionals including physician and

trained midwife/nurses. As expected, urban womenwere more likely to have at least one prenatal careconsultation than rural women (77.6 vs. 56.3%). With

respect to the birth delivery, 65.4% reported deliveringtheir last birth in a health care facility, 15.4% deliveredat home with the assistance of a doctor, nurse, or

trained midwife, or 19.3% delivered at home withoutthe assistance of a health care professional. Rural

women were found to be three times more likely tohave traditional home deliveries than urban women(33.0 vs. 10.1%).

Table 2 presents descriptive statistics for the inde-pendent variables. The women's characteristics thatwere included in the models were age at the time of

the last child's birth, educational attainment and paritylevel. The age of the mother is considered to be one of

the most important factors a�ecting health care utiliz-ation and child survival. In order to capture the e�ectsof age, women were classi®ed into four groups: 20

years of age and younger (25.2%), 21±25 years old(34.1%), 26±30 years old (23.4%), or 31 years of ageand older (17.3%). The reference group consists of

woman 20 years of age and younger.The other individual-level characteristics included in

the model were maternal education and parity level. Inour sample, 26.8% of women report that they have noformal education, 56.1 have one to ®ve years of

schooling and 17.1% have six years or more of school-ing. Two dichotomous indicators measure parity:

whether the woman's last birth was her ®rst birth(34% of woman) and whether the woman's last birthwas her second birth (26% of woman). The reference

category consists of woman whose last birth was herthird or more.The household-level factors consist of the occu-

pation of the household head, whether the householdwas covered by a health insurance plan, ethnicity and

household wealth. With respect to occupation, theTDHS collected information on nine employment cat-egories. The dummy indicator on the employment sta-

tus was coded as one if the husband was primarilyengaged in clerical, sales, service and skilled manual

Y. Celik, D.R. Hotchkiss / Social Science & Medicine 50 (2000) 1797±1806 1799

work and zero if the husband was primarily engaged

in other activities (agriculture, household domestic

work, unskilled/manual work, or did not work). Of the

2000 woman in the sample, 45% had husbands in the

®rst group while the remaining 55% had husbands in

the second group.

Ethnicity may also have a potentially important

e�ect on service utilization. Respondents were grouped

into three ethnicity categories: Turkish, Kurdish and

others. The majority of respondents (80.5%) reported

themselves as Turkish, while the remaining respondents

were from other groups (16.6% Kurdish and 2.8 other

ethnic groups).

Health insurance coverage was also included as an

independent variable thought to be a potentially im-

portant determinant of service utilization. It is

expected that coverage would improve service utiliz-

ation by reducing the out-of-pocket costs associated

with service use. The TDHS collected information on

the health insurance status of the father. Half of the

total number of respondents was covered by some type

of health insurance, although information on which

services were covered and the level of coverage were

not collected in the TDHS.

Household income and assets may increase the abil-

ity and willingness of households to pay for health

care services. Like all of the USAID-sponsored Demo-

graphic and Health Surveys, the TDHS did not include

questions on household income. However, information

on household assets was collected. In this study, we

use three indicators of household wealth: car owner-

ship, the type of sanitation facilities used by the house-

hold members and the type of ¯oor in the woman's

house. Over 80% of the respondents (1617 women)

reported that their household did not own a car. The

type of ¯oor was categorized into two groups: natural

and modern. Almost two-thirds of respondents (64.6)

reported living in a house with a modern ¯oor, which

we classi®ed as being constructed of cement, wood,

vinyl, asphalt, ceramic, or carpet. The responses on the

type of sanitation used by the household were grouped

into two categories: (1) ¯ush toilet and (2) pit and

others. The majority of women resided in householdsthat had a ¯ush toilet (54.9%).

The community-level factors included in the modelconsist of two indicators of the location of thewoman's household: urban/rural status and geographic

region. As presented in Table 2, 60.3% of total respon-dents reside in urban areas and 39.6% reside fromrural areas. With respect to region, 22.8% live in the

West, 20.3% live in the South, 21.3% live in CentralAnatolia, 16.1% live in the North and 19.2% live inthe East region of Turkey. In Turkey, policy discus-

sions often include the issue of the disparate utilizationrates between urban and rural areas and between theeastern and western portion of the country. One of theprimary aims of this study is to investigate how health

care utilization varies by geographic region in order toprovide recommendation on how resources can be bet-ter allocated to reduce geographic di�erences in health

outcomes.

Multivariate results

In this section, we discuss the logistic regression

results of the models predicting the utilization of pre-natal care and birth delivery assistance. For each typeof health care utilization, models were ®tted for all

women who had a birth delivery in the three yearsprior to the survey, for urban women and for ruralwomen. For each model, we display the coe�cients,

standard errors and odds ratios, which are calculatedby exponentiating the respective coe�cients.

Prenatal care use

The results of the prenatal care model are presentedin Table 3. Of the individual-level characteristics con-sidered in the analysis, the educational attainment of

the woman has a positive and statistically signi®cantimpact on the use of prenatal care. For example, bothwomen with one to ®ve years of schooling and women

with six or more years of schooling were substantially

Table 1

Used prenatal care and distribution of birth delivery choice

Variable Total Urban Rural

N % N % N %

Used prenatal care 1385 69.2 938 77.6 447 56.3

Birth Delivery 1996 100.0 1205 100.0 791 100.0

Home/untrained assistance 383 19.2 122 10.1 261 33.0

Home/trained assistance 308 15.4 161 13.4 147 18.6

Facility 1305 65.4 922 76.5 383 48.4


more likely to use prenatal care than women without

any schooling. With respect to parity, women who

were pregnant with their ®rst child were also more

likely to use prenatal care than woman who have hadtwo or more previous pregnancies, after controlling for

the other variables in the model. Both education and

parity are signi®cant in both the urban and rural

models as well. The remaining individual characteristic,

the age of the woman at the time of the child's birth,

was not found to have a signi®cant e�ect on prenatal

care use.

With respect to household-level characteristics, hav-

ing health insurance coverage was found to have apositive and signi®cant impact on using prenatal care,

after controlling for the other factors in the model. In

addition, household wealth was also found to be as-

Table 2

Descriptive statistics for independent variables

Variable N %

Individual-level characteristics

Age at last birth 2002 100.00

20 yr and younger 505 25.20

21±25 yr 683 34.10

26±30 yr 468 23.40

31 yr and older 346 17.30

Education attended 2002 100.00

No education 536 26.80

Primary school 1123 56.10

Secondary and more 343 17.10

Birth order 2002 100.00

First child 680 33.97

Second child 520 25.97

Third child or more 802 40.06

Ethnicity 2002 100.00

Turkish 1613 80.57

Kurdish 333 16.63

Other 56 2.80

Household-level characteristics

Husband's occupation 2000 100.00

Agriculture/never worked/household domestic/unskilled manual 1100 54.95

Clerical/sales/services/skilled manual 900 44.96

Husband's health insurance 2002 100.00

No 1000 49.95

Yes 1002 50.05

Car ownership 2002 100.00

No 1617 80.77

Yes 385 19.23

Type of ¯oor 2002 100.00

Natural 207 10.34

Modern 1795 89.66

Type of toilet 1998 99.80

Flush 1099 54.90

Pit and others 899 44.91

Community-level characteristics

Urban-rural status 2002 100.00

Urban 1208 60.34

Rural 794 39.66

Region 2002 100.00

West 457 22.83

South 408 20.38

Central 428 21.38

North 324 16.18

East 385 19.23


sociated with prenatal care use. For example, owning a

car, having a ¯ush toilet and having a modern ¯oor

were all positively associated with prenatal care use.

However, the latter e�ect was not statistically signi®-

cant.

With respect to ethnicity, the logistic regression

results of all three prenatal care models shows that

Kurdish women are less likely to use prenatal care ser-

vices, after other determinants are held constant. How-

ever, the e�ect is statistically signi®cant only for the

model based on the total sample of women.

With respect to occupational status, women who

reported that they were married to husbands in skilled

and service-related occupations were signi®cantly less

likely to have used prenatal services. Interestingly, this

e�ect was negative and signi®cant in model speci®ca-

tions that excluded the community-level variables

(which are not reported).

When the e�ects of living in di�erent geographic

regions of Turkey were examined, it was found that

living in the relatively developed regions of the

country, compared to living in the East, was positivelyand signi®cantly associated with prenatal care utiliz-

ation. The impact of living in the Western region ofthe country is particularly strong. This may re¯ect thefact that health care is likely to be more accessible in

the West, compared to the East.The other community-level factor considered, urban/

rural status, did not emerge as statistically signi®cant,

after holding constant regional status and the othervariables in the model. Moreover, it is interesting tonote that the results that emerge from the separate

urban and rural models are very similar to those basedon the total sample. The only exception is the impactof car ownership, which was found to be signi®cantamong urban women but not rural women.

Birth delivery assistance

The results of the multinomial logistic regressionmodel are presented in Table 4. The results show thee�ects of the independent variables on the probability

Table 3

Logistic regression results on the determinants of using prenatal carea


beta exp(B) S.E. beta exp(B) S.E. beta exp(B) S.E.

Age at birth

21±25 yr 0.20 1.23 0.22 0.10 1.11 0.31 0.26 1.30 0.32

26±30 yr 0.30 1.35 0.20 0.34 1.40 0.28 0.23 1.25 0.29

31+ yr 0.08 1.09 0.17 0.27 1.30 0.24 ÿ0.13 0.87 0.24

Education attended

1±5 yr 1.52 4.57 0.27�� 1.36 3.91 0.32�� 2.04 7.70 0.65��

6+ yr 0.59 1.80 0.14�� 0.59 1.80 0.21�� 0.60 1.82 0.20��

Child's birth order

1st child 0.80 2.23 0.18�� 0.88 2.41 0.26�� 0.72 2.05 0.26��

2nd child 0.27 1.32 0.16� 0.32 1.38 0.22 0.13 1.13 0.24

Husband's occupation ÿ0.15 0.86 0.12 ÿ0.14 0.87 0.16 ÿ0.16 0.85 0.19

Health insurance 0.58 1.79 0.12�� 0.64 1.90 0.17�� 0.51 1.67 0.18��

Ethnicity

Kurdish ÿ0.39 0.67 0.18�� ÿ0.33 0.72 0.25 ÿ0.38 0.68 0.27

Other 0.25 1.28 0.35 0.03 1.03 0.51 0.43 1.53 0.49

Car ownership 0.40 1.50 0.17�� 0.54 1.72 0.25�� 0.33 1.39 0.25

Modern ¯oor 0.25 1.28 0.19 ÿ0.01 0.99 0.37 0.24 1.27 0.23

Flush toilet 0.43 1.54 0.16�� 0.37 1.45 0.20� 0.68 1.98 0.27��

Urban 0.23 1.26 0.16

Region

West 1.57 4.79 0.22�� 1.50 4.48 0.28�� 1.78 5.92 0.38��

South 1.03 2.81 0.19�� 0.87 2.39 0.25�� 1.38 3.96 0.32��

Central 0.24 1.27 0.18 0.44 1.55 0.27� 0.05 1.05 0.27

North 0.55 1.74 0.21�� 0.67 1.95 0.36� 0.55 1.73 0.29�

Intercept ÿ1.48 0.30�� ÿ1.09 0.50�� ÿ1,37 0,42��

N 1996 1205 791

Psuedo R 2 0.24 0.20 0.22

a ��p<0.01,��p<0.5, �p<0.10.


Table 4

Multinominal logistic regression results of the determinants of birth delivery choicea


beta exp(B) S.E. beta exp(B) S.E. beta exp(B) S.E.

Facility delivery vs. home delivery without trained providers

Age at birth

21±25 yr 0.65 0.29 1.92�� 0.41 0.47 1.51 0.72 0.37 2.05��

26±30 yr 0.36 0.27 1.44 0.40 0.45 1.49 0.21 0.34 1.24

31+ yr 0.10 0.23 1.10 ÿ0.04 0.40 0.96 0.09 0.29 1.09

Education attended

1±5 yr 1.95 0.54 7.01�� 2.10 0.77 8.20�� 1.78 0.80 5.96��

6+ yr 0.74 0.17 2.09�� 1.03 0.29 2.81�� 0.54 0.23 1.71��

Child's birth order

1st child 1.93 0.25 6.90�� 2.54 0.46 12.70�� 1.69 0.32 5.44��

2nd child 1.00 0.22 2.73�� 1.25 0.36 3.49�� 0.82 0.29 2.27��



Ethnicity

Kurdish ÿ1.24 0.23 0.29�� ÿ1.54 0.35 0.21�� ÿ1.08 0.33 0.34��

Other 0.03 0.47 1.03 0.72 1.10 2.05 ÿ0.18 0.55 0.83

Car ownership 0.85 0.26 2.33�� 0.95 0.48 2.60�� 0.99 0.32 2.69��

Modern ¯oor 0.21 0.23 1.24 ÿ0.28 0.53 0.75 0.16 0.26 1.17

Flush toilet 0.84 0.21 2.33�� 0.72 0.28 2.05�� 1.15 0.37 3.16��

Urban 1.04 0.21 2.83��

Region

West 1.22 0.30 3.39�� 0.22 0.41 1.25 2.23 0.49 9.32��

South 0.43 0.25 1.54� ÿ0.05 0.37 0.95 0.80 0.37 2.22��

Central 0.37 0.24 1.44 ÿ0.24 0.45 0.78 0.60 0.32 1.82��

North 0.73 0.28 2.07�� ÿ0.17 0.62 0.84 1.16 0.35 3.17��

Intercept ÿ1.98 0.39�� 0.00 0.75 ÿ2.14 0.50��

Home delivery with trained providers vs home delivery without trained providers

Age at birth

21±25 yr 0.13 0.31 1.14 ÿ0.40 0.50 0.67 0.58 0.43 1.79

26±30 yr ÿ0.02 0.29 0.98 ÿ0.29 0.48 0.75 0.23 0.40 1.26

31+ yr ÿ0.09 0.25 0.91 ÿ0.57 0.42 0.57 0.37 0.33 1.45

Education attended

1±5 yr 1.66 0.57 5.26�� 1.72 0.80 5.61�� 1.27 0.87 3.55

6+ yr 0.37 0.20 1.45� 0.49 0.33 1.62 0.40 0.26 1.50

Child's birth order

1st child 0.91 0.28 2.47�� 1.43 0.50 4.16�� 0.82 0.36 2.26��

2nd child 0.66 0.24 1.94�� 1.09 0.39 2.96�� 0.28 0.33 1.32



Ethnicity

Kurdish ÿ0.81 0.25 0.44�� ÿ1.42 0.40 0.24�� ÿ0.33 0.33 0.72

Other 0.13 0.51 1.14 0.90 1.15 2.46 ÿ0.13 0.63 0.88

Car ownership 0.42 0.29 1.51 0.76 0.51 2.15 0.14 0.39 1.15

Modern ¯oor 0.44 0.26 1.55� ÿ0.66 0.55 0.52 0.67 0.31 1.95��

Flush toilet 0.03 0.23 1.03 ÿ0.21 0.30 0.81 0.71 0.42 2.04�

Urban 0.65 0.23 1.92��

Region

West 0.52 0.33 1.69 ÿ0.61 0.46 0.54 1.60 0.52 4.97��

South 0.12 0.27 1.13 ÿ0.53 0.41 0.59 0.65 0.38 1.91�

Central ÿ0.45 0.27 0.64� ÿ1.43 0.51 0.24�� 0.02 0.34 1.02

North ÿ0.37 0.32 0.69 ÿ1.19 0.70 0.30� 0.04 0.39 1.04

Intercept ÿ1.15 0.42 �� 1.58 0.79 �� ÿ2.11 0.56 ��

N 1996 1205 791

Psuedo R 2 0.34 0.28 0.31

a ��p<0.01, ��p<0.5, �p<0.10.


of choosing either a facility delivery or a home delivery

with the assistance of a trained practitioner vs. a tra-ditional home delivery without trained assistance.With respect to the individual-level characteristics,

women with higher educational attainment levels andlower parity levels were found to be signi®cantly more

likely to choose a facility delivery vs. a traditionalhome delivery and a modern home delivery vs. a tra-ditional home delivery. As in the prenatal care model,

the age of the woman at the time of the last birth wasnot found to be signi®cantly associated with the choiceof birth delivery alternative.

Of the household-level characteristics, the multivari-ate results provide strong evidence that having insur-

ance coverage increases the probability of choosing amodern delivery vs. a traditional home delivery. This®nding is consistent with the results of a previous

study by the Ministry of Health (1994), which showedthat having health insurance increased the use ofhealth care services independent of the other factors.

Moreover, household wealth was also found to bepositively and signi®cantly associated with choosing

either facility deliveries or modern home deliveries.When the e�ect of ethnicity was examined, it was

found that Kurdish women were substantially less

likely to have had facility deliveries vs. traditionalhome deliveries and modern home deliveries vs. tra-

ditional home deliveries. This ethnicity e�ect, whichwas statistically signi®cant for each of the models esti-mated Ð all women, urban women and rural women

Ð indicates that Kurdish women are not as likely touse assistance from health care professionals, perhapsdue to cultural and economic factors that we were not

able to control in this study, or because the quality ofhealth care services is poor.

With respect to the indicators of geographic lo-cation, urban women were found to be more likelythan rural women to choose a facility delivery vs. a

traditional home delivery and a modern home deliveryvs. a traditional home delivery. In addition, regionalstatus also emerged as an important determinant of

birth delivery choice. For example, for the modelbased on all women, living in the Eastern region of

Turkey, compared to living in the Western and North-ern regions, signi®cantly decreased the probability ofchoosing a facility delivery vs. a traditional home

delivery. In the model based on rural women, living inthe East also decreased the probability of choosing amodern home delivery vs. a traditional home delivery.

We also estimated models that compared the prob-ability of choosing a facility delivery vs. a home deliv-

ery that was assisted by a trained practitioner. Theresults, which are not presented here in order to savespace, indicate that wealth, insurance coverage, living

in an urban area and living in the Western, Centraland Northern regions, are signi®cantly and positively

associated with choosing to deliver in a health carefacility.

Summary and conclusions

Despite the progress that has been made in Turkeyin improving maternal and child health outcomes inrecent decades, maternal and infant mortality rates

remain unacceptably high and regional and ethnic dis-parities remain unacceptably wide. While many factorscontribute to maternal and child health outcomes, theuse of maternal health care services from well-trained

and well-equipped medical professionals is widelyrecognized as an important causal factor. This studyhas investigated the social and economic determinants

of the use of prenatal care and birth delivery services,with the aim of improving the information that isavailable to decision-makers responsible for planning

and administering maternal care programs.This study has identi®ed a number of individual-,

household- and regional-level factors that have import-ant in¯uences on maternal service utilization. The indi-

vidual-level characteristics found to be particularlyimportant are educational attainment and parity level.Many previous studies conducted in other developing

countries have found maternal education to be amongthe most important determinants of maternal healthcare utilization, after controlling for other factors (Elo,

1992; Pebley et al., 1996; Raghupathy, 1996; Hotch-kiss, 1998). Moreover, in three studies of the determi-nants of overall health service utilization in Turkey,

education was found to have a large impact (Ulusoy1988; Yasamis, 1991; Ministry of Health, 1995). Thereare a number of explanations for why education is akey determinant of demand. Education is likely to

enhance female autonomy so that women developgreater con®dence and capabilities to make decisionsregarding their own health, as well as that of their chil-

dren (Raghupathy, 1996). Its also likely that educatedwomen seek out higher quality services and have agreater ability to use health care inputs to produce bet-

ter health. This is consistent with research by Streat-®eld et al. (1990), who found that more educatedwomen are more likely to be aware of the bene®ts ofhealth care and as a result, are more likely to use pre-

ventive health care services. While there are manypathways that may be at work in the relationshipbetween education and service use, the data that we

have available does not allow us to identify the relativeimportance of these pathways among our sample.With respect to parity, women who delivered their

®rst child were also found to be signi®cantly morelikely to use prenatal care and trained assistanceduring the birth delivery than women at higher parity


levels. This result is consistent with those of previous

studies carried out by Pebley et al. (1996) and Raghu-pathy (1996). One possible explanation for this resultis that women pregnant with their ®rst child were

more cautious about their pregnancies and thereforesought out trained professionals and that women whohave had at least three pregnancies may tend to believe

that modern health care is not as necessary due to theexperience and knowledge accumulated from previous

pregnancies and births.A number of enabling factors were also found to be

important determinants of health care utilization. One

factor that has important policy implications concernshealth insurance coverage. Having health insurance

was found to have an important in¯uence in increasingthe probability of both prenatal care use and birthdelivery assistance. Health insurance coverage emerged

as statistically signi®cant in the models based on allwomen, urban women and rural women. With respectto the indicators of household wealth, owning a car

was a signi®cant predictor of maternal care utilization.While the impact of car ownership may be due to the

increased ability of the women to travel to health carefacilities, it may also re¯ect the woman's ability andwillingness to pay the out-of-pocket expenditures that

are associated with health care utilization. This mayalso explain why women who lived in homes with toi-

lets were found to be more likely to use maternal ser-vices.Health care policy makers frequently discuss re-

gional disparities in the delivery of health care services.With respect to this equity issue, our ®ndings regardingthe e�ects of urban/rural status, geographic region and

ethnicity are of particular interest. Living in urbanareas was found to have a positive e�ect on the prob-

ability of using trained professionals for birth deliv-eries, but we found no signi®cant urban/ruraldi�erence with respect to use of prenatal care. Geo-

graphic region was found to be a particularly import-ant predictor of service utilization, as women living in

the Eastern region of the country were signi®cantlyless likely to use both types of prenatal care and birthdelivery assistance than women from the Western

region. One possible explanation for this pattern con-cerns the inequitable accessibility of health care ser-vices. Many studies in other countries indicate the

large in¯uence of the health care supply environmenton maternal health care utilization. For example, Peb-

ley et al. (1996) found that distance to the nearestclinic was signi®cantly and negatively related to bothprenatal care and delivery assistance in Guatemala.

While a previous survey of health services utilization inTurkey (1994) showed that distance and travel timehad a deterrent e�ect on health services utilization

(Ministry of Health, 1995), relevant studies on thisissue are rare and mostly descriptive.

The disparity in the use of health care servicesbetween Kurdish and Turkish citizens is also an area

of concern. Our results indicate that Kurdish womenare signi®cantly less likely than Turkish women to uti-lize prenatal care and birth delivery assistance, after

other demand determinants are controlled. Again, this®nding may be possibly be due to inequities in thehealth care supply environment Ð services that are

o�ered to Kurdish women may be of lower qualitycompared to those o�ered to Turkish women. A num-ber of previous studies in other countries have found

ethnicity to be an important determinant of serviceutilization (Pebley et al., 1996). The nonuse of healthcare services, especially formal care, may re¯ectsocially- and culturally-imposed constraints as well as

poor organizational policies and practices (Raghupa-thy, 1996).The results of this study provide a basis for a num-

ber of policy recommendations. First, that educationwas found to have an important impact on the use ofhealth care suggests that improving educational oppor-

tunities to women may have a large impact on improv-ing utilization of maternal health care services in thefuture. Second, that women at higher parity levels

were found to be less likely to have deliveries assistedby modern professionals suggests that parity should beused as a criterion for targeting educational campaignson the bene®ts of safe motherhood programs. Third,

that regional status and ethnicity were found to be sig-ni®cant predictors of using modern maternal servicessuggests that the government's maternal health care

programs should be intensi®ed in the Eastern region ofTurkey and among Kurdish women in all regions inorder to further reduce disparities in health care utiliz-

ation.

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