Contextual influences on the use of antenatal care in Nepal

Geographic variation in gender development and empowerment across districts in Nepal suggest that research on women"s antenatal care behaviors may be enhanced by incorporating contextual data at the district level with individual and household level data from the 2001 Nepal Demographic and Health Survey (NDHS). This study of antenatal care uses DHS cluster geocodes to link with contextual data at the district level. The analysis focuses on two dichotomous outcome measures associated with antenatal care: (1) whether a woman received any antenatal care; and (2) for those women who made at least one antenatal care visit, whether she made four or more antenatal care visits during the pregnancy. A renewed focus on women"s empowerment and place can help direct attention to the study of social contexts and processes, particularly those relating to maternal health behaviors. Many studies of the use of maternal health services have focused on individual-level or micro characteristics. In contrast, this study explores the use of hierarchical models, specifically hierarchical generalized linear models (HGLM), to investigate whether contextual or macro characteristics also matter. The macro-micro framework postulates that social forces at the macro level determine micro-level opportunities and constraints and thereby influence individual decisions. Policies and programs conceived without consideration for local context and place will have limited impact, unless they are informed by data that appreciates the vital connection between women"s health and women"s status across different spatial scales and analytical levels. (Author abstract)