FACTORS ASSOCIATED WITH THE USE OF MATERNITY SERVICES
CHAPTER TWO
LITERATURE REVIEW
In this section, a systematic analysis of the studies conducted on issues of maternal and child health services has been made. An analysis of these works will not only be instrumental in providing a conceptual framework to the present study but it will also help in identifying the important variables related to research in this field. A number of scholarly works have argued that the problem of health services can be divided into two factors: demand factor and supply factor (conceptual framework). On the demand side, societal, cultural, economic and individual factors (like education, income, status of women, individual attitude and promptness to seek health services, family size, sex preference and nature of socio-cultural setting etc) influence the demand and utilization of maternal and child health services. And on the supply side, management of adequate, affordable and qualitative services are most essential to encourage people to utilize maternal and child health services. The literature on maternal and child health services has been reviewed. In the conceptual framework it is assumed that utilization of maternal and child health services could be determined broadly by demand side and supply side. Thus, in this section the review ofliterature is arranged accordingly.
2.1.1 Demand Side Factors
Demand side includes the variables such as education, income, occupation, women
decision-making power, women's status, knowledge about health centre/MCH,
chance of exposure, age of women, parity/order of birth, family size, ethnicity,
culture/tradition, health beliefs and need etc. Identifying such factors may be
important in recoiilD;lending policy implications to improve maternal and child health services. Numerous research studies in developing countries have demonstrated consistent relationships between these factors (education, income, occupation, women status, age, parity or birth order, family size, ethnicity etc) and use of maternal zmd child health services.
1. Education
A number of researchers have pointed out that women's education is positively
associated with the utilization level of maternal and child health services. It is argued that better educated women are more aware of health problems, know more about the availability of health care services, and use this information more effectively to maintain or achieve good health status. Mother's education may also act as a proxy variable of a number of background variables representing women's higher socioeconomic status, thus enabling her to seek proper medical care whenever she perceives it necessary. Chowdhury et al. (2003) found that educated women were more likely to seek treatment from doctors/nurses than women who were not educated in Bangladesh. The results of their multivariate analysis showed that women with secondary or higher education were almost 1.8 times more likely to seek treatment from doctors/nurses to treat their antepartum morbidities than the women who were not so. Caldwell (1986) and Cleland & van Ginneken (1988) also found that the utilization level of biomedical services was higher among more educated women in comparison to women who were not so in developing countries. According to them, educated women could be better able to manage economic resources in better way and they could be relatively aware too about their social and economic rights and thus, could have greater autonomy and decision-making power in their household activities. As a result, educated women would have greater control over their economic resources and could demand satisfactory services from health practitioners and have greater control over these resources.
Similarly, a study in Peru using DHS data, Elo (1992) found that mother's education was a strong significant factor affecting the use of prenatal care and delivery assistance. In another study, Becker et al. (1993) found that mother's education as the most consistent and important determinant of the use of child and maternal health services in Metro Cebu, Philippines. Costello et al. (1996) also found the same impact of education in another study in Philippines.
ln a study using data from Ghana Demographic and Health Survey 1993 in Ghana, the result of multivariate analysis showed that women with no education and primary/junior school education were less likely to consult a doctor for prenatal care.
Similarly, the odds of seeking antenatal check-ups were also lower among women
with no education compared with their counterparts with secondary/higher education (Addai, 2000).
Pavalavalli and B.M. had analyzed the data of Indian National Family Health Survey (1992-93) and reached similar conclusions that point towards the positive and significant influence of mother's schooling on maternal-care utilization. According to them, education emerges as the single most important determinant of maternal healthcare utilization in India when the influence of other intervening factors was controlled. For example, educated women with at least middle schooling were nearly eight times ·as likely to receive antenatal care for their births as illiterate women, and literate women with less than middle schooling were more than three times as likely.
The pattern was similar for utilization of the other maternal health-care services. Mother's education was also fi)und even a powerful, positive, and significant predictor of the utilization of child health-care services in India. Children of mothers with at least a middle-school education were 62 percent and 45 percent more likely to be taken to a health facility for treatment of ARI and diarrhoea, respectively, than children of illiterate mothers. The difference in utilization of child health-care services was not as strong when we compare children of illiterate mothers with children of mothers who were literate with less than middle-school education (Pavalavalli and B.M., 1997).
In a study from rural areas of Rajasthan in India, Mishra (2000) also found that educational level of women and husband education had positive and significant effect on the utilization of maternal and child health services. For example, the utilization level of antenatal care service increased by 121.77 percent and 35.37 percent respectively with one-lmit inc.rease in women's and husband's level of education. The utilization of TT injection of pregnant women was increased by 27.07 percent and immunization of children by 1.63 percent when husband' education level increased by one-unit (Mishra, 2000). Iil a study based on data from NFHS-1 India, indicated that the utilization of maternal health services was greatly affected by women's education in both north and south India (Govindasamy and Ramesh, 1997). Mother's level of education has a large positive effect on the odds of institutional delivery in Andhra Pradesh in both NFHS-1 and NFHS-2. With all the other predictor vruiables controlled, the odds of institutional delivery are two to three times higher for mothers with middle school or higher education than for illiterate mothers (Sugathan and friends, 2001 ).
Other researchers found also in India that women's educational level was positively
correlated with the use of safe delivery care and the effect was significant. They
stated that with one-unit increase in women's educational level, the utilization level
of trained attendant was doubled (Bloom, Lippeveld, and Wypij, 1999). Sunil et al.
(2005) observed the relative effect of women and their husbands' education on use of maternal care services in rural India using data obtain from National Family Health Survey. They did not only find positive significant relative effect of spousal
education on use of maternal care services, but also found impact of women education was higher in comparison to their husbands' education. As elsewhere, in Nepal, mother's education is found positively correlated with the use of maternal and child health services. This gets revealed from the fact that ninety-five percent of women with a school-leaving certificate and above received antenatal care services, compared with 39 percent of women with no education. Use of a doctor for antenatal care increases from 10 percent among uneducated women to sixty-six percent among women who have completed their SLC. Only 57 percent of children of mothers with no education are fully immunized as compared to 91 percent of children whose mothers have completed an SLS or above (New Era, and Ministry of Health of Nepal, 2001). In an individual study, Joshi found that mothers with schooling were more active seekers· of health services, such as prenatal care and hospital delivery. These women were more competent providers of child care and they spent more time on child care (Joshi, 2001). Joshi stated that though antenatal care was freely available in the village, women with some schooling used it more than women with no schooling. Educated women used hospitals for delivery, though it was found clearly more difficult than making a prenatal visit to the clinic in the village (Joshi, 1994).
In a study on utilization of health services in Nepal, World Bank also reached similar conclusions. According to this study, the utilization of health services was higher for those whose education level was higher than those who were less educated. Increase in level of education of women and their husbands showed a trend towards increase in utilization of all health services including maternal and child health services (World Bank, 2001). Similarly, Dhungel (2002) and Sharma (2004) also found that education of women had a significant positive impact on use of antenatal care in Nepal.
According.to Dhungel's findings, the odds of antenatal use were about 7 times higher among literate women in comparison to illiterate women while Sharma fow1d the same 6 times higher for women whose education level was secondary and high than the women who were une~ucated. Dhungel analysed the data obtained from 1997 Nepal Multiple indicator Surveillance (NMIS) Fifth cycle whereas Sharma utilized the data obtained from the survey of 'Between Census Household Information Monitoring and Evaluation System (BCHIMES) 2000.
2. Economic factors (Income, cost living standard)
Many researchers have pointed out that economic factors may play important role
affecting maternal and child health services. As an economic factor, measures of
income and wealth form important indicators determining the women's capability to access pregnancy care. For instance, the odds ratio of adequate antenatal care was found 4 time higher for those women whose economic status was higher than the women whose eco~omic status was lower in a research done in Nepal based on
BCHIMES - 2000 (Sharma, 2004). Monda! analyzed the data of Rajasthan based on National Family Health Survey and found that the accessibility of utilization of
antenatal services varied significantly in accordance with the woman's standard of
living or income. Mishra (2000) also found that husband with higher income
preferred to take their wives to the private clinic for the maternity care in Rajasthan.
The result of a recent study in India based on National Family Health Survey-2 data showed the positive and significant effects of standard living index in the utilization of maternal health care services in rural India. For example, the percentage of odds of excellent utilization of maternal care services was found to be about 20 percent of women who belonged to high standard living index as compared to 10 percent for women who belonged to low standard living index (Sunil et al., 2005).
Chowdhury et al. (2003) found in rural Bangladesh that women from families with
good economic condition were more likely to receive treatment from a doctor or
nurse. However, the positive impact of higher economic status on health care use was not found to be statistically significant. Type of housing, like occupation, can also be considered a proxy for socioeconomic status of the household and may have a similar impact upon the utilization of health care. The results indicate that women who belong to families with houses made of cement or tin were more likely to seek treatment from qualified medical personnel. About 29 percent of women living in pacca/tin houses went to doctors/nurses, compared to 27.4 percent who lived in rudimentary houses. However, the differences were not found to be statistically significant. They also found that women's involvement in gainful employment was one of the important factors positively affecting the use of quality medical care to treat complications. They argued that gainful employment may also empower womento take part in decision-making processes about health care in the family. Results from their study indicated that women who were involved in gainful employment were more lik~ly to use modern health care services to treat complications during their pregancy. About 35.4 percent of women who worked for cash went to some qualified medical personnel for treatment, compared with only 25.3 percent of those who did not work.
Another research also found higher income (as measured by per capita consumption in the household) associated with a higher probability of visiting each kind of provider, but especially doctors. Unmarried respondents (who were primarily single or divorc~d) were much more likely than those who were married or in a consensual union to consult a pharmacist or doctor for their sick child in rural Guatemala (Goldman et al., 2002).
Study done by Gertler and Gaag (1988) in Cote d'Ivoire concluded that poorer women could not afford health services because of high fees. Similar result was found in Peru by the· research done by Gertler (1988). As he concluded that fees deterred everyone from using health services, but deterred poor women most of all.
The cost of services also puts constraint on the utilization of maternal and child health services, particularly, in developing countries. As Goldman and Glei (2003) found that a large number of women in rural areas in Guatemala prefer to avail the services provided by midwives rather than going to the professional doctors. This is because the average fee charged by midwives was about ten times as low as the fee charged by doctors. Hence, lack of availability of money was a major deterrent to seeking medical help.
In Nigeria, a study found that the shift from free to fee-based services for obstetric
care reduced admissions overall but significantly increased emergency cases. The
number of maternal deaths rose correspondingly (Harrison ( 1997)
3. Women's Decision-making Power
A number of studies pointed out that women decision making power is one of the
factors that determines the utilization level of maternal and child health services in
many instances. Such as World Bank found in a study of five districts in Nepal that
women who discussed their health problems with their husbands were found more
likely to use antenatal care, delivery and postnatal care services in Nepal (World
Bank, 2001 ).
In a North Indian city study, women's role in household decision-making relative to their spouse and other family members may also affect their use of health services (Bloom, Wypij, & Das Gupta (2001).
In Ghana, a study of women who died of pregnancy-related complications found that 64 percent of the women had sought help from an herbalist, soothsayer or other traditional provider before going to a health facility. Families cited cost and the belief that the woman's condition would improve or that the woman was not ill enough to justify the cost involved, a.'> the main reasons for not taking a woman to a hospital (Odoi-Agyarko et at. 1993).
In Nepal, mothers-in-law attend most deliveries, and additional care or help is sought only if the mother-in-law decides that such care is needed. One study found that 7 5percent of mothers-in-law did not believe an antenatal check-up was necessary (Family Care International, New York, 1990).
A study in Nigeria found that in almost all cases, a husband's permission is required for a woman to seek health services, including life-saving care. If a husband is away from home during a delivery, those present are often unwilling to take the woman for care- no matter how pressing the need appears to be (Thaddeus and Maine, 1994).
The household decision-making index (HDI), measured only for married women, was found to have a modest impact on seeking a provider in rural Guatemala. Higher levels of decision-making authority were associated with a greater probability of consulting a pharmacist and a doctor and a lower probability of consulting ''other' providers, but only the last association was statistically significant. Co-residence or proximity. to. parents or parents-in-law was also found affecting the likelihood of seeking health providers. Women who have at least one parent or in-law nearby were considerably more likely than their counterparts to treat their children's illnesses at health posts or centers. Those who had at least two nearby, were also much more likely e.g., almost four times as likely as other women to consult a curer (Goldman, 2002).
4. Chance of Exposure
Many researchers emphasized the positive role of any kind of exposure i.e. exposure to external institutions either through direct or indirect contact or through m€~dia. They argued that any kind of exposure, particularly media may enable women to be aware about availability of health services, its benefit and even to information regarding providers, and in some cases even financial and material assistance, which increases their use of modem medicine during pregnancy. According to Goldman et al, social contacts outside their community in Guatemala (e.g., in larger urban areas or abroad) increase the likelihood that women hold biomedical beliefs about illness causation (Goldman et al. 200lb). According to Becker (1993), women's exposure to electronic media could be a positive factor to raise the utilization level of maternal
and child health services.
In Philippines, he found a significant difference in use of antenatal care among women who were exposed to radio and TV and who were not so. Some research works done in India also indicated the same role of women's exposure to media. Such as Sugathan et al (2001) analyzed the data of India NFHS - 2 and found that mother's exposure to media had positive effect on the odds of institutional delivery in Rajasthan. The odds ratio of institutional delivery was two times higher for mothers with exposure to media than for without exposure to media. Another finding of Indian data based on NFHS 1992-93 also concluded the same. This finding found that exposure to mass media (watching TV and listening to radio) had significant effect in both Andhra Pradesh and Karnataka for the use of antenatal care. Women with high degree of exposure to mass media were more likely to have received antenatal care by 1.9 times in Andhra Pradesh and 1.6 times Karnataka than those with no or low degree exposure (Navaneetham et al. 2000). The recent study done by Sunil et al. (2005) by using data of National Family Health Survey -2 found that women's mass media exposure was a positive and significant factor affecting the utilization of maternal care services in rural India. According to them, the percentage of utilization of maternal care services was about 19 percent almost a double for women who were exposed to media than the 10 percent of women who were not exposed to any medium of mass media. Similarly, Shariff and Singh (2000) also emphasized the important role of women's
exposure to media on maternal health services. According to them, the utilization
level of maternal health services was significantly higher for those women who were
listening to the radio and watching TV in India even if controlling their education and their husbands.
In a comparative study done by Obenneyer (1993) it was found that the antenatal use of the pregnant women was positively associated with their exposure to media than of those who were not so in Morocco and Tunisia. The findings of some studies carried out in Nepal also found the positive association between the utilization level of maternal health and child health service and exposure to media. Such as Gubhaju and Matsumura (2001) argued that utilization level of maternal and child health services could be higher among people who are exposed to media. Exposure to media may help to create awareness among people about availability of maternal and child health services as well as its importance. Similarly, Sharma (2004) found that the impact of listening to the reproductive health ra:dio programme (cut your coat according to your cloth) and watching TV for antenatal care was positive and significant. According to him, the odds ratios of attendance of some and adequate antenatal care were increased by 44 percent and 28 percent for women who were supposed to listen to the reproductive health radio programme whereas the same were increased by 56 percent and 60 percent for women who were supposed to watch TV at least once a week as compared to women who did not watch TV.
5. Women's Age and the Parity of Birth
The findings of some studies revealed that women's age is negatively associated with the use of maternal and child health services. For example, Sundari believed that older mothers may ignore seeking maternity care as they may feel it is unnecessary to seek antenatal care, especially if their earlier pregnancies were problem-free. It may not only result from lack of time and money but due to lack of motivation on pat1 of the women to seek health care services (Sundari, 1992). In Nepal too younger women were more likely to use antenatal services, to receive tetanus injections, to receive assistance from doctor during delivery than older women. For example, twO••thirds of mothers below the age of 20, received one or more dose of tetanus toxoid injections as compared to one-third of mothers' age of between 35-49 years. Dhungel (2002) 45 and Shanna (2004) also found in their research works that younger women were more likely to receive antenatal check-up than the older women in Nepal. Dhungel found that the proportion of antenatal check-up is 2:1 for age of women below 35 and above 35. While Shanna found that the odds ratios of antenatal check-up for women in age group 15-19, 20-24, 25-29 and 30-34 were 2.4 times, 1.7 times, 1.8 times and 1.7 times higher than the women in age group 35 and above. Their research work was based on data obtained from Nepal Multiple Indicator Surveillance (NMIS) 1997 Fifth Cycle and Between Census Household Information Monitoring and Evaluation System (BCHMES) 2000 respectively.
Similarly, in a study located in Uttar Pradesh India, Bloom, Lippeveld and Wypij found that younger age and with no previous births women were more likely to use safe delivery care. Contrary to it, Heidi et al (2006) found that women aged 18 or younger were less likely than women aged 19-23 to use either antenatal care or delivery care, or both (odds ratios, 0.5-0.9). Younger mothers in six cmmtries were less likely than older mothers to have their infants immunized, particularly for diphtheria, pertussis and tetanus and for measles (0.5-0.8). The association of age and health care use was largely limited to Bangladesh, India, Indonesia, Nicaragua, Pem and Uganda. Bu t in another research in L~dia based on NFHS-2, the effect of mother's age was found to be a strong statistically significant positive factor (Sugathan, 2001; Sunil et al., 2005). For instance, the odds ratio of institutional delivery was 3 times higher in Andhra Pradesh among mothers who were in age group of 25-29 years than those mothers who were in age group of 15-19 years. Whereas the odds ratio was 3.4 times higher in Bihar among mothers who were in age group of 30-49 years than among those mothers who were in age group of 15-19 years (Sugathan, 2001). While Sunil et al. (2005) found that the excellent utilization of maternal care services was 15 percent for women in age group of 30 and above, in contrary to about 10 percent for women in age group less than 19 years. The effect of higher child birth order was foWld negative on seeking maternal and child health services in India (Navaneetham, 2000; Sugathan et al, 2001; Sunil et al., 2005). For example, the odds ratios of institutional delivery were three to four times in Andhra Pradesh, 3 times in Gujarat, 3.8 times in Bihar and 3.4 times in Rajasthan as high for first-order births as for fourth or higher-order births (Sugathan et al. (2001). The probability of a woman receiving antenatal care was reduced by 60 percent to the order of birth4 and above as compared to births of second order, but there was no difference in the likelihood of obtaining antenatal care between first and second order births (Navaneetham, 2000). The percentage of excellent utilization of maternal care services was decreased to 6.5 percent to the order of birth 5 and above from 21.8 percent to the birth order 1 (Sunil et al., 2005).
The result of Demographic Health Survey 2001 of Nepal also indicates the same effect of order of birth on use of maternal health services in Nepal. It shows that mother with lower parity were more likely to use antenatal services, to receive tetanus injections, to receive assistance from doctor during delivery as compared to high parity women. For example, more than 71 percent of first and second order births were fully immunized as compared to only 54 percent for sixth and higher order births in Nepal (New Era, and MOH, 2001).
6. Family Size
Mishra observed large family size as a negative factor influencing the utilization of maternal and child health services in rural Rajasthan. According to the researcher, the probability of receiving TT Injection by pregnant women decreases by 32.78 percent when family size increases. Similarly, the effect of family size was found negative and significant on child immunization, which decreases by 22.21 percent when there is one unit increases in family size (Mishra, 2000). Like large family size, joint family was found as a negative factor on use of maternal care services in another study in rural India base on data obtained from National Family Health Survey-2. For instance, the excellent utilization of maternal care services was 11.6 percent for women who belonged to the joint family whereas the same was 13.3 percent for women who belonged to the nuclear family (Sunil et al., 2005). World Bank also revealed that in Nepal, women from nuclear families were more likely to use antenatal care and postnatal care services than women who belonged to the joint family (World Bank, 2001). In a research based on rural Bangladesh, the relative effect of large family was found negative on use of maternal health services. For example, women who belong to family with 3 or less than 3 members were 1.8 times more likely to receive treatment from qualified medical personnel, i.e. a doctor, nurse or FWV than the women who belong to family with 4 to 6 members. It was found that there was much higher on use of traditional and other health services between two family sizes i.e. about 8 times higher in family with 3 or less than 3 members than in family with 4 to 6 members (Chowdhury et al, 2003): In one study carried out in Philippines by Wong et al., found the same negative effect of large family size on health service utilization. Titey reasoned that larger family size might have resource constraints to utilize health services comfortably as compared to smaller family size (Wang et al., 1987).
7. Ethnicity, Socio-Cuiture and Tradition
Some researchers claimed that the health seeking behavior of people might be influenced by their ethnicity and cultural and traditional beliefs. In some communities, pregnancy is considered as a private issue and talking about it openly is considered as a taboo. In these societies the introduction of biomedical facilities to provide prenatal case is often met with indifference. They take pregnancy and birth a •normal biological process and biomedical intervention is seen an unnecessary, irrelevant, or even •dangerous. Even in a developed country like America, maternal mortality widely differes due to ethnicity. In a research, it is found that the risk of maternal death for African American women is four times greater than for white women (Maine, 1997).
Formal h~alth services can conflict with cultural norms surrounding childbirth., including preferences for privacy, modesty and female attendants. Among Saraguro Indians in Ecuador, hospital-based deliveries are perceived to violate privacy, many health providers are men, which is unacceptable culturally, and birth preparedness preferred by providers are not those preferred by women in labour. As a result, affordable and accessible maternal health services are under-utilized (Leslie, 1989) . . In Papua New Guinea, and particularly among Angal Heneng ,population cultural taboo is very strong that prevents women to seek maternal and child health services. According to prevailing cultural taboo, the Angal Heneng-speaking woman is expected to deliver alone (Townsend, 1985). This is due to the fact that in this community woman's blood is considered dangerous and contact with her blood is believed to result in illness or death .. Other village women are not willing to assist one another in labour or delivery for fear of becoming contaminated. Also conception ar1d pregnancy are forbidden topics of discussion between men and women and a source of embarrassment even between women themselves. Congenital defects are believed to be caused by a cultural violation by the mother, and twins are often attributed to . maternal adultery. Killing of such infants at birth is a common practice (William, 1991 ). Such kind of traditions or cultural taboos may have a significant negative effect on the utilization of maternal and child health services. However, in Papua New Guinea, because of the efforts of the local churches and government effort, the percentage of Angal Heneng women who attended antenatal care is found to be increased. Even in some communities in Nepal, in some society, there is a ritual practice of untouchability period during which contact v.ith the mother and/or infant is avoided, . which may hinder peopie to seek postpartwn services for mother and child. The majority of maternal deaths (62 percent) in Nepal occurred during the postpartum period, particularly in the seven days immediately following the birth. Twenty-eight percent maternal deaths occured during childbirth (Safe Motherhood Newsletter/Nepal, 2003). A maternal mortality and morbidity study of Nepal found that out of 93 direct maternal deaths more than 46 percent were due to postpartum haemorrage with or without retained• placenta. Out of 46 percent, nearly one quarter died within 2 hours of the birth of the baby (MOH of Nepal, 1998). Because of male dominant culture and lack of women empowerment in Nepal, majority women are forced to depend on their husbands or mothers-in-law consent to get treatment or utilize the health sefvices. Moreover, pregnancy is considered a normal part of life. Thus, most family members or pregnant woman herself do not think there is a need for antenatal care. Usually, pregnant woman labors alone at a designated birthing place. In a community-based retrospective study of a remote area of Nepal, Jumla district, it was found that approximately 50 percent of children are born in an animal shed without an assistance of anyone. It is so because the prevailing traditional norms and beliefs of that community are such. It was believed that household deity would be angry if delivery takes place at home and it would be easier to clean the shed following the birth. Such traditional value places women in situation of high risks. Giving birth in an animal shed is even more risky both for the mother as well as the child than giving birth at home. A study revealed that children born in an animal shed were at significantly higher risk of dying than those born at home even adjusting for socio-economic status and biological variables.The association was stronger in the neonatal period (OR=2.8, 95% CI 1.9-4.1) than during the post-neonatal period (OR=1.3, 95% CI 1.02-1.6). It was obvious that the preparation of the delivery place was inadequate and thereby facilitated infection of both the newborn and the mother (Thapa, 2000). Similar traditions and norms are found in other communities of Nepal. Thapa found in Bajura district that no one, not even family members, touches a woman during and for several weeks after delivery. According to him, a mother with her newly born baby should be confined to a cow-shed (hence the term gotha basne) and must look after all the details of birth herself, including cutting the umbilical cord. Not even the local traditional birth attendants (TBAs) touch these women during the 'polluted days'. They believe that "God will get angry if we touched the polluted women". He further added that a woman with three children told him that "at the time of giving birth and for quite some time afterwards, we are treated even by our own Jati (that is, women) worse than the dead animals; no one touches us." She expressed her discontent by recalling that "at least the sick animals get care from their owners (Thapa, 1996)." It is generally believed that the demographic behaviour of members of 'socially backward' communities such as scheduled caste and scheduled tribes are different from that of other communities. But Navaneetham, (2000) found in a research that caste was not a differentiating factor for the use of antenatal services and TT vaccine in all three states of India. However, it was found to be an important factor for institutional delivery: women belonging to scheduled castes and tribes were less likely to have their babies at hospitals than other caste women, particularly in Kamataka and Tamil Nadu. In Andhra Pradesh there was no difference between schedule castes and other caste groups in institutional delivery of births. Elizabeth and others found that in Bangladesh because of socio-cultural factors, pregnant women's mobility is restricted. This clearly reflects the lack of autonomy of women and may have important implications limiting the access of women to medical services (Elizabeth, 1995).
Similarly, in a conference, which was held on 12 March 2002 in Jakruta about Maternal Deaths, participants identified social, cultural, and religious factors that may contribute to the high incidence of ma~mal deaths in Indonesia. For example, traditional Islamic beliefs play a role in shaping the Indonesian perception regarding childbirth. Many Indonesians believe that because pregnancy and childbirth are natural processes, a mother who dies will go straight to heaven because she is a shahid (heroine). It means, people may not perceive pregnancy as a special case and seek for antenatal and postnatal services for safe motherhood in general. In Benin, the government put significant pressure on women to have institutional deliveries, including fines. Still, many women continued to deliver at home, due to the honour brought to families if they were seen as "stoic" during labour and childbirth (Sargent, 1985). Some •researchers believe in cultural perspective on use of available maternal and child health services. According to them, only physical illness of individual does not determine to seek medical treatment, but it also determined by his or her cultural perception of illness. The rational behind this concept is that individuals may perceive some illness as a minimal seriousness or they may consider such conditions to be normal based on their cultural understanding and experience of that condition (Azevedo et al., 1991;• Davis-Roberts, 198). According to World Bank, individual's perception of health threat, especially among pregnant women and children, tends to be culturally relative (World Bank, 1994). Sergent (1982) also pointed out the same as proposed by the World Bank. In a study based on the response of parents to childhood diseases in the Nigeria.! Yoruba community, Adetul\ii (1991) it was found that mothers used alternative sources of health care rather than hospitals (Biosocial Science Article 366 Maternal-child health services in Ghana 3 clinics and maternity centres). The study reports that parents' perception of the seriousness of a condition and the religious beliefs of mothers were important determinants in their healthseeking response.
EMPIICAL REVIEW
Many empirical studies have been conducted across the world on socio-economic inequality, most as it concerns healthcare, with some of the studies arguing that women and children are vulnerable to healthcare inequality. Others opined that women from affluent households are more likely to avail themselves of adequate maternal care than those from poorer households. Gage and Calixte (2006) had examined inequalities using National Sample Survey Data on Morbidity and Treatment of Ailments during 1980s, they observed that income of the households exert considerable influence in child survival, particularly in the early years of life and likelihood of a child getting immunized with increase in economic status of the households.
Wagstaff (2002) in his cross-national comparison of health inequalities, observed that poor children in poorer countries are less likely to get immunized or oral rehydration therapy in case of diarrhea. The study identified significant inequality in maternal mortality, and opined that unequal access to financial resources is one of the major barriers impeding access to preventive as well as curative health services.
Idris et al. (2012) studied inequality trends in maternal and child healthcare services access and noted that interventions have been more effective in reaching the better-off than the worst-off. Their index measure showed improved movements through equal distribution. They observed some trend differentials from health index which reveal a significant correlation between health
outcomes, deprivation and geographic affiliation. In their conclusion, they argued that healthcare services access and use are determined by both socio-economic status and a number of factors including resource allocation and contextual factors.
Chukuezi and Comfort (2010) studied the socio-cultural factors associated with maternal mortality and morbidity in rural Nigeria using the gender perspective. The study argued that socio-economic, cultural factors and gender discrimination contribute to high maternal mortality and morbidity in rural Nigeria.
Owumi and Raji (2013) carried out an assessment on the maternal health in a view to determine the available maternal healthcare services and the level of accessibility to residents, to find out the pattern of the maternal health seeking behavior and to examine the relationship between the socio-cultural characteristic and maternal healthcare seeking behavior among the residents of the Same Border Community in Republic of Benin. The findings show that residents tend to have a terrible level of access to the maternal services as there is no enough publicity either through word of mouth referrals or information from social service workers. The findings also discovered that a very large proportion of the residents of the area use both the western maternal care services and traditional substances.