Utilization of maternal health-care services in Peru : the role of women ’ s education

This article explores the hypothesis that formal education of women influences the use of maternal health-care services in Peru, net of the mother’s childhood place of residence, household socioeconomic status and access to health-care services. The findings are consistent with the hypothesis; both cross-sectional and fixed-effects logit models yield quantitatively important and statistically reliable estimates of the positive effect of maternal schooling on the use of prenatal care and delivery assistance. In addition, large differentials were found in the utilization of maternal health-care services by place of residence, suggesting that much greater efforts on the part of the government are required if modern maternal health-care services are to reach women in rural areas. Findings from numerous studies of infant and child mortality conducted in developing countries over the last decade show a nearly universal, positive association between maternal education and child survival, a relation which has persisted in many societies even when the household’s socioeconomic status has been held constant (Cochrane, O’Hara and Lesley 1980, Rutstein 1984, United Nations 1985, Cleland and van Ginneken 1988, 1989). As a result, the study of the pathways through which female schooling exercises its positive leverage has become of increasing interest to researchers in recent years (Cleland and van Ginneken 1988, Cleland and van Ginneken 1989, Barrera 1990, Streatfield, Singarimbun and Diamond 1990). It has been suggested, for example, that educating women alters the traditional balance of power within the family, leading to changes in decision-making and allocation of resources within the household (Caldwell 1979, Caldwell, Reddy and Caldwell 1983); that education modifies women’s beliefs about disease causation and cure and thus influences both domestic child-care practices and the use of modern health-care services (Caldwell 1979, Caldwell, Reddy and Caldwell 1983); that schooling enhances the woman’s knowledge of modern health-care facilities, improves her ability to communicate with modern health-care providers and, by increasing the value she places on good health, results in heightened demand for modern health-care services (Caldwell 1979, Schultz 1984, Caldwell and Caldwell 1988); and that maternal schooling reflects a higher standard of living and access to financial and other resources, because better educated women are more likely to marry wealthier men or because of their own increased earnings (Schultz 1984, Ware 1984). *This research was supported by a National Institutes of Health Traineeship in Demography and a MacArthur Foundation Fellowship for the study of population and development. The data were made available by the Demographic and Health Survey Project and were collected by the DHS in conjunction with the Instituto Nacional de Estad’stica (INE) and Consejo de Poblaci—n. I am grateful to Michael Foster, and especially Andy Foster, for assistance with fixed-effects models. I also wish to thank Noreen Goldman, James Trussell, Sam Preston, Jane Miller, Lorenzo Moreno and an anonymous reviewer for comments on earlier drafts of this paper. 2 MATERNAL HEALTH -CARE SERVICES IN PERU ELO HEALTH TRANSITION REVIEW VOL. 2 NO. 1 1992 Because one of the principal objectives of primary health-care programs in developing countries is to improve child survival through increased utilization of preventive maternal and child health-care services, the question of whether mothers’ education affects health service use is of considerable interest to health-policy makers. An improved understanding of the role played by female education can assist in the design of health interventions and, at the same time, advance our knowledge of the association between maternal education and child mortality. Evidence from previous research suggests that maternal education has a positive effect on the use of health-care services in Africa (MbackŽ and van de Walle 1987), some Middle-Eastern countries (Tekce and Shorter 1984, Abbas and Walker 1986), Asia (Akin et al. 1986, Wong et al. 1987, Streatfield, Singarimbun and Diamond 1990) and Latin America (Fern‡ndez 1984, Monteith et al. 1987). Furthermore, both Barrera (1990) and Caldwell (1979, 1990) have argued that educated mothers are more likely than uneducated women to take advantage of modern medicine and comply with recommended treatments because education changes the mother’s knowledge and perception of the importance of modern medicine in the care of her children. In a study of child nutrition in the Philippines, Barrera (1990) found that access to health-care services benefited children of educated mothers more than children of mothers with less schooling, a finding which suggested to the author that educated mothers were more likely to take advantage of available public health-care services than uneducated women. In Nigeria, Caldwell (Orubuloye and Caldwell 1975, Caldwell 1979) also found that educated women benefited more from available public health-care services than did uneducated mothers. In contrast, Rosenzweig and Schultz (1982) view female schooling and health-care services as partial substitutes for information regarding knowledge of diseases, treatment of illness and child-care practices, and hypothesize that the effect of education on child health becomes less important as access to public health-care services improves. Presumably, in areas where such services are readily accessible, they are used by both educated and uneducated women, and thus the advantage conferred by schooling on health outcomes is narrowed. Using data from Colombia, Rosenzweig and Schultz (1982) found partial support for this hypothesis. Their results are consistent with the findings of other studies that have shown that differentials in child mortality by maternal education are less pronounced in countries with strong public-health programs, such as Costa Rica and Cuba (Behm 1979, Palloni 1981, Schultz 1990). It is unlikely that the observed effects of maternal education on child-health outcomes simply reflects health knowledge and habits acquired in school, although they may play some role (Lindenbaum, Chakraborty and Elias 1989). Since the positive influence of maternal education on child health has been documented in a wide range of developing countries and in rural and urban areas of the same societies, where quality of schooling and teaching about healthy behaviours are likely to differ widely, persistent educational effects, found even at very low levels of schooling, seem more likely to reflect the development of cognitive skills, exposure to new ideas and ‘modern’ institutions (Caldwell 1990). Education could thus influence a woman’s beliefs about disease causation and cure and the value she places on modern medicine. We should note, however, that some portion of the observed effects of education may be spurious. Behrman and Wolfe (1987a, 1987b) have proposed that the association between female schooling and health outcomes may reflect not the influence of education, but the woman’s childhood background, for which education serves as a proxy. The authors suggest that, in analyses without controls for the woman’s childhood environment, education may serve as a proxy for human capital more generally, including health-related skills and habits acquired during childhood, and thus standard estimates of MATERNAL HEALTH -CARE SERVICES IN PERU 3 ELO HEALTH TRANSITION REVIEW VOL. 2 NO. 1 1992 education effects may overstate their impact on health outcomes. The authors found support for this thesis from a study of health outcomes in Nicaragua. In this article we investigate the hypothesis that female schooling influences the use of maternal health-care services in Peru. We should note at the start, however, that our purpose is not to measure the effects of education on changes in attitudes or to model health-service demand in low-income countries per se, but rather to investigate the broad nature of the association between female education and the behaviour of the mother with respect to utilization of maternal health-care services. We are especially interested in examining the extent to which the relation between maternal education and the use of health-care services is confounded by the woman’s childhood background, the household’s socioeconomic status and access to health-care services; and whether female schooling retains a net effect on maternal health-service use, independent of such other determinants. The overall objectives of this study are to provide information for health-policy makers charged with the implementation of maternal health-service programs, and to enhance our understanding of the potential role played by health-service utilization in the association between maternal education and child survival. To examine these issues, we use data from the Peruvian Demographic and Health Survey conducted in 1986.