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Utilization of institutional delivery services across successive births in India

facility with adequate maternal care. Proper delivery care for all births is an important indicator
for both maternal and child health. The benefits of delivering births in an institution is related to the
life-saving equipment and hygienic conditions that help reduce the risk of complications that may
result in death or illness to mother and/or child (Campbell, Graham and On behalf of The Lancet
Maternal Survival Series steering group, 2006). The data of 15 major states of India confirmed the
negative relationship between utilization of institutional delivery and maternal mortality. It is ob-
served that states where mothers prefer to deliver births in an institution had a lower rate of maternal
mortality (Dixit, 2013). For example, Southern states such as Kerala and Tamil Nadu had more than
95% of deliveries in health facilities and had maternal mortality ratios of only 66 and 90 maternal
deaths per 100, 000 live births, respectively, in 2012. By contract, Central and Northern regions had
only 25% to 45% institutional deliveries. In Uttar Pradesh and Rajasthan, the maternal mortality ra-
tios were 292 and 255 per 100, 000 live births, respectively, in 2012 (RGI, 2013).
In recent decades, several studies have attempted to determine the socioeconomic and demo-
graphic factors affecting the utilization of institutional delivery. However, these studies were either
based on the most recent birth — ignoring information from previous births within five years of the
survey — or overlooked the geographic variation in the utilization of institutional deliveries. Most
studies in the literature documented a negative correlation between increased levels of fertility and
the utilization of institutional deliveries based on the evidence that mothers at high parity were less
enthusiastic and reluctant about the utilization of institutional delivery and had a preference for home
delivery (Agha and Carton, 2011; Amponsah and Moses, 2009; Kebede, Gebeyehu, and Andargie,
2013; Magadi, Diamond, and Rodrigues, 2000; Sonneveldt, Plosky, and Stover, 2013). However,
these studies overlooked the geographical variation in fertility across India and were typically at the
state level. The total fertility rate (TFR) in India has declined from 3.39 in the years 1992–1993 (Na-
tional family health survey-I (NFHS-I)) to 2.68 in 2005-2006 (NFHS-III). The rate of decline in the
fertility rate in southern states was much faster than in the Northern part of the country where the
TFR rate remains at approximately three (Dixit, 2009). These variations could have impacted the
utilization of institutional delivery services. Some studies have further found that geographical
access may have a greater effect on utilization of services than socioeconomic factors. For example,
utilization of institutional delivery in Southern and western regions was higher than in Central and
Northern parts of India because Southern and Western regions are expected to have better provision
of services in the form of safe and affordable methods (Das, 1999). The overall development indica-
tor in terms of per capita GDP indicates that development took place much faster in Southern and
Western regions than other parts of India.
Over the past two decades there has been an increasing interest in the field to examine how the
utilization of maternal and child health (MCH) care services influence subsequent utilization of
MCH services in developing countries, including India (Agha and Carton 2011; Dixit, Dwivedi, and
Ram, 2013a; 2013b; Kesterton, Cleland, Slogett et al. 2010; Sugathan, Mishra and Retherford, 2001).
That is, during pregnancy, whether a mother receives antenatal care, then deliveries a birth in an in-
stitution, and receives postnatal care and immunization services for the same child at a proper age.
This can be considered as a type of consistency in which utilization of previous health services af-
fects utilization of subsequent health service for a particular birth. In the literature, the consistency in
the utilization of same services across all births is normally defined as a woman utilizing the same
types of health services for all of her births (i.e., across births). Limited evidence from other devel-
oping countries suggests that the likelihood of utilization of particular maternity care services is
strongly related to whether a women receives the same services for the immediately preceding birth
(Adekunle, Filippi, Graham et al., 1990; Govendasamy, Stewart, Rutsein et al., 1993; Mekonnen, 2003).
Another shortcoming of the existing literature is that most studies do not take into account factors
determining the utilization of services as a hierarchical structure and the analysis for each child was
statistically independent. Because regional variations in socioeconomic conditions and health sys-
tems in India do not correspond to established models from other developing countries, no cohe-

124 International Journal of Population Studies | 2016, Volume 2, Issue 2