The main determinants of infant mortality in Nepal

Multilevel log linear model to estimate the risk factors associated with infant mortality in Ethiopia: further analysis of 2016 EDHS

BACKGROUND

Infant mortality is defined as the death of a child at any time after birth and before the child's first birthday. Sub-Saharan Africa has the highest infant and child mortality rate in the world. Infant and child mortality rates are higher in Ethiopia. A study was carried out to estimate the risk factors that affect infant mortality in Ethiopia.

METHOD

The EDHS- 2016 data set was used for this study. A total of 10,547 mothers from 11 regions were included in the study's findings. To estimate the risk factors associated with infant mortality in Ethiopia, several count models (Poisson, Negative Binomial, Zero-Infated Poisson, Zero-Infated Negative Binomial, Hurdle Poisson, and Hurdle Negative Binomial) were considered.

RESULT

The average number of infant deaths was 0.526, with a variance of 0.994, indicating over-dispersion. The highest mean number of infant death occurred in Somali (0.69) and the lowest in Addis Ababa (0.089). Among the multilevel log linear models, the ZINB regression model with deviance (17,868.74), AIC (17,938.74), and BIC (1892.97) are chosen as the best model for estimating the risk factors affecting infant mortality in Ethiopia. However, the results of a multilevel ZINB model with a random intercept and slope model revealed that residence, mother's age, household size, mother's age at first birth, breast feeding, child weight, contraceptive use, birth order, wealth index, father education level, and birth interval are associated with infant mortality in Ethiopia.

CONCLUSION

Infant deaths remains high and infant deaths per mother differ across regions. An optimal fit was found to the data based on a multilevel ZINB model. We suggest fitting the ZINB model to count data with excess zeros originating from unknown sources such as infant mortality.

A Spatial Survival Model for Risk Factors of Under-Five Child Mortality in Kenya

Child mortality is high in Sub-Saharan Africa compared to other regions in the world. In Kenya, the risk of mortality is assumed to vary from county to county due to diversity in socio-economic and even climatic factors. Recently, the country was split into 47 different administrative regions called counties, and health care was delegated to those county governments, further aggravating the spatial differences in health care from county to county. The goal of this study is to evaluate the effects of spatial variation in under-five mortality in Kenya. Data from the Kenya Demographic Health Survey (KDHS-2014) consisting the newly introduced counties was used to analyze this risk. Using a spatial Cox Proportional Hazard model, an Intrinsic Conditional Autoregressive Model (ICAR) was fitted to account for the spatial variation among the counties in the country while the Cox model was used to model the risk factors associated with the time to death of a child. Inference regarding the risk factors and the spatial variation was made in a Bayesian setup based on the Markov Chain Monte Carlo (MCMC) technique to provide posterior estimates. The paper indicate the spatial disparities that exist in the country regarding child mortality in Kenya. The specific counties have mortality rates that are county-specific, although neighboring counties have similar hazards for death of a child. Counties in the central Kenya region were shown to have the highest hazard of death, while those from the western region had the lowest hazard of death. Demographic factors such as the sex of the child and sex of the household head, as well as social economic factors, such as the level of education, accounted for the most variation when spatial differences were factored in. The spatial Cox proportional hazard frailty model performed better compared to the non-spatial non-frailty model. These findings can help the country to plan health care interventions at a subnational level and guide social and health policies by ensuring that counties with a higher risk of Under Five Child Mortality (U5CM) are considered differently from counties experiencing a lower risk of death.

Revisit the correlates of infant mortality in Bangladesh: findings from two nationwide cross-sectional studies

OBJECTIVE

The main objective of this study is to investigate how the direction and strength of the association between infant mortality and its predictors are changing over time in Bangladesh using a nationally representative sample for the period 2011-2014.

DESIGN, SETTING AND PARTICIPANTS

Data from two repeatedly cross-sectional Bangladesh Demographic and Health Surveys (BDHSs) for the years 2011 and 2014 were used. A total of 7664 (with 312 infant death) and 7048 (with 264 infant death) complete cases, respectively, from BDHS 2011 and 2014 datasets were included in the study.

METHODS

Cox's proportional hazard model with robust standard error (SE) that adjusts for the complex survey design characteristics was implemented to assess how the risk factors associated with infant mortality change their paths.

RESULTS

Results reflected that administrative division remained as a potential risk factor of infant death for both periods. Household's socioeconomic status, father's employment status, age difference between parents turned out to be potential risk factors in 2014, though they did not show any significant association with infant death in the year 2011. In contrast to 2011, mothers' individual-level characteristics such as age at childbirth, education, media exposure, employment status did not remain as significant risk factors for infant death in 2014. Younger fathers increased the burden of death among infants of adolescent mothers. At higher order births, the burden of infant death significantly shifted from rural to urban areas. From the year 2011 to 2014, urban areas achieved socioeconomic equity in infant survival, while the extent of inequity was increased in rural areas.

CONCLUSION

Community-based programmes should be designed for urban mothers who are expecting higher order births. To eradicate the socioeconomic inequity in infant survival, the government should design strong and sustainable maternal and child healthcare facilities, especially for rural areas.

The comparing of infant mortality rate in different World Health Organization regions during 1990–2017

Background

Infant mortality rate is an important index of community health status and mortality rate. It is also one of the most prominent indexes showing the development of various societies. Regarding the importance of infant mortality rate (IMR), the purpose of current study was to compare and trend analysis of IMR in different areas of the WHO during 1990–2017. In current ecological study, IMR per 1000 live births in different WHO regions from 1990 to 2017 data were derived from the WHO website. The required information included the data about IMR per 1000 live births in different WHO regions from 1990 to 2017. The analysis was performed by using descriptive and analytical methods.

Results

The IMR during the study period had a significant decreasing trend in all the regions (p < 0.001) but the slope of decrease was greater in Africa than in other regions. The African and European regions had the highest (55.7%) and lowest (17.2%) annual decrease in the infant mortality rate (from 106.3 cases in 1990 to 50.6 in 2017, and from 24.9 in 1990 to 7.7 in 2017), respectively.

Conclusion

Our results showed that the trend of IMR had a decreasing trend in all WHO regions. It can be due to improving the public health situation in different areas. But the identification of effective factors on IMR needs individuals based studies.

Trends and risk factors for infant mortality in the Lao People's Democratic Republic

A high infant mortality rate (IMR) indicates a failure to meet people's healthcare needs. The IMR in Lao People's Democratic Republic has been decreasing but still remains high. This study aimed to identify the factors involved in the high IMR by analyzing data from 53,727 live births and 2189 women from the 2017 Lao Social Indicator Survey. The estimated IMR decreased from 191 per 1000 live births in 1978-1987 to 39 in 2017. The difference between the IMR and the neonatal mortality rate had declined since 1978 but did not change after 2009. Factors associated with the high IMR in all three models (forced-entry, forward-selection, and backward-selection) of multivariate logistic regression analyses were auxiliary nurses as birth attendants compared to doctors, male infants, and small birth size compared to average in all 2189 women; and 1-3 antenatal care visits compared to four visits, auxiliary nurses as birth attendants compared to doctors, male infants, postnatal baby checks, and being pregnant at the interview in 1950 women whose infants' birth size was average or large. Maternal and child healthcare and family planning should be strengthened including upgrading auxiliary nurses to mid-level nurses and improving antenatal care quality.

Socio-economic, macroeconomic, demographic, and environmental variables as determinants of child mortality in South Asia

The study empirically examines the effects of socio-economic (human capital), macroeconomic (per capita GDP), demographic (fertility rate, urbanization), and environmental variables (carbon emissions) on child mortality in South Asia. For empirical analysis, panel cointegration technique is used by using data for five South Asian countries for the period 1973 to 2015. First, it is found that the variables have unit roots at levels but are stationary at first differences, which indicates the possibility of cointegration. Cointegration test results show that long-run cointegrating relationship holds among variables. Fully Modified OLS (FMOLS) and Dynamic OLS (DOLS) methods are applied to find the parameter estimates. The results of long-run estimates show that human capital, per capita income, and urbanization reduce child mortality while high fertility rate and environmental degradation increase child mortality in the region. It is also found that trade openness, immunization, food security, and high life expectancy also decrease child mortality and that population density increases child mortality.

Neonatal mortality and child health in a remote rural area in Nepal: a mixed methods study

OBJECTIVE

To assess neonatal and under-five mortality and the health situation for children in Dolpa, a remote rural area of Nepal.

STUDY DESIGN

Mixed methods: quantitative (retrospective cross sectional) and qualitative (semistructured interviews).

RATIONALE

Progress in reducing child and newborn mortality in Nepal has reached the remote areas to a limited extent. Furthermore, there may be substantial under-reporting and data may be unreliable.

SETTING AND PARTICIPANTS

The population of Dolpa district is approximately 35 000. We visited 10 randomly selected villages (plus one settlement) with approximately 12 000 inhabitants.

METHODOLOGY

Records of the number of deliveries, neonatal and under-five deaths were collected. 100 children (10 different villages) were evaluated for common diseases present during the month prior to the investigation. 20 interviews were conducted about the cultural perceptions of neonatal death and morbidity; in each village at least one interview was undertaken.

RESULTS

The population of the 10 villages (plus one settlement) under investigation was 12 287. 300 deliveries have taken place during the last 12 months before the study. There were 30 children reported to have died; out of those 20 were in the neonatal period. This reflects an estimated neonatal mortality rate in Dolpa district of 67/1000 live births (95% CI 41-101/1000) and an estimated under-five mortality rate of 100/1000 (95% CI 70-140/1000). In the previous month, out of 100 children surveyed there had been 11 cases of acute lower respiratory infection (ALRI), 7 cases of diarrhoea, 3 cases of isolated malnutrition and 5 cases of malnutrition combined with ALRI or diarrhoea.Based on qualitative interviews traditional beliefs still play a major role, and are partly a hindrance to progress in health. There is also mistrust in the health services and misconceptions about 'modern' medicine and treatment facilities.

CONCLUSION

Despite progress in child morbidity and mortality in Nepal, some areas remain underserved by health services and neonatal mortality is far above the Nepalese average, which is 29/1000 live births. There is a substantial need to increase and train health staff. Health promotion should be encouraged but cultural perceptions have to be understood if positive behavioural change is to be achieved.

Application of a QMRA Framework to Inform Selection of Drinking Water Interventions in the Developing Context

The aim of this study was to develop a modified quantitative microbial risk assessment (QMRA) framework that could be applied as a decision support tool to choose between alternative drinking water interventions in the developing context. The impact of different household water treatment (HWT) interventions on the overall incidence of diarrheal disease and disability adjusted life years (DALYs) was estimated, without relying on source water pathogen concentration as the starting point for the analysis. A framework was developed and a software tool constructed and then implemented for an illustrative case study for Nepal based on published scientific data. Coagulation combined with free chlorine disinfection provided the greatest estimated health gains in the short term; however, when long-term compliance was incorporated into the calculations, the preferred intervention was porous ceramic filtration. The model demonstrates how the QMRA framework can be used to integrate evidence from different studies to inform management decisions, and in particular to prioritize the next best intervention with respect to estimated reduction in diarrheal incidence. This study only considered HWT interventions; it is recognized that a systematic consideration of sanitation, recreation, and drinking water pathways is important for effective management of waterborne transmission of pathogens, and the approach could be expanded to consider the broader water-related context.

Exclusive breastfeeding practice in Nigeria: a bayesian stepwise regression analysis

Despite the importance of breast milk, the prevalence of exclusive breastfeeding (EBF) in Nigeria is far lower than what has been recommended for developing countries. Worse still, the practise has been on downward trend in the country recently. This study was aimed at investigating the determinants and geographical variations of EBF in Nigeria. Any intervention programme would require a good knowledge of factors that enhance the practise. A pooled data set from Nigeria Demographic and Health Survey conducted in 1999, 2003, and 2008 were analyzed using a Bayesian stepwise approach that involves simultaneous selection of variables and smoothing parameters. Further, the approach allows for geographical variations at a highly disaggregated level of states to be investigated. Within a Bayesian context, appropriate priors are assigned on all the parameters and functions. Findings reveal that education of women and their partners, place of delivery, mother's age at birth, and current age of child are associated with increasing prevalence of EBF. However, visits for antenatal care during pregnancy are not associated with EBF in Nigeria. Further, results reveal considerable geographical variations in the practise of EBF. The likelihood of exclusively breastfeeding children are significantly higher in Kwara, Kogi, Osun, and Oyo states but lower in Jigawa, Katsina, and Yobe. Intensive interventions that can lead to improved practise are required in all states in Nigeria. The importance of breastfeeding needs to be emphasized to women during antenatal visits as this can encourage and enhance the practise after delivery.

Community development and livestock promotion in rural Nepal: effects on child growth and health

BACKGROUND

More than 50% of children in Nepal are malnourished. Economic growth and poverty reduction are not always sufficient to improve the health and nutritional status of children. Heifer Nepal uses livestock training as a tool for community development and poverty alleviation but does not directly address child health and nutrition.

OBJECTIVE

To systematically assess the effects of Heifer activities on child health and nutrition.

METHODS

The study was a 2-year, longitudinal, randomized, controlled trial in six communities in Nepal (both Terai and hills), pair-matched for specific characteristics, randomly assigned to receive Heifer community development activities at baseline (intervention) or 1 year (control). At 6-month intervals over a period of 2 years, child anthropometric and comprehensive household surveys were performed.

RESULTS

Four hundred fifteen households were enrolled containing 607 children 6 months to 5 years of age. The intervention and control communities were equivalent for baseline socioeconomic status, household size, ownership of land and animals, and child nutrition and health. At 12 months (prior to animal donations), the Terai intervention group had improved child weight (p = .04), improved child height (p = .05), and reduced sick days (p = .03), as well as increased household income (p = .004), increased ownership of animals (p = .04) and land (p = .04), and improved sanitation practices (p < .01). In all districts, longer participation in Heifer activities corresponded to more improvement in child height-for-age z-scores.

CONCLUSIONS

Heifer interventions resulted in improved socioeconomic status and household income per family member. Children under 60 months of age in the intervention group had greater incremental improvement in height-for-age and weight-for-age z-scores than children in the control group, and longer participation in Heifer activities was associated with better growth. Poverty alleviation programs, such as Heifer, may indirectly benefit child growth.

Factors associated with small size at birth in Nepal: further analysis of Nepal Demographic and Health Survey 2011

Background

The global Low Birth Weight (LBW) rate is reported to be 15.5% with more than 95% of these LBW infants being from developing countries. LBW is a major factor associated with neonatal deaths in developing countries. The determinants of low birth weight in Nepal have rarely been studied. This study aimed to identify the factors associated with small size at birth among under-five children.

Methods

Data from the 2011 Nepal Demographic and Health Survey (NDHS) were used. The association between small size at birth and explanatory variables were analysed using Chi-square tests (χ²) followed by logistic regression. Complex Sample Analysis was used to adjust for study design and sampling.

Results

A total of 5240 mother- singleton under five child pairs were included in the analysis, of which 936 (16.0%) children were reported as small size at birth. Of 1922 infants whose birth weight was recorded, 235 (11.5%) infants had low birth weight (<2500 grams). The mean birth weight was 3030 grams (standard deviation: 648.249 grams).

The mothers who had no antenatal visits were more likely (odds ratio (OR) 1.315; 95% confidence interval (CI) (1.042-1.661)) to have small size infants than those who had attended four or more antenatal visits. Mothers who lived in the Far-western development region were more likely to have (OR 1.698; 95% CI (1.228-2.349)) small size infants as compared to mothers from the Eastern development region. Female infants were more likely (OR 1.530; 95% CI (1.245-1.880)) to be at risk of being small than males.

Conclusion

One in every six infants was reported to be small at birth. Attendance of antenatal care programs appeared to have a significant impact on birth size. Adequate antenatal care visits combined with counselling and nutritional supplementation should be a focus to reduce adverse birth outcomes such as small size at birth, especially in the geographically and economically disadvantaged areas such as Far-western region of Nepal.

Residual confounding explains the association between high parity and child mortality

Background

This study used data from recent Demographic and Health Surveys (DHS) to examine the impact of high parity on under-five and neonatal mortality. The analyses used various techniques to attempt eliminating selection issues, including stratification of analyses by mothers’ completed fertility.

Methods

We analyzed DHS datasets from 47 low- and middle-income countries. We only used data from women who were age 35 or older at the time of survey to have a measure of their completed fertility. We ran log-binominal regression by country to calculate relative risk between parity and both under-five and neonatal mortality, controlled for wealth quintile, maternal education, urban versus rural residence, maternal age at first birth, calendar year (to control for possible time trends), and birth interval. We then controlled for maternal background characteristics even further by using mothers’ completed fertility as a proxy measure.

Results

We found a statistically significant association between high parity and child mortality. However, this association is most likely not physiological, and can be largely attributed to the difference in background characteristics of mothers who complete reproduction with high fertility versus low fertility. Children of high completed fertility mothers have statistically significantly increased risk of death compared to children of low completed fertility mothers at every birth order, even after controlling for available confounders (i.e. among children of birth order 1, adjusted RR of under-five mortality 1.58, 95% CI: 1.42, 1.76). There appears to be residual confounders that put children of high completed fertility mothers at higher risk, regardless of birth order. When we examined the association between parity and under-five mortality among mothers with high completed fertility, it remained statistically significant, but negligible in magnitude (i.e. adjusted RR of under-five mortality 1.03, 95% CI: 1.02-1.05).

Conclusions

Our analyses strongly suggest that the observed increased risk of mortality associated with high parity births is not driven by a physiological link between parity and mortality. We found that at each birth order, children born to women who have high fertility at the end of their reproductive period are at significantly higher mortality risk than children of mothers who have low fertility, even after adjusting for available confounders. With each unit increase in birth order, a larger proportion of births at the population level belongs to mothers with these adverse characteristics correlated with high fertility. Hence it appears as if mortality rates go up with increasing parity, but not for physiological reasons.

Determinants of infant mortality in community of Gilgel Gibe Field Research Center, Southwest Ethiopia: a matched case control study

BACKGROUND

Infant mortality accounts for almost 67 percent of under-five child mortality that occurs globally. An understanding of factors related to infant mortality is important to guide the development of focused and evidence-based health interventions to reduce infant deaths. But no community based studies have been conducted to identify determinants of infant mortality in Ethiopia for the past two decades. The purpose of this study is to identify determinants of infant mortality in community of Gilgel Gibe Field Research Center, Southwest Ethiopia.

METHODS

A community based matched case-control study was conducted. The study covered 133 infants who died during infancy between January 2010 and February 2011 in the study area. For each case, a control with approximately same date of birth and survived his/her first year of live and alive at time data collection was selected. Conditional logistic regression method was used to identify determinant factors of infant mortality using Epi-info 3.5.1 statistical software.

RESULTS

According to the final logistic regression model, not attending antenatal care follow-up [AOR=2.04, 95% CI:(1.04,4.02)], not using soap for hand washing before feeding child [AOR=2.50, 95% CI: (1.32,4.76)], negative perceived benefits of mother to modern treatment and prevention [AOR=2.76, 95% CI: (1.21,6.09)], small birth size [AOR=2.91, 95% CI: (1.01,8.46)] and high birth order with short birth interval [AOR=3.80, 95% CI: (1.20,11.98)] were found to be independent determinants of infant mortality.

CONCLUSIONS

Antenatal care follow-up, hand washing habit with soap before feeding child, birth size, perceived benefits of mothers to modern treatment, birth order and preceding birth interval were determinants of infant mortality.

ASSESSING THE UTILIZATION OF MATERNAL AND CHILD HEALTH CARE AMONG MARRIED ADOLESCENT WOMEN: EVIDENCE FROM INDIA

This study explores the prevalence and factors associated with the utilization of maternal and child health care services among married adolescent women in India using the third round of the National Family Health Survey (2005–06). The findings suggest that the utilization of maternal and child health care services among adolescent women is far from satisfactory in India. A little over 10% of adolescent women utilized antenatal care, about 50% utilized safe delivery services and about 41% of the children of adolescent women received full immunization. Large differences by urban–rural residence, educational attainment, religion, economic status and region were evident. Both gross effect and fixed effect binary logit models yielded statistically significant socioeconomic and demographic factors. Women's education, wealth quintile and region are the most important determinants for the utilization of maternal and child health care services. Health care programmes should focus more on educating adolescents, providing financial support, creating awareness and counselling households with married adolescent women. Moreover, there should be substantial financial assistance for the provision of delivery and child care for married women below the age of 19 years.

Inequalities in under-5 mortality in Nigeria: do ethnicity and socioeconomic position matter?

BACKGROUND

Each ethnic group has its own cultural values and practices that widen inequalities in child health and survival among ethnic groups. This study seeks to examine the mediatory effects of ethnicity and socioeconomic position on under-5 mortality in Nigeria.

METHODS

Using multilevel logistic regression analysis of a nationally representative sample drawn from 7620 females age 15 to 49 years in the 2003 Nigeria Demographic and Health Survey, the risk of death in children younger than 5 years (under-5 deaths) was estimated using odds ratios with 95% confidence intervals for 6029 children nested within 2735 mothers who were in turn nested within 365 communities.

RESULTS

The prevalence of under-5 death was highest among children of Hausa/Fulani/Kanuri mothers and lowest among children of Yoruba mothers. The risk of under-5 death was significantly lower among children of mothers from the Igbo and other ethnic groups, as compared with children of Hausa/Fulani/Kanuri mothers, after adjustment for individual- and community-level factors. Much of the disparity in under-5 mortality with respect to maternal ethnicity was explained by differences in physician-provided community prenatal care.

CONCLUSIONS

Ethnic differences in the risk of under-5 death were attributed to differences among ethnic groups in socioeconomic characteristics (maternal education and to differences in the maternal childbearing age and short birth-spacing practices. These findings emphasize the need for community-based initiatives aimed at increasing maternal education and maternal health care services within communities.

Correlation between national income, HIV/AIDS and political status and mortalities in African countries

OBJECTIVES

To investigate associations between mortalities in African countries and problems that emerged in Africa in the 1990s (reduction of national income, HIV/AIDS and political instability) by adjusting for the influences of development, sanitation and education.

METHODS

We compiled country-level indicators of mortalities, national net income (the reduction of national income by the debt), infection rate of HIV/AIDS, political instability, demography, education, sanitation and infrastructure, from 1990 to 2000 of all African countries (n=53). To extract major factors from indicators of the latter four categories, we carried out principal component analysis. We used multiple regression analysis to examine the associations between mortality indicators and national net income per capita, infection rate of HIV/AIDS, and political instability by adjusting the influence of other possible mortality determinants.

RESULTS

Mean of infant mortality per 1000 live births (IMR); maternal mortality per 100,000 live birth (MMR); adult female mortality per 1000 population (AMRF); adult male mortality per 1000 population (AMRM); and life expectancy at birth (LE) in 2000 were 83, 733, 381, 435, and 51, respectively. Three factors were identified as major influences on development: education, sanitation and infrastructure. National net income per capita showed independent negative associations with MMR and AMRF, and a positive association with LE. Infection rate of HIV/AIDS was independently positively associated with AMRM and AMRF, and negatively associated with LE in 2000. Political instability score was independently positively associated with MMR.

CONCLUSIONS

National net income per capita, HIV/AIDS and political status were predictors of mortality indicators in African countries. This study provided evidence for supporting health policies that take economic and political stability into account.

Cultural background and infant survival in Ghana

This study is premised on the hypothesis that ethnic specific socio-cultural practices such as dietary taboos and food avoidances on mothers and infants, as well as perceptions of disease aetiology and treatment patterns may be salient to understanding infant mortality differentials in Ghana. To inform policy, the paper explores if there are significant ethnic differences in infant survival, and whether such differences reflect socio-economic disparities or intrinsic factors. Using data from the 1998 Ghana Demographic and Health Survey, there was evidence of significant ethnic differences in infant survival at the bivariate level. Using Asante mothers as reference, the risk of death was significantly higher among children whose mothers were Mole-Dagbani, Grussi, Gruma, Dagarti, Fanti and Other Akan. In the multivariate models, however, the higher mortality risks associated with these children significantly attenuated after controlling for the socio-economic and bio-demographic factors except for the Fanti. The findings are discussed with reference to the characteristics and cultural theoretical paradigms.

Cross-national variation in family influences on child health

Drawing on the family process literature, child health models, and recent studies of macro-level effects on health, we examine the effects of household structure, resources, care-giving, reproduction, and communication on child nutritional status and infant mortality. Using Demographic and Health Surveys, we analyze the influence of these factors across 42 countries in Latin America, Africa, and Asia. We also consider country-level including nontraditional family structure, level of economic development and expenditures on health care. Our results underscore the importance of family resources, decision-making, and health and feeding practices on child well-being in less developed countries. Although there is cross-national variability, the size of the variability was small relative to the overall effect. The country-level measures had modest effects on infant mortality and child nutritional status.

Gender inequality, family planning, and maternal and child care in a rural Chinese county

This study examines the determinants of prenatal and obstetric care utilization within the context of recent social and economic changes in contemporary rural China. The aim of this study is to test the general hypothesis that gender inequality (women's status and son preference) and the state's family planning policy have a significant influence on maternal and childcare utilization. Both qualitative and quantitative data from a field survey in 1994 in rural Yunnan were used in the study. The findings lend support to this hypothesis. For example, the extent to which the husband shares housework and childcare, as an important marker of rural Chinese women's position within the family, is positively associated with the likelihood that a woman receives prenatal examinations, stops heavy physical work before birth, and gives birth under aseptic conditions. Also, a woman's exposure to the larger world beyond the village increases her chances of giving birth with the assistance of a doctor or health worker. Son preference is an impeding factor for maternal and child health care utilization. Already having a son in the family reduces the chances that the mother will stop heavy physical work before birth for a subsequent pregnancy. Female infants with older sisters are the least likely to receive immunizations. Women with "outside the plan" pregnancies are less likely than those with "approved" pregnancies to receive prenatal examinations, to stop strenuous work before birth, and to deliver under aseptic conditions. Thus, the study provides further evidence that the family planning policy has a negative impact on women and their families, whose fertility and son preferences conflict with the birth control policy.