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      Examining the Effect of Household Wealth and Migration Status on Safe Delivery Care in Urban India, 1992–2006

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          Abstract

          Background

          Although the urban health issue has been of long-standing interest to public health researchers, majority of the studies have looked upon the urban poor and migrants as distinct subgroups. Another concern is, whether being poor and at the same time migrant leads to a double disadvantage in the utilization of maternal health services? This study aims to examine the trends and factors that affect safe delivery care utilization among the migrants and the poor in urban India.

          Methodology/Principal Findings

          Using data from the National Family Health Survey, 1992–93 and 2005–06, this study grouped the household wealth and migration status into four distinct categories poor-migrant, poor-non migrant, non poor-migrant, non poor-non migrant. Both chi-square test and binary logistic regression were performed to examine the influence of household wealth and migration status on safe delivery care utilization among women who had experienced a birth in the four years preceding the survey. Results suggest a decline in safe delivery care among poor-migrant women during 1992–2006 . The present study identifies two distinct groups in terms of safe delivery care utilization in urban India – one for poor-migrant and one for non poor-non migrants. While poor-migrant women were most vulnerable, non poor-non migrant women were the highest users of safe delivery care.

          Conclusion

          This study reiterates the inequality that underlies the utilization of maternal healthcare services not only by the urban poor but also by poor-migrant women, who deserve special attention. The ongoing programmatic efforts under the National Urban Health Mission should start focusing on the poorest of the poor groups such as poor-migrant women. Importantly, there should be continuous evaluation to examine the progress among target groups within urban areas.

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          Most cited references47

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          Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India.

          Using data from India, we estimate the relationship between household wealth and children's school enrollment. We proxy wealth by constructing a linear index from asset ownership indicators, using principal-components analysis to derive weights. In Indian data this index is robust to the assets included, and produces internally coherent results. State-level results correspond well to independent data on per capita output and poverty. To validate the method and to show that the asset index predicts enrollments as accurately as expenditures, or more so, we use data sets from Indonesia, Pakistan, and Nepal that contain information on both expenditures and assets. The results show large, variable wealth gaps in children's enrollment across Indian states. On average a "rich" child is 31 percentage points more likely to be enrolled than a "poor" child, but this gap varies from only 4.6 percentage points in Kerala to 38.2 in Uttar Pradesh and 42.6 in Bihar.
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            Utilization of maternal health care services in Southern India.

            This paper examines the patterns and determinants of maternal health care utilization across different social settings in South India: in the states of Andhra Pradesh, Karnataka, Kerala and Tamil Nadu. Data from the National Family Health Survey (NFHS) carried out during 1992-93 across most states in India are used. Results show that utilization of maternal health care services is highest in Kerala followed by Tamil Nadu, Andhra Pradesh and Karnataka. Utilization of maternal health care services is not only associated with a range of reproductive, socio-economic, cultural and program factors but also with state and type of health service. The interstate differences in utilization could be partly due to variations in the implementation of maternal health care program as well as differences in availability and accessibility between the states. In the case of antenatal care, there was no significant rural-urban gap, thanks to the role played by the multipurpose health workers posted in the rural areas to provide maternal health care services. The findings of this study provide insights for planning and implementing appropriate maternal health service delivery programs in order to improve the health and well-being of both mother and child.
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              Internal migration and health in China

              China has a highly mobile population of 140 million rural-to-urban migrants (10% of the total population), a number that is expected to increase in the coming decade. Migrants tend to follow a temporary and circular pattern, moving between cities and provinces in search of improved opportunities. Overall, the migrant population tends to be younger, and is more likely to be male and single, than the general population, although more women and families have also started to migrate in recent years and more people are settling in cities. Indicators of socioeconomic status place the migrants below that of the urban population but above their rural counterparts. Migrants are largely excluded from urban services, including access to public health. National policy has long been established on locality-based schemes that depend on household registration (hukou), which is not easily transferable from rural to urban areas. Migrants, therefore, do not qualify for public medical insurance and assistance programmes, and have to pay out-of-pocket expenses for medical services in cities. 1 City governments are faced with the dilemma of not wanting to overburden public finances by extending medical cover to migrants versus the need to provide some services to prevent potential public-health crises. Local policies are being piloted in various cities to meet this challenge. The health-care community in China has focused on three main concerns about migrant health. The first is infectious diseases: this highly mobile group can be both victims and vectors of such diseases, which was particularly highlighted during the epidemic of severe acute respiratory syndrome. The range of diseases in migrants tends to be different from that in the non-migrant urban population. Migrants have more communicable diseases, such as acute respiratory infections, diarrhoeal, parasitic, and sexually transmitted diseases, and tuberculosis.2, 3, 4 Hence health authorities are concerned about these diseases, especially sexually transmitted diseases and tuberculosis.5, 6, 7 The second issue is maternal health. On every indicator of maternal and infant health, the migrant population fares worse than the urban population.8, 9 Maternal health of migrants is a challenge for urban health-care systems, and many cities have started pilot programmes to address needs. For example, Shanghai has experimented by offering subsidies to migrant women to be able to deliver in public hospitals (instead of illegal private clinics), and has achieved good outcomes. 10 But this success has created an ambivalent attitude about making the policy public for fear of attracting too many people into Shanghai. The third concern has been occupational disease and injuries in migrant workers, including silicosis, chemical poisoning, and accidents caused by machinery. The outsider status of migrants in the city's health-care system, lack of medical insurance, weak enforcement of occupational health and safety regulations, and little awareness of occupational risks contribute to this widespread problem. 11 Improved access to proper emergency or preventive care can help this situation, but the solution goes beyond the health sector. Improvement will need much stronger governmental regulations and enforcement of safety laws at workplaces. Those three main concerns, however, are only part of a broader picture that is poorly indicated in research about health issues for migrants. At the root of the issue is the self-selection of migrants that affects health in two ways. First, young and healthy people are more likely to migrate than elderly people, leaving the weak and sick at home. Second, more serious and incapacitating diseases and intensive-care conditions (including old age, pregnancy, and delivery of the newborn child) result in a migrant's return to the home in the village to seek family support and to avoid the high medical and living costs in cities.12, 13 In essence, the countryside is exporting good health and reimporting ill-health. As a result, counterintuitively, rural migrants on average are healthier than the urban population. This situation has the perverse effect of making the total urban populations (with improved health-care systems) healthier than the rural population in terms of able-bodied workers per sick individual, while the burden of the negative consequences of migration is in the countryside (with poor health-care systems). The ongoing rapid extension of the New Rural Cooperative Medical System, which now officially covers 87% of all villages in the country should, if it works, stem the crisis affecting the rural health-care system since the start of economic reforms.14, 15 However, the double self-selection of migration could overwhelm any rural insurance system in the future, by decreasing healthy contributors and increasing the number of unhealthy ones. On the other hand, studies that include migrants into the urban health system (in the form of reimbursement of some medical expenses incurred in their cities of work, rather than their original rural residences) are still at an early stage. 16 Two additional issues deserve more attention. One is mental and behavioural health, a domain that is understudied in China. International experience suggests that, as with physical health, immigrants also have better mental health than the general population. 17 Whether this is true of China's internal migrants is unknown. Clearly, migrants face a different set of stressors from non-migrants that include high mobility, high risk, low social status, and separation from family and familiar social surroundings. We expect that their mental-health issues will have a degree of specificity that deserves more research and specific intervention. The second area is risk perception. Apart from some research on views about AIDS and tuberculosis,18, 19 little systematic research exists on how Chinese rural migrants perceive health, disease, and the health-care system. Their high geographical mobility has consequences. When expected residency in a given location is limited, strong disincentives exist for migrants to invest time and money in locality or employer-based insurance programmes, or even to invest in personal health and safety measures. 20 Youth mining (conscious and unconscious trading of future ill health for present economic opportunities) is a prevalent behaviour in migrant populations, and might cause grave health consequences in the long term. What is needed is an understanding of how this group perceives the various possibilities for health care: self-medication, informal healers, traditional medicine, private clinics with varied levels of care, and more formal hospital treatment. These notions of risk and care opportunities, combined with their traditional models of medicine and of healing, play a big part in health-related behaviours in migrants. Understanding them will be crucial to prevention, intervention, and other health-related measures for the migrant population in China.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2012
                7 September 2012
                : 7
                : 9
                : e44901
                Affiliations
                [1 ]International Institute for Population Sciences, Mumbai, Maharashtra, India
                [2 ]Tata Institute of Social Sciences, Mumbai, Maharashtra, India
                Kenya Medical Research Institute - Wellcome Trust Research Programme, Kenya
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: PKS. Performed the experiments: PKS RKR LS. Analyzed the data: PKS RKR LS. Contributed reagents/materials/analysis tools: PKS RKR LS. Wrote the paper: PKS RKR LS.

                Article
                PONE-D-12-09611
                10.1371/journal.pone.0044901
                3436793
                22970324
                5b12d7d5-c5f7-473b-b9a2-77a8c1c8c201
                Copyright @ 2012

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 31 March 2012
                : 9 August 2012
                Page count
                Pages: 12
                Funding
                No specific funding was received for this study. PKS & LS is supported by the Government of India/National Eligibility Test (UGC/NET) Doctoral Fellowship Award from the Ministry of Health and Family Welfare, Government of India. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine
                Epidemiology
                Social Epidemiology
                Global Health
                Non-Clinical Medicine
                Health Services Research
                Obstetrics and Gynecology
                Labor and Delivery
                Pregnancy
                Public Health
                Socioeconomic Aspects of Health
                Women's Health

                Uncategorized
                Uncategorized

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