Health, attitudes and beliefs of working women

Voting with their feet: patient exit and intergroup differences in propensity for switching usual source of care

Many analysts advocate patient exit as a strategy for consumers who experience poor-quality care. Exit is believed to have the potential to improve patient welfare by having patients leave (or "exit") poor-performing health care providers, thus signaling their dissatisfaction with the quality of care they have received and thereby admonishing those providers to improve. However, the validity of exit as a signal of consumer dissatisfaction hinges on how closely it reflects dissatisfaction. Intergroup differences in the propensity to exit could also result in unintended consequences. This article examines the association between consumer experience and the decision to change one's usual care providers. It also investigates if there are any intergroup differences in the propensity for changing providers according to insurance status, gender, and race or ethnicity. Data come from household surveys conducted by the Center for Studying Health System Change. Results show significant intergroup differences in propensity for switching usual source of care for voluntary or involuntary reasons related to insurance, rural residency, age, income, race, and ethnicity. Policy implications of the empirical results on exit, voice, and consumerism are discussed.

Fertility and infant mortality trends in Nicaragua 1964-1993. The role of women's education

OBJECTIVES

To assess trends in fertility and infant mortality rates (IMR) in León, Nicaragua, and to examine the effect of women's education on these trends during 1964-1993, a period of rapid social change.

DESIGN

Cross sectional survey, based on random cluster sampling. A retrospective questionnaire on reproductive events was used.

SETTING

The municipality of León, which is the second largest city in Nicaragua, with a total population of 195,000 inhabitants.

SUBJECTS

10,867 women aged 15-49 years, corresponding to 176,281 person years of reproductive life. Their children contributed 22,899 person years under 12 months of age to the IMR analysis.

MAIN OUTCOME MEASURES

Fertility rate (number of pregnancies per 1000 person years) for specific age groups and calendar periods, total fertility rate, and IMR.

RESULTS

Fertility rates and IMR declined in parallel, especially during the 1980s. However, education specific fertility rates did not decline, but the proportion of educated young women increased from 20% to 46%. This had also an impact on the overall IMR decline, although IMR reduction mainly took place among infants of women without formal education, decreasing from 118 to 69 per 1000 during the observation period.

CONCLUSIONS

In this demographic transition over three decades, fertility and IMR declined simultaneously. The decreasing trend in fertility was mainly explained by an increase in women's education, while the IMR decline seemed to be the result of health interventions, specially targeted to poorer groups of women and their infants. Thus, social differences in fertility rates remained unchanged, while equity in chances of child survival increased.