Academic journal article International Perspectives on Sexual and Reproductive Health

A Deviance Approach to Understanding Use of Maternal Health Care Services in Bangladesh

Academic journal article International Perspectives on Sexual and Reproductive Health

A Deviance Approach to Understanding Use of Maternal Health Care Services in Bangladesh

Article excerpt

Although the global maternal mortality ratio dropped by 44% between 1990 and 2015,1 maternal mortality remains high. Approximately 303,000 women died from complications of pregnancy and childbirth in 2015, (1) and for every such death, 20-30 women experience chronic maternal morbidity. (2) In Bangladesh, 5,500 women died of pregnancy- and childbirth-related causes in 2015, equivalent to a maternal mortality ratio of 176 per 100,000 live births.1 Although this figure represents a decline from the ratio of 242 per 100,000 in 2010, (1) much work is needed if Bangladesh is to reduce its maternal mortality ratio to less than 70 deaths per 100,000 live births by 2030, the global target specified in the United Nations' Sustainable Development Goals. (3) Improving women's use of maternal health care services is important for reducing both maternal morbidity and mortality. (4) Given the high rates of maternal morbidity and mortality in Bangladesh, we need greater understanding of the factors that facilitate the use of maternal health care services.

Studies have identified a variety of individual-level characteristics that are associated with use of maternal health care, including maternal age and education, household wealth, parity, husband's occupation and woman's autonomy. (5) However, recent work has recognized the potential role of the community in women's utilization of services. (6-11) In particular, evidence indicates that a community's economic prosperity, gender norms, fertility norms and provision of health care services are all associated with women's use of maternal health care. (8,9) For example, a study conducted in six African countries found that women's likelihood of delivering in a facility was positively associated with their community's levels of women's educational attainment and previous use of delivery care, and of men's approval of family planning. (8) The study also found that the mean parity in the community was negatively associated with a woman's likelihood of delivering in a facility. (8) Another study, conducted in Bangladesh, Egypt and Rwanda, found that residing in a community where women had higher levels of health knowledge and decision-making autonomy was associated with greater use of antenatal care and delivery care. (9) Collectively, these studies suggest that living in communities where social scripts place greater value on women and on women's rights, autonomy and socioeconomic opportunities may be positively associated with the use of maternal health care services.

Most global research examining the relationship between community characteristics and use of maternal health care has analyzed potential community effects as though they apply equally to all women within communities. (6,7,9-11) However, some individuals may deviate from community norms, and this deviance may be related to health outcomes. (12,13) Deviance is a well-established concept and can be explored using a statistical approach in which it is defined as being different from the average. (13) In the context of global maternal health programming, it is useful to focus on two groups of people who deviate from community norms: women who are positively deviant and those who are negatively deviant. Positive deviance can be defined as individuals' having better outcomes than other persons in their community or, using a strengthsbased lens, as individuals' succeeding despite facing hardships that contribute to vulnerability. (12-18) Women who are positively deviant may help inform public health programming by serving as models for how to improve the health of other women in the community. (14,17) Negative deviance is defined as being less successful than others in one's community; individuals who are negatively deviant may be especially hard to reach through interventions. To help women who are negatively deviant obtain maternal health services, public health programs need to focus on these individuals' specific needs. …

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