Social Networks, Decision Making and Use of Skilled Birth Attendants to Prevent Maternal Mortality in Matlab, Bangladesh Open Access

Edmonds, Joyce Katherine (2010)

Permanent URL: https://etd.library.emory.edu/concern/etds/2z10wq86h?locale=en
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Abstract

Social Networks, Decision Making and Use of Skilled Birth Attendants to Prevent Maternal Mortality in Matlab, Bangladesh

By Joyce Katherine Edmonds

Background: Worldwide an estimated 529,000 women die annually from pregnancy-and childbirth-related complications. Use of a skilled birth attendant (SBA) is an effective means to reduce maternal mortality. However, SBA services remain underused even in settings where SBAs are available.

Purpose: This retrospective, cross sectional, two-phased study employed ethnographic decision tree modeling (EDM) and social network analysis to: 1) test the utility of the Network-Episode Model (NEM) in explaining women's health service utilization decisions in uncomplicated pregnancy and childbirth, and 2) examine the predictive power of women's self-identified decision-making criteria on choice of birth attendant.

Sample: A representative sample of 246 Bangladeshi women, 18-45 years of age, disproportionately stratified by place of birth, residing in the Matlab Health Service Area, who had an uncomplicated pregnancy and delivery resulting in a live birth in the 3 months prior to data collection participated in the main phase. A purposive sample of 25 women participated in the preliminary phase.

Method: In-depth and structured interviews using survey and social network techniques were conducted. Descriptive statistics were used to categorize individual and pregnancy episode attributes. The association between the structure and content of women's discussion networks and place of birth was assessed with logistic regression. The association between the decision criteria and place of birth was assessed with ethnographic decision models and logistic regression.

Findings: Network content was more strongly associated with place of birth than a woman's individual attributes. Indicators of network structure were not associated with place of birth nor did they modify the relationship between network content and place of birth. A women's intention during pregnancy, her perception of time in labor, transportation availability and dai availability were the decision criteria predictive of SBA use along with marital age.

Discussion: The NEM together with the EDM has utility in the study of decision processes that result in preventive health seeking behaviors. Yet, the effect of network structure may be overestimated in certain cultural contexts. Findings can inform future research and public health practice.

Table of Contents

CHAPTER

1. Introduction

Statement of the Problem 1

Specific Aims 3

Conceptual Framework 4

Rationale for Selecting the Conceptual Framework 6

Conceptual Domains of the NEM 10

Decision Criteria and Ethnographic Decision Modeling 12

Network-Episode Model Hypotheses 13

Modified Network-Episode Model 15

Relevance of the NEM in the Broader Context of Maternal Health 18

Relevance of the Proposed Study 20

Summary 21

References 23

2. Background and Significance: A Review of the Literature

Section One

Maternal Mortality 28

Skilled Birth Attendants, a Global Strategy to Reduce Maternal Mortality 29

Maternal Mortality and Skilled Birth Attendant Use in Bangladesh 32

Maternal Mortality and Skilled Birth Attendant Use in Matlab 33

The Paradox of Decreasing Maternal Mortality & Low SBA Use in Bangladesh 36

Section Two

Factors Influencing the Use of Skilled Birth Attendants in Bangladesh 38

Section Three

Social Networks and Health Service Utilization 46

Empirical Evidence: Social Networks and Health Utilization Decision-Making 47

Decision Task and Use of Skilled Birth Attendants in Bangladesh 53

Decision Makers and Use of Skilled Birth Attendants in Bangladesh 58

Interaction Among Decision Makers and Use of Skilled Birth Attendants in Bangladesh 59

Summary 61

References 63

3. Research Design and Methodology

Study Overview 77

Description of the Study Area-Matlab, Bangladesh 78

Preliminary Phase of Study 81

Design 81

Approach 81

Sample 83

Instrument 84

Recruitment, Selection and Training of Research Team 85

Recruitment, Screening and Informed Consent of Subjects 85

Data Collection 86

Analysis 87

Main Phase of Study 88

Specific Aims 88

Design 89

Sample 92

Instrument 93

Translation, Back-Translation and Pretesting 99

Recruitment, Selection and Training of Research Team 99

Recruitment, Screening and Informed Consent of Subjects 101

Data Collection 102

Analysis 103

Protection of Human Subjects 112

Assumptions, Challenges and Limitations 113

Summary 120

References 122

4. Results

Preliminary Study Data Analysis 128

Social and Demographic Characteristics of Participants 128

Results for Preliminary Study Aim 1 131

Results for Preliminary Study Aim 2 132

Main Study Phase Data Analysis 135

Social and Demographic Characteristics of Participants 135

Differences in Social and Demographic Characteristics by Place of Delivery 140

Results for Main Study Specific Aim 1 141

Results for Main Study Specific Aim 2 157

Results Summary 182

Social and Demographic Characteristics 182

Differences in Social and Demographic Characteristics by Place of Delivery 182

Network Variables 182

Specific Aim 1 183

Post-Hoc Analysis Specific Aim 1 184

Specific Aim 2 184

Comparison of RQ1 and RQ2 Results 185

Post-Hoc Analysis Specific Aim 2 185

Chapter Summary 185

References 187

5. Discussion

Social and Demographic Characteristics 188

Discussion of Findings 190

Specific Aim 1 190

Specific Aim 2 198

Summary of Findings 207

Validity of the Ethnographic Decision Model 208

Implications for Theory and the Conceptual Framework 209

Study Limitations and Challenges 211

Study Strengths 212

Recommendations 212

Chapter Summary 215

References 216

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