Couples’ reports of household decision-making and the utilization of maternal health services in Bangladesh

Abstract

This study examines the association between maternal health service utilization and household decision-making in Bangladesh. Most studies of the predictors of reproductive health service utilization focus on women’s reports; however, men are often involved in these decisions as well. Recently, studies have started to explore the association between health outcomes and reports of household decision-making from both husbands and wives as matched pairs. Many studies of household decision-making emphasize the importance of the wife alone making decisions; however, some have argued that joint decision-making between husbands and wives may yield better reproductive health outcomes than women making decisions without input or agreement from their partners. Husbands’ involvement in decision-making is particularly important in Bangladesh because men often dominate household decisions related to large, health-related purchases. We use matched husband and wife reports about who makes common household decisions to predict use of antenatal and skilled delivery care, using data from the 2007 Bangladesh Demographic and Health Survey. Results from regression analyses suggest that it is important to consider whether husbands and wives give concordant responses about who makes household decisions since discordant reports about who makes these decisions are negatively associated with reproductive health care use. In addition, compared to joint decision-making, husband-only decision-making is negatively associated with antenatal care use and skilled delivery care. Finally, associations between household decision-making arrangements and health service utilization vary depending on whose report is used and the type of health service utilized.

Introduction

The study of reproductive health, including health care utilization, has been primarily individualistic in nature, with a focus on women (Becker, 1996). However, decisions about reproductive health care utilization are not made independent of one’s social context, and are often strongly influenced by spousal relationships (Allendorf, 2010). Although women’s reports often dominate analyses of reproductive health care utilization, an increasing number of “couples studies” examine responses from both husbands and wives as matched pairs. These studies make unique contributions because they reveal discrepancies between men’s and women’s reports of reproductive health attitudes and behaviors. Most of these studies focus on fertility, family planning, or sexual behavior as the outcome of interest (Bankole and Singh, 1998, Becker, 1999, Gipson and Hindin, 2008, Kulczycki, 2008, McDougall et al., 2011, Miller et al., 2001, Mullany, 2010).

Recently, couples studies have started to explore the association between health outcomes and couples’ reports of household decision-making (Allendorf, 2007, Becker et al., 2006, Ghuman et al., 2006, Jejeebhoy, 2002). These studies frame their analyses of decision-making as an examination of women’s relative power (Becker et al., 2006) or women’s autonomy (Allendorf, 2007, Ghuman et al., 2006, Jejeebhoy, 2002). It has been suggested that the autonomy paradigm is not adequate for understanding women’s reproductive health in the South Asian context because of the importance of inter-dependence within families (Mumtaz & Salway, 2009). Specifically, women’s independence and autonomy, with respect to health-related decision-making, may be restricted in a society where women are embedded in social relationships and have strong cultural and structural ties to men. Furuta and Salway (2006) argue that focusing on a woman’s independence from her husband and family is inappropriate in South Asia and greater attention should be placed on household decision-making processes that involve multiple people.

Autonomy is not always defined as women’s “full” control over decision-making. In the context of credit programs in rural Bangladesh, Kabeer (2001) suggests that greater equality in a woman’s contribution to household decisions with her spouse has the potential to lead to more positive outcomes compared to independent decision-making. On the other hand, “joint” control over loans has been described as a disguise for male dominance (Montgomery, Bhattacharya, & Hulme, 1996) and insufficient for improving women’s position (Goetz & Sen Gupta, 1996). Others have suggested that couples’ joint decision-making may yield better reproductive health outcomes (Mullany, Hindin, & Becker, 2005) compared to men making decisions alone or women making decisions without input or agreement from their partners. This could arise because joint decision-making is associated with greater male involvement in health behaviors (Mullany et al., 2005) or because joint decision-making allows the husband and wife to share the responsibility of the decision, especially in cases where there are negative consequences (Carter, 2002). Very few studies explore the ways in which different patterns of household decision-making predict health service utilization (Allendorf, 2007, Becker et al., 2006).

Understanding the decision-making process as a negotiation between husbands and wives is particularly important in Bangladesh. The husband is often involved in decisions about his wife’s health care, especially when it requires her to leave the home. This is ostensibly due to women’s limited mobility and limited educational and economic opportunities in Bangladesh (Paul and Rumsey, 2002, Rozario, 1998). Women’s limited mobility likely arises from the Muslim institution of parda (or purdah), which creates a strict separation between men and women. Since most doctors in Bangladesh are male, women often need their husband’s permission before seeking care. Women’s limited educational and economic opportunities give men more authority in the household, which leads to male involvement in women’s health care needs. These social barriers may, in part, be responsible for the low rates of maternal health service utilization. Currently, only 27% of all births in Bangladesh are assisted by skilled professionals and only 23% of births take place in a health facility. In addition, only 54% of women received at least one antenatal care visit from a medically trained provider and only 23% received four or more antenatal care visits (Bangladesh Maternal Morality and Health Care Survey, 2010). Improvements in the use of adequate antenatal care and professional delivery care have the potential to reduce the high rates of maternal and neonatal mortality in Bangladesh (Campbell and Graham, 2006, Moss et al., 2002); therefore, it is critical to better understand the kinds of relationships that may encourage or inhibit use.

The current literature on antenatal care and delivery care in Bangladesh focuses on socioeconomic, demographic, and geographical barriers to service utilization (Collin, Anwar, & Ronsmans, 2007). Studies that address interpersonal factors related to maternal health service utilization, such as decision-making and husband’s involvement, tend to focus on specific, non-representative subpopulations (Amin et al., 2010, Choudhury and Ahmed, 2011). Using a nationally representative sample from Bangladesh, this study will make two primary contributions to the existing literature. The first contribution is methodological: we propose a new way to operationalize household decision-making information from surveys that interview both husbands and wives by examining concordant responses (wife and husband agree that the wife alone makes the decision, the husband alone makes the decision, the couple makes the decision together, or someone else is involved in the decision) and discordant responses (wife and husband do not agree about who makes the decision) to each household decision-making question. The second contribution is substantive: using this detailed measure, we describe the association between different household decision-making arrangements and maternal health service utilization from the couple’s perspective.