Dissertation proposal maternal child health in east bali
Download
1 / 43

DISSERTATION PROPOSAL : MATERNAL & CHILD HEALTH IN EAST BALI - PowerPoint PPT Presentation


DISSERTATION PROPOSAL : MATERNAL & CHILD HEALTH IN EAST BALI. Mellissa Withers Doctoral Committee: Osman Galal, Chair Donald Morisky, Bonnie Taub Elizabeth Frankenberg, Carole Browner. SUMMARY OF DISSERTATION PROPOSAL. THREE PUBLISHABLE PAPERS

Related searches for DISSERTATION PROPOSAL : MATERNAL & CHILD HEALTH IN EAST BALI

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha

Download Presentation

DISSERTATION PROPOSAL : MATERNAL & CHILD HEALTH IN EAST BALI

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


DISSERTATION PROPOSAL:MATERNAL & CHILD HEALTH IN EAST BALI

Mellissa Withers

Doctoral Committee:

Osman Galal, Chair

Donald Morisky, Bonnie Taub

Elizabeth Frankenberg, Carole Browner


SUMMARY OF DISSERTATION PROPOSAL

  • THREE PUBLISHABLE PAPERS

    • 1. Qualitative study of health care utilization for

      prenatal care & delivery services

    • 2. Quantitative study of determinants of fertility

      intentions & behavior, as well as contraceptive use

    • 3. Qualitative study of fertility intentions & behavior

Withers Dissertation Proposal


SUMMARY OF THE INTRODUCTION

  • INTRODUCTION:

    • Background on the study location

    • Background on the community

    • Background on the NGO

    • Rationale for this study

Withers Dissertation Proposal


BACKGROUND ON STUDY LOCATION: BALI, INDONESIA

INDONESIA:

  • Made up of 17,000 islands in South East Asia

  • 4th largest population in the world (240 million)

  • Predominantly Muslim (90%)

    BALI:

  • Total population of 3 million

  • Predominantly Hindu (90%)

  • Tourist destination receiving over 1 million visitors per year

Withers Dissertation Proposal


BACKGROUND ON THE COMMUNITY

SIZE & LOCATION:

  • LOCATION: East Bali in the saddle of two active volcanoes, Mt Agung and Mt Abang

  • POPULATION: 11,000 in approx. 2500 families

  • MADE UP OF 19 SUB-VILLAGES located about 3 kilometers apart

  • LAND AREA IS 7,100 Hectares

  • TOPOGRAPHY: Rising from 250 meters to 1500 meters above sea level

Withers Dissertation Proposal


THE POPULATION:

OCCUPATION: 99% Farmers

RELIGION: Hindu, in the same caste of agricultural workers

EDUCATION: 89% illiterate, many speak only Balinese

ANNUAL INCOME: $60-$100 per household (1999)

Very Homogenous

BACKGROUND ON THE COMMUNITY

Withers Dissertation Proposal


Withers Dissertation Proposal


REMOTE LOCATION

Withers Dissertation Proposal


BACKGROUND ON THE NGO: THE EAST BALI POVERTY PROJECT

  • Has worked in this community in 1998

  • Conducted a community survey of about half of all households in all 19 villages in 1999

  • Implemented numerous community development projects in several villages, including improved roads, goat breeding, improved agricultural techniques, 4 schools for local children, water systems, micronutrient supplementation

  • Has a field staff of 62 locals

Withers Dissertation Proposal


RATIONALE FOR THIS DISSERTATION

OVERVIEW OF MATERNAL MORTALITY

  • More than one-half million maternal deaths occur annually worldwide; 90% take place in Africa or Asia

  • Maternal mortality ratio (MMR) in Bali is estimated at 390 per 100,000 live births, one of the highest in the Asian region

  • 23% of deaths to women ages 15-49 in Bali are due to maternal causes

  • The Indonesian Ministry of Health set a goal of reducing the MMR to 125 by the year 2010

Withers Dissertation Proposal


RATIONALE FOR THIS DISSERTATION (cont)

MATERNAL HEALTH CARE IN INDONESIA

  • Indonesian women do not have adequate maternal health care-only about 1/3 of pregnant women have the recommended 4 pre-natal care visits (UNICEF, 2000; Thind & Banerjee, 2004)

  • 2/3 of Indonesian women deliver their babies without any skilled attendants; 3/4 deliver their babies at home (Shiffman, 2003)

  • 3/4 of pregnant women are anemic, the highest in the Southeast Asian region (Udayana University, 2003)

Withers Dissertation Proposal


PAPER #1

MATERNAL HEALTH SERVICES

IN EAST BALI

Withers Dissertation Proposal


Withers Dissertation Proposal


BACKGROUND

MATERNAL HEALTH CARE IN THIS COMMUNITY

  • Only 38.2% of married women reported use of contraceptives

  • Most women become pregnant at young ages-14-17 yrs old

  • 31.8% of women received a TT immunization during their last pregnancy

  • Of the 69.4% of women who had received pre-natal care during their last pregnancy, 75.1% received it at their home, indicating the use of dukuns

  • Only 50% of currently pregnant women had received pre-natal care from doctor or midwife. Of these, more than ½ had received care only once

Withers Dissertation Proposal


PAPER #1: OBJECTIVES

  • Qualitative study of health care utilization among pregnant women

  • STUDY OBJECTIVES:

    • To explore barriers & reasons for choice of maternal health services

    • To determine if traditional medical systems are preferred over formal health care

    • To determine if local beliefs & practices may contribute to maternal and infant mortality

Withers Dissertation Proposal


PAPER #1: LITERATURE REVIEW

  • Studies show a high correlation between maternal/infant mortality & maternal health service utilization

  • Maternal care is associated with:

    • Maternal factors (age, education, ethnicity)

    • Pregnancy factors (birth order, parity)

    • Service factors (distance to health center, cost)

    • Socio-cultural factors (traditional practices, lower status of women, preference of TBA)

      SOURCES: World Bank 2006; WHO, 1994; Paul & Rumsey, 2000; Reynolds et al., 2006; Bolam et al., 1998; Beegle et al., 2001)

Withers Dissertation Proposal


PAPER #1: METHODOLOGY

  • Question guides were designed using the Health Belief Model as a theoretical framework

  • 3 focus groups & 26 semi-structured interviews with key informants, such as traditional healers, midwives & local mothers conducted in 2004-2006

  • All questions were pre-tested with local staff, translated into Balinese & Indonesian & back-translated.

  • Interviews were conducted in 15 sub-villages by EBPP field staff & myself in the participants’ homes or in a community meeting area

  • Interviews were audio-taped, transcribed & translated

  • Content analysis was used to extract themes

  • UCLA IRB approval was obtained

Withers Dissertation Proposal


PAPER #2

REPRODUCTIVE BEHAVIOR:

A LONGITUDINAL ANALYSIS

Withers Dissertation Proposal


THEORETICAL FRAMEWORK

Withers Dissertation Proposal


PAPER #2: BACKGROUND

FERTILITY IN INDONESIA

  • TFR decreased 50% in past 3 decades-2.6 births per woman

  • The average woman is a mother by age 21

  • Contraceptive use among married women is only about 55%

  • Unmet need for family planning is still relatively high (8.6%)

  • More than ½ of all married women want no more children but about 10% of these are not using any contraception

    SOURCES: IDHS, 2003; PRB, 2005; WHO, 2004

Withers Dissertation Proposal


PAPER #2: LITERATURE REVIEW

  • Studies show that fertility behavior depends on many factors, including:

    • Parental factors (age, education, income, occupation, religion, length of marriage)

    • Cultural factors (son preference, family size norms, fatalism, family member input)

    • Service factors (availability & use of contraception)

    • Child factors (parity, number of currently living children, child mortality)

      SOURCES: Islam & Bairagi, 2003; Tan & Tey, 1994; Roy et al., 2003;

Withers Dissertation Proposal


POTENTIAL SUPPLY

OF CHILDREN

SOCIAL-STRUCTURAL FACTORS

MOTIVATION TO

CONTROL FERTILITY

USE OF FERTILITY REGULATION

ADDITIONAL FERTILITY

DEMAND FOR CHILDREN

COSTS OF REGULATION

INDIVIDUAL CHARACTERISTICS

CONCEPTUAL FRAMEWORK

FIGURE 1: BASIC MODEL OF FACTORS

DETERMINING ADDITIONAL FERTILITY

SOURCE: HERMALIN, 1983

Withers Dissertation Proposal


THEORY

  • Bongaarts framework:

    • 3 proximate categories: exposure to intercourse, exposure to conception, & probability of successful gestation/birth.

    • distal categories: culture, socioeconomic status, etc

  • Environmental influences:

    • Fertility in the developing countries is a complex phenomenon, affected by cultural preferences, family structures that distribute power over fertility decisions in different ways, customs and taboos relating to sexual behavior, childbirth, and childrearing, varying and rapidly changing economic conditions.

Withers Dissertation Proposal


Social institutions, cultural norms, economic & environmental conditions

Demand for Children

Motivation to control fertility

Tastes, constraints

Perceptions of children:

values and disvalues

Socioeconomic characterisitics

Fertility regulation to limit family size

Family-size desires

Reproductive history

Nuptiality

Supply of children

Natural fertility

-postpartum infecundability

-waiting time of

conception

-intrauterine mortality

-permanent sterility

-entry into

reproductive cycle

Childbearing experience

Fertility

Fertility regulation costs

Costs of access

Costs of use

SOURCE: BULATAO & LESS, 1983

Withers Dissertation Proposal


PAPER #2: OBJECTIVES

  • To explore the determinants of fertility among this population-specifically, how do infant mortality, cultural factors & MCH service utilization impact fertility

  • To explore the determinants of the desire for more children-is having more children seen as a conscious decision or an act of fate?

  • To explore the determinants of contraceptive use

  • To determine how accurately fertility intentions predict fertility behavior & subsequent outcomes

Withers Dissertation Proposal


DESCRIPTIVES OF THE TOTAL SAMPLE (n=2160)

Withers Dissertation Proposal


DESCRIPTIVES OF THE TOTAL SAMPLE (n=2160)

Withers Dissertation Proposal


SAMPLE CHARACTERISTICS

Withers Dissertation Proposal


METHODOLOGY

  • Sub-sample of married women ages 15-45 living in this community & still married was collected in 2006 (n= 1393)

  • Follow-up rate 90%

  • Fertility is defined as having at least one live birth during study period

Withers Dissertation Proposal


OUTCOMES OF INTEREST

CROSS-SECTIONAL:

  • 1. What are the determinants of current

    contraceptive use in 2002?

  • 2.What predicts the desire for more

    children in 2002?

    These questions “do you want more children” & “are you currently using birth control” were dichotomized as “yes” and “no.”

Withers Dissertation Proposal


OUTCOMES OF INTEREST

LONGITUDINAL:

  • 3. What predicts additional fertility in the

    inter-survey period?

  • 4. What predicts consistency between

    fertility intentions & subsequent

    behavior?

Withers Dissertation Proposal


VARIABLES

Withers Dissertation Proposal


DEPENDENT VARIABLES

  • 4 MODELS-LOGISTIC REGRESSION:

    • Wanting additional children (Y/N)

    • Use of contraception (Y/N)

    • Having at least one live birth during study period (Y/N)

    • Matching stated intentions with actual fertility (Y/N)

Withers Dissertation Proposal


OUTCOME #1: BIVARIATE RESULTS OF WANTING MORE CHILDREN

Withers Dissertation Proposal


OUTCOME #2: BIVARIATE RESULTS OF CONTRACEPTIVE USE

Withers Dissertation Proposal


Withers Dissertation Proposal


PAPER #3

QUALITATIVE STUDY OF THE DETERMINANTS OF FERTILITY AMONG WOMEN IN THIS COMMUNITY

Withers Dissertation Proposal


PAPER #3: OBJECTIVES

  • To explore more in-depth the reasons why some women’s stated intentions & behavior were different

  • To explore why some women perceive more control over their fertility while others feel it is an act of God/fate

  • To analyze the determinants of fertility that were found to be most influential in paper #2-including cultural factors, such as family size norms & son preference

  • To explore how couples’ interactions influence fertility

Withers Dissertation Proposal


PAPER #3: QUALITATIVE METHODS

  • Recruit women from the sub-sample of women who participated in both surveys

  • Using a randomly selected sample, stratified according to concordant versus discordant fertility intentions & behavior

  • In-depth interviews using a question guide

  • Estimated sample size is 25

Withers Dissertation Proposal


Withers Dissertation Proposal


STRENGTHS & LIMITATIONS

STRENGTHS:

  • Longitudinal data (with same sample of women)

  • High follow-up rate; little loss to follow-up

    LIMITATIONS:

  • Not generalizable to other populations

  • Intra-study period not long enough to capture all births

Withers Dissertation Proposal


SIGNIFICANCE

  • Policy Implications: women who want no more children represent a latent demand for family planning

  • Help couples gain control over their own fertility

  • Understand the determinants of fertility among a homogeneous population

  • Understand how couples make fertility decisions

Withers Dissertation Proposal


CONCLUSION

  • What have we learned about reproductive behavior among women in this community?

  • How are the findings from this study be used in other similarly isolated, underdeveloped communities?

  • What are the barriers to maternal health care utilization & family planning?

  • What programs can be designed to improve the quality of services in this community?

  • How can women be empowered to take more control over their health?

Withers Dissertation Proposal


ad
  • Login