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DISSERTATION PROPOSAL : MATERNAL & CHILD HEALTH IN EAST BALI

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

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DISSERTATION PROPOSAL : MATERNAL & CHILD HEALTH IN EAST BALI

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

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. Withers Dissertation Proposal

  8. REMOTE LOCATION Withers Dissertation Proposal

  9. 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

  10. 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

  11. 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

  12. PAPER #1 MATERNAL HEALTH SERVICES IN EAST BALI Withers Dissertation Proposal

  13. Withers Dissertation Proposal

  14. 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

  15. 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

  16. 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

  17. 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

  18. PAPER #2 REPRODUCTIVE BEHAVIOR: A LONGITUDINAL ANALYSIS Withers Dissertation Proposal

  19. THEORETICAL FRAMEWORK Withers Dissertation Proposal

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. DESCRIPTIVES OF THE TOTAL SAMPLE (n=2160) Withers Dissertation Proposal

  27. DESCRIPTIVES OF THE TOTAL SAMPLE (n=2160) Withers Dissertation Proposal

  28. SAMPLE CHARACTERISTICS Withers Dissertation Proposal

  29. 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

  30. 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

  31. 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

  32. VARIABLES Withers Dissertation Proposal

  33. 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

  34. OUTCOME #1: BIVARIATE RESULTS OF WANTING MORE CHILDREN Withers Dissertation Proposal

  35. OUTCOME #2: BIVARIATE RESULTS OF CONTRACEPTIVE USE Withers Dissertation Proposal

  36. Withers Dissertation Proposal

  37. PAPER #3 QUALITATIVE STUDY OF THE DETERMINANTS OF FERTILITY AMONG WOMEN IN THIS COMMUNITY Withers Dissertation Proposal

  38. 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

  39. 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

  40. Withers Dissertation Proposal

  41. 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

  42. 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

  43. 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

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