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Maternal Health Care Service Access to Disabled and Dalit Women in Nepal a Thesis Submitted to University College London

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Maternal Health Care Service Access to Disabled and Dalit Women in Nepal a Thesis Submitted to University College London Maternal Health Care Service Access to Disabled and Dalit Women in Nepal Hridaya Raj Devkota A Thesis Submitted to University College London (UCL) For the Degree of Doctor of Philosophy Department of Epidemiology and Public Health January 2017 Page | 1 DECLARATION I, Hridaya Raj Devkota, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. Signature: Date: 30/01/2017 Page | 2 ABSTRACT Background: The access and utilization of maternal health care services by disabled and Dalit women in Nepal has not been well studied, and yet disparities in these may result in poor health outcomes. Co-existence of caste and disability may lead Dalit women with disability to further exclusion and marginalization, preventing them to access basic human rights and opportunities such as maternal health care services. It is therefore important to understand disabled and Dalit women’s access and utilization of health care service and the effect of intersectionality between their caste status and disability in the use of services. Previous efforts have focused on disability, gender and caste separately, but few studies have attempted to understand the inter-relationship between them or where they co-exist. This study explored this complex relationship and the multiple perspectives of Dalit women with and without disability about their access and utilization of maternal health care services with the assumption that all of these factors interacting together lead to exclusion and marginalization preventing their access and utilization of services. The study objectives were: (i) to compare and determine maternal health care service access and utilization patterns among disabled and non-disabled, Dalit and non-Dalit women in the Rupandehi district; (ii) to understand the attitude and behaviours of society and maternal health care providers towards disability; and (iii) to identify inhibiting and enabling factors for disabled and Dalit women with regards to access and utilization of maternal health care service. Methods: The study employed a mixed methods design combining quantitative and qualitative components of data collection and analysis. Quantitative data was obtained from survey questionnaires administered to women between aged 15 - 49 years and also of their health care providers. A total 354 women, of which 79 were disabled (18 disabled Dalit and 61 disabled non- Dalit) and 275 non-disabled (133 non-disabled Dalit and 142 non-disabled non-Dalit) participated in the survey. While qualitative data was gathered from 37 in-depth interviews, six focus group discussions with women (disabled and non-disabled; Dalit and non-Dalit), and six key informant interviews with activists, community leaders and policy makers. Quantitative data was analysed using descriptive statistics, bivariate and multivariate analysis with a logistic regression model and theme content analysis was applied to the qualitative data. Results: The study found inequitable utilization of maternal health care services, with disabled women having lower utilization of ANC one (83.5% vs 96.7%, P<0.001), HF delivery (52.6% vs 69%, P<0.05) and PNC (18.4% vs 32.5%, P<0.05) services compared to non-disabled women. Household indicators relating to education, wealth and family circumstances were the main determinants for Page | 3 disabled women having less service utilization (P<0.05). Low utilization of postnatal care (PNC) services among all groups found due to the poor information received by women from local health providers and strong negative traditional beliefs among communities. The study did not find differences in the utilization of maternal health care services between Dalits and non-Dalits (P>0.05). Rather it found that maternal health care services are not easily or equitably accessible to all social groups, preventing full utilization for disabled. Societal and health care providers’ attitudes towards disability were often found to be negative, although there were positive and negative user experiences and perceptions of provider’s attitude and behaviours. A further finding of the study was that the health care needs of disabled women are invisible at the policy level, which appeared to translate into unsuitable health care settings and ill-prepared health care providers to cater for them. Women from all social groups encountered a number of barriers to access, relating to personal, socio-cultural, and policy or system factors; however, disabled women faced additional barriers. Women with disabilities from all social groups faced physical, attitudinal, socio-cultural and policy related issues, including a lack of knowledge and skills among providers were critical barriers for women with disabilities; whereas having positive providers, a favourable family environment, as well as education and information, were enabling factors for disabled women’s access and utilization of care. Women with disabilities from all social groups also have higher levels of fear and perceived risks associated with pregnancy and delivery. This is primarily linked to worries about delivery complications associated with their disability and also that the baby would inherit their disability. The study did not find any compounding effect of caste and disability in access and utilization of maternal health care services. Conclusion: Improving equity and maternal health care access and utilization for disabled and other marginalised women requires that policy and existing traditional strategies be re-examined, re-developed and implemented through a human rights-based lens, with programme interventions focused on addressing persistent negative attitudes and socio-cultural barriers. Women’s education, social status, decision-making power and access to resources are critical factors associated with health care access and utilization among all groups of women. Significantly, women with disabilities, no matter what their social group, faced greater barriers than non- disabled women. Therefore, in order to increase access and utilization of maternal health care services across the population, holistic approaches including multi-sectoral interventions should be adopted. Page | 4 TABLE OF CONTENTS DECLARATION ............................................................................................. 2 ABSTRACT ................................................................................................... 3 TABLE OF CONTENTS ................................................................................... 5 LIST OF TABLES ......................................................................................... 10 LIST OF FIGURES........................................................................................ 11 ACKNOWLEDGEMENT ............................................................................... 12 ABBREVIATION & ACRONYMS .................................................................. 13 CHAPTER ONE: INTRODUCTION ................................................................ 16 1.1 BACKGROUND ........................................................................................................... 16 1.1.1 Maternal Health ........................................................................................................ 16 1.1.2 Disability .................................................................................................................... 17 1.1.3 Caste System and Dalits ............................................................................................ 18 1.1.4 Health Inequalities .................................................................................................... 20 1.1.5 Public Policy to Deliver Human Rights Commitments to Health in Nepal ................ 20 1.1.6 Maternal Health Situation in Nepal .......................................................................... 21 1.1.7 Trends in Maternal Health Care Service Utilization in Nepal.................................... 22 1.2 RESEARCH PROBLEM ................................................................................................. 23 1.2.1 Rationale/Significance of the Study .......................................................................... 26 1.3 RESEARCH SETTING ................................................................................................... 28 1.4 STUDY PROCESS ........................................................................................................ 30 1.5 CHAPTER PLAN OF THE THESIS ................................................................................. 31 CHAPTER TWO: REVIEW OF LITERATURE ................................................... 34 2.1 CHAPTER OVERVIEW ................................................................................................. 34 2.2 REVIEW METHODS .................................................................................................... 34 2.3 MATERNAL HEALTH GLOBAL PERSPECTIVES............................................................. 37 2.4 MATERNAL HEALTH IN NEPAL ................................................................................... 39 2.5 GENDER AND MATERNAL HEALTH CARE SERVICE UTILIZATION............................... 40 2.6 DISABILITY AND MATERNAL HEALTH CARE SERVICE UTILIZATION ........................... 41 Page | 5 2.7 CASTE AND MATERNAL HEALTH CARE SERVICE UTILIZATION .................................. 42 2.8 SUPPLY FACTORS AND MATERNAL
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