Western University Scholarship@Western Electronic Thesis and Dissertation Repository 6-16-2017 12:00 AM Maternal Healthcare Utilization Among Muslim Mothers From India, Pakistan, and Bangladesh: Is There Equity? Rohin J. Krishnan The University of Western Ontario Supervisor Dr. Bridget Ryan The University of Western Ontario Graduate Program in Epidemiology and Biostatistics A thesis submitted in partial fulfillment of the equirr ements for the degree in Master of Science © Rohin J. Krishnan 2017 Follow this and additional works at: https://ir.lib.uwo.ca/etd Part of the Health Services Research Commons Recommended Citation Krishnan, Rohin J., "Maternal Healthcare Utilization Among Muslim Mothers From India, Pakistan, and Bangladesh: Is There Equity?" (2017). Electronic Thesis and Dissertation Repository. 4613. https://ir.lib.uwo.ca/etd/4613 This Dissertation/Thesis is brought to you for free and open access by Scholarship@Western. It has been accepted for inclusion in Electronic Thesis and Dissertation Repository by an authorized administrator of Scholarship@Western. For more information, please contact [email protected]. i Abstract To date, literature exploring maternal healthcare utilization among Muslim populations has largely focused on religious differences. However, little research exists exploring maternal healthcare utilization within Muslim populations. This highlights a research gap because studies across religious groups may obscure important variation within Islamic women. The primary objective of this study assessed if there is equity in MHU among Muslim mothers in India, Pakistan, and Bangladesh. Multivariate logistic regression revealed inequities to be present in the three countries. Predicted probabilities revealed a narrower equity gap in MHU in Bangladesh compared to India and Pakistan. The successes of Bangladesh’s recent efforts to reduce inequity within its Muslim community offer lessons for policy-makers in India and Pakistan. The results from this study underscore the need to look past Islam as a reason for inequity and look further within Muslim communities for solutions. Keywords Islam, Muslim, antenatal care, skilled birth attendant, institutional delivery, equity, India, Bangladesh, Pakistan ii Acknowledgments First and foremost, I would like to acknowledge the Department of Epidemiology and Biostatistics, the faculty, and my fellow colleagues at Western University for this rewarding journey. Also, special thanks go out to Dr. Saverio Stranges, Dr. Anita Kothari, and Dr. Michael Clarke for taking time out of their busy schedules to adjudicate my thesis defense. Lastly, I would also like to thank Dr. Tom Pullum for his expertise as I navigated the DHS datasets. My sincerest gratitude goes to Dr. Bridget Ryan. Thank you for your guidance, encouragement, and relentless support as I completed my thesis. I would also like to also extend my gratitude and appreciation to Dr. Thind, for without whom, this journey would not have begun. Thank you both for challenging me and making me see my true potential. I would like to thank my roommates (PK, IS, & LU), favorite fraternal twins (RB & SB), Jasmine Tung, Amneet Sidhu, and Esther Rai for their unconditional love, friendship, and support as I completed this program. I wish you all nothing but success and happiness in your future endeavors. Finally, I would like to extend my love and gratitude to my mother, father, brother, sister- in-law, and nephew/niece to be, who have given me the strength and courage to pursue all things in life, including this Master’s degree. iii Table of Contents Abstract ............................................................................................................................ i Acknowledgments ...........................................................................................................ii Table of Contents .......................................................................................................... iii List of Tables ................................................................................................................ vii List of Figures ................................................................................................................. x List of Abbreviations ...................................................................................................... xi List of Appendices ....................................................................................................... xiv Chapter 1 ......................................................................................................................... 1 1 Introduction ................................................................................................................ 1 1.1 Background ......................................................................................................... 1 Chapter 2 ......................................................................................................................... 5 2 Literature Review ....................................................................................................... 5 2.1 South Asia ........................................................................................................... 5 2.1.1 India ......................................................................................................... 5 2.1.2 Pakistan .................................................................................................. 14 2.1.3 Bangladesh ............................................................................................. 20 2.2 Maternal Healthcare Utilization ......................................................................... 26 2.2.1 Antenatal Care Visits.............................................................................. 26 2.2.2 Skilled Birth Attendant Use .................................................................... 26 2.2.3 Institutional Delivery .............................................................................. 27 2.3 Inequity and Maternal Healthcare Utilization ..................................................... 27 2.4 Islam .................................................................................................................. 29 2.5 Maternal Healthcare Utilization and Islam ......................................................... 30 2.5.1 Search Strategy ...................................................................................... 30 iv 2.5.2 Inclusion criteria .................................................................................... 31 2.5.3 Qualitative Literature ............................................................................. 35 2.5.4 Quantitative Literature ........................................................................... 39 2.5.5 Conclusions and Knowledge Gap ........................................................... 45 2.6 MHU – Religious Differences in India and Bangladesh ..................................... 45 2.6.1 India ....................................................................................................... 47 2.6.2 Bangladesh ............................................................................................. 51 2.6.3 Conclusions and Knowledge Gap ........................................................... 54 2.7 Objectives .......................................................................................................... 56 Chapter 3 ....................................................................................................................... 57 3 Methods .................................................................................................................... 57 3.1 Data Sources ...................................................................................................... 57 3.1.1 National Family and Health Survey 3rd Edition (NFHS-3) ...................... 58 3.1.2 Pakistan Demographic and Health Survey .............................................. 58 3.1.3 Bangladesh Demographic Health Survey ................................................ 60 3.2 Conceptual Framework ...................................................................................... 61 3.2.1 Contextual Characteristics ...................................................................... 61 3.2.2 Predisposing Characteristics ................................................................... 62 3.2.3 Enabling Characteristics ......................................................................... 62 3.2.4 Need Characteristics ............................................................................... 62 3.2.5 Health Behaviors .................................................................................... 63 3.3 Selection and Definition of Variables ................................................................. 65 3.3.1 Dependent Variables .............................................................................. 65 3.3.2 Independent Variables ............................................................................ 69 3.4 Creation of Final Sample ................................................................................... 76 v 3.5 Missing Values .................................................................................................. 80 3.6 Technical Standards ........................................................................................... 80 3.7 Statistical Methods............................................................................................