In our blog in September, we discussed how women’s health decisions are typically household decisions rather than individual – involving factors like bargaining power, women’s paid work outside the home which can bring empowerment but possibly also male backlash, gendered norms that may be internalized by women as well, and men’s knowledge or lack thereof of women’s healthcare.
The literature on family economics has traditionally focused on bargaining between the husband and wife within a nuclear household structure (Anukriti et al. 2022). For instance, Ashraf (2009) examines how household financial choices around saving and spending are determined by dynamics of the husband-wife relationship including communication and privacy of information. However, patrilocality or the co-residence of women with the husband’s family, is common in several low- and middle-income countries (LMICs) – implying that family members besides the husband likely play a role in decisions that have a bearing on women’s welfare. Research has begun to take this aspect into account. In urban clusters of North India, Maxwell and Vaishnav (2021) show that how much say a woman has in household decision-making is contingent on her relationship with the head of the household: wives hold the strongest position and daughters-in-law the weakest. There is also evidence that living with the mother-in-law is a significant barrier to a woman’s mobility and ability to tap into social networks, leading to negative effects on access to and utilization of reproductive health services (Anukriti et al. 2020).
Moreover, these multigenerational households are situated within communities and the society at large. Hence, the potential influence of factors such as religion and culture on women’s healthcare decisions operates not just via beliefs held by them or their husbands but also those of the older generations who may exert control.
Matter of faith
Analyzing data from 13 West African countries, Onah et al. (2023) demonstrate that belonging to a particular religion or being in a polygynous household is associated with disempowerment in women’s social independence and decision-making, which in turn is associated with a lower number of antenatal care visits. The authors underline that while the tenets of the religion do not disempower women, religion and culture have become entwined over the years with religion becoming a part of the cultural context of many LMICs. The integration of the religion into the cultural and traditional practices of West Africa led to the emergence of relatively conservative societies with constraints on female autonomy. For example, it is noted that polygamy is not at the core of the practice of this religion nor non-existing in certain other religions, indicative of multifarious linkages between culture, religion, and marriage practices leading to the creation of gendered norms. Based on the findings of the study, the authors recommend the tailoring of policies and interventions to contextual characteristics like religion and marriage type, such that women may be empowered to access health services.
Munshi and Myaux (2006) put forth that societies typically have norms to regulate decisions such as fertility. Religious authority provides legitimacy and enforces rules, which sustains the equilibrium. Such social regulation may prevent individuals from responding immediately to new economic opportunities. When there are changes in the economic environment such as availability of modern contraceptives, the community possibly moves towards a new “reproductive equilibrium” at a slow pace. This may explain why responses to external intervention are slow and varied, as individuals go through a gradual process of learning via social interaction. In their study of a family planning program in rural Bangladesh, it is seen that even if all individuals in a village have access to the same family planning inputs, changes in reproductive behaviors occur independently across religious groups.
Taboos and superstitions
Kumar and Maity (2021) highlight the prevalence of menstrual taboos and restrictions on females in several cultural settings around the world, based on the belief that women are ritually impure during menstruation. Given that similar restrictions are also practised around the time of childbirth, the researchers use 2014 micro-data from Nepal (nationally representative Multiple Indicator Cluster Survey, conducted by UNICEF) to examine the association between menstrual restrictions and maternal healthcare access. It is observed that women who face any menstrual restrictions are more likely to give birth at home sans the assistance of trained medical personnel – raising the risk of maternal mortality. However, menstrual restriction is not correlated with receiving antenatal care such as tetanus injections or supplements during pregnancy. This suggests that it is the beliefs around menstruation that prevent the seeking of proper healthcare for delivery rather than an overall unwillingness to utilize modern medical care. Further, menstrual restrictions are linked with reduction in the subjective well-being of women (self-reported overall happiness), but only in the strictest cases as those involve seclusion and mandated behavioral changes.
In many parts of Africa, there is a superstition that maternal health risk stems from marital infidelity by either spouse. This traditional belief discourages women from seeking medical help in case of complications because of the associated stigma (Nsemukila et al. 1999). In their 2017 paper on Zambia, Ashraf et al. argue that such stigma can impede social learning in two ways: (i) most individuals hold both traditional and non-traditional beliefs about health risks and hence, learn more slowly about medical factors, causing them to underestimate personal risk; and (ii) since the victim stands to be blamed of being unfaithful, she has an incentive to hide indicators of risk from the spouse as well as other women, hindering social learning.
Gender-based practices and preferences
Another ancient gendered practice that may have a bearing on women’s healthcare decision-making is “bride price”. In many parts of sub-Saharan Africa, money or wealth transfer is given by or on behalf of the groom to the bride and her family as part of the marriage contract. The negotiated amount may be fully paid in one go or in installments over time. In their 2013 paper, Horne et al. examine whether “bridewealth” is linked to women’s reproductive autonomy, which in turn affects factors such as HIV risk, high fertility, and exposure to domestic violence. They conduct a study in Ghana to empirically establish that bridewealth, once paid, strengthens constraints on women’s choice over their reproductive behavior. The reasoning is that by paying bridewealth, the husband gains right over the wife’s “reproductive services”. This right is socially enforced and hence, any attempts by the woman to take autonomous action will likely be met with societal disapproval.
Further, the level of bride price holds relevance. Anthropological literature suggests that by paying a high bride price, the groom demonstrates his willingness to treat his wife well and avoid the risk of divorce. At the same time, based on the bride price, the wife can assess how much she is appreciated and if she is required to “gain reputation in the groom’s family by giving birth to many children.” Based on analysis of data from a survey of married couples in rural Senegal, carried out in 2009 and 2011, the researchers find that the higher the bride price, the lower is the fertility pressure on women. However, these payments hold less power over women who are economically independent (Mbaye and Wagner 2017).
Okereke et al. (2020) note the coexistence of gender-based preferences for primary healthcare providers and gender inequality within the health workforce in LMICs. In the context of maternal newborn and child health (MNCH) services in Nigeria, they find that 44% of the women in their study sample report having a preference for female health workers – reflecting “cultural norms, stereotypes and practices”. The researchers conclude that efforts to promote the acceptability of healthcare services from male health workers, can help increase the uptake of MNCH services.
Correcting beliefs around stigma, and leveraging religious leaders
It is possible that some individuals overestimate the degree of a stigma in their community, and correcting their beliefs may improve related healthcare-seeking behaviors. In the context of HIV testing, Yu (2019) conducted a baseline survey in Mozambique to measure the associated social stigma. Study participants who were found to overestimate the degree of stigma in their community were randomly assigned to receive an intervention to alleviate their concerns. This individually tailored intervention revealed the true extent of stigma, that is, it conveyed to the participant that people in their community were more accepting of those infected with HIV than what they thought. It is found that being subjected to the intervention raised the uptake of tests as well as the willingness to pay for tests – implying that the fear of being seen and stigmatized by neighbors was keeping people from taking an HIV test. Further, this information intervention was more effective for participants with more years of education as they were able to process the new information better. These findings make a case for public health campaigns to include informational components that raise awareness regarding diseases and also promote supportive attitudes towards affected persons.
Along the same lines, with regard to women’s work in Saudi Arabia, Bursztyn et al. (2020) explore the idea of “pluralistic ignorance” (Katz and Allport 1931) – a situation where most people privately hold an opinion but incorrectly believe that most other people hold the contrary opinion and hence, end up acting against their own views. Undertaking experiments and surveys, the researchers uncover that most married men in Saudi Arabia in fact support women working outside the home but substantially underestimate the level of support of the same by other men – even those from their own social setting such as neighbors. Addressing these beliefs makes married men more willing to let their wives look for work.
Based on the premise that a major reason women do not use family planning methods is uncertainty about compatibility with religious beliefs, Mwakisole et al. (2023) experimented with targeting an education intervention at religious leaders in rural Tanzania. It is seen that relevant medical information provided to religious leaders spreads beyond the leaders and religious institutions and into the communities – manifesting as an increase in uptake of family planning. The authors contend that the outcomes are driven by trust in religious leaders and prevalence of devout faith in the region. They note that “religious leaders are trusted community messengers who are highly skilled and culturally attuned to address sensitive health topics such as family planning in their own communities.” Similar results have been obtained in the context of one-off surgical or diagnostic health procedures like male circumcision (Downs et al. 2017) or HIV testing (Ezeanolue et al. 2015).
What about women’s non-reproductive health?
The literature summarized above explores the role of religion, culture, and stigma in relation to women’s reproductive health. Similar factors may be at play with regard to women’s health outside of reproductive health, such as women avoiding preventive care or screening that requires intimate examinations, fear of being labelled as “flawed”, expectations of modesty and privacy, and so on. Generating evidence in the context of women’s non-reproductive health can provide insights on the barriers to their healthcare-seeking more broadly, and inform the design and implementation of public health programmes as well as the development of more gender-sensitive health systems.
The kind of research summarized in this blog often involves the elicitation of preferences and measurement of beliefs. This tends to be challenging because of concerns such as “social desirability bias”, which is the reporting of opinions by survey respondents in accordance with what they believe would be viewed more favorably by others, rather than based on their true attitudes. To address these issues, various experimental and other methods are employed – which will be the focus of our next blog in November.
FOOTNOTES
1 In recent years, the practice of bride price has also been followed in other countries such as China (Davin 2005).
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