Women's Status, Reproductive Behavior and Context in Nepal

Bina Gubhaju, Pennsylvania State University
Stephen Matthews, Pennsylvania State University

This research focuses on the influence of gender context on reproductive behavior among 1594 Nepali married women included in the 1996 Nepal Living Standards Survey (NLSS). The analysis is based on four dichotomous outcomes: use of prenatal care, assistance during delivery, knowledge of, and use of contraception. While many studies of reproductive behavior focus on individual-level or micro characteristics this research uses hierarchical models, specifically hierarchical generalized linear models (HGLM), to investigate whether contextual or macro characteristics matter. Geographical variation in gender development and empowerment across districts in Nepal suggest that research on women's status issues would be enhanced by the incorporation of contextual data. The macro-micro framework postulates that social forces at the macro-level determine micro-level opportunities and constraints, thereby influencing individual decisions. A renewed focus on the role of health and place can help direct attention to studying social contexts and processes particularly those relating to gender empowerment. Extended Abstract Preamble: This research described here will be presented as a poster though we intend having copies of papers to distribute to interested parties. Our analysis has only just begun and we do not have definitive findings to report at this stage but all the pieces for our analysis are in place. Our research takes advantage of geographic information system (GIS) technologies, such as exploratory spatial data analysis and data visualization tools as well as for the construction of the district-level contextual database. Analytically, we are currently constructing and testing models where the individual outcomes of interest are dichotomous. Incorporating contextual level variables in the models necessitates the use of hierarchical generalized linear models (HGLM). Our poster and accompanying paper will have the following structure. First we describe the theoretical framework, providing a brief review of the literature on gender development, women's status and empowerment at both the individual and contextual level. While this literature recognizes the potential importance of contextual variables our review finds that the degree to which such variables are explicitly incorporated in to the analysis varies. Second, we discuss the setting of Nepal and the importance of examining contextual variations at the district level as well as issues of women's status and empowerment in Nepal. Third, we introduce our chosen data set, the NLSS 1996 and the analytical methods we employ. As one of our primary aims is to discuss the derivation and linking of contextual-level data with NLSS, we include a brief description of geographic information systems (GIS) technologies and hierarchical linear modeling (HLM). Fourth, we present and discuss our findings. Finally, we broaden the discussion in the conclusions to suggest further avenues of research on women's empowerment, arguing that attention to processes operating at various spatial scales will help us better understand gender differences in health. Policies and programs conceived without consideration for local context will have limited impact unless they are informed by data that appreciates the vital connection between gender context and women's health. This abstract includes segments of the first three sections identified above: theory, significance, and data. Theoretical Review The U.N. Cairo Conference (1994) and the Beijing Conference (1995) on the status of women brought women's health status to center stage. There has been considerable discussion in the literature as to the precise definition and conceptualization of women's status as it is a broad and complicated concept. Women's status typically incorporates issues of women's autonomy, empowerment and various other dimensions within women's lives. The general consensus is women's status is an important determinant of reproductive behavior. Recently increasing attention has been given to the significance of contextual measures in sociological and demographic research, especially within the area of women's health. A woman's health is dynamic and responsive to her surroundings and is being shaped and influenced by the social, political, economic and environmental contexts in which she lives. The contextual focus raises the issue among researchers as to whether it is the individual woman's status that is more important in determining reproductive health outcomes or whether it is the larger social structure of gender systems that has more of an effect (Mason, 1987). The macro-micro framework postulates that social changes at the macro-level determine micro-level opportunities and constraints, thereby influencing individual decisions (Axinn and Yabiku, 2001). Empirical investigations of the macro-level gender context and its impact on reproductive behavior have been looked at in various contexts of Bangladesh (Balk, 1994), Nepal (Morgan and Niraula, 1995) and Nigeria (Kritz etal., 2000). These recent studies have found that regional differences in aggregate measures of the overall position of women produce significant differences on an individual's reproductive behavior. It has generally been noted in these studies that while the status of an individual woman is an important factor, the macro-level context of gender equality that surrounds an individual also contributes substantially to differences in reproductive health outcomes. In the prior literature that has been reviewed, not much has been done with linking individual-level data with contextual-level measures that have been collected specifically at the macro level. In both of the studies by Balk (1994) and Kritz etal. (2000) contextual level gender equity indices have been obtained by aggregating responses at the individual-level. The linking of individual data with community level data has been noted in research examining determinants of infant mortality (Sastry, 1996; Andes, 1996). The lack of similar types of research is attributed to the limited availability of community data that can be linked to household and individual surveys. Research using similar methods would be of particular importance and relevance to policy makers since it has been noted that omitted community variables can play a significant role in determining a particular outcome (Sastry, 1996). Significance Nepal is a very poor country and one of the few where women's life expectancy is less than their male counterpart. The lower female life expectancy is a consequence of higher childhood mortality among girls and very high maternal mortality (850 to 1000 per 100,000 live births). The maternal mortality of a country is a good indicator of the overall health status of women. Sub-nationally, there exist wide variations on gender development indices (GDI) and gender empowerment measures (GEM). These variations are evident across the frequently used geographical typologies of Nepal - ecological zones, development regions and districts - suggesting that research examining women's status factors might be enhanced if they are able to consider contextual factors. District level data compiled from government sources including the Nepal Human Development Report and the Department of Health Services annual reports show vast inter-district disparities in fertility, morbidity, mortality as well as measures of health and human development. To date no nationally representative study of Nepal has explicitly incorporated contextual data at the district level, linked them with individual data responses and then analyzed them using multivariate hierarchical methods. We would argue that our macro-micro level analysis, using the district as context, contributes substantially to the existing literature. Data The 1996 Nepal Living Standards Survey (NLSS) is a nationally representative multi-topic survey. Date was collected on different aspects of household welfare (consumption, income, housing, labor markets, education, and health). The sample used for the present study consists of currently married women ages 15-49 that have given birth in the last 3 years (N=1594). Our analysis will focus on four dichotomous dependent variables: measures of prenatal care, assistance during delivery, knowledge of, and use of, contraception. Following from our literature review our models include an array of salient independent individual-level variables on ethnicity, literacy, education, age, age at marriage, birth order, women's wage employment, economic status of household, urban/rural residence, and measures of access to health facilities. We have used geospatial data and geographic information systems (GIS) to link NLSS women to district-level contextual variables. These district level variables include two indices derived for the Human Development Report 1998: GDI and GEM. In addition, we draw on other district level data including measures of community development, per capita income, density of health professionals and measures of the availability of health services, infant mortality rate, contraceptive prevalence rate, life expectancy, and literacy. References Andes, N. 1989. "Socioeconomic, Medical Care, and Public Health Contexts Affecting Infant Mortality: A Study of Community-Level Differentials in Peru." Journal of Health and Social Behavior 30(4):386-397. Axinn, W.G.and S.T. Yabiku. 2001. "Social Change, the Social Organization of Families, and Fertilty Limitation." American Journal of Sociology 106(5): 1219-1261. Balk, D. 1994. "Individual and Communtiy Aspects of Women's Status and Fertility in Rural Bangladesh." Population Studies 48(1):21-45. Kritz, M.M., P. Makinwa-Adebusoye, and D.T. Gurak. 2000. "The Role of Gender Context in Shaping Reproductive Behavior in Nigeria." 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