title: Context and heterogeneity: a novel approach to explaining maternal health inequalities in Zambia
Creators: name: Sochas, Laura
Publisher: name: London School of Economics and Political Science (LSE)
Year: 2022

description: Quantitative data from low- and middle-income countries show that inequalities in skilled birth attendance and health facility birth remain higher than inequalities in access to all other primary care interventions. Improving maternal health equity is increasingly prioritised in key policy, advocacy and accountability frameworks, such as the Global Strategy for Women’s, Children’s and Adolescents’ Health, the Sustainable Development Goals, and Countdown to 2030. However, we lack theoretically grounded evidence on why inequalities in healthcare access and experience persist, without which effective policies cannot be developed. This thesis by papers demonstrates a novel approach to the empirical explanation of maternal health inequalities, using the case study of Zambia. This thesis’ approach is rooted in social epidemiological, feminist, and sociological theories and makes use of mixed methods, including Bayesian multilevel modelling, interaction effects, decomposition, and analysis of in-depth interviews. This thesis advances our understanding of inequalities by theorising, measuring, and analysing the context in which individuals operate, instead of essentialising individual-level characteristics. Using multilevel models, I analyse the power of multidimensional health service environments to predict access to a health facility birth in Paper 11. Rather than solely defining the context geographically, I combine geographic characteristics (distance to any health facility, to a midwife, and/or to a hospital capable of conducting Caesarean sections) with social characteristics we know are discriminated against in the Zambian health system (being poor, having many children). I find that multidimensional health service environments have high discriminatory accuracy in the Zambian context. Social context is further explored in Paper 32, which analyses the role of social exclusion, shame and stigma in shaping women’s experiences of pregnancy and childbirth, particularly in their relationship with the health facility. I demonstrate that health facility rules play a key role in perpetuating social exclusion and reinforcing unequal power relations, both between patients and health workers, and among patients themselves. Paper 4 uses decomposition analysis to explore the extent to which health service environments are unequally distributed across more vs. less advantaged groups. I show that these environments explain a large share of socio-economic inequalities. This thesis also critically examines the assumption that policies, environments and individual characteristics have the same meaning and effect for different socio-economic groups. In Paper 23, I explore whether the association between facing a specific healthcare access barrier and having a facility birth differs according to how many other barriers a person faces. I find that for three out of the six barriers defined, the association is weaker the more other barriers are present. I theorise the implication of this finding for policies that seek to remove one barrier at a time in order to reduce inequalities and propose and formalise a new hypothesis I call: “The Concurrent Barrier Hypothesis”. In Paper 32, I show that while facility rules can be unequally applied, social exclusion works more strongly through “institutional bias”, in that the rules are harder to follow for women with fewer economic or social resources. In Paper 4, I use Kitagawa-Oaxaca-Blinder decomposition to investigate whether health service environments and individual or household attributes have different effects on access to facility birth depending on socio-economic status. I find that many individual characteristics (such as marital status, autonomy, and employment) have contradictory meanings across different socio-economic groups. This thesis not only contributes to the field of global health empirically, but brings a number of conceptual contributions by (1) Modelling an abstract and multidimensional social structure using random effects; (2) Developing and testing a new hypothesis on the unintended consequences of assumed pro-equity health policies; (3) Suggesting that the global discourse around disrespectful maternity care should be modified to include routine practices such as health facility rules; and (4) Proposing a novel empirical approach for quantitative researchers of global health inequalities to avoid “categorical thinking” (the practice of treating social categories as de-contextualised, natural, and internally homogeneous). The thesis concludes that the manner in which we conduct research matters for the policy and politics of maternal health, particularly from a social justice perspective.