Married women who have good relationships with their husband and in-laws are more likely than those with poorer relationships to obtain maternal health care, according to a study conducted in India.1 Among women who lived in nuclear families, those who reported having few problems with their husband were more likely than those with many difficulties to have obtained antenatal care (odds ratio, 4.1) and delivered in a health facility (2.3). Among women who lived with their husband's family, those reporting very few difficulties with their in-laws were more likely to have received antenatal care than women who had some or many difficulties (1.5). Women's agency in controlling money and their own mobility accounted for much of the association between relationship quality and receipt of maternal health care services.
The data come from the 2002 Women's Reproductive Histories Survey, conducted in Madhya Pradesh, India. The randomly selected, household-based sample consisted of 2,444 married women aged 15–39 who had at least one child. Respondents provided information concerning their education, caste, parity and other factors that may affect health care use and relationship quality.
In addition, for each pregnancy interval in the past 15 years that had ended in a live birth, respondents were asked about the type of maternal health care they had received, as well as their degree of agency, wealth and relationship quality with their husband and in-laws. A pregnancy interval was defined as the period between marriage and the end of a woman's first pregnancy, or between the end of one pregnancy and the start of the next. Maternal health care services included in the analyses were antenatal care (having any checkups vs. none) and delivery in a formal health care facility. Two aspects of a woman's perceptions of her agency were assessed: the number of restrictions placed on her mobility (measured on a four-point scale ranging from too many to no restrictions) and how frequently she needed permission to spend money (ranging from always to never). Wealth was categorized according to how easily the household was able to meet expenses at the beginning of the pregnancy interval; the four response options ranged from easy to difficult. Finally, relationship quality was categorized according to whether the respondent reported having many, some or very few difficulties with her husband and in-laws at the start of the pregnancy interval.
Analyses were conducted separately according to whether women lived in a joint family (with their in-laws) or in a nuclear family (without in-laws) at the start of the pregnancy interval. In addition to tabulating descriptive data, the researcher created multi- variate models to identify associations between health care use and other variables; the models of antenatal care excluded the 28% of pregnancies that occurred to women who believed such care is unnecessary.
Of the 7,031 pregnancies included in the sample, two-thirds (68%) occurred to women in joint families. Women received antenatal care during 34% of pregnancies, and delivered in a facility in 21%. In 56% of pregnancies to women with in-laws (regardless of whether they were living with them), women reported having very few difficulties with their husband's family; 36% had some difficulties and 7% many. Very few marital difficulties were reported during 74% of pregnancies, some difficulties for 22% and many difficulties for 4%. In the majority of pregnancies, women had no formal education (64%); the same was true for only 31% of husbands.
Women's agency was stronger in nuclear than joint families. During 75% of pregnancies to women in nuclear families, women reported few or no restrictions on their mobility, compared with 58% of pregnancies to women in joint families. Similarly, during 59% of pregnancies to women in nuclear families, women reported sometimes or never needing permission to spend money, compared with 42% of those to women who lived with in-laws.
In multivariate analyses, women in joint families had a higher likelihood of obtaining antenatal services if they reported very few, rather than some or many, difficulties with in-laws (odds ratio, 1.5). Among women in nuclear families, having no in-laws was associated with increased odds of hospital delivery (1.7); relationship quality with in-laws was not associated with facility births. Marital relationship quality was a predictor of maternal health care use only in nuclear families: Compared with women who reported many difficulties with their husband, those who reported very few were more likely to have obtained antenatal care (4.1) and delivered in a health facility (2.3); those with some difficulties also had elevated odds of a facility delivery (2.5).
In nuclear families, the odds that women had obtained antenatal care or delivered in a facility were higher when covering household expenses during pregnancy was easy rather than difficult (odds ratios, 3.6 and 2.3, respectively); in joint families, finding it easy to meet expenses was associated only with antenatal care (2.2). In both types of families, women with some education were more likely than those with no schooling to have used maternal health services; the odds were particularly high among those with 10 or more years of education (5.1–14.8). Having a husband with at least 10 years' education was associated with elevated odds of receiving services among women in joint families (1.7–2.1).
Many of the associations between relationship quality and maternal health care use disappeared when measures of women's agency were added to the model. In nuclear families, women without in-laws had elevated odds of hospital delivery in the expanded model (odds ratio, 1.8); however, the three other associations between relationship variables and maternal health care use were no longer significant once agency was taken into account. In joint families, the association between having a good relationship with in-laws and receiving antenatal care was reduced slightly after agency was accounted for (1.4).
The results, according to the author, suggest that the association between relationship quality and health care use may depend in part on family structure. In nuclear families, where the husband tends to head the household, marital relationship quality is particularly important; in joint households, in-laws may have substantial decision-making power, so relationships with in-laws may have a vital impact on women's health. However, she points out that women's agency appears to be an important mediator: "High-quality family relationships bestow greater agency, which, in turn, helps women secure access to maternal health-care services."
The researcher also notes that research on the link between relationship quality and health outcomes has typically focused on whether domestic violence occurs in the relationship. While this research is very important, "focusing exclusively on domestic violence … conceptualizes family relationships as varying in quality from negative to neutral," and thus may overlook the benefits of good relationships. She acknowledges, however, that this concern was only partially addressed in the current study: Because most women reported having very few problems in their relationships, the measure used was not able to distinguish between the very best relationships and those that were simply good.—H. Ball
1. Allendorf K, The quality of family relationships and use of maternal health-care services in India, Studies in Family Planning, 2010, 41(4):263–276.