Women's social networks and child survival in Mali
Introduction
A large and established literature conceptualizes child heath and survival as the causal outcome of proximate and more distal social and economic influences that operate at individual, household and community levels. Among the most well-known of these models is the Mosley and Chen (1984) framework for child survival,1 which links the proximate causes of child death to broader socioeconomic determinants ranging from: (1) caregiver attributes such as mother's education and health related beliefs and practices; (2) household level factors including food availability and resources for preventive and sickness care, and (3) community-level ecological, political and health systems characteristics.
There is a growing awareness, however, of the limitations of causal models of child survival that fail to capture the complex interactions between individual characteristics, household circumstances and community-level attributes. In their discussion of the problems associated with household-level analysis, Berman, Kendall, and Bhattacharyya, 1994 note that “the boundaries of (a woman's) household and mechanisms of influence on decision-making, service use and expenditure depend on the particular (life) stage…being studied and differ across regional, religious and other social groupings” (1994:207). In short, the physical and temporal boundaries inherent in prevailing models of child survival hamper our understanding of the complex social mechanisms by which health is produced. A woman may be located in a household with limited material resources, however, due to her position within the local social hierarchy, is able to access sources of support beyond the confines of her household even in resource-poor communities.
While underdeveloped in models of health and child survival, the argument that women's social ties or networks are instrumental in resource mobilization is well established in the economic and anthropological literatures (Guyer, 1981; Rogers, 1978). Indeed, some authors have found evidence of a link between women's involvement in formal and non-formal networks and increased self-esteem and control over resources (Hashemi & Schuler, 1996; Huda & Mahmud, 1998). Curiously, however, there have been relatively few attempts to systematically explore the influence of women's social networks on health outcomes in the developing country context (Dyson & Moore, 1983; Shisana & Celentano, 1987; Carey, 1993; Myntti, 1993; Castle, 1994)—even more surprising given the prominence of this area in the Western sociological literature. Starting with the pioneering work of Berkman and Syme (1979) in Alameda county, subsequent explorations have revealed a powerful connection between the structure and supportive function of social networks, and increased individual survival and physical health (Cohen & Syme, 1985; House, Landis, & Umberson, 1988). While the precise mechanisms remain elusive, social networks are seen to benefit health by reducing stress and/or insulating individuals from stress or events, and enabling coping through access to needed support (Cobb, 1976; Cohen & Syme, 1985; Oakely, 1992; Thoits, 1995).
With the exception of a small body of work that concerns the implications of social disruption such as parental divorce or immigration on the health and wellbeing of children, the bulk of published work on social networks and health has focused on the health of ego, or the individual concerned (Mechanic & Hansell, 1989; Amato & Keith, 1991; Mauldon, 1990; MacIntyre, 1992). In the Western context, this emphasis is understandable, given the insignificant influence of a caregiver's social networks on child survival relative to institutionalized social services and medical care. In the context of developing countries, on the other hand, where access to health and social services are limited, a mother's ability to command social resources may make an important difference to child health and survival. In resource-scarce environments such as Mali, West Africa, the pertinence of a social network approach to understanding and promoting child survival becomes apparent. First, it overcomes the artificial boundaries between the mother–child dyad, and the household and community in which they are physically located. Specifically, a network approach incorporates the wide range of resources that mothers mobilize to support the health and wellbeing of their children, both within and beyond the household. Second, the measurement of women's social networks presents an opportunity to assess one of the potential mechanisms that mediate the known (yet poorly understood) association between child survival and caregiver psychosocial and educational attributes.
This paper explores the influence of women's social networks on child survival through a comparative investigation of the relationship between social network size, function and composition and child survival in Mali. In doing so, the typical focus on care provided within the confines of the mother–child dyad is broadened to include the supportive function of social worlds beyond this dyad. Implicit in the paper's focus on the social networks of the mother is the assumption that they will have greater impact on child survival than the networks of other caregivers. Indeed, it is presumed that a mother's network will incorporate the influence of other caregivers. The paper considers two ethnic groups, the Bamanan and Fulbe, due to their poignant demographic and cultural differences, and rich potential for cross-cultural comparison and theory building. Child mortality (1–5 years) is chosen as the health outcome of interest given that death at this age is largely attributable to social environmental or exogenous causes, and hence, more likely to be sensitive to variations in caregiver attributes or social resources than infant mortality rates. The paper begins by describing the study context, and the data and measures used in analysis. Bivariate and multivariate results are presented and subsequently discussed in light of verbal autopsy data and the broader literature.
Section snippets
Background
Mali ranks among the poorest of developing countries according to standard indicators of macroeconomic performance and human development. 70% of its 7.7 million inhabitants live in rural areas, 50% are under 15 years of age and just 18% of rural men (aged 6+) and 10% of rural women have attended school (DHS, 1996). With a GNP estimated at $250 per capita, basic social services in Mali are extremely limited in scope and coverage, including healthcare infrastructure and provision (WDR, 1997). The
Data and methods
The data used in this paper are drawn from a comparative study of women's social networks and their impact on child and maternal health in Mali conducted during the period February 1996 to May 1997 (Adams & Castle, 1995). The survey was administered in two geographically distinct sites that represent Bamanan and Fulbe populations respectively. With the assistance of NGOs working in each region, a range of villages were chosen based on criteria of village size, and proximity to market and health
Analysis techniques
Cox regression models are used to examine the association between women's social networks, and the odds of a child dying between the ages of 1 and 5. Cox models are preferred given that child survival is conditional on having survived till the age of 1. All the independent variables with the exception of mother's age are treated as time constant co-variates. A death is treated as an event while the end of observation is treated as censored. It should be noted that although separate models were
Results
Table 1 presents the demographic characteristics of the full sample of Bamanan and Fulbe women included in the study.
While woman's median age at marriage, median age at first birth, and age distribution are similar in both groups, notable differences are also apparent. Consistent with the literature, the percentage of women in polygynous unions is far greater among the Bamanan, while the probabilities of infant and child death, estimated using the life table method, are markedly higher among
Discussion
This paper documents inter-cultural variation in the structure and function of women's social networks in Mali, and explores, in a preliminary fashion, their implications for child survival. Much of the observed variation between Bamanan and Fulbe can be attributed to group differences in household size, formation and function, and to their distinctive ecological and economic circumstances. Indeed, a combined model that tests the effect of ethnicity on the odds of child death reveals its
Acknowledgements
The research on which this paper is based was funded by the National Science Foundation, and supported by the Mali field offices of Save the Children USA and UK. We also acknowledge the contributions of Sarah Castle and our Malian colleague, Aisse Diarra, whose understanding and commitment to rural women inspired and facilitated every aspect of the research.
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