RMH Individual Assignment

Neelabh Kashyap (H2019027)

Research question / Research Problem:

Does maternal literacy affect the rate of institutional deliveries in rural Assam?

Background or justification of the research question:

Institutional delivery is very much crucial for the health of both mother and the child. Skilled
attendance at the time of birth is very essential. Apart from skilled professionals, delivery at a
proper setup is of utmost importance as it provides hygienic and life-saving equipment and
facilities which significantly reduces birth related complications. Hence institutional delivery is
commonly targeted strategy to combat national health problems like high IMR (Infant Mortality
Rate) and MMR (Maternal Mortality Rate).
In several studies related to determining the factors affecting institutional deliveries, it was found
that almost in every studies the mothers’ literacy played an important role. If the quantitative
relationship between mothers’ education and institutional delivery rates can be established, it will
be a great advantage in setting proper strategy to improve maternal as well as perinatal health
condition in India.

Literature review related to research question:

A. Name of the article: Determinants of Institutional Delivery among Childbearing Age
Women in Western Ethiopia,2013: Unmatched Case Control Study.
Authors: Tesfaye Regassa Feyissa, Gebi Agero Genemo
PLoS ONE; Published May8,2014
This paper contains a study about the various factors affecting institutional delivery in
Western Ethiopia in 2013. The study assessed 6 determinants regarding institutional
deliveries. Total sample size was 320 and data were collected with the help of
structured and tested questionnaires. Data were analysed using SPSS software. It was
found that along with five other factors, Education of mothers played an important role
in institutional deliveries (Adjusted Odds Ratio=2.754(1.510-8.911) at 95% confidence
interval).
B. Name of the article: Determinants of Institutional Delivery in Rural Jhang, Pakistan.
Authors: Sohail Agha, Thomas W Carton.
International Journal for Equity in Health
This study determines the factors associated with institutional deliveries in Jhang
district in Pakistan through a household survey. Data were collected from around 2000
women and were analysed with the help of Regression tool. The study reveals that
education and parity are among the most influential factors.
C. Name of the paper: Institutional delivery in public and private sectors in South Asia: a
comparative analysis of prospective data from four demographic surveillance sites.
Authors: Sushmita Das, Glyn Alcock, Kishwar Azad, Abdul Kuddus, Dharma S
Manandhar, bjhim Prasad Shrestha, Nirmala Nair, Shibanand Rath, Neena Shah More,
Naomi Saville, Tanja A J Houweling, David Osrin.
BMC Pregnancy and Childbirth.
The study aims to summarize the effect of four parameters i.e. household asset index,
maternal age, maternal schooling and parity on institutional deliveries. A logistic
regression model was used to analyse the collected data. The study shows that the
incidence of institutional delivery increased in private facilities with the increase in
wealth, maternal education and age.
RMH Individual Assignment
Neelabh Kashyap (H2019027)

Study objective:
Objectives of the study are:
 To find out whether is there any association between maternal literacy and institutional
deliveries.
 To quantify the relationship statistically if such association exists.
Variable of the study:
The dependent variable involved in the study is the percentage of institutional deliveries out of
total deliveries. This variable is continuous in nature and can be measured by obtaining the
number of institutional deliveries and total number of deliveries.
Independent variable involved here is maternal literacy. It can be obtained in a discrete form
on the basis of the following categories: i) no education, ii) up to 10 th std, iii) up to 12th std, iv) up
to graduate and v) above graduate level.
The following may act as confounding factors in the study:
a. Economic status of the mother: Economically sound mothers can afford private hospitals
for delivery, which may not be possible with economically lower strata of population. It
can affect the dependent variable apart from the independent variable under the study i.e.
maternal literacy.
b. Geographical location: Accessibility to healthcare depends largely on the government and
private providers in a particular location. For example: in India, the healthcare
accessibility is very high in states like Goa, Kerala, Tamil Nadu etc. whereas in the North
-Eastern states accessibility is relatively very less. This factor may unwantedly affect the
dependent variable.
c. Rural-urban divide: In a particular state also, the accessibility to healthcare differs
significantly in the rural and urban areas. The rate of institutional delivery in the urban
areas will probably be high as compared to the rural areas irrespective of the educational
status of mothers. Hence, this may act as a confounding factor.

Hypothesis:
The Null hypothesis (H0): there is no association between maternal education and institutional
deliveries.
The Alternate hypothesis (H1): there is significant association between maternal education and
institutional deliveries.
Research Design
d. Brief description of the overall design:
The study involves the comparison of the percentage of institutional deliveries among the
previously mentioned groups having different educational qualifications. The number of
samples and sampling technique has been described in the following sections. Data will be
collected through structured interviews with specific questions.
To remove the confounding variables the study is designed in a specific way. To remove
the interference of rural urban disparity, the study will only be conducted in the rural areas.
To remove the effect of Government policies the study is to be conducted in Assam only.
At the end, to remove economic status as a confounding variable the sample will contain
equal weightage from each economic stratum.
e. Sampling design:
i. Description of population –
All women who have given birth to their siblings between 2015-2019 in Assam.
ii. Sample size:
Sample size (n) is given by the formula mentioned below,
RMH Individual Assignment
Neelabh Kashyap (H2019027)

N= (z2)P(1-P)/d2 = 385
Where, z= 1.96 for confidence level= 95%
Probability of picking a choice(P)=0.5
Error (d)= 0.05

iii. Sampling technique:

Due to a large number of populations, multi-stage sampling technique can be used.
a. Stage 1: The state is divided district-wise into 33 areas.
b. Stage 2: From each district 5 villages is to be selected randomly.
c. Stage 3: From each selected village 3 mothers are needed to be interviewed.

f. Observational design:
i. Specific data to be collected:
We need to collect the following data: i) whether delivery was in hospital or at
home, ii) their educational qualification in the already mentioned five categories.
ii. Method of data collection:
Data is to be collected via interviews. The following questions are needed to be
asked:
1. Demographic details including name(optional), age and address.
2. Location of delivery.
3. Educational qualification: i) no education, ii) up to 10 th std, iii) up to 12th
std, iv) up to graduate and v) above graduate level.
iii. Possible biases: Biases that can affect your data
iv. Strategy to reduce bias
g. Statistical design:
For analysis and interpretation, the collected data can be arranged as given below.
Education of the No. of institutional No. of home Percentage of
mother deliveries deliveries institutional
deliveries
No education
Up to 10th std.
Up to 12th std.
Up to graduate
>graduate
We can obtain an education of the mother (along the x axis) vs percentage of institutional
deliveries (along the y axis) and interpret the trend.
h. Operational design:
The following protocols should be adhered while data collection and sampling:
To remove acquiescence bias, the proper interviews with the clear-cut question should be
taken instead of circulating questionnaires. To avoid any social desirability, name of the
interviewed mother should be made optional. While collecting data the respondents should
be informed about the purpose of collection of data and the collected data should be kept
confidential with the interviewer.
Limitations in the above design:
The study has some limitations on the basis of its design. The first one is the analysis of data. It
will only depict the trend between maternal education and the rate of institutional deliveries
graphically. Whether the differences in the percentage among the various educational categories
RMH Individual Assignment
Neelabh Kashyap (H2019027)

are statistically significant or not could not be found out. A modification in the study design may
be required to eliminate this limitation.
Another limitation is that the findings from the study can be generalized only to those areas the
healthcare environment including government policies, public/private health insurance availability
resembles to that of rural Assam.
Findings and conclusion:
From the study, we will be able to know the following g facts:
 Whether maternal education affects the rate of institutional deliveries or not
 If it does, what the trend is.
Overall from the study we will be able to know the significance of maternal education with
respect to institutional delivery rates. It is well known fact that with education comes
awareness. But up to what extent education can promote institutional deliveries apart from the
other influencing factors such as transportation, mother’s age, house hold conditions etc is the
main aim of this study. This study fills the gap between availability of healthcare facilities and
their extent of utilization.
Implication:
Findings obtained from the study will be very much helpful for the healthcare policy makers. If
there is a significant positive impact of maternal education on the rate of institutional deliveries,
maternal education might be targeted more in the future in setting policies to combat IMR and
MMR. Government spends a significant amount of resources in building healthcare infrastructure
and providing healthcare. But all of these won’t be useful until and unless they are utilized by
common population. Education has a great power in creating awareness among people. This study
will guide such awareness in terms of utilization of resources available for safer delivery of birth.
References:
1. Agha S, Carton TW. Determinants of Institutional Delivery in Rural Jhang, Pakistan.
International Journal for Equity in Health. 2011.
http://www.equityhealthj.com/content/10/1/31
2. Das S, Alcock G, Azad K. Institutional delivery in public and private sectors in South
Asia: a comparative analysis of prospective data from four demographic surveillance
sites. BMC Pregnancy and Childbirth. 2016. DOI 10.1186/s12884-016-1069-7.
3. Feyissa TR, genemo GA. Determinants of Institutional Delivery among Childbearing
Age Women in Western Ethiopia,2013: Unmatched Case Control Study. PLoS ONE.
2014.