Is religion the forgotten variable in maternal and child health? Evidence from Zimbabwe
Introduction
The role of religion in explaining health access and health outcomes in Africa has received increasing attention (Ensor and Cooper, 2004, Ellison and Levin, 1998). This is certainly welcome as Africa is poised to be one of the most religious continents in terms of both religious affiliation and religious practices (PEW Research Centre, 2010). Existing research differs in explaining the causal mechanisms behind observed relationships between religion and health. Followers of the ‘particularized theology hypothesis’ consider that the doctrinal teachings, beliefs and values of religious groups directly influence health outcomes. Alternatively, those supporting the ‘selectivity hypothesis’ claim that disparities in observed behaviour between religious groups mainly reflect differential access to social and human capital which in turn determines health access and outcome rather than religion per se (Gyimah et al., 2006, Addai, 1999). Results from studies carried out in the Sub-Saharan African context have so far yielded equivocal support for each view. Studies examining relationships between religion and health outcome largely substantiate the selectivity hypothesis (Gyimah et al., 2006 and Antai et al., 2009). In contrast, studies focussing on the pathways between religion and access to healthcare tend to support the ‘particular theology’ hypothesis (Gyimah et al., 2006 and Antai et al., 2009).
One difficulty is that these studies generally combine many denominations into a single Christian or Muslim group and have neglected inter-denominational diversity. In particular, little attention has been paid to the African Independent Churches, a formidable force of religion in Africa. These churches have come from the spiritual revolution under western colonial rule during the late nineteenth century when African traditional religions encountered the Christian faith (Ranger, 1999). By one account, their adherents are estimated at around 55 million on the African continent and in the diaspora (Barrett and Johnson, 2001). This study will focus on the ‘spiritual’ churches known as Zionist or Apostolic which sought independence from more conventional missionary churches on doctrinal grounds including the role of spiritual healing and ‘Jordan baptism’ (Hayes, 1992, Andersen, 1995, Imunde and Padwick, 2008).
Zimbabwe has been one of the strongholds of the African Apostolic church. Although the exact following of the Apostolic movement in the country has not been determined with certainty, we have pieced together the best available estimates from available Demographic and Health Surveys and the Multiple Indicator Cluster Survey (MICS). Data indicate a rather rapid growth of the group from 20% of the population in 1994 and 21.5% in 1999 to 27% in 2009 (Central Statistical Office Zimbabwe and Macro International Inc, 1995, Machingura, 2011, ZIMSTAT, 2010). This would put the current population following the Apostolic faith at 3.5 million and translates into a 1.4 million increase over the 15-year period. This growth of Apostolic faith coincided with the development of an HIV/AIDS crisis, a downward spiral of the Zimbabwean economy and the consequent collapse of the health sector, arguably once one of the best in Africa. Since 2009, the Inclusive Government with support from development partners has been trying to rebuild the health system and increase the coverage of important maternal and child health interventions (Government of Zimbabwe and UN, 2010, UNICEF, 2010). It is more urgent than ever to ensure that the available critical maternal and health services are taken up in a timely and effective manner without undue interference (Pearson and Makadzange, 2008).
Apostolic churches in Zimbabwe have been found to affect adherents' health access and health outcomes in several ways. Firstly, the churches provide necessary social support to their members in times of great change or adversity which can positively support improved physical and mental health (Mpofu et al., 2011). Secondly, their strict doctrine and moral codes on sexual behaviour may offer perceived protection from HIV infection. These have been confirmed in small sample surveys by Gregson et al. (1999) and Pearson and Makadzange (2008). Lastly, but most pertinent to our focus on maternal and child health, Apostolic churches emphasize prophet-healing through prayers and the action of the Holy Spirit. Any use of western and modern medicine is seen as exhibiting little faith in God and is strongly prohibited. Despite recent changes in ideology aimed at improving access to health services for members of the Apostolic faith and spearheaded by the Union for the Development of Apostolic Churches in Zimbabwe (UDA-CIZA), traditional beliefs still prevail especially among the ultra-conservative Marange and Madhidha Apostolic groups (Maguranyanga, 2011). The recent rise and spread of measles outbreaks were allegedly linked to Apostolic gatherings. Despite nationwide campaigns to ensure that every child in Zimbabwe is immunized, pockets of religious objection exist and these remain of concern (UNICEF, 2010). These deleterious impacts on access to health can also be exacerbated by the asymmetric power that the churches bestow to men and husbands which constrains women's decision-making in relation to health. Indeed, Gregson et al. (1999) found that in the 1980s, children from the Apostolic churches had much higher infant mortality rates. By the 1990s, however, in Honde Valley in Manicaland, this difference had disappeared. Hove et al. (1999) have documented that mothers belonging to Apostolic faith were less likely to have used postnatal care services in Kuwadzana, a suburb of Harare. These studies are however based on small samples in a few confined areas and thus their results cannot be extrapolated to other parts of the country. A notable exception is the work of Hallfors et al. (2013) where data from Zimbabwe's Demographic and Health Survey 2005 was used to show that Apostolic women were at a higher risk of HIV infection via the early marriage channel. Yet, this study controlled only for age and omitted other potential mediating factors, it cannot be used to refute the ‘selectivity’ hypothesis with confidence.
It is against this background that this present study will contribute to the literature by using the latest nationally representative household data and the established Andersen conceptual framework on access to health services (Andersen, 1995, Andersen, 2008) to examine the relationship between the Apostolic faith and the take-up of child immunization and maternal health care services in Zimbabwe while controlling for a large set of mediating factors.
Section two introduces the data and the empirical strategy used in this paper. Section three reports the empirical findings followed by Section four that draws conclusions and discusses the implications of this paper.
Section snippets
Data
This study utilizes data from the Multi Indicator Monitoring Survey (MIMS) 2009, a customized version of the Multi Indicator Cluster Survey (MICS). MICS is designed to collect statistically sound data to assess the situation of children and women in the areas of education, health, gender equality, rights and protection. As part of a worldwide survey programme, MIMS is a nationally representative survey implemented by the Zimbabwe National Statistics Agency (ZIMSTAT) in collaboration with
Maternal health
The results obtained from the logit regression models relating maternal health outcomes to predisposing and enabling factors are presented in Table 3 below. The table shows only the impact of religious affiliation and other significant mediating factors on maternal health care services. Results from the full model are available upon request from the authors. In specification 1, only religion variables were included while specification 2 included all the predisposing factors, enabling factors
Conclusion and discussion
Employing the latest household survey data from MIMS 2009 and applying the established Andersen model on access to health services (Andersen, 1995, Andersen, 2008), our study shows that membership of the Apostolic faith in Zimbabwe was associated with significantly lower odds for access to basic maternal and child health services. This association remained even after adequately controlling for other mediating factors. Moreover, even when services are readily available at little cost and when
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