Key Social Norms Take-aways This study illustrates how social norms at the community level—and how individuals deviate from them—play a significant role in shaping maternal health care utilization in Bangladesh. The concept of “positive” and “negative” deviance is used to understand how individuals who differ from prevailing community norms experience different health outcomes. Women who deviated positively from norms (e.g., higher education or delayed marriage) were sometimes more likely to use services, while others who were negatively deviant (e.g., unemployed in highly employed communities) also accessed care, possibly due to increased household privilege. Crucially, norms around gender—especially the justification of intimate partner violence—negatively influenced care-seeking when widely accepted in communities. This approach reveals that deviation from dominant norms, in either direction, can matter for health behaviors and points to the need for social norms change to improve equitable access to maternal health services.
Objectives To examine whether women’s positive or negative deviation from local community norms related to socioeconomic status, fertility, gender, and media exposure are associated with their use of antenatal care, delivery care, postpartum care, or all three services in Bangladesh.
Methods The authors analyzed data from 4,106 ever-married women aged 15-49 from the 2014 Bangladesh Demographic and Health Survey. A multilevel logistic regression approach was used to model associations between maternal health care outcomes and deviance variables, which compared individual characteristics to community-level averages (constructed from primary sampling units). Deviance was categorized as positive or negative based on whether a woman’s characteristic exceeded or fell below the community norm.
Results Use of maternal health services was low overall: 27% of women had four or more antenatal care visits, 40% had delivery care, 63% had postpartum care, and only 17% had received all three. Deviance measures revealed nuanced associations: positive deviance in exposure to family planning messages, low justification of IPV, and husband’s employment were linked to greater use of delivery care. Conversely, positive deviance on husband’s employment was associated with lower postpartum care—possibly due to men’s absence for work. Community norms justifying IPV and favoring larger families were negatively associated with service use. Higher community education levels, especially among women, were consistently linked to increased service uptake.
Conclusions Maternal health interventions should consider not just individual and community-level factors, but also how women diverge from local norms. Programs that target community norms—especially those related to gender roles, violence, and autonomy—are essential to improve health service utilization and maternal outcomes in Bangladesh.