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Health Prospect
Journal of Public Health
Open Access
http://www.healthprospect.org/archives/14/1/2.pdf
Correspondence:
1Prof. Edwin van Teijlingen, PhD
Centre for Midwifery, Maternal & Perinatal Health
Bournemouth House
19, Christchurch Road
Bournemouth University,
England, UK.
Tel: +44 (0)1202-961564
Email: vanteijlingen@bournemouth.ac.uk
van Teijlingen E1, Benoit C2, Bourgeault I3, DeVries R4, Sandall J5, Wrede S6
2 Cecilia Benoit, PhD, University of Victoria, Canada
3 Ivy Bourgeault, PhD, University of Ottawa, Canada
4 Raymond DeVries, PhD, University of Michigan USA & Hogeschool Zuyd, Maastricht University, the Netherlands
5Jane Sandall, PhD, King’s College London, UK
6Sirpa Wrede, PhD, University of Helsinki, Finland
Abstract
It is widely accepted that policy-makers (in Nepal and elsewhere) can learn valuable lessons from the way other coun-
tries run their health and social services. We highlight some of the specic contributions the discipline of sociology can
make to cross-national comparative research in the public health eld. Sociologists call attention to often unnoticed
social and cultural factors that inuence the way national reproductive health care systems are created and operated.
In this paper we address questions such as: ‘Why do these health services appear to be operating successfully in one
country, but not another?’; ‘What is it in one country that makes a particular public health intervention successful and
how is the cultural context different in a neighbouring country?’ The key examples in this paper focus on maternity
care and sex education in the Netherlands and the UK, as examples to highlight the power of cross-national research.
Our key messages are: a) Cross-national comparative research can help us to understand the design and running of
health services in one country, say Nepal, by learning from a comparison with other countries, for example Sri Lanka
or India. b) Cultural factors unique to a country affect the way that reproductive health care systems operate. c) There-
fore, we need to understand why and how services work in a certain cultural context before we start trying to implement
them in another cultural context.
Keywords: sociology; comparative studies; culture.
Submitted: 24 October 2014; Revised: 03 April 2015; Accepted: 28 June 2015
Vol 14 | Issue I | July 2015
Introduction
Cross-national comparative research is a key tool in the
social and health sciences, but such comparative research
is not without its challenges (1, 2). When the organisation
of health care is the topic at hand, such research is typi-
cally concerned with making comparisons across coun-
tries that are relatively similar in regard to their economy
and policy (3). One area of keen interest in cross-national
health care research has been the organisation of public-
ly-funded reproductive health care and, more particularly
maternity care (4-6). A quick glance at the available evi-
dence shows that the care system as well as the public/
private mix of “services” available to residents can vary
signicantly, even in countries that are relatively similar.
Socio-economic factors, including income and wealth dis-
tribution, have been linked to variation in and between
health care systems (7, 8), as has the impact of neoliberal
market-mindedness on the medicalisation of maternity
care (9). Cultural factors also play a major role in shaping
the content and delivery of health services (10).
One of the earliest comparative studies of the organisa-
tion of health care found that the countries considered
-- the United States (US), England, West Germany and
France -- had similar life expectancies and other broad
health outcomes but had widely differing approaches to
how health services are organized (11). We recognize the
dangers of stereotyping; nevertheless we hold that com-
parative research on health care systems must take into
account the socio-cultural context of different countries in
order to explain such variation, often recognised as path
dependency, meaning that past policies condition the
policy alternatives available in future. The socio-cultural
context and related path dependency shape the organisa-
tion and provision of health care through policies and in-
stitutions as dominant cultural ideas are embedded within
them. These dominant ideas include, for example, percep-
Learning from health care in other countries: the
prospect of comparative research
Health Prospect: Journal of Public Health 8
View Point
tions of the role of the state vis-à-vis the private market
in the provision of health care: is health care seen as a
public good or private commodity? Gender ideologies of-
fer another example. Conceptions of gender shape the hi-
erarchy of health professions and social roles in families.
A focus on these core values highlights the way a given
health system recognises (or not) the needs of a diverse
population, including that society’s most vulnerable mem-
bers (3,12). Yet it is also important to accommodate for
the dynamics of change in health systems, considering,
for instance, the globally salient neo-liberalization of ma-
ternity care systems in recent decades (13).
In this paper we shed light on variation in two key areas
of reproductive health – sex education and maternity care
– in two neighbouring European countries, England/UK
and the Netherlands. We selected these two countries for
the sake of brevity as we have research experience in
various countries including Canada, the US and Finland.
Thus these countries merely act as an example of the ap-
plication of the comparative method, thus someone else
might want to compare maternal health services in Nepal
and Bhutan or compare reproductive health services in
Nepal and Bangladesh. After outlining the advantages
and disadvantages of comparative studies of health care
systems, we show how these two national cases reect
different approaches to organising reproductive health
care. Both countries have diverse populations and have
developed a range of responses – that vary within and
between countries – to reproductive health. We show how
the health systems of the two countries, having evolved
over a long period of time and reecting their respective
value systems, have their own distinctive approaches to
reproductive health.
Comparative Studies: Benets &
Challenges?
Benets
One of the main benets of comparative studies is that
they challenge unquestioned assumptions through con-
stant comparative means, as such they provide an al-
ternative lens through which to view the organisation of
health systems and their strategies for delivering ser-
vices. We are all, to a greater or lesser degree, cultur-
ally-bound, and geographically embedded. Comparative
studies that include different cultures or communities can
help us to see common events from a new perspective
that challenges common assumptions. A major advan-
tage of cross-national comparative research is that it al-
lows study of approaches that have not been considered
in certain countries. The result is that problems can be
looked at from a different angle, current practices can be
questioned, and the effectiveness, efciency and experi-
ences of service users can be compared and contrasted
(14).
Second, we can learn from each other’s experiences and
ndings. Thus doctors and nurses working in reproductive
health services with similar disadvantaged populations in,
for example, inner-city London and Amsterdam, will likely
develop slightly different outreach strategies. This may
reect the differences in what constitutes the most dis-
advantaged groups in the two cities, but also expectation
of services on offer by the intended target population lo-
cally. Moreover, identical solutions can have very different
intended and unintended consequences in different coun-
tries or settings. Comparisons allow us to see how or-
ganisational constraints and different cultural ideas about
what is desirable, good, and proper shape the delivery
and utilization of health care.
Third, comparative studies can help us avoid making
assumptions about any one particular cultural or ethnic
minority group. These comparisons do not always have
to be cross-national as highlighted in the following exam-
ple on perception about teenagers from different ethnic
minority groups in the UK. A qualitative study conducted
with a relatively homogeneous sample of young Scottish
people highlighted embarrassment as a key element in
their discussions around sexual heath and sex education
(15). A very similar nding has also been reported among
teenagers in a multicultural area of London. Participants
from a range of ethnic minority communities in the latter
study “expressed feelings of embarrassment, discomfort
and scepticism that parents might be able to understand
them and their relationships” (16). Any one reading only
the latter study with ethnic minorities could easily come
to the conclusion that ethnic minority youths are too em-
barrassed to speak to their parents. But comparative re-
search allows us to go beyond stereotypes and see the
common ground (and the differences) between different
groups of young people. Looking at both studies we learn
that the embarrassment expressed by ethnic minority
youths mirrors that of most people of that age group in
the UK. Finally, the comparative method helps us to learn
from each other in the process of doing research, chal-
lenging our ethnocentric view about what is “normal” or
“abnormal” in other cultural contexts (17). The benets
gained from cross-national work include a deeper under-
standing of other cultures and of their research processes
(18), as well as how to alter health care systems to better
meet the needs of their diverse populations.
Challenges
This is not to say that comparative research is easily ac-
complished (19). A signicant challenge of comparative
studies concerns the way any social institution is bound
to its socio-cultural context. As noted above, some have
warned against trying to transfer ideas/solutions from
one setting to another: the fact that something works well
in one context does not guarantee that it will work else-
where. For example, Benoit warns about the impossibility
of transplanting the basic elements of the Canadian pub-
lic health care system to the US because of its different
core principles (20). In a similar manner, Mander ques-
tioned the feasibility of implementing aspects of the Dutch
maternity care system elsewhere because its system was
similarly created around country specic principles and
practices (21). This, as we shall see, is relevant to repro-
ductive health care when viewed more broadly.
Comparative Case Studies of Reproductive
Health Care
Below we briey introduce two examples of comparative
Learning from comparative studies
Health Prospect: Journal of Public Health 9Vol 14 | Issue I | July 2015
Health Prospect: Journal of Public Health
Learning from comparative studies
Vol 14 | Issue I | July 2015
research, starting with sex education and followed by
pregnancy and childbirth in England/UK and the Neth-
erlands. Table 1 describes key differences in the repro-
ductive health outcomes and methods of childbirth in our
two countries of comparison at one point in time. As the
data in Table 1 make clear, there are large differences be-
tween the two countries in terms of teenage pregnancies
and abortions, and in the way babies are brought into the
world. This raises an interesting question: “How is it that
countries in Northwest Europe that are similar in so many
respects (e.g. socio-economic development, proportion
of public funds spend on health services, proportion of
migrants in the populations) have such differences in re-
productive health and health care?”
I: Sex education
The Netherlands is often praised as a country providing
comprehensive and effective sex education for its young
people (22-25). The international reputation of the Dutch
is partly based on its comparatively low teenage preg-
nancy rates as well as very low abortion rates. England
and Wales have much higher teenage pregnancy rates
(63 per 1000 young women) when compared with 8.1
per 1000 young women (aged 15–19) in the Netherlands
(26). The comparative low Dutch teenage conception and
abortion rates hold up to comparison with other countries
as well. Some years ago, Keys and colleagues com-
pared the birth rate for the under 20s in the Netherlands
(6.2/1,000) with that of the US (52.2/1,000), arguing that
in countries where “public health policies adopt a com-
prehensive approach, birth rates among the young tend
to be lower” (27). Until recently, the Dutch teenage preg-
nancy and teenage abortion rates are amongst the lowest
in the world; in contrast, England and Wales have one of
the highest rates of teenage pregnancy rates in Western
Europe (28-29). However, the latest data for England and
Wales show that teenage (under 18s) conception rates
are at their lowest since 1969 (30).
10
The low Dutch teenage pregnancy rates (Table 1) have
been attributed to, amongst others: (a) the willingness
of parents to discuss safe sex, birth control and related
matters; (b) assertiveness training in relation to sex edu-
cation in primary schools; and (c) widespread availability
of reproductive healthcare (22). Sex education in Dutch
schools is also less contentious than that in England and
Wales. A recent systematic review (of English-language
publications) on the topic of sex and relationship education
revealed that important barriers to effective sex education
persist: (a) resistance from schools; (b) teachers refusing
to deliver (some) behavioural aspects of sex education
to students, including proper use of condoms, especially
in primary schools; and (c) attitudes of staffs delivering
the interventions; conversely, involvement and approval
of the community and parents are positive factors in im-
proving behavioural intentions (31). Furthermore, this re-
view indicated that the majority of interventions targeted
young people who were already sexually active, despite
the evidence that suggests starting sex education before
young people become sexually active, may delay sexual
debut (31). These facts suggesting that both sex educa-
tion policy and practice are driven (or hindered) by cul-
tural values, the consequences for young people’s sexual
and reproductive health are notable.
II: Maternity care
The Netherlands is known globally for its relatively high
proportion of home births – compared other high-income
countries, including England – and the high degree of
professional independence community Dutch midwives
enjoy. Key characteristics of the way the Dutch organise
midwifery and maternity care include the: (1) role and
position of midwives; (2) high proportion of home births;
(3) support of obstetricians for a health system in which
midwives do the risk selection; (4) availability of maternity
home care assistants supporting midwives and women
at home; and (5) long-term government support for home
Characteristics The Netherlands
England & Wales
Teenage (under 20s) conception rate per 1,000 61.7 14.3 (age 15-19)
Teenage abortion rate per 1,000 42.6 9.1 (age 15-19)
Total fertility rate (average number of children per woman) 1.97 (2008) 1.77 (2008)
Home birth rate 2.7% (2007) 29% (2005-08)
Table 1: Selected reproductive health & maternity care data*
Caesarean Section rate 24.6 (2007-08) 15.4 (2007)
* The following UK sources were used for the data in Table 1: ONS (Ofce for National Statistics) Table 4.1 Con-
ceptions: age of woman at conception, www.statistics.gov.uk/STATBASE/Expodata/Spreadsheets/D9558.xls; ONS
(Ofce for National Statistics) Home births continue gradual increase Population Trends 133 - Autumn 2008 (25
Sept.) www.statistics.gov.uk/pdfdir/poptrdhb0908.pdf ; NHS Maternity Statistics, England 2008-09: Headline Tables;
and the following Dutch sources: CBS ‘Bevallingen naar plek en thuisbevallingen naar opleidingsniveau, 1997-2008,
http://www.cbs.nl/NR/rdonlyres/E4C58356-27F3-4E20-B172-55D156AAAB83/0/2696T.xls; CBS STATLine, http://
www.statline.cbs.nl/StatWeb/publication/?VW=T&DM=SLNL&PA=37422ned&D1=0,4-5,7,9,11,13,17,26,35,40-
41&D2=0,10,20,30,40,(l-4)-l&HD=090218-0953&HDR=G1&STB=T ; Stichting Perinatale Registratie Nederland
(2009) Perinatal Care in the Netherlands 2007, Utrecht: Stichting Perinatale Registratie Nederland Report available
from www.perinatreg.nl.
Health Prospect: Journal of Public Health
Learning from comparative studies
Vol 14 | Issue I | July 2015
11
birth. Of course, several of these characteristics can be
found in other countries, for example in Britain risk selec-
tion is a very much part a midwife’s task, and there are a
growing number of maternity assistants.
In order to better understand this Dutch/British differ-
ence in homebirth, pregnant women’s experiences or the
place of midwives in the maternity services, it is useful to
lift one’s gaze and consider the organization of maternity
care practices in other countries. Important clues for ex-
plaining the differences we see here can be found in the
book, Birth by Design (19). This edited volume collected
cross-national comparisons of maternity care in a number
of high-income, technologically-sophisticated countries,
including Canada, the US, the UK and the Netherlands
(19). Using a decentred approach that was sensitive to
the cultural, socio-economic and organisational context of
maternity care in different countries, the researchers dis-
covered interesting and important cultural and structural
variations in everything from the training of the providers of
maternity care, to public policy, to the attitudes of women
about desirable care (2).
Comparative research as a method
To explain our observed differences in reproductive care
in two seemingly similar countries, we need to examine
the underlying cultural values of each society. Cultural val-
ues are not xed essences but symbolic boundaries that
all of us invoke to order and make sense of our lives and
of issues that provoke controversy in a community. When
making health policy, governments are called on by social
movement actors and members of the general public to
make a stand on intervening (or avoiding intervention) in
matters that are subject to value judgements and moral
views.
In the Netherlands, the government has refrained from
making policies that intervene in the sexuality of teenag-
ers, instead seeking to minimise the negative consequenc-
es by offering sex education and making prevention ac-
cessible (21). Some outsiders praise and others condemn
the liberal Dutch approach that is ‘soft’ on drugs, prostitu-
tion, home birth, sex education and euthanasia. Generally,
the government has chosen approaches that limit value-
based interventions in matters that concern the realm of
personal life, while promoting harm reduction to protect its
citizens from negative consequences. Of course, giving
women the right to opt for a home birth ts very well with
this philosophy.
Public policy in the Netherlands is generally pragmatic.
The Dutch style of policymaking has been described as
“weigh up the problems and solutions and adapt” (22).
This comes through in the aversion to using policy to take
moralistic stances and in a willingness to experiment on
a small-scale with new approaches to health and social
policy, testing its efcacy and efciency. Health policies in
the UK have a more rational evidence-based approach,
whereby largely independent organisations, such as NICE
(National Institute for Health and Care Excellence), oper-
ate at a distant from government and thus help deal with
politically unpopular rationing decisions (32).
Summary & Conclusion
Comparative studies, especially when conducted using a
decentred method (3), can help us to see the “oddness” of
the ways our own society deals with core issues of human
life such as reproductive health. The discipline of sociol-
ogy augments comparative research by encouraging us
to question the assumptions about our own ways of doing
things by observing the “strange” ways of others. At the
same time we should not forget that (a) signicant varia-
tions exist within countries and between sub-regions; and
(b) it is all too easy to fall into the trap of perpetuating cul-
tural stereotypes. Our ndings indicate that public health
practitioners, health care professionals, health promoters
and policy makers need to take more seriously the wider
social and cultural context shaping the delivery of sex ed-
ucation and maternity services. It is clear that the design
of reproductive health care and services varies widely
between countries and clearly bears the marks of the so-
ciety in which it is found. Of course, many of us are not
just interested in studying differences in services and sys-
tems for its own sake, we want to show that one is more
successful than another in, for example, reducing health
inequities and increasing access to quality reproductive
services. Thus we want to introduce what we have learnt
in one country or system, not by simply copying what was
done there, but by ensuring that what we introduce in an-
other is culturally and socially appropriate.
Reproductive health is a matter that engages both indi-
viduals at the level of their personal lives and societal
actors making policies about the different practices that
intervene in the personal lives of the members of society.
Sexual health and maternity care are contentious arenas
of health intervention as they are surrounded with cultural
and moral issues (or ‘problems’) this is something all soci-
eties must come to terms with and each society does this
within its own national cultural context. We hope this pa-
per will be of use to researchers in Nepal who are thinking
about doing comparative research. For example, a Nepa-
lese researcher might consider comparing condom distri-
bution in India and Nepal. Our methodological reections
may help him or her to consider why the Indian solution
distributing condoms may or may not work in Nepal.
Thus value-laden issues, for which there are different cul-
tural approaches to care, have different outcomes - and
indeed, may be completely contrary to what the policy-
makers are intending. Using a cross-national lens to ex-
amine reproductive health systems highlights not just
what works best, but why some strategies of care are
better suited to some cultures, regions or countries than
others, and why some strategies are more difcult/easy to
implement in some contexts than in others.
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