MATERNAL MORBIDITY IN RURAL BANGLADESH: WOMEN’S
PERCEPTIONS AND CARE SEEKING BEHAVIORS
by,
Allisyn C. Moran
A dissertation submitted to the Johns Hopkins University in conformity with the
requirements for the degree of Doctor of Philosophy
Baltimore, Maryland
April 2006
© Allisyn C. Moran 2006
All rights reserved
ABSTRACT
Background
Death and illness related to pregnancy and childbirth are significant health problems in
developing countries. The World Health Organization estimates that 529,000 women die
from complications related to pregnancy and childbirth each year, with 99% of these
deaths in developing countries. An additional 300 million women suffer from illness and
long-term disability related to childbearing. The vast majority of maternal mortality and
morbidity is avoidable through timely use of obstetric care. Use of skilled care remains
low in developing countries, especially in South Asia where home-based birth is the
norm. Safe motherhood programs focus on improving recognition of life-threatening
complications and subsequent care seeking behaviors.
Objective
This research examined maternal morbidity in Bangladesh by exploring women’s
perceptions of complications and care seeking behaviors.
Methods
This study utilized three methodologies: a literature review and both qualitative and
quantitative methods. The literature review compared methods of morbidity
measurement in Bangladesh and India. The qualitative study included 24 in-depth
interviews on women’s perceptions of complications and care seeking behaviors.
Bivariate and multivariate analyses were used to explore associations between sociodemographic/reproductive factors and care seeking behaviors.
ii
Results
The literature review revealed a variety of measurement methods as well as a wide range
in the proportion of women reporting complications. The qualitative and quantitative
studies demonstrated high levels of self-reported maternal morbidity in rural Bangladesh,
although few women sought skilled care even for complications perceived to be
“serious.” Among women who did seek care, traditional providers or pharmacy shops
were the preferred locations. Factors associated with seeking skilled care included
primiparity, antenatal care visits, previous pregnancy loss, and higher wealth status.
Knowledge of danger signs was significantly associated with seeking skilled care but was
moderated by the number of antenatal care visits.
Conclusion
These findings have important implications for safe motherhood programs and future
research. We suggested guidelines for definition and measurement of community-based
reports of maternal morbidities. We also suggested recommendations for safe
motherhood programs, including the necessity of formative research, combining
qualitative and quantitative methods to capture perceived “severity” and care seeking
processes. Additional research into the mechanisms that translate knowledge into
seeking skilled care is needed.
iii
Dissertation Committee:
Carl Latkin, MS, Ph.D., Professor, Health, Behavior and Society (Primary Advisor)
Peter J. Winch, MD, MPH, Associate Professor, International Health (Chair)
Abdullah H. Baqui, MBBS, MPH, DrPH, Associate Professor, International Health
Cynthia K. Stanton, MPH, Ph.D., Assistant Professor, Population Family Health Sciences
Katherine Clegg-Smith, Ph.D., Assistant Professor, Health, Behavior and Society
iv
ACKNOWLEDGEMENTS
I would first like to acknowledge the Bangladeshi women who participated in this
research. Without their participation, this research wouldn’t have been possible. For
some women, this study was the first time they had been asked about their pregnancyand delivery-related health problems. I thank them for their willingness to share their
stories with us, and I hope that we can continue the dialogue to provide a vehicle for
discussion on these important health issues. I also had the great pleasure of working with
an incredible team in Bangladesh. The Projahnmo I project staff at the International
Centre for Population and Health Research (ICDDR,B) provided hours of input in the
research design, instruments, as well as its successful implementation in the field.
Specifically I would like to thank Dr. Shams el Arifeen for his leadership as well as Dr.
Habib Seraji, Moshfiqur Rahman, and Ishtiaq Mannan for technical input into the study
as well as invaluable advice regarding implementation in Sylhet. Dr. Mohiudeen
Chowdhury and Dr. Arif Mahmoud were indispensable in helping with the logistics of
data collection in the field. I cannot thank them enough for the long nights in Sylhet
discussing the best sampling strategies for locating recently delivered women in the study
area. I also thank Nighat Sultana and Nahid Kalim. They conducted and transcribed the
in-depth interviews under challenging conditions in the field as well as tight time
restrictions. This research benefited greatly from their technical input, as well as their
experience in conducting qualitative research on maternal health. Finally, Dr. Kazi
Monira Afzal has been the driving force in ensuring that these data were collected – and I
am indebted to her for her dedication to this project as well as her support as a friend.
v
She endured difficult personal circumstances to ensure that these data were collected in a
quality manner.
I would also like to acknowledge the support of my dissertation committee, as well as
other faculty at Johns Hopkins and ICDDR,B. First, I thank Rajiv Rimal who spent hours
providing input to my dissertation proposal, and introduced me to different behavioral
theories that have greatly impacted my thinking about behavior change within safe
motherhood. My advisor, Carl Latkin, has been a great source of support throughout this
entire process. He allowed me the freedom to pursue my individual research interests,
while ensuring that I received a solid foundation in social and behavioral sciences. Carl
has always made time for all my questions and provided invaluable comments and insight
into this research study as well as the final dissertation. Abdullah Baqui, the principle
investigator for the Projahnmo I project, provided me with a perfect opportunity to study
my research questions nested within his project. He has been very supportive of me since
the beginning, and I greatly appreciate all I have learned working with him. Peter Winch
has been a friend and mentor for several years. He has encouraged me throughout this
process, and he has provided invaluable comments and suggestions for this research. I
don’t know anyone who answers e-mails or gives comments more quickly than Peter, and
I cannot express how helpful this was in preparing the final manuscript. I cannot thank
Marge Koblinsky enough for her support in this process. We had only met a few times
previously, but she opened her home to me during my time in Dhaka. I thank her for her
generosity and for the hours of discussions during the long car rides home from the office
as well as over dinner about safe motherhood and our thoughts for research questions. I
vi
would never have survived my four months in Dhaka without her. Finally, Cindy Stanton
has been a teacher, boss, mentor and great friend for the last eight years or so. She was
the one who put me in touch with Abdullah Baqui to work on this project as my
dissertation research. I can’t thank her enough for her never-ending support and critical
input into my research questions, study design and analysis. Her support as a mentor and
friend have kept me engaged in this process, and I admire her for her incredible energy in
pushing the field of safe motherhood forward.
I would also like to thank my colleagues at JHPIEGO, who supported me to go back to
school while I was still working. Judith Robb-McCord and Susan Griffey were an
incredible help in allowing me to work part-time while taking classes. I also need to
thank Cindy Stanton, Sereen Thaddeus, Nancy Russell, Bill Terry, and Joy Fishel for our
lively discussions on how to measure behavior change interventions in safe motherhood.
Some of the ideas from those conversations inspired the research questions in this
dissertation. I have also been fortunate to have a supportive group of friends who have
provided invaluable advice on this research topic as well as about life in general. There
are too many to name them all – but I would like to specifically thank Rachel Haws, Gina
Pistulka, Tiffany Lefevre, Melissa Davey, and Vanya Jones. I would also like to thank
my good friend Kristen Malecki who probably feels like she has endured this process
with me. I thank her for all the phone calls and the encouragement – I never would have
finished without her help.
vii
Finally, my husband and family have provided immeasurable support throughout the last
few years. I thank my parents for their never-ending encouragement, especially
throughout my fieldwork in Bangladesh. They have endured numerous phone calls and
have always been there when I needed someone to remind me that all the work would be
worth it in the end. Thanks to my sister, Kristin Moran, for editing this manuscript. It
was an incredible help to have fresh eyes (and editing skills) make the final edits. My
husband, Michael Behan, has been incredible throughout this process. During our first
year of marriage I was in Bangladesh for almost four months, and instead of complaining,
he came to visit me for four short days. I think he spent more time flying than he did in
Bangladesh, but he never complained. He also endured the endless hours of working
weeknights and weekends in addition to not being able to plan vacations for fear that I
would have too much work. He has only known me as a student, and I am looking
forward to spending time with him now that my student days are behind me.
viii
TABLE OF CONTENTS
ABSTRACT ........................................................................................................................ ii
ACKNOWLEDGEMENTS .................................................................................................v
TABLE OF CONTENTS ................................................................................................... ix
LIST OF TABLES ............................................................................................................ xii
LIST OF FIGURES ......................................................................................................... xiii
CHAPTER 1: INTRODUCTION .......................................................................................1
1.1
Problem Statement .......................................................................................1
1.2
Purpose of this Study ...................................................................................3
1.3
Objectives ....................................................................................................4
1.4
Research Questions ......................................................................................5
1.5
Hypotheses ...................................................................................................6
1.5.1
Literature review ..........................................................................................6
1.5.2
Exploratory qualitative investigation of local terminology, classifications
and perceptions of careseeking behavior .....................................................6
1.5.3
Multivariate analysis of data from household survey of recently-delivered
women ..........................................................................................................7
1.6
Significance of the Research ........................................................................7
CHAPTER 2: LITERATURE REVIEW ............................................................................9
2.1
Maternal Mortality and Morbidity in Bangladesh .......................................9
2.2
Maternal Health Behaviors are Different ...................................................11
2.3
Care Seeking for Obstetric Complications ................................................11
2.4
Barriers to Care Seeking ............................................................................12
2.5
Three Delays Model ...................................................................................13
2.6
Facility Characteristics and Birthing Care .................................................14
2.7
Barriers to Access: Transport and Cost of Services...................................15
2.8
Status of Women ........................................................................................16
2.9
Local Understandings of Illness Etiology ..................................................18
2.10
Pollution .....................................................................................................20
2.11
Facilitators to Care Seeking .......................................................................22
2.12
Knowledge of Danger Signs ......................................................................22
CHAPTER 3: CONCEPTUAL FRAMEWORK ..............................................................27
CHAPTER 4: STUDY DESIGN AND METHODS ........................................................29
4.1
Study Site and Parent Project .....................................................................29
4.2
Study Methods ...........................................................................................30
4.2.1
Literature review ........................................................................................30
4.2.1.1 Methods......................................................................................................30
4.2.1.2 Data analysis ..............................................................................................32
4.2.1.3 Main findings .............................................................................................32
4.2.2
Qualitative research ...................................................................................33
4.2.2.1 Methods......................................................................................................33
4.2.2.2 Data analysis ..............................................................................................34
4.2.2.3 Main findings .............................................................................................35
4.2.3
Quantitative research .................................................................................36
4.2.3.1 Methods......................................................................................................36
ix
4.2.3.2 Measures ....................................................................................................37
4.2.3.3 Data analysis ..............................................................................................38
4.3.3.4 Main findings .............................................................................................39
4.3
Strengths and Limitations ..........................................................................42
CHAPTER 5: A REVIEW OF POPULATION-BASED ESTIMATES OF MATERNAL
MORBIDITY IN BANGLADESH AND INDIA..............................................................45
5.1
Abstract ......................................................................................................45
5.2
Introduction ................................................................................................47
5.3
Study Methods ...........................................................................................51
5.3.1
Methods......................................................................................................51
5.3.2
Data analysis ..............................................................................................52
5.4
Results ........................................................................................................52
5.5
Discussion ..................................................................................................59
5.5.1
Terms used to describe “maternal health problems ...................................60
5.5.2
“Classification” of maternal morbidities ...................................................62
5.5.3
Maternal morbidities measured at different time points ............................63
5.5.4
Inclusion criteria ........................................................................................64
5.5.5
Assessment of morbidities by health workers ...........................................65
5.5.6
Definition and measurement of maternal morbidities ...............................66
5.5.7
Perceived severity and subsequent care seeking behaviors .......................67
5.6
Conclusion .................................................................................................69
CHAPTER 6: CARE SEEKING FOR MATERNAL HEALTH PROBLEMS IN
SYLHET DISTRICT, BANGLADESH ............................................................................87
6.1
Abstract ......................................................................................................87
6.2
Background ................................................................................................89
6.3
Methods......................................................................................................91
6.3.1
Study site ....................................................................................................91
6.3.2
Data collection ...........................................................................................92
6.3.3
Data Analysis .............................................................................................93
6.4
Results ........................................................................................................94
6.4.1
Care seeking patterns .................................................................................95
6.4.1.1 No care seeking ..........................................................................................95
6.4.1.2 Private domain ...........................................................................................96
6.4.1.3 Public domain ..........................................................................................100
6.4.1.4 Care in both domains ...............................................................................101
6.4.2
Case study ................................................................................................102
6.5
Discussion ................................................................................................105
6.6
Conclusion ...............................................................................................111
CHAPTER 7: CARE SEEKING FOR PERCEIVED MATERNAL COMPLICATIONS
IN SYLHET DISTRICT, BANGLADESH: WHAT IS THE ROLE OF KNOWLEDGE
OF DANGER SIGNS? ....................................................................................................118
7.1
Abstract ....................................................................................................118
7.2
Introduction ..............................................................................................120
7.3
Background ..............................................................................................122
7.4
Methods....................................................................................................124
7.4.1
Study site ..................................................................................................124
x
7.4.2
Eligibility .................................................................................................125
7.4.3
Analysis....................................................................................................126
7.4.4
Measures ..................................................................................................128
7.5
Results ......................................................................................................129
7.5.1
Background characteristics ......................................................................129
7.5.2
Perceived complications ..........................................................................130
7.5.3
Care seeking from traditional providers/family members .......................132
7.5.4
Care seeking from pharmacy shops .........................................................133
7.5.5
Care seeking from skilled providers ........................................................133
7.6
Discussion ................................................................................................134
7.7
Conclusion ...............................................................................................141
CHAPTER 8: DISCUSSION AND IMPLICATIONS ...................................................159
APPENDICES .................................................................................................................165
REFERENCES…………………………………………………………………………215
CURRICULUM VITAE ..................................................................................................231
xi
LIST OF TABLES
Table 2.1:
Table 4.1:
Table 5.1:
Table 5.2:
Table 5.3:
Table 5.4:
Table 5.5:
Table 6.1:
Table 6.2:
Table 7.1:
Table 7.2:
Table 7.3:
Table 7.4:
Barriers and facilitators to use of skilled care ..............................................23
Description and measurement of variables ....................................................42
Description of community-based maternal morbidity studies .......................68
Number of variables to measure pre-eclampsia/eclampsia ...........................72
Number of variables to measure bleeding .....................................................73
Number of variables to measure postpartum infection ..................................75
Description of maternal morbidity studies by study characteristics ..............77
Description of health providers .....................................................................108
Self-reported complications ...........................................................................110
Selection of covariates ...................................................................................138
Percent distribution of background characteristics ........................................142
Percentage of respondents with perceived complications .............................145
Percent distribution of women who sought care among women with any
complication ...................................................................................................147
Table 7.5: Adjusted odds ratios of seeking care among women with any
complication ...................................................................................................151
Table 7.6: Interaction effects of knowledge of danger signs ..........................................153
xii
LIST OF FIGURES
Figure 5.1: Percentage of women with at least one morbidity ....................................80
Figure 5.2: Number of variables reported ....................................................................81
Figure 6.1: Care seeking patterns for “serious” complications....................................113
xiii
CHAPTER 1: INTRODUCTION
1.1
Problem Statement
Death and illness related to pregnancy and childbirth are significant health problems in
developing countries. The World Health Organization (WHO) estimates that 529,000
women die from complications related to pregnancy and childbirth each year, with 99%
of these deaths occurring in developing countries (World Health Organization, UNICEF
et al. 2004). Maternal mortality ratios can be up to 200 times higher in developing
countries when compared to developed countries, resulting in the largest health disparity
between the developed and the developing world yet reported (Koblinsky MA 1995). In
sub-Saharan Africa, the cumulative risk of maternal death over a lifetime due to
complications related to pregnancy, abortion and childbirth is one in every 16 women,
compared with one in every 3,800 women in developed countries (World Health
Organization, UNICEF et al. 2004).1 Improving maternal mortality has received
recognition as a global priority as evidenced by its inclusion in the Millennium
Development Goals (United Nations 2004).
Among problems experienced by women related to child-bearing, maternal mortality is
the “tip of the iceberg.” Maternal morbidity, defined as illness and/or disability caused
by pregnancy-related complications, is more prevalent and widespread than maternal
mortality. The World Health Organization (WHO) estimates that 52 million women
suffer from morbidity related to the five direct obstetric causes of maternal death,2 with
1
Includes Europe, Canada, the United States of America, Japan, Australia and New Zealand.
Direct obstetric causes of maternal death include: post-partum hemorrhage; puerperal sepsis; preeclampsia and eclampsia; obstructed labor; and abortion.
2
1
millions more suffering from morbidity related to non-fatal outcomes of obstetric
complications as well as indirect causes of death (AbouZahr C 2003).3
The death of a woman during her reproductive years has negative consequences for her
children and family. In Bangladesh, if a mother dies, her children less than 10 years of
age have a mortality rate three to five times higher than children whose mother is alive or
whose father has died. In Tanzania, if a mother dies, there are detrimental educational
effects on the children, especially for secondary education (World Bank 1999).
The World Health Organization defines a maternal death as “the death of a woman while
pregnant or within 42 days of termination of pregnancy, irrespective of the duration or
site of the pregnancy, from any cause related to or aggravated by the pregnancy or its
management, but not from accidental causes” (World Health Organization 1992). The
five principal direct causes of maternal mortality are severe bleeding/hemorrhage
(accounting for approximately 25 percent of maternal deaths), infection/sepsis, unsafe
abortion, eclampsia/hypertension, and obstructed labor. Other direct causes (ectopic
pregnancy, embolism and others) account for eight percent of maternal deaths, while
indirect causes such as anemia, malaria, tuberculosis and heart disease account for 20
percent of maternal deaths (World Health Organization 1998).
3
Due to paucity of data, estimates of morbidity related to non-fatal health outcomes of other direct obstetric
complications (ectopic pregnancies, cerebrovascular accidents, embolisms, etc) as well as indirect causes of
death (anemia, malaria, tuberculosis, puerperal psychoses, postpartum depression, and suicide) are not
included in this estimate.
2
The vast majority of maternal mortality is avoidable. The major causes of death are
known, and 80 percent of these deaths could be prevented with appropriate management
and treatment (World Health Organization 2005). Obstetric complications that lead to
maternal morbidity and mortality cannot be predicted; therefore, receiving care from a
skilled provider (doctor, nurse, or midwife) has been identified as the single most
important intervention in safe motherhood programs (Starrs A 1997). In developing
countries, use of skilled care remains low, with less than half of women giving birth with
a skilled provider at last delivery (48%) (Demographic and Health Surveys 2004).
Thaddeus and Maine (1994) outlined three factors that contribute to maternal morbidity
and mortality: 1) the delay in deciding to seek care if a complication occurs, 2) the delay
in reaching care, and 3) the delay in receiving care from a medical facility. These delays
are influenced by social and cultural factors, accessibility of services, and quality of
obstetric care. The Three Delays framework has been widely used to structure safe
motherhood programs (Thaddeus S and Maine D 1994).
1.2
Purpose of this Study
Almost half of all maternal deaths occur in Asia (47.5%) where home-based births are the
norm (World Health Organization, UNICEF et al. 2004). In Bangladesh, 16,000 women
die due to maternal causes each year, and the lifetime risk of maternal death is 1 in 64.
Almost all women give birth at home without a skilled provider (87%) (National Institute
of Population Research and Training (NIPORT), Mitra and Associates et al. 2005), and
the majority of women (60.1%) reported at least one complication during last pregnancy,
3
childbirth, or postpartum (National Institute of Population Research and Training
(NIPORT), ORC Macro et al. 2003). In this context, there are a variety of social and
economic barriers that inhibit care seeking outside the home for obstetric complications
(Blanchet 1984; Nahar S and Costello A 1998; Afsana K and Rashid SF 2000; Haider SJ
2000; Rahman SA, Parkhurst JO et al. 2003). Safe motherhood programs focus on
improving recognition of complications by family members and traditional providers,
facilitating use of skilled care for women with complications, and strengthening the
availability and quality of obstetric care. Programs disseminate messages on recognition
of danger signs that may indicate life-threatening complications, planning for
transportation to a pre-selected facility if a complication occurs, and saving money to pay
for care. Unfortunately, there is no evidence that these strategies work, and care is
typically sought too late or not at all (Uzma A, Underwood P et al. 1999; Stanton CK
2004; Fronczak N, Antelman G et al. 2005). This study will explore the barriers and
facilitators around seeking care for obstetric complications in rural Bangladesh in an
effort to improve maternal health and survival.
1.3
Objectives
The objectives of this research were to:
1. Summarize existing data on self-reported maternal morbidity in
Bangladesh and categorize the methods used to collect these data;
2. Categorize patterns of careseeking in Sylhet District, Bangladesh, describe
women’s perceptions of care seeking behaviors and identify factors that
influence these perceptions;
4
3. Describe the factors that affect care seeking for perceived maternal
complications in Sylhet District, Bangladesh; and
4. Examine the role of knowledge of danger signs in relation to care seeking
for perceived maternal health complications.
1.4
Research Questions
The primary research questions in this study all relate to levels of self-reported maternal
morbidity in rural Bangladesh, women’s perceptions of these problems, and how they
seek care for these problems. Both qualitative and quantitative methodologies were
employed to address these questions.
The research questions were:
1. What methods have been used to measure self-reports of maternal morbidity in
Bangladesh and India?
2. Are the community-based estimates of maternal morbidity consistent, and if not,
how can measurement be improved?
3. Do women seek care for these perceived complications, and if so, what type of
care do they seek?
4. What factors are associated with seeking care among women with perceived
complications at individual, household, and community levels?
5. Is knowledge of danger signs associated with care seeking behaviors?
6. How can safe motherhood programs improve measurement of morbidity as well
as programs that aim to improve care seeking behaviors?
5
1.5
Hypotheses
1.5.1
Literature review
Hypotheses were not tested in the review of the literature. A systematic approach was
undertaken to identify peer reviewed and unpublished literature on community-based
measurements of maternal morbidity in Bangladesh and India. The three objectives of
this review were to: 1) to compare methods of population-based measurement of
maternal morbidity in India and Bangladesh identified via a literature review, 2) to
document the prevalence of self-reported maternal morbidity from the literature in these
two countries, and 3) to propose recommendations for safe motherhood programs that
measure maternal morbidity in an effort to understand and improve care seeking
behavior.
1.5.2
Exploratory qualitative investigation of local terminology, classifications and
perceptions of care seeking behavior
The main purpose behind the qualitative research was to elucidate women’s care seeking
patterns for perceived complications. In the literature, the biomedical definition of care
seeking is fairly specific– care is sought and received in a health facility with a skilled
provider. The health care system in Bangladesh is pluralistic, and although use of skilled
care is low, use of “other” types of care is prevalent. We, therefore, wanted to explore
these care seeking patterns. Since this research was exploratory and descriptive, there
were no explicit hypotheses tested.
6
1.5.3
Multivariate analysis of data from household survey of recently-delivered women
H-1. Women with higher knowledge of danger signs will be more likely to seek care
from a skilled provider than women with less knowledge of danger signs, controlling for
covariates.
H-2. Women with less knowledge of danger signs will be more likely to not seek care or
to seek care from a traditional provider than women with more knowledge of danger
signs, controlling for covariates.
H-3. Women with at least one antenatal care visit will be more likely to seek care from a
skilled provider than women who didn’t attend antenatal care, controlling for covariates.
H-4. Women with a previous pregnancy loss (abortion/miscarriage) will be more likely
to seek care from a skilled provider than women without a previous pregnancy loss,
controlling for covariates.
Each of the papers presented is a separate entity. The findings regarding these research
questions and hypotheses will be explored in Chapter 8: Discussion and Implications.
1.6
Significance of the Research
The findings from this study have policy and programmatic implications. Resources for
maternal health are scarce in developing countries, especially with the competing
demands for resources to combat HIV/AIDS, malaria, and tuberculosis. Thus,
information to inform the measurement of maternal morbidity at the community level,
how women construct morbidity and care seeking for obstetric complications, as well as
the implementation of programs effective at increasing care seeking behaviors for women
with complications are essential. Currently, increasing knowledge of danger signs during
7
pregnancy, childbirth, and the postpartum is a key component of safe motherhood
programs. This study will assess the effectiveness of those messages at increasing use of
skilled care in an effort to inform future programs. The findings from this research will
be used to develop more focused behavior change strategies for programs that seek to
improve maternal health and survival in developing countries.
8
CHAPTER 2: LITERATURE REVIEW
2.1
Maternal Mortality and Morbidity in Bangladesh
Each year, between 500,000 to 600,000 women die from complications related to
pregnancy and childbirth, with 48% of these deaths occurring in Africa, 47.5% of
maternal deaths occurring in Asia, 4% of deaths occurring in the Latin
America/Caribbean region, and 0.5% of deaths taking place in developed countries
(World Health Organization, UNICEF et al. 2004). In Bangladesh, maternal mortality
and morbidity are estimated to be high- the maternal mortality ratio is 322 per 100,000
live births (National Institute of Population Research and Training (NIPORT), ORC
Macro et al. 2003), and only 13% of women are assisted by a medical doctor or other
skilled assistant during childbirth (National Institute of Population Research and Training
(NIPORT), Mitra and Associates et al. 2005). Sixty-nine percent of maternal deaths are
due to direct obstetric causes, 17% of deaths are due to indirect obstetric causes, while
14% of deaths are caused by injury and violence (UNICEF 1999).
Morbidity associated with complications related to pregnancy, childbirth, and the
postpartum is also quite severe in Bangladesh. Using community-based data generated
from surveys of self-reported illness, recent studies have suggested that a large proportion
of women experience pregnancy- and delivery- related complications (National Institute
of Population Research and Training (NIPORT), ORC Macro et al. 2003), and more than
80% of the women giving birth in rural areas suffer from a serious postpartum illness
(Bangladesh Institute of Research for Promotion of Essential and Reproductive Health
and Technologies (BIRPERHT) 1994; Goodburn EA, Chowdhury M et al. 1994).
9
Women in rural areas of Bangladesh experience lower literacy rates, lower social status,
poorer economic conditions, oppressive social customs, and poor quality health care
services (Afsana K and Rashid SF 2000). According to the Bangladesh Maternal Health
Services and Maternal Mortality Survey 2001 (BMMS), 60.1% of women reported at
least one complication during pregnancy, delivery or the postpartum period; 27.2% of
women reported headache/blurry vision/high blood pressure; 13.5% of women reported
edema/pre-eclampsia; and 16.3% of women reported prolonged labor (National Institute
of Population Research and Training (NIPORT), ORC Macro et al. 2003). In a baseline
survey in Sylhet district, a total of 75% of women reported at least one maternal
complication during pregnancy, delivery, and the postpartum. Women who had given
birth in the past year were prompted on four specific maternal health complications
(excessive bleeding, high fever, foul vaginal discharge, convulsions). About 19% of
women reported at least one complication during the pregnancy period. Thirty percent of
women reported at least one complication during their delivery which included
conditions such as excessive bleeding, high fever, foul vaginal discharge, convulsion, and
prolonged labor (Baqui A and Ahmed S 2004).
Problems associated with pregnancy and childbirth can also result in long-term
morbidities. In Bangladesh, it is estimated that nine million women suffer from fistulae,
uterine prolapse, inability to control urination, and painful intercourse. With 2.9 million
women estimated to give birth annually, maternal mortality and morbidity are substantial
problems that need to be addressed (Rahman SA, Parkhurst JO et al. 2003).
10
2.2
Maternal Health Behaviors are Different
Research has indicated that health behaviors are influenced by one’s confidence in one’s
abilities (Bandura A 1977; Bandura A 1986), attitudes toward the behavior (Ajzen I and
Fishbien M 1980), risk perceptions (Weinstein ND 1989; Weinstein ND and Nicolich M
1993), perceived barriers (Rogers RW 1975; Janz NK and Becker MH 1984), and
perceptions about others’ beliefs (Ajzen I and Fishbien M 1980) and behaviors (Asch SE
1951; Deutsch M and Gerard HB 1955). The combination of these factors leads to
enacting or not enacting behaviors (Rimal RN and Real K 2003). Care seeking for
maternal health problems is different than other health behaviors in the literature.
Pregnancy is not a habitual behavior; typically, women are pregnant 3-10 times over a
lifetime. Pregnancy is not a disease or illness that people try to avoid; it is a normal
physiological event which is embedded in cultural traditions (Blanchet 1984). Pregnancy
does have risks, however, and can become life-threatening if a complication occurs. It is
impossible to predict who will experience a complication or to prevent its development.
2.3
Care Seeking for Obstetric Complications
Care seeking for complications is a combination of traditional and modern practices,
depending on the condition, the availability and accessibility of services, and local
models of illness etiology (Obermeyer CM and Potter JE 1991). In Bangladesh, local
knowledge of complications strongly influences care seeking; women perceive that some
pregnancy- and childbirth-related complications are caused by supernatural agents such
as spirits, and thus traditional healers are often more appropriate to handle these problems
than skilled medical providers (Blanchet 1984; Afsana K and Rashid SF 2000). Studies
11
have shown that women with a perceived complication will seek care from traditional
providers and medical facilities depending on the problem, its severity, location of the
facility, and perceptions about quality of care in facilities (Fronczak 1997; Ahmed S,
Khanum PA et al. 1998; Uzma A, Underwood P et al. 1999).
2.4
Barriers to Care Seeking
The barriers to using skilled care have been researched in a variety of developing
countries. The literature demonstrates that higher socioeconomic status, urban residence,
and maternal education are strongly associated with giving birth in a facility (Gwatkin
DR, Rustein R et al. 2000; Kunst AE and Houweling T 2001). Cost also plays a large
role and may be prohibitive for women to seek care (Brieger WR, Luchok KJ et al. 1994;
Nachbar N, Baume C et al. 1998; Curtis S, Bell J et al. 2003). Traditional understandings
of the ethnophysiology of pregnancy, and causes and appropriate solutions for health
problems occurring during pregnancy are also salient, as there are often restrictions on
women’s ability to make decisions regarding their own care and their movement outside
the household (Puentes-Markides C 1992; Rozario S 1992; Thaddeus S and Maine D
1994). Use of antenatal care and use of medical facilities for previous births are other
strong predictors of use of maternal health services (Graham WJ and Murray SR 1997;
Bell J, Curtis SL et al. 2003). There is evidence that inequity in use of services is getting
larger, especially in countries such as Bangladesh (Curtis S, Bell J et al. 2003).
12
2.5
Three Delays Model
Thaddeus and Maine (1994) outlined three factors that contribute to maternal morbidity
and mortality: 1) delay in deciding to seek care if complication exists, 2) delay in
reaching care (such as arranging transportation, locating the appropriate facility, and
finding someone in the family to accompany the women to care), 3) and delay in
receiving care in a timely fashion from a medical facility (Appendix 1). Another
framework was developed by the MotherCare program that includes a fourth delay–
recognizing that a problem exists (MotherCare 1995). Both of these frameworks have
been used extensively by safe motherhood programs. While the third factor is mostly
beyond what individual women or their families can do, the first two factors related to
recognizing a complication, deciding to seek care, and reaching care are largely within
their or their family’s control. Seeking care for a health problem has been defined as
activities undertaken by individuals who perceive being ill or having a health problem to
locate an appropriate treatment (Christman N 1977; Ward H, Mertens TE et al. 1996).
Care seeking is prompted by recognizing symptoms and developing a plan for seeking
treatment (Christakis NA, Ware NC et al. 1994). Research has focused on the barriers to
care seeking for a maternal health problem within this framework.
Barriers and facilitators to the first and second delays can be categorized as occurring at
multiple levels. Pregnancy is a shared responsibility between a woman, her family, her
community, and health care providers/facilities (Maternal and Neonatal Health Program
2001). The literature indicates similar barriers at each of these levels across countries
and cultural settings (Moore M, Copeland R et al. 2002). At the facility/provider level,
13
fear of medical facilities and procedures, physical and emotional mistreatment by care
providers, and rivalries and hostilities between traditional and skilled providers are
prevalent. At the community level, social norms as well as lack of transportation inhibit
care seeking. Finally, women’s lack of decision-making power, cost of care, perceptions
of poor quality of care, and local practices justified by ethnophysiologic models of
pregnancy and ethnomedical models of illnesses during pregnancy and are barriers to
using care if needed. Table 2.1 outlines these barriers and facilitators to care seeking
from medical facilities/providers for normal or complicated births at various levels.
These barriers and facilitators are evident in Bangladesh. In a study conducted in 2000,
the most frequently cited barriers to giving birth in a health facility were: lack of
education and information about services, “superstition”, fear of losing family prestige,
costs of services, negligence of service providers, lack of adequate drugs and
medications, shortage of skilled doctors, and the predominance of male doctors in
government hospitals (Haider SJ 2000).
2.6
Facility Characteristics and Birthing Care
Poor quality of care at health facilities is one of the most important barriers to care
seeking for maternal health problems. Research has shown that perceptions of quality are
an important predictor to seeking care, even in emergency situations. If clinical services
are poor, women will not seek those services (Mbaraku G and Bergstrom S 1995; Afsana
K and Rashid SF 2000; Afsana K and Rashid SF 2001; Eisner MD, Ackerson LM et al.
2002; Duong DV, Binns CW et al. in press). One of the major barriers to seeking care
for maternal complications is poor treatment, and often verbal and physical abuse, from
14
providers at health facilities. This provider/patient relationship is paramount to ensure
quality services and use of those services, especially in a developing country context.
There is often a hierarchal relationship between rural Bangladeshi women and skilled
health care providers. The unequal power relationships that exist in the home are
exacerbated in the medical system and tend to undermine women’s sense of identity.
Women have a more horizontal relationship with traditional providers and community
health workers, making these providers more accessible and preferred among rural
women (Afsana K and Rashid SF 2000). In Bangladesh, life is often shaped by “patronclient” relationships, and poor people’s ability to obtain quality health care is often linked
to having a personal friend, relative or other advocate associated with the facility (Schuler
SR, Bates LM et al. 2002).
The gender of the physician is an important barrier to care seeking for maternal health
problems. The majority of doctors in government health facilities are male. Local norms
strongly discourage women from being viewed by male doctors, except in the cases of
life-threatening emergencies (Afsana K and Rashid SF 2000).
2.7
Barriers to Access: Transport and Cost of Services
Although health and family planning services are fairly accessible in Bangladesh,
delivery services are less available. Ninety-five percent of women reported having a
clinic one to two miles from their home; however, only 17.5% of these facilities offer
delivery services (National Institute of Population Research and Training (NIPORT),
Mitra and Associates (MA) et al. 2001). In one study, women that lived close to a health
15
center were much more likely to deliver with a skilled provider (Hlady WG and Fauveau
VA 1992/1993). It is often difficult to arrange transportation to facilities if a problem
occurs, especially during the night when most births take place. In the case of an
obstetric complication, the mode of transport is chosen based on the following elements
in Bangladesh: distance to facility, economic status, availability of vehicles, and stage of
labor (Afsana K and Rashid SF 2000). The primary means of transport to a facility in the
case of a maternal health problem in both urban and rural areas is a rickshaw or van
(Rahman SA, Parkhurst JO et al. 2003).
Cost also plays a large role, and may be prohibitive for women to seek care (Brieger WR,
Luchok KJ et al. 1994; Nahar S and Costello A 1998; Curtis S, Bell J et al. 2003). In
Bangladesh, home birth is perceived as low cost, as traditional birth attendants can be
reimbursed with cash or an in-kind payment. Services are free in government facilities,
but there are often hidden costs for medicines, travel, and other supplies. It is estimated
that the hidden costs for normal childbirth at a facility is US$31.9, and about US$130 for
Caesarean sections (Nahar S and Costello A 1998).
2.8
Status of Women
In low-income countries, women tend to have little power or influence within the
household (Kureshy N 2000). Bangladesh is a society with a strong patriarchal structure
(Rozario S 1992). This structure results in poor status of women in family and in society
evidenced through restrictions of women’s movement, low self esteem, poor community
support structure, culture of acceptance, early marriage, and lack of access to financial
16
and other resources (Rahman SA, Parkhurst JO et al. 2003). Decisions to seek care for
maternal health problems are mostly made by men and often depend on the perceived
quality of care at the health facility (Rahman SA, Parkhurst JO et al. 2003).
It is unclear who makes decisions regarding birthing care in the home. One study found
that female family members make decisions regarding birth place and attendant within
the home as birth is the domain of women (Afsana K and Rashid SF 2000). A recent
review of safe motherhood in Bangladesh found that males predominately make the
decision regarding birth attendant (70% of cases) (Rahman SA, Parkhurst JO et al. 2003).
Nonetheless, husbands have the authority to decide whether or not women can seek care
outside of the home for health problems (Blanchet 1984; Afsana K and Rashid SF 2000).
The decision-making process is the consideration of costs versus benefits– economic as
well as social costs (Rahman SA, Parkhurst JO et al. 2003). In slum areas of Dhaka, one
study found that women can recognize when symptoms/complications necessitate care
seeking. Women were able to make decisions about seeking care within their local area,
which normally includes traditional providers. Seeking care from medically trained
providers, however, required transportation to other areas and these decisions were often
made by the husband (Uzma A, Underwood P et al. 1999).
Poor families in Bangladesh tend to seek care at health facilities for problems seen as
life-threatening or those that would interfere with family’s income earnings (Schuler SR,
Bates LM et al. 2002). Families are often unlikely to spend money on treating women’s
health problems, so thresholds for defining a “health crisis” are often higher for women
17
(Schuler SR, Bates LM et al. 2002). Thus, families tend to wait until a maternal health
problem is very severe (or they perceive it as very severe) before seeking care.
2.9
Local Understandings of Illness Etiology
There is much debate in the literature regarding the role of local knowledge in utilization
of health services, including maternal health services. Some studies have found that
“modernization,” increasing urbanization, or changing traditional systems is the only way
to ensure that services are used. Other studies have shown that uneducated, poor
individuals use modern medicine if it is accessible and the perceptions of quality of care
are adequate (Obermeyer CM and Potter JE 1991).
In Bangladesh, care seeking is strongly influenced by cultural understandings of the
nature of illness and disease (Afsana K and Rashid SF 2000; Ahmed SM, Adams AM et
al. 2003; Rahman SA, Parkhurst JO et al. 2003). According to Asfana and Rashid (2000,
p. 8) “In the context of rural Bangladesh, behaviour during childbirth is largely
influenced by the inter-play of factors such as the cultural constructions of illness
causation, the practical reality of people’s everyday lives, and accessibility to health care
services.” Social barriers to seeking care are also important in this context. Bremmer
and Van Den Broek (1995) found that social norms were the main factor in refusal of
referrals for maternal health problems (Bremmer M and Van Den Broek G 1995).
Pregnancy is universally perceived as a “normal” event in the life of a woman (Blanchet
1984). In Bangladesh, pregnancy is not considered to be risky and seeking care from
18
medical facilities is not routine (Rahman SA, Parkhurst JO et al. 2003). The majority of
behaviors during pregnancy, childbirth, and the postpartum in Bangladesh are focused on
guarding the mother and child from malevolent spirits that are responsible for maternal
health problems, infections, the death of mother or small children, especially during
periods of pollution (see below for description of pollution) (Blanchet 1984). Malevolent
spirits can cause pregnancy- and childbirth-related complications, and even death for the
woman and her baby (Blanchet 1984; Jeffrey PM, Jeffrey R et al. 1989; Afsana K and
Rashid SF 2000; Van Hollen CC 2003; Winch PJ, Alam MA et al. 2005). Folk healers
are perceived as having the power to expel malevolent spirits (Blanchet 1984). Modern
medicine can cure other illnesses, but traditional healers are perceived as the appropriate
providers for illnesses/problems caused by the supernatural forces (Ahmed SM, Adams
AM et al. 2003), which often delays seeking skilled care for complications. For example,
Goodburn et al (1995, p.28) found “women believe that abnormal discharge is due to
supernatural influences of the intake of certain foods”; thus, it is unlikely that they would
consider seeking care for this treatment from a skilled health provider (Goodburn EA,
Gazi AR et al. 1995). Women who experience a complication are more likely to seek
care from a traditional healer than from a skilled provider.
Traditional birth attendants are the preferred providers for the majority of women for
several reasons, including their availability, lower service cost, and women’s confidence
in their abilities. Women can more easily negotiate with their husbands and families for
traditional birth attendants due to lower costs and social acceptance of these providers
(Afsana K and Rashid SF 2001).
19
One of the major barriers to seeking care at medical facilities is the fear of having to
undergo surgery. Women are often intimidated by the equipment in medical facilities,
and this fear originates in the fact that doctors used to conduct episiotomies for all
primigravidae having normal vaginal deliveries. Having surgery and an episiotomy can
inhibit a woman’s ability to work after giving birth, which can result in domestic
conflicts, social stigma, as well as fear of limited sexual relations and sterility (Afsana K
and Rashid SF 2000). In Sylhet, women mentioned the fear of reduced fertility after a
Cesarean section. These perceptions greatly influence women’s care seeking at medical
facilities.
Afsana and Rashid (2000) have indicated that social norms may be changing in
Bangladesh, especially among younger and more educated women. These changing
attitudes are central to health seeking behavior. Thus, these norms must not be assumed
to be universal.
2.10
Pollution
In Bangladeshi society, the woman and her newborn are in a state of impurity or pollution
that begins immediately after birth or other exposure to birth-related fluids or to blood
(Blanchet 1984; Winch PJ, Alam MA et al. 2005). The mother or mother-in-law helps
deliver the baby in most cases. Since birth is a polluting event, there are specific rituals
that must be followed for both the woman and the attendant. Cutting the umbilical cord
is perceived as a polluting act, and in Sylhet, the woman herself cuts the cord most of the
20
time, although in other parts of Bangladesh this task often is performed by traditional
birth attendants (Blanchet 1984; Winch PJ, Alam MA et al. 2005).
Another study by Bremmer and Van Den Broek (1995, p. 9) found that “post partum
haemorrhage causes no panic for it is believed that this impure blood must be cleared
away before the woman can recover her health.” Local knowledge systems indicate that
the passage of discharge after delivery should last between seven days and two months to
cleanse the birth passage and relieve cramps (Goodburn EA, Gazi AR et al. 1995), which
can inhibit care seeking in the event of post partum hemorrhage.
After birth, women are secluded between seven and forty days to ensure that others in the
family do not become polluted, as well as to protect the mother and the child from
malevolent spirits (Winch PJ, Alam MA et al. 2005). During the initial part of this period
of seclusion, traditional birth attendants or other family members may conduct the
mother’s chores, but soon after women assume their previous responsibilities, especially
those performed within the home. Unfortunately, women are often confined in rooms
with unhygienic conditions and poor ventilation that can be detrimental to the mother and
the baby (Afsana K and Rashid SF 2000). In addition, this seclusion acts as a barrier to
seeking care in the event of a problem, especially outside the local area where most
skilled providers are located (Goodburn EA, Gazi AR et al. 1995), although it is best
understood a relative (contributing to delay) rather than an absolute barrier to care
seeking (Winch PJ, Alam MA et al. 2005).
21
2.11
Facilitators to Care Seeking
There are many facilitators to seeking care for perceived complications. A review of the
literature has indicated that confidence in the technical competence of providers as well
as supportive husbands and communities contributes to care seeking for obstetric
complications. One study measured dimensions of women’s autonomy and care seeking
for antenatal and delivery care in North India. This study demonstrated a significant
effect of women’s freedom of movement on care seeking– this effect was equal to the
effect of maternal education on care seeking (Bloom SS, Wypij D et al. 2001). In
Bangladesh, women have more freedom of movement outside of the household than in
the past, especially in regards to family planning services (Schuler SR, Bates LM et al.
2002). However, women’s social mobility for delivery and postpartum services is
limited. See Table 2.1 for further description of facilitators.
2.12
Knowledge of Danger Signs
The majority of safe motherhood programs disseminate messages about “danger signs”
indicating obstetric complications that require seeking care at a health facility. The
assumption is that increased knowledge about “danger signs” will lead to prompt
recognition of a problem – either by the woman, her family, or the traditional birth
attendant – which will lead to care seeking behavior. However, there is no clear evidence
as to whether knowledge of danger signs leads to recognition of a problem or to care
seeking (Langer A, HernandezB et al. 2000; Perreira KM, Bailey PE et al. 2002; Portela
A and Santarelli C 2003). In addition, there is some evidence that these “danger signs”
may be misinterpreted within local knowledge systems (Bremmer M and Van Den Broek
22
G 1995; Goodburn EA, Gazi AR et al. 1995; Kureshy N 2004). Portela & Santarelli
(2003) maintain that this knowledge/behavior gap is partially accounted for by programs
not incorporating existing knowledge or capacity into messages or associating knowledge
with culturally and socially appropriate practices.
23
Table 2.1 Barriers and Facilitators to Use of Skilled Care for Normal or Complicated
Births at Various Levels
Barriers
Facilitators
Facility/Provider
Provider treatment:
Service providers indifferent, neglectful1,4,3,12,20
Providers rude and vulgar1,12,13,17
Shortage of skilled doctors20
Verbal abuse including yelling1,4,3
Physical violence4 – hitting; refusal to give
medication when indicated1
Sexual abuse1
Facility/Provider
Facility characteristics:
Discomfort with male health providers2,3
Predominance of male doctors in government
hospitals20
Long delays once in facility for emergency care2
Poor quality of services13,14,15,17
Lack of blood banks17
Limitations of medical equipment and technical
capacity of health personnel13,17,20
Facility characteristics:
Confidence in the technical competence of
skilled birth attendants; in the better equipped
facilities to manage complications4,12,13
Babies can get injections, eye treatment, new
clothes at a facility4
Birthing care:
Poor-quality, inhuman, or cold treatment at health
facility 2,13
Information about procedures not given or not clear
Birthing care:
Being accompanied to skilled care by a TBA
improved acceptance and reduced delay in
receipt of care4
3
No respect for ‘our’ customs (e.g. birthing position,
clothing, food, placental burial)2,8
Do not like to be undressed, lack of privacy linked
with shame2,3
Concerns and fears of users:
Feelings of intimidation due to hierarchical and
class distinctions3
Hospitals treat ‘pathological’ phenomenon and may
force surgery3, want to avoid episiotomy or csection, fear bad experience in hospital14
Fear of death in a hospital, lack of confidence in
staff17
If can’t manage complications, should not be
advised to go there3
During ANC providers say that pregnancy is
“normal”, so women perceive that they are OK to
birth at home12
Concerns and fears of users:
Fear of dying, of vesico-vaginal fistula/rectovaginal fistula4
Want to get antenatal card as ‘passport’ to
skilled care, especially if emergency4,12
Previous experience in health clinic and
previous delivery experience of relatives12
Access:
Costs for facility birthing and complications
considered high3,4,5,12,13,16,17,18,20,22
Facilities far away4,12,13
Community
Access:
Living near a facility4
Community
24
Barriers
Facilitators
Birthing care:
Traditional birth attendants delay in making
referrals9
Traditional birth attendants provide services that
modern providers do not provide, such as herbs for
treatment and prevention of maternal and some
childhood diseases.12
Cultural norms:
Religious leaders, traditional birth attendants,
elderly women talk against use of providers at
facilities4
Social norm is to deliver at home with family
members or traditional birth attendant21
Childbirth is normal13,3
Women prefer traditional birth attendants because
they are ‘comfortable4 ; they feel more
‘interpersonal trust’2 ; traditional birth attendants
provide neonatal, childcare and household care3,14
cost is minimal or in kind3
Birthing is ‘women’s business’ and men do not get
involved; couples do not discuss11
Preparations for birthing brings bad luck7
Access:
Long distances to facilities, transportation problems
and transportation operators charging higher fees for
emergencies15
Lack of transport to facilities9,12
Household
Knowledge:
Do not recognize danger signs of complications9 in
a timely way10
Lack of knowledge and understanding of childbirth,
unpreparedness for childbirth13
Lack of knowledge about services20
Social status:
Husbands/influential others are decision makers
when
travel16,
referral,
funds
are
involved6,11,12,13,15,22
Less empowered situation in family; less decisionmaking power13,15,22
Local understandings of health and illness::
Some complications considered natural10, attributed
to non-medical causes8, severity not recognized
owing to lack of distinctive characteristics11,9, lack
of awareness of severity16,22, traditional religious
beliefs13
Delivery depends on God12
Non-attendance of ANC where it was available and
could have been beneficial9
Fear of losing family prestige20
Superstition20
25
Household
Knowledge:
Educate husband and influential others,
including traditional birth attendants, on
complications and birth plan6,7
Social status:
Support of husband/close friends and relatives,
shared workload13
Freedom of woman’s movement18
Barriers
Facilitators
Woman are secluded for 40 days after delivery23
Problems are caused by infidelity or other problems
that require punishment – traditional healers more
appropriate17
Access/logistics:
Access/logistics:
Time, funds needed to purchase ‘birth supply kits’ Access to family budget13
for hospital delivery,4 to find and pay for
transportation5,16
Labor starting at night or unexpectedly so no time to
go to health units12
Nobody to leave at home12 with children9,17
Heavy workload13
Unexpected onset of labour4
Convenience of delivering at home14
Previous delivery at home without any problems13
Sources: 1 (d'Oliveira AFPL, Diniz SG, & Schraiber LB, 2002); 2 (Nachbar N, Baume C, & Parekh A,
1998); 3 (Afsana K & Rashid SF, 2001); 4 (Moore M et al., 2002); 5 (Olaniran N, Offiong S,
Ottong J, Asugui E, & Duke F, 1997); 6 (Ganatra BR, Coyaji KJ, & Rao VN, 1998); 7
(Alisjahbana A, Suroto-Hamzah E, Tanuwidjaja S, Wiradisuria S, & Abisujak B, 1983) ; 8 (Kaune
V, 2000); 9 (Fawcus S, Mbizvo M, Lindmark G, & Nystrom L, 1996); 10 (Langer A, HernandezB,
Garcia-Barrios C, & National Safe Motherhood Committee of Mexico, 2000); 11 (Kureshy N,
2000); 12 (Amooti-Kaguna B & Nuwaha F, 2000); 13 (Duong DV et al., in press); 14 (Obermeyer
CM & Potter JE, 1991); 15 (Eissien E et al., 1997); 16 (Shehu D, Ikeh AT, & Kuna MJ, 1997); 17
(Opoku SA et al., 1997) ;18 (Schuler SR, Bates LM, & Islam MK, 2002); 19 (Bloom SS, Wypij D,
& Gupta MD, 2001); 20 (Haider SJ, 2000) ; 21 (Afsana K & Rashid SF, 2000); 22 (Uzma A et al.,
1999); 23 (Goodburn EA, Gazi AR, & Chowdhury M, 1995)
26
CHAPTER 3: CONCEPTUAL FRAMEWORK
The conceptual model for this study was based on the framework developed by Aday and
Anderson (Aday LA, Anderson R et al. 1980), and it includes predisposing and enabling
factors that influence seeking care for perceived complications (Appendix 2).
Predisposing factors include individual factors, reproductive factors, household factors,
and community factors. The enabling factors to facilitate seeking care include
knowledge of danger signs, attending antenatal care, and availability and access to quality
services. In this model, these factors influence the ability to recognize an obstetric
complication and seek care for that complication. Use of services for complications will
ultimately improve maternal and neonatal survival.
These predisposing and enabling factors were examined through exploratory qualitative
methods and analysis of data from a household survey administered to recently-delivered
women. In the qualitative study, descriptive information on predisposing factors and
availability and access to services (including cost) informed perceptions of complications
and subsequent care seeking behaviors. In the analysis of the survey data, covariates
included variables at the individual, household, and community levels. At the individual
level, socio-demographic factors included woman’s age, women’s education level, parity,
knowledge of danger signs, and belonging to an organization, while reproductive factors
included the number of antenatal care visits, previous pregnancy loss
(abortion/miscarriage), loss of a child, and place of residence during delivery. At the
household level, the husband’s education level, wealth status, religion, and having a
27
relative working overseas were measured. Location of residence (sub-district) was used
as a proxy variable for access to services.
28
CHAPTER 4: STUDY DESIGN AND METHODS
4.1
Study Site and Parent Project
This study is nested in the Project for Advancing the Health of Newborns and Mothers
(Projahnmo I) in Sylhet district, Bangladesh, which is an on-going, three-arm clusterrandomized trial. Projahnmo I was conducted in three rural sub-districts of Sylhet
division of Bangladesh (Beanibazar, Zakigang and Kanaighat), in partnership with
Bangladeshi institutions, including the International Centre for Diarrheal Disease
Research, Bangladesh (ICDDR,B), Institute of Child and Mother Health, and the nongovernmental organization Shimantik. The primary purpose of Projahnmo I was to
develop feasible and cost-effective packages of maternal and newborn care interventions
and to evaluate the impact of interventions on maternal morbidity and neonatal mortality.
Sylhet District was chosen because of its poor health indicators compared with the rest of
Bangladesh. The maternal mortality ratio is 471 per 100,000 live births compared with
322 per 100,000 live births in the rest of the country (National Institute of Population
Research and Training (NIPORT), ORC Macro et al. 2003), and the neonatal mortality
rate is the highest in the country at 81.7 per 1,000 live births (National Institute of
Population Research and Training (NIPORT), Mitra and Associates (MA) et al. 2001),
although the baseline survey for the Projahnmo I study recorded a slightly lower figure
(Baqui A and Ahmed S 2004).
The Projahnmo I study included three arms– clinic care (CC), home care (HC), and a
comparison arm. In the CC model, services were delivered through the Government of
29
Bangladesh and NGO facilities. Community mobilizers hired by the project conducted
community mobilization activities to reinforce project messages and encourage antenatal,
delivery, and postpartum care for mother and newborns. In the HC model, selected
services were provided at the home by project-supported Community Health Workers
(CHW). The CHW reinforced project messages and encouraged the family to seek
antenatal care and to receive delivery and postpartum care at facilities. The project
comparison area maintained current services as provided by the Ministry of Health and
non-governmental organizations.
4.2
Study Methods
This study was conducted using three distinct methodologies: an extensive literature
review, in-depth interviews, and a quantitative survey. The literature review examined
all studies (peer-reviewed and gray literature) on self-reported maternal morbidity from
community-based studies in Bangladesh and India. Semi-structured in-depth interviews
were conducted with 24 women who had recently given birth in the Projahnmo I study
area as part of the qualitative research. The quantitative data are from the Projahnmo I
baseline survey. Over five thousand women with a live birth or stillbirth in the 12
months prior to the survey were interviewed about health knowledge, maternal
complications, and care seeking behaviors.
4.2.1
Literature review
4.2.1.1 Methods
PubMed, Old Medline (pre-1966), PsychInfo, and Sociological Abstract databases,
indexing a wide range of health, medical, epidemiologic and social science peer-reviewed
30
articles were searched from 1965 through November 2005. MeSH search terms included:
pregnancy complication, pregnancy complications, labor complication, labor
complications, and pregnancy complication infectious, combining these terms with
Bangladesh, South Asia, and/or India. Free text terms included: maternal morbidity,
maternal morbidities, maternal health, safe motherhood, labour complication, and
obstetric complications in combination with Bangladesh, South Asia, and/or India. There
were no restrictions on date, language, or type of publication. Details and abstracts were
managed using EndNote software Version 8.0.2. Authors also reviewed personal files,
gray literature, dissertations, and Demographic and Health Survey reports, as well as
secondary references in selected articles/reports.
Of the 2,207 references, 7 reports, and 1 dissertation resulting from the search, 250
articles, 6 reports, and 1 dissertation were identified as potentially relevant. Inclusion
criteria in the title, keywords, or abstract included: any type of maternal complication
and/or morbidity assessed through maternal self- reports, maternal mortality, Bangladesh,
or India. Studies that measured gynecologic morbidities were not included, as it was not
possible to ascertain if the morbidities were specifically related to pregnancy and/or
childbirth. In addition, studies that relied solely on lab testing or other technology to
diagnose morbidity (such as measurements of anemia) were excluded. Full-text versions
were obtained and reviewed for 156 articles, 6 reports, and 1 dissertation. Of these
papers, 27 included estimates of self-reports of maternal morbidity in Bangladesh or
India.
31
4.2.1.2 Data analysis
Separate variables were created for each reported maternal morbidity and entered into
Microsoft Excel. Care was taken to ensure that morbidities were not combined across
studies unless their definitions were exactly the same, as one of the objectives was to
describe all definitions used to measure similar conditions. The data were analyzed using
STATA 8.0 (STATA Corporation, College Station, TX).
4.2.1.3 Main findings
Twenty-seven papers met the inclusion criteria for this literature review: 20 articles from
peer-reviewed journals, 6 reports from gray literature, and 1 dissertation. Eighteen of the
studies were from Bangladesh, 8 were from India, and one included 9 countries, one of
which was India. All papers relied on women’s self-reports of maternal morbidities, with
eight studies including some type of health worker validation. Four studies were from
the Matlab study area in Bangladesh, where pictoral cards that contain information on
morbidities were completed by midwives. One third of the studies (30%) included
questions on morbidities from all phases of the birthing process (pregnancy, childbirth,
and postpartum period), 22% focused on the postpartum period, 15% focused on
pregnancy, and 11% focused on labor and birth. The most significant finding is the large
percentage of women who reported maternal health problems in this population.
Between 18.0% and 93.9% of women reported at least one morbidity during pregnancy,
between 8.0% and 34.6% reported at least one morbidity during childbirth, and between
22.0% and 81.1% of women reported at least one morbidity during the postpartum
period.
32
Several common themes emerged. First, these studies used a variety of terms to describe
self-reported illnesses/problems occurring during the birthing process. The terms to
describe these illnesses (complications, problems, morbidity, and chronic and acute
disability) were used interchangeably throughout the literature. Secondly, maternal
morbidities were classified differently in these articles– some conditions were classified
as occurring during childbirth in some studies and during the postpartum period in other
studies. There were 162 different variables used to measure morbidity during pregnancy,
delivery, and the postpartum period, which made comparisons among and between
studies problematic. Only eight studies measured perceived severity of complications,
and 16 studies reported care seeking behaviors. Recommendations for programs include
standardizing the terms used to describe morbidities, clearly defining study objectives
and methods, conducting formative research, and measuring perceived severity of
morbidities as well as care seeking behaviors.
4.2.2
Qualitative research
4.2.2.1 Methods
Twenty-four in-depth semi-structured interviews were conducted with women who had
recently given birth. Women who reported a maternal health problem during their last
pregnancy were identified from a community-based survey for the parent project.
Communities were purposively sampled to ensure adequate representation of women
living near and far from health facilities as well as from the study area. Women who
gave birth within six to twelve months of the survey were randomly selected from these
communities. The in-depth interview included questions about the woman’s birth
experience, health problems experienced, care seeking behaviors, decision-making, and
33
costs of treatments. Each respondent completed a free listing exercise on complications
during pregnancy, childbirth, and 40 days after delivery. For each complication
mentioned in the free listing, women were asked to rate the severity of that complication
on their general health (mild, neither mild or severe, or severe) as well as on their ability
to perform daily chores after birth (prevent you from working, restrict you to the home,
or require others to do your work).
Two female Bangladeshi interviewers with masters-level training in medical
anthropology conducted the interviews. After interviewer training, ten pre-tests were
conducted in the study area. The interview instrument was finalized in Bangla with the
local research team. Each interview took between one and one and one-half hours to
administer. Data were collected over four weeks in 2005.
4.2.2.2 Data analysis
The interviews were audio-recorded, and the interviewers also took extensive notes. The
notes and recordings were transcribed and translated into English by the interviewers.
The English versions were typed in Microsoft Word and reviewed by the research team.
Inconsistencies and questions were discussed and consensus was reached. Analysis
included manual coding of the transcripts by the female interviewers and the authors, as
well as discussions with the research team. Dominant themes were identified, and the
female interviewers used the constant comparative method to synthesize the data
(Boychuk Duchscher JE 2004). A list of key terms for maternal illnesses informed the
development of a quantitative instrument as well as qualitative analysis.
34
4.2.2.3 Main findings
In the interviews, women were asked about all health problems experienced during
pregnancy, childbirth, and in the first 40 days postpartum. Of the 90 problems reported,
50% occurred during pregnancy, 13% occurred during childbirth, and 36% took place
during the postpartum. If more than one complication was stated in each phase, women
were asked which complication was the “most serious.” A total of 61 serious
complications were reported, and care was sought for 55 of these conditions (90%).
These problems were diverse and ranged the continuum of severity. Women reported
lower abdominal pain, fever, and body ache during pregnancy; prolonged labor and
uterus prolapse during childbirth; and fever, bleeding, and swollen legs during the
postpartum period.
Almost all women sought care for serious health problems (90%). Four distinct care
seeking patterns emerged: 1) receiving traditional care and treatments available in the
home, 2) bringing treatment/medicine from an outside source into the home by another
family member, 3) bringing a provider into the home, and 4) leaving the home to go to a
health facility or provider’s office for treatment. Thirty-two (58%) complications were
first addressed by seeking care at home and 23 (42%) were first addressed outside of the
home. Care was sought at multiple places for 22 (40%) of the complications, and women
tended to consult doctors and pharmacy shops if the problem persisted. Based on these
data, we adapted a framework developed by Coreil, categorizing care seeking as
occurring inside the home (private domain) or outside the home (public domain) (Coreil J
1991).
35
The majority of women sought care at home for complications they perceived to be
“serious.” The interviews illustrated several advantages to seeking and receiving care in
the private domain where care is often brought to the home and the woman remains out
of view of the community. First, women/families retain decision-making power for type
of treatment administered, type of provider consulted, as well as costs of
medicine/treatment. Local models of illness etiology also play a large role in these
considerations. If the complication was perceived to be caused by evil spirits [upri,
bhut], then the spiritual healer [moulana] was consulted. For a condition such as
postpartum fever, care is often not sought, as this condition is perceived to help the
production of breast milk. Economic costs were minimized by treating the woman in the
home– both by purchasing medications/treatments within the financial limits of the
family and by limiting transportation costs to and from facilities. Women can be treated
in the comfort of the home, thus minimizing uncomfortable travel over unpaved routes to
health facilities. The reputation of the provider was another important theme. Women
reported deciding which provider to consult based on previous experiences. Finally,
social barriers, such as lack of decision-making power as well as limited social mobility
restricted care seeking outside the household. These factors may partially explain why
care seeking in facilities was so low.
4.2.3
Quantitative research
4.2.3.1 Methods
Stratified random sampling was used to identify women with a live or stillbirth in the 12
months prior to the survey within the study area. A total of 85,625 households were
enumerated. Of the 7,379 recently delivered women (RDW) randomly sampled for
36
knowledge, practices, and coverage modules on the survey, 6,050 (82%) were
successfully interviewed, yielding data for 5,625 women. No incentives were given to
participate in the research, and the major reason for the failure to interview women was
their absence from the household (Baqui A and Ahmed S 2004). Household heads were
asked about socio-economic information including household durable goods and water
and sanitation. Women were asked about socio-demographic information (age, education
level, religion, organization membership), as well as knowledge of danger signs during
pregnancy, childbirth, the postpartum, and for the newborn. Reproductive history
including parity, previous pregnancy losses, deaths to other children, number of antenatal
care visits, as well as place of residence during last delivery was ascertained. Women
were asked if they experienced any health problems during last pregnancy, childbirth,
and/or postpartum period as well as subsequent care seeking behaviors. Complications
included six potentially life-threatening complications: excessive bleeding, high fever,
bad smelling vaginal discharge, convulsions, prolonged labor (more than 12 hours),
and/or retained placenta. Data were collected by trained female health interviewers in
2003.
4.2.3.2 Measures
Variables were constructed to test the hypotheses listed in Section 1.5. Care seeking for
perceived complications was defined as a four-category outcome variable: 1) no care
seeking, 2) care seeking from traditional providers/family members, 3) care seeking from
pharmacy shops, and 4) care seeking from skilled providers. No care seeking was the
reference category. (See Table 4.1 for description of measures)
37
4.2.3.3 Data analysis
Data were reviewed for accuracy, consistency and completeness and entered into a
database designed using FoxPro version 9.0 (Microsoft, Redmond, WA, USA). Range
and consistency checks identified errors in data collection and entry. Data analysis was
conducted using STATA software version 8.0 (Stata Corporation, College Station, TX,
USA). Bivariate analysis measured associations between covariates and care seeking
behaviors using Pearson’s chi-square test. Multinomial logistic regression was used to
test for significant associations with care seeking behaviors controlling for other
covariates, with no care seeking as the reference category (Hosmer D and Lemeshow S
2000; Long JS and Freese J 2001). Models were adjusted for clustering at the union level
using the generalized estimating equation approach (Zeger SL, Liang KY et al. 1988).
Missing responses for the number of antenatal care visits were imputed using multiple
imputation (Little RJA and Rubin DB 1987).
Covariates for multivariate analyses were chosen based on prior findings. Wald tests
were used to determine which covariates were significantly associated with the outcome,
and covariates that did not contribute significantly to care seeking behaviors were
dropped from the model (Hosmer D and Lemeshow S 2000).4 Woman’s age and parity
were highly correlated (r=0.6705), so only parity was included in the model.
4
Since data were adjusted for clustering at the union level, they are not based on log likelihood estimation.
Therefore, Wald tests were used to test for significance instead of likelihood ratio tests.
38
Nine interaction terms5 based on the literature and research questions were tested for
significance using the Wald test as well as examining coefficients for differences in
coefficients across categories. An interaction term for number of antenatal care visits and
knowledge of danger signs was included in the final model. Hosmer-Lemenshow
Goodness of Fit was calculated to assess overall model fit (Hosmer D and Lemeshow S
2000).6
4.3.3.4 Main findings
Overall, 65.7% of women reported at least one complication, with 18.0% of women
reporting a complication during pregnancy. Thirty percent of women reported at least
one complication during delivery, and 51.8% of women reported at least one
complication during the postpartum period.
Of the 5,625 women, thirty-six percent reported excessive bleeding (36.5%), with
bleeding during the postpartum most prevalent (84.8%). About two in five women
reported high fever (39.6%), again with the majority of cases occurring during the
postpartum period (80.5%). Few women reported foul smelling vaginal discharge
(14.6%), but of those women, 87.6% reported discharge during the postpartum period. A
total of 14.1% of women reported convulsions, occurring equally during pregnancy and
the postpartum (59.3% and 50.6% respectively). About one-quarter of the women
5
Interaction terms included knowledge X education; knowledge X ANC visits; education X ANC visits;
parity X ANC visits; ANC visits X wealth status; education X wealth status; ANC visits X previous
pregnancy loss; education X parity; and knowledge X parity.
6
Bivariate outcome variables were created, and goodness of fit was tested separately for each outcome.
The final model included covariates that maximized goodness of fit in each of the outcome categories
(Hosmer D and Lemeshow S,2000).
39
experienced prolonged labor of more than 12 hours (24.0%), with only 6.6% of women
reporting retained placenta.
Of the women who reported at least one complication (n=3,697), 3,689 reported care
seeking behaviors by type of provider (99.9%). Of these women (n=3,689), about two in
five (42.3%) did not seek any care. Twenty-two percent of women sought care from
traditional providers or from family members, although few women turned to trained or
untrained traditional birth attendants or to family members for care. Almost thirteen
percent of women sought care from pharmacy shops, while 23.1% of women sought
skilled care either in the home or at a health facility. Women tended to seek skilled care
for bleeding during pregnancy (42.4%), for convulsions (28.9%), and for prolonged labor
(29.2%). Care from pharmacy shops was sought for high fever and for vaginal discharge
(16.2% and 13.9% respectively).
In the bivariate analysis, lower parity, higher education, having a child who died,
attending at least one antenatal care visit, and higher knowledge of danger signs were
significantly associated with seeking care for perceived complications. Household
factors of husband’s education level, Muslim religion, higher wealth, having a relative
working overseas, staying at natal home during delivery, and living in a more urban subdistrict were also significantly associated with seeking care. Belonging to an
organization and previous pregnancy loss were not significantly associated with care
seeking behaviors at the p=0.05 level.
40
In the multivariate analysis, care seeking behaviors among women with self-reported
complications were explored. The final multivariate model included women’s education,
parity, previous pregnancy loss, number of antenatal care visits, staying at natal home
during delivery, wealth status, having a relative working overseas, and sub-district.
Women who sought care from traditional providers and/or family members were more
likely to have primary education, have a relative working overseas, and to live in
Zakiganj or Kanaighat (the more remote, rural sub-districts), controlling for other
covariates.
Thirteen percent of women reported seeking care from pharmacy shops for perceived
complications. These women were more likely to have had at least one antenatal care
visit and be from a household with higher wealth status. Women from Zakiganj (more
rural) were 43% less likely to seek care from pharmacy shops than women from
Beanibazar (more urban) (OR: 0.57; 95% CI: 0.376-0.877).
Individual, reproductive, and household level characteristics were significantly associated
with seeking skilled care for perceived complications. Using no care seeking as the
reference category, women with secondary or more education were 1.50 times more
likely to seek skilled care, while women with at least three antenatal care visits were 2.77
times more likely to seek skilled care (95% CI: 0.915-1.449 and 1.463-5.253
respectively). Primiparity, a previous pregnancy loss, living in the woman’s natal home
during delivery, and higher wealth status were also significantly associated with seeking
41
skilled care versus no care. Women who lived in the more remote sub-districts were no
less likely to seek skilled care than women who lived in the more urban sub-district.
Knowledge of danger signs also had a significant effect on seeking skilled care. For
women with one to two ANC visits, women with higher levels of knowledge were 1.65
times more likely to seek skilled care compared with women with lower levels of
knowledge (95% CI: 1.027-2.647). For women with three or more ANC visits, the
effects were stronger. Women who spontaneously cited seven to nine danger signs were
2.54 times more likely to seek skilled care compared with women who cited zero to three
danger signs, while women who cited ten or more danger signs were 1.92 times more
likely to seek skilled care (95% CI: 1.33-4.853 and 1.103-3.356 respectively).
4.3
Strengths and Limitations
There are strengths and limitations to this study. The strengths include the thoroughness
of literature review, size of the sample, including both quantitative and qualitative
methods, quality of data management, and the ability to contribute to the safe
motherhood and behavior change literature.
There are limitations as well. First, the morbidities reported in this study are based on
self-reports. Research has shown that women’s self reports of obstetric complications do
not accurately correspond to medical diagnoses, and tend to over- or under-estimate
complications (Stewart MK and Festin M 1995; Danel I, Ponce de Leon R et al. 1996;
Ronsmans C, Achadi E et al. 1997; Seoane G, Castrillo M et al. 1998; Fortney JA and
Smith JB 2000; Sloan NL, Amoaful E et al. 2001). Nonetheless, women’s perceptions of
42
life-threatening problems are essential in relation to care seeking behaviors (Fortney JA
and Smith JB 2000; Yassin K, Laaser U et al. 2003). These findings indicate that
although a majority of women perceive experiencing “serious” or potentially lifethreatening complications, few seek care from a skilled provider. We cannot assess the
appropriateness of care sought, since we do not know the medically-defined severity of
the problem. Secondly, this research is limited to recently delivered women. To more
fully understand care seeking patterns, it is crucial to interview husbands, mothers-in-law,
mothers, and both traditional and skilled providers. Next, these findings may be limited
by recall bias. Although the recall period was relatively short (6 to 12 months for the
qualitative study and 12 months for the quantitative study), women may be able to more
clearly recall complications and care seeking behaviors within a shorter period (Stanton
CK 2004). Finally, the study was conducted in three sub-districts of Sylhet District. This
part of the country is culturally and linguistically different than the rest of the country,
and thus, the results may not be generalizable. However, the findings were consistent
with national level surveys, such as the Bangladesh Maternal Health Services and
Maternal Mortality Survey 2001, and the Demographic and Health Survey 2004
(National Institute of Population Research and Training (NIPORT), ORC Macro et al.
2003; National Institute of Population Research and Training (NIPORT), Mitra and
Associates et al. 2005).
43
Table 4.1: Description and measurement of variables in quantitative study
Measure
Dependent Variable
Care seeking for
reported complication
Covariates
Individual level
Woman’s age
Parity
Knowledge
Organization
Education level of
woman
Reproductive
Child death
Pregnancy loss
No. ANC visits
Place of residence
during delivery
Household
Education level of
husband
Wealth index
Relatives working
overseas
Religion
Community
Sub-district
Definition
Level of
Measurement
Care seeking for a reported maternal
complications (0=no care, 1=traditional/family,
2=pharmacy, 3=skilled care at home, facility, or
office). No care is reference category.
Categorical
Woman’s age at time of interview (1=14-19,
2=20-24, 3=25-29, 4=30-34, 5=35-39, 6=40+)
Number of births in lifetime (1=0-1, 2=2-4, 3=5+)
Knowledge of danger signs spontaneously cited
during pregnancy, childbirth, postpartum, and for
the newborn (4 item additive index; Cronbach’s
alpha=0.8913). (Categories: 0=0-3, 1=4-6, 2=7-9,
3=10+)
Woman belongs to at least one micro-credit
organization or Mother’s Club (Grameen Bank,
BRAC, BRDB, etc.)
(0=no, 1=yes)
No. of years of schooling completed by woman
(0=none, 1=primary, 2=secondary or more)
Ordinal
Woman had at least one child die (0=no, 1=yes)
Woman had at least one pregnancy loss
(miscarriage, abortion, stillbirth) (0=no, 1=yes)
Number of ANC visits with skilled provider
during last pregnancy (0=0 visits, 1=1-2visits, 3=3
or more visits)
Woman’s location when she gave birth
(0=in-laws house, 1=natal home)
Binary
Binary
No. of years of schooling completed by husband
(0=none, 1=primary, 2=secondary or more)
Wealth index based on Demographic and Health
Surveys (5 quintiles, 1=lowest, 5=highest)
At least one relative working overseas
(0=no, 1=yes)
Religion of household (0=Hindu, 1=Islam)
Categorical
Sub-district (0=Beanibazar, 1=Zakiganj,
2=Kanaighat)
Categorical
44
Categorical
Categorical
Binary
Categorical
Categorical
Binary
Ordinal
Binary
Binary
CHAPTER 5: A REVIEW OF POPULATION-BASED ESTIMATES OF
MATERNAL MORBIDITY IN BANGLADESH AND INDIA
5.1
Abstract
5.1.1
Background
Maternal mortality accounts for 500,000 to 600,000 deaths per year. Among problems
experienced by women related to child-bearing, maternal mortality is the “tip of the
iceberg.” The World Health Organization estimates that 50 million women suffer from
short- or long-term illnesses related to pregnancy and childbirth. These estimates vary
greatly among countries, and variability is due, in part, to the differing definitions of what
constitutes “morbidity” as well as differing methods of measurement. The objectives of
this paper are to: 1) to compare methods of population-based measurement of maternal
morbidities in India and Bangladesh identified via a literature review, 2) to document the
prevalence of self-reported maternal morbidity from the literature in these two countries,
and 3) to propose recommendations for safe motherhood programs that measure maternal
morbidity in an effort to understand and improve care seeking behaviors.
5.1.2
Methods
An extensive literature review in peer-reviewed databases and gray literature resulted in
2,207 references, 7 reports, and 1 dissertation of which full-text versions were obtained
and reviewed for 156 articles, 6 reports, and 1 dissertation. A total of 27 studies met the
inclusion criteria for self-reported maternal morbidity in Bangladesh or India.
5.1.3
Results
Of the 27 studies, 30% reported maternal morbidity during pregnancy, childbirth, and the
postpartum period, 22% focused on the postpartum period, 15% focused on pregnancy,
45
and 11% focused on labor and birth. There was much variation in definitions used to
measure specific morbidities as well as timing and classification of those conditions. Of
the 162 different variables to measure morbidities, 43 (27%) occurred during pregnancy,
36 (22%) occurred during childbirth, and 83 (51%) occurred during the postpartum
period. Eight (30%) of the studies included some validation of women’s reports by
trained community health workers and/or physicians, while others relied solely on the
woman’s self-report. Sixteen of the studies (60%) reported care seeking behaviors.
5.1.3
Conclusion
The authors present recommendations for safe motherhood programs including clearly
defining study objectives and methods, conducting formative research, and measuring
perceived severity of morbidities as well as care seeking behaviors.
46
5.2
Introduction
Maternal mortality remains a significant health burden in developing countries. Each
year, 500,000 to 600,000 women die from complications related to pregnancy and
childbirth, with 99% of these deaths occurring in developing countries (World Health
Organization, UNICEF et al. 2004). The majority of maternal deaths are avoidable by
ensuring access to appropriate management and treatment of obstetric complications
(Starrs A 1997). Improving maternal mortality has received recognition as a priority at
the global level as evidenced by its inclusion in the Millennium Development Goals
(United Nations 2004).
Among problems experienced by women related to child-bearing, maternal mortality is
the “tip of the iceberg”. Maternal morbidity, defined as illness and/or disability caused
by pregnancy-related complications, is more prevalent and widespread than maternal
mortality. The World Health Organization (WHO) estimates that 52 million women
suffer from morbidity related to the five direct obstetric causes of maternal death,7 with
millions more suffering from morbidity related to non-fatal outcomes of obstetric
complications as well as indirect causes of death (AbouZahr C 2003).8 Indirect maternal
morbidity results from previously existing conditions or disease which are aggravated by
pregnancy and this type of disability can occur at any time during a woman’s life.
Psychological morbidity can result from life-threatening complications or cultural
7
Direct obstetric causes of maternal death include: post-partum hemorrhage, puerperal sepsis, preeclampsia and eclampsia, obstructed labor, and abortion.
8
Due to paucity of data, estimates of morbidity related to non-fatal health outcomes of other direct obstetric
complications (ectopic pregnancies, cerebrovascular accidents, embolisms, etc.) as well as indirect causes
of death (anemia, malaria, tuberculosis, puerperal psychoses, postpartum depression, and suicide) are not
included in this estimate.
47
practices and most often manifests as postpartum depression (Fortney JA and Smith JB
1996).
The term maternal morbidity is not universally used in the literature. Studies often report
“maternal health problems,” “complications,” and “maternal morbidity” interchangeably,
while other studies report long-term chronic morbidities, acute morbidities, and disability
without specifying the definitions of these terms. In this paper, we define maternal
morbidity as any illness, complication, or health problem directly related to pregnancy or
childbirth, including conditions related to childbearing that present up to one year
postpartum.
The estimated prevalence of maternal morbidities varies greatly among countries. In
West Africa, for example, the incidence of delivery-related morbidity in a large
prospective study ranged between 2.8% to 8.4% in seven cities with great variability in
complications reported (MOMA group 1998). In another population-based study in
Bangladesh, 60.1% of women reported experiencing at least one morbidity during
pregnancy, delivery, or the postpartum period (National Institute of Population Research
and Training (NIPORT), ORC Macro et al. 2003). This variability is due to three
causes: 1) differing numbers of health conditions subsumed under “maternal morbidity”,
2) differing definitions of the same condition, and 3) differing methods of measurement.
First, there is no consensus in the literature regarding the number of health conditions that
comprise “morbidity.” For example, UNICEF/WHO/UNFPA include hemorrhage
(antepartum and postpartum), prolonged/obstructed labor, complications of abortion,
48
postpartum sepsis, pre-eclampsia/eclampsia, ectopic pregnancy, and ruptured uterus as
“maternal morbidities” (UNICEF/WHO/UNFPA 1997), while the former MotherCare
and the Prevention of Maternal Mortality (PMM) programs added severe anemia,
embolism and twins in addition to the above mentioned conditions (Maine, Akalin et al.
1997; McGinn 1997; Koblinsky 1999). This lack of specificity regarding the conditions
considered maternal morbidities is exacerbated by the variability in how these individual
conditions are defined. How severity is specified, if at all, varies widely and is critical to
the interpretation and the ultimate use of the morbidity estimates.
Finally, there are various methods to measure maternal morbidity at the population level,
facility level, or a combination using both population and facility-based data. At the
individual-level, population-based surveys document women’s self-reports of morbidities
experienced during pregnancy, childbirth, and the postpartum period. These surveys are
often preceded by qualitative research to explore the language needed to formulate
questions on perceived severity and care seeking behaviors. There is a lack of consensus
in the literature about which complications to ask about (potentially life-threatening or all
health problems), as well as how to ask about these problems (prompted versus
spontaneous responses). Although self-reports cannot accurately measure prevalence or
incidence of maternal morbidities, they can be useful in estimating the gross burden of
maternal morbidity and women’s perceptions of problems in relation to care-seeking
behaviors (Stewart MK and Festin M 1995; Danel I, Ponce de Leon R et al. 1996;
Ronsmans C, Achadi E et al. 1997; Seoane G, Castrillo M et al. 1998; Fortney JA and
Smith JB 2000; Sloan NL, Amoaful E et al. 2001; Yassin K, Laaser U et al. 2003).
49
In this paper we focus on population-based estimates of maternal morbidity in
Bangladesh and India. Bangladesh and India account for 29% of the world’s maternal
deaths, and 87% of maternal deaths in WHO’s South East Asia region (World Health
Organization, UNICEF et al. 2004). Women in these countries report high levels of
maternal morbidity. In Bangladesh, 60.1% of women reported at least one complication
during last pregnancy (National Institute of Population Research and Training (NIPORT),
ORC Macro et al. 2003), and 39.2% of women in India reported at least one reproductive
health problem during last pregnancy (International Institute for Population Sciences and
ORC Macro 2000). Home-based care is the norm in both these countries, with the
majority of births taking place at home without assistance from skilled providers (93%
and 58% respectively) (International Institute for Population Sciences and ORC Macro
2000; National Institute of Population Research and Training (NIPORT), ORC Macro et
al. 2003; National Institute of Population Research and Training (NIPORT), Mitra and
Associates et al. 2005). Thus, safe motherhood programs rely on women, families, and
traditional birth attendants to recognize danger signs of maternal morbidity to initiate
appropriate care seeking behavior. The objectives of this paper are threefold: 1) to
compare methods of population-based measurement of maternal morbidity in India and
Bangladesh identified via a literature review, 2) to document the prevalence of selfreported maternal morbidity from the literature in these two countries, and 3) to propose
recommendations for safe motherhood programs that measure maternal morbidity in an
effort to understand and improve care seeking behavior.
50
5.3
Study Methods
5.3.1
Methods
PubMed, Old Medline (pre-1966), PsychInfo, and Sociological Abstract databases,
indexing a wide range of health, medical, epidemiologic and social science peer-reviewed
articles were searched from 1965 through November 2005. MeSH search terms included:
pregnancy complication, pregnancy complications, labor complication, labor
complications, and pregnancy complication infectious, combining these terms with
Bangladesh, South Asia, and/or India. Free text terms included: maternal morbidity,
maternal morbidities, maternal health, safe motherhood, labour complication, and
obstetric complications in combination with Bangladesh, South Asia, and/or India. There
were no restrictions on date, language, or type of publication. Details and abstracts were
managed using EndNote software Version 8.0.2. Authors also reviewed personal files,
gray literature, dissertations, and Demographic and Health Survey reports, as well as
secondary references located in selected articles/reports.
Of the 2,207 references, 7 reports, and 1 dissertation resulting from the search, 250
articles, 6 reports, and 1 dissertation were identified as potentially relevant. Inclusion
criteria in the title, keywords, or abstract included: any type of maternal complication
and/or morbidity assessed through maternal self- reports, maternal mortality, Bangladesh;
or India. Studies that measured gynecologic morbidities were not included, as it was not
possible to ascertain if the morbidities were specifically related to pregnancy and/or
childbirth. In addition, studies that relied solely on lab testing or other technology to
diagnose morbidity (such as measurements of anemia) were excluded. Full-text versions
51
were obtained and reviewed for 156 articles, 6 reports, and 1 dissertation. Of these
papers, 27 included estimates of self-reports of maternal morbidity in Bangladesh or
India.
5.3.2
Data analysis
Separate variables were created for each maternal morbidity reported and entered into
Microsoft Excel. Care was taken to ensure that morbidities were not combined across
studies unless their definitions were exactly the same, as one of the objectives of this
review was to describe all definitions used to measure similar conditions. The data were
analyzed using STATA 8.0 (STATA Corporation, College Station, TX).
5.4
Results
Twenty-seven papers met the inclusion criteria for this literature review: 20 articles from
peer-reviewed journals, 4 reports from gray literature, 2 reports from Demographic and
Health Surveys, and 1 dissertation. The gray literature reports and dissertation have not
been published in their entirety (Bangladesh Institute of Research for Promotion of
Essential and Reproductive Health and Technologies (BIRPERHT) 1994; Goodburn EA,
Chowdhury M et al. 1994; Fortney JA and Smith JB 1996; Fronczak 1997; Baqui A and
Ahmed S 2004). Four articles from the BIRPERHT et al. report (1994) have been
published; these papers were included separately in this review since they present
additional findings (Chakraborty, Islam et al. 2002; Chakraborty, Islam et al. 2003a;
Chakraborty, Islam et al. 2003b; Islam, Chowdhury et al. 2004). Several articles have
been published from the Goodburn et al. report (1994) (Goodburn EA, Gazi AR et al.
52
1995; Goodburn, Chowdhury et al. 2000), and one article was recently published from
the Fronczak dissertation (1997) (Fronczak N, Antelman G et al. 2005). These articles
were excluded as the report and dissertation provide the most comprehensive description
of the findings.
Table 5.1 describes characteristics of the 27 studies included in this literature review.
Eighteen of the studies were from Bangladesh, 8 were from India, and one included 9
countries, one of which was India (Gordon, Gideon et al. 1965; Bangladesh Institute of
Research for Promotion of Essential and Reproductive Health and Technologies
(BIRPERHT) 1994; Goodburn EA, Chowdhury M et al. 1994; Bhatia and Cleland 1996;
Fortney JA and Smith JB 1996; Maine, Akalin et al. 1996; Fronczak 1997; Uzma A,
Underwood P et al. 1999; Affonso, De et al. 2000; Chowdhury, Akhter et al. 2000;
Kumari, Walia et al. 2000; Kusiako, Ronsmans et al. 2000; Vanneste AM, Ronsmans C
et al. 2000; Chakraborty, Islam et al. 2002; Chandran, Tharyan et al. 2002; Khan 2002;
Mishra U and Ramanathan M 2002; Mukhopadhyay, Ray et al. 2002; National Institute
of Population Research and Training (NIPORT), ORC Macro et al. 2003; Chakraborty,
Islam et al. 2003a; Chakraborty, Islam et al. 2003b; Bang, Bang et al. 2004; Baqui A and
Ahmed S 2004; Islam, Chowdhury et al. 2004; National Institute of Population Research
and Training (NIPORT), Mitra and Associates et al. 2005; Razzaque, Da Vanzo et al.
2005; Sibley, Caleb-Varkey et al. 2005). Almost all studies were quantitative in nature,
with one qualitative study and one study with both quantitative and qualitative methods.
All papers relied on women’s self-reports of morbidities, with eight studies including
some type of validation by a trained health worker. Four studies are from the Matlab
53
study area in Bangladesh, where pictoral cards that contain information on maternal
morbidities are completed by midwives. Maternal morbidities reported in these studies
were most likely recorded by a midwife, but in some cases the community-based health
worker may have filled in the card (Koblinsky, personal communication 2005). Half the
studies used a retrospective methodology while half were prospective.
The inclusion criteria for each study varied greatly. Some studies included women
(currently married or ever-married) who had recently given birth to a live or stillbirth,
while others included women with a miscarriage/abortion. The prospective studies
included women of six to seven months gestation and often followed them up to 90 days
postpartum. The definition of the postpartum period varied greatly with studies
measuring morbidities up to 28 days, 42 days, or 90 days postpartum.
One third of the studies (30%) measured morbidity during all phases of the birthing
process (pregnancy, childbirth, and postpartum period), 22% focused on the postpartum
period, 15% focused on pregnancy, and 11% focused on labor and birth. The remaining
studies included questions on a combination of these phases, and one study focused
solely on bleeding during any stage of pregnancy. All studies measured morbidities
using structured, prompted questions, with three studies using open-ended questions to
gather additional qualitative information. In the prompted questions, few studies
specified parameters (exact definitions) of morbidities or duration of the symptom(s).
Fourteen studies (52%) provided specific definitions of at least one of the morbidities
measured, while the other studies asked about morbidities in general terms. For example,
of the studies that asked women about bleeding, three studies asked “Did you bleed so
54
much that it wet your clothes and you feared it was life-threatening?” (National Institute
of Population Research and Training (NIPORT), ORC Macro et al. 2003; Baqui A and
Ahmed S 2004; National Institute of Population Research and Training (NIPORT), Mitra
and Associates et al. 2005), while other studies asked about “excessive bleeding” without
defining “excessive.”9
One of the most frequently cited indicators was the proportion of women who reported at
least one morbidity during pregnancy, childbirth, and/or the postpartum period (nine,
eleven, and twelve studies respectively). The range of morbidities experienced within
each phase varied greatly. Eighteen to 93.9% of women reported at least one
complication during pregnancy, 8.0% to 34.6% of women reported at least one
complication during childbirth, and 22.0% to 81.1% of women reported at least one
complication during the postpartum period. Figure 5.1 displays the variation in the range
of women who reported at least one morbidity during pregnancy, childbirth, and the
postpartum period by study.
The questions/variables used to measure maternal morbidities varied greatly among the
27 studies. Overall, there were 162 different maternal morbidities reported. Of these 162
morbidities, 43 (27%) occurred during pregnancy, 36 (22%) occurred during childbirth,
and 83 (51%) occurred during the postpartum period. There were two studies (Maine,
1996 and Khan, 2002) that reported eclampsia, but the timing of measurement was not
specified. The morbidities with the most variation in measurement during pregnancy
9
Other articles may have specified parameters for symptoms. Questionnaires were not available for all
papers included in the review.
55
included symptoms of pre-eclampsia/eclampsia (16 variables), symptoms of infection (8
variables), bleeding (2 variables), and anemia (2 variables). During childbirth, symptoms
of eclampsia (6 variables), bleeding (6 variables), and prolonged labor (5 variables)
included the most variation, while symptoms of infection (24 variables), bleeding (6
variables), and prolapse (4 variables) included the most variation during the postpartum
period. Variables to measure hemorrhoids, shock/loss of consciousness, malaria,
jaundice, tetanus, leg weakness/pain, urinary problems and retained placenta were also
reported, with only one variable to describe each of these conditions. Figure 5.2 displays
the number of variables used to measure morbidities in pregnancy, childbirth, and the
postpartum period.
It is not possible to explore all 162 reported morbidities in this paper. We focus on preeclampsia/eclampsia, hemorrhage, and postpartum infection since they were measured in
the majority of studies, and they comprise three of the five direct causes of maternal
death (World Health Organization 1998).
Pre-eclampsia/eclampsia in pregnancy
Pre-eclampsia/eclampsia or symptoms of pre-eclampsia/eclampsia during pregnancy
were reported in 13 studies, with 16 different variables to measure this condition. Table
5.2 presents these variables, the number of studies that reported each variable, as well as
the range of reported prevalence. Six of the studies reported “swelling of hands or face”
(range 4.3%-22.9%), with five studies reporting “fits/convulsions” (range 0.3%-8.9%).
Four studies reported “convulsions/eclampsia” (range 1.0%-17.7%), “pre-elampsia”
56
(range 1.5%-2.7%), and “proteinuria” (1.0%-9.0%) were reported in three studies each.
Other morbidities included “tibial edema” (11.1%-19.5%), “headache/blurry vision/high
blood pressure” (25.2%-43.7%), “high blood pressure” (3.3%-4.2%), “hypertension”
(3.6%-3.6%), “symptoms of pre-eclampsia” (9.0%), and “all hypertension” (3.8%). The
majority of these conditions were based on women’s self-reports with some validation by
trained community-based health workers and/or physicians/midwives. Some studies
were more specific about how complications were classified into categories of preeclampsia/eclampsia, while others were less explicit. For example, Goodburn et al
(1994) defined “pre-eclampsia” as two of the following symptoms as assessed by trained
community health workers: high blood pressure, proteinuria, and/or pre-tibial pitting
oedema. Fronczak et al (1997) defined “pre-eclampsia” as two of the following
symptoms: non-dependent oedema, headache, and/or dizziness where symptoms began in
the third trimester. These symptoms were not assessed by health providers.
Bleeding
Bleeding during pregnancy, childbirth, and/or the postpartum was measured in the
majority of these studies (15, 13, and 13 respectively). Table 5.3 describes the variables
used to measure bleeding during pregnancy, childbirth, and the postpartum period, as
well as the number of studies that reported each variable and the range of reported
prevalence. From this table, we can see that most studies reported “antepartum bleeding”
(n=12; range 0.4%-23.8%), while three other studies reported “excessive bleeding”
(range 1.6%-12.5%) during pregnancy. There were a variety of definitions used to
describe bleeding during childbirth. Eleven studies reported “excessive bleeding” (range
1.3%-28.6%), two studies reported “severe intrapartum bleeding” (range 2.7%-5.0%),
57
and other studies reported “intra or immediate postpartum hemorrhage” (5.0%),
“intrapartum bleeding” (25.0%), “moderate intrapartum bleeding” (21.0%), and “primary
postpartum hemorrhage” (3.2%).
Postpartum bleeding/hemorrhage was also measured in the majority of these studies.
“Excessive bleeding” was reported in nine studies (range 5.0%-56.0%), “postpartum
bleeding” reported in two studies (range 47.6%-69.9%), and “secondary postpartum
bleeding” reported in two studies (range 1.4%-4.5%). Other studies reported “secondary
postpartum hemorrhage at 2 weeks postpartum” (16.0%), “secondary postpartum
hemorrhage at 6 weeks postpartum” (5.6%), and “secondary postpartum hemorrhage at
12 weeks postpartum” (3.1%). Three studies also reported “shock/loss of consciousness”
(range 1.4%-4.5%).
Postpartum infection
Postpartum infection or the symptoms of postpartum infection were reported in 12 of the
studies. This condition is usually measured by assessing symptoms of postpartum fever,
foul smelling vaginal discharge, and/or abdominal tenderness/pain. In these studies, 24
different variables were used to measure postpartum infection. Six studies measured
“fever” (range 3.30%-32.10%), with two studies measuring “fever for more than three
days postpartum” (range 16.60%-18.30%). One study measured “fever at 2 weeks
postpartum” (32.40%), and at 6 weeks postpartum (28.70%). Other studies measured
“postpartum infection” (n=2; range 7.53%-24.00%), “postpartum infection during the
first two weeks after delivery” (26.00%), and “postpartum infection at 2-6 weeks
postpartum” (14.7%). Some studies measured “urinary tract infections” (n=1; 37.00%),
58
“genital tract infections” (n=1; 10.20%), “vaginal tract infection” (n=1; 5.00%), and “foul
discharge” (n=5; 1.40%-47.70%). Table 5.4 describes the variables used to measure
postpartum infection as well as signs and symptoms of postpartum infection in each of
the studies.
Severity and Care seeking behaviors
It is hypothesized that perceived severity of signs and symptoms of maternal morbidity
will trigger care seeking behaviors (Thaddeus S and Maine D 1994). Table 5.5 outlines
the methodologies used to ask about maternal morbidities, measures of severity, and care
seeking behaviors. In this review, eight studies (30%) measured perceived severity by
asking women if they believed their condition was serious and/or life-threatening based
on how it impacted their health and/or their ability to perform daily activities. Another
eight studies (30%) retrospectively classified morbidities based on the medical literature,
but the morbidities included in each of these classifications varied greatly.10 More than
half of studies reported subsequent care seeking behaviors (60%).
5.5
Discussion
Using an extensive literature review, the authors located 27 studies that measured
women’s self-reports of maternal morbidity in Bangladesh and India. Overall, a large
proportion of women reported experiencing pregnancy- and delivery-related morbidity.
Between 18.0% and 93.9% of women reported at least one morbidity during pregnancy,
between 8.0% and 34.6% of women reported at least one morbidity during childbirth, and
10
Groups were typically defined according to potential severity and life-threatening nature of the condition.
The first group included life-threatening complications such as bleeding and/or fits; the second group
included high-risk conditions that were uncomfortable but not medically dangerous; while the third group
often included pre-existing conditions which can complicate delivery.
59
between 22.0% and 81.1% of women reported at least one morbidity during the
postpartum period. A variety of questionnaire items to measure maternal morbidities
were employed in these studies, thus resulting in 162 different variables. Few studies
measured or reported women’s perceived severity of these morbidities and only 60%
reported subsequent care seeking behaviors. Several common themes emerged that
require further discussion and recommendations for safe motherhood programs.
5.5.1
Terms used to describe “maternal health problems”
These studies used a variety of terms to describe self-reported illnesses/problems that
occur as a result of the birthing process. Complications, maternal health problems,
morbidity, and chronic and acute disability were cited in this review; however, these
terms were not consistently used throughout the literature. One study referred to
complications during pregnancy and childbirth, and morbidities during the postpartum
period (Fronczak 1997). Two studies separated measurement of “postpartum
morbidities” and “long-term chronic postpartum morbidities” into discrete categories
(Bangladesh Institute of Research for Promotion of Essential and Reproductive Health
and Technologies (BIRPERHT) 1994; Fortney JA and Smith JB 1996), while other
studies combined all these conditions into one category of “postpartum problems.” The
duration of the “postpartum period” also varied greatly among studies. Some studies
limited it to 28 or 42 days, while others included morbidities up to 90 days postpartum.
This lack of clarity around terms to describe problems/complications/morbidities during
pregnancy, childbirth, and the postpartum as well as the duration of each pregnancy
phase creates difficulties in interpreting the findings from these studies. Moreover, few
60
studies captured long-term chronic morbidities, such as fistula or uterine prolapse, which
greatly contribute to long-term maternal disability.
Recommendations: There is a need to standardize the definitions of these terms at a
global level to facilitate understanding and comparison across studies. The World Health
Organization Technical Working Group defined obstetric morbidity as “morbidity in a
woman who has been pregnant from any cause related to or aggravated by the pregnancy
or its management but not from accidental or incidental causes” (World Health
Organization 1989).11 However, specific definitions for self-reports of “complications”
and/or “disability” were not provided. Based on the review of the literature, we
recommend the following definitions:
Maternal morbidity is a general term that refers to any illness or long-term
disability directly related to pregnancy and/or childbirth. Morbidity is not lifethreatening, but can have significant impact on quality of life. Morbidities
include conditions such as vomiting, diarrhea, urinary incontinence, breast
problems, and postpartum depression.
Obstetric complications are acute conditions reflected by the direct and indirect
causes of maternal deaths. According to the UNICEF/WHO/UNFPA (1997),
“complicated cases” include antepartum or postpartum hemorrhage, prolonged or
obstructed labor, postpartum sepsis, complications of abortion, preeclampsia/eclampsia, ectopic pregnancy, and ruptured uterus
(UNICEF/WHO/UNFPA 1997). Anemia, malaria, tuberculosis and other pre11
There was some discussion on including morbidities due to accidental or incidental causes.
61
existing conditions that may complicate delivery may also be considered obstetric
complications.
Long-term chronic morbidity refers to any long-term illness directly related to
pregnancy and/or childbirth. These conditions are caused by the birthing process,
but are not life-threatening. They are permanent disabilities that greatly impair
quality of life such as fistula, uterine prolapse, and dyspareunia.
5.5.2
“Classification” of maternal morbidities
All studies with one or two exceptions classified self-reports of maternal morbidities into
the pregnancy, childbirth, and/or postpartum period. Reports of “women who
experienced at least one morbidity during pregnancy, childbirth, and/or the postpartum”
were commonly cited; however, this was problematic as the morbidities classified within
each of these phases were often different. When comparing this indicator between and
among studies, one has to be careful to ensure that categories include the same
morbidities; otherwise, these comparisons could result in erroneous statements. For
example, the majority of studies classified “retained placenta” as a complication of
childbirth. One study included it as a complication of the postpartum period, and another
study included it separately in both categories. The same issue is pertinent to perineal
tears– some studies include this problem in childbirth and others include it in the
postpartum period.
The studies also differed in their classification of “co-morbidities.” All studies in this
review allowed multiple reports of morbidities, thus percentages were often more than
62
100 percent as women were likely to report more than one morbidity within each phase
of the birthing process. Some other studies, especially facility-based studies, only count
the most serious morbidity. Thus, there is a discrepancy in classifying and reporting
these problems between studies using population- and facility-based measurements.
Recommendations: There is a need to standardize how maternal morbidities are
classified and reported at a global level. Based on the review of the literature, we
recommend the following:
Pregnancy – any condition directly related to pregnancy including, but not limited
to: bleeding, symptoms of pre-eclampsia/eclampsia, complications of abortion,
fever, diarrhea, vomiting, depression, and anemia.
Childbirth – any condition directly related to childbirth including, but not limited
to: bleeding, symptoms of eclampsia, prolonged labor, obstructed labor, retained
placenta,12 perineal tears, and ruptured uterus.
Postpartum – any condition directly related to the postpartum period, from the
delivery of the placenta to 42 days postpartum. The time period may be extended
up to one year, as long-term morbidities often occur after 42 days postpartum.
These conditions include, but are not limited to: postpartum hemorrhage,
symptoms of postpartum infection, eclampsia, breast problems, fatigue/weakness,
depression, uterine prolapse, and fistula.
5.5.3
Maternal morbidities measured at different time points
These studies differed greatly in measuring the timing of certain morbidities. For
12
The third stage of labor is defined as birth of the baby to birth of the placenta; thus retained placenta
should be categorized as a complication of childbirth (World Health Organization, 2003).
63
example, some studies asked about “fever in the postpartum period,” while other studies
specified fever for three or more days after delivery, up to two weeks, and up to 6 weeks
postpartum. The same can be said about postpartum depression. Some studies looked at
postpartum depression in general, while others measured postpartum depression at less
than two weeks after delivery, 4-6 weeks after delivery, and 10-12 weeks after delivery.
The timing of the measurement is based on the objective of the study as well as study
design. Prospective studies are more likely to accurately capture morbidities at specific
time points, whereas retrospective studies are subject to recall bias and should limit
measurement to general morbidities.
Recommendations: Programs need to carefully define study objectives and methodology
prior to data collection. If the study is prospective, measuring perceived morbidity at
specific time points is feasible. It is important to select time points that are medically
viable and consistent with other research conducted in the study area to facilitate
comparability. In a retrospective design, morbidity measurements should not include
specific time points due to recall bias.
5.5.4
Inclusion criteria
Another pertinent issue is the inclusion criteria for respondents. Some studies recruited
women with a recent live or stillbirth, while others included women with a recent
abortion/miscarriage. These variations result in different denominators across studies,
thus making it more difficult to compare results and findings. There is also the question
of recall bias. Some studies included women with a live birth up to five years prior to the
study, while others limited inclusion to women with a live birth within two to three years
64
of the survey. There is no clear evidence as to the recall period for maternal morbidity
(Stanton CK 2004). In high fertility countries, women may experience more than one
pregnancy within a five year period, and thus, it may be difficult to recall specific
morbidities associated with each pregnancy. In addition, under-reporting of
abortions/miscarriages as well as stillbirths makes it unlikely that women with these
outcomes are adequately represented in survey research.
Recommendations: Programs need to carefully define inclusion criteria, depending on
study objectives and methodology. Every effort should be made to recruit women with a
live or stillbirth within one to two years of the survey to minimize recall bias.
5.5.5
Assessment of morbidities by health workers
In Bangladesh and India, home-based births are the norm, and thus medical assessment of
maternal morbidity must take place in the home. This is logistically difficult, especially
since the majority of life-threatening complications that lead to maternal morbidity occur
during the birth itself or in the first 48 hours postpartum (World Health Organization
2005). Physicians and other skilled providers are often unaware of births in the
community until several days after the birth, unless there is a problem and the woman
arrives at a health facility. Thus, research studies often rely on trained community health
workers to validate women’s reports of morbidities. In this review, eight studies included
some sort of community health worker and/or physician assessment (Goodburn EA,
Chowdhury M et al. 1994; Maine, Akalin et al. 1996; Fronczak 1997; Uzma A,
Underwood P et al. 1999; Kusiako, Ronsmans et al. 2000; Vanneste AM, Ronsmans C et
65
al. 2000; Bang, Bang et al. 2004; Razzaque, Da Vanzo et al. 2005). The level of training
and supervision of health workers varied by study and by research questions. Studies that
included some sort of validation varied in level of detail regarding the training level,
supervision, and ability of these health workers to diagnose and treat conditions. In one
study (Fronczak, 1997), health workers/physicians did not examine women until 2 weeks
postpartum, while in the Bang et al. study (2004), community health workers were
present at the birth itself. Uzma et al. (1999) included some physical exam at 6 weeks
postpartum. In the Matlab, Bangladesh study area, midwives diagnosed conditions and
recorded them on a pictoral card (Maine, Akalin et al. 1996; Kusiako, Ronsmans et al.
2000; Vanneste AM, Ronsmans C et al. 2000; Razzaque, Da Vanzo et al. 2005). It is
often difficult to ascertain which conditions were assessed by health workers and which
were based on self-reports.
Recommendations: Programs should clearly state whether the morbidity was measured
via self-report or via health worker in the methods section of any paper and/or report. If
health workers were used to measure morbidity, training, supervision, and other quality
assurance mechanisms should also be clearly reported.
5.5.6
Definition and measurement of maternal morbidities
There was great diversity in measurement of maternal morbidity resulting in 162 different
variables. This variation is understandable, especially since studies have different
objectives and study methodologies, and they often focus on different outcomes in
diverse cultural settings. Moreover, some morbidities require asking a series of questions
to capture symptoms (i.e. eclampsia, postpartum infection), while others can be captured
by a single question (i.e. excessive bleeding).
66
These studies also varied greatly in providing parameters on questions about symptoms,
both in terms of severity and duration. Symptoms that have a threshold after which they
become serious, like bleeding and fever, require specified parameters on severity and
duration to ensure valid responses across respondents. “Excessive” bleeding may mean
different things to different women. Other symptoms, which describe discrete conditions
such as fits/convulsions, may not require these parameters.
Recommendations: Formative research is a critical component of programs that aim to
measure maternal morbidity. The findings will provide appropriate terms for signs and
symptoms to be used in developing valid questionnaire items.
5.5.7
Perceived severity and subsequent care seeking behaviors
There are several ways to classify “severity” of maternal morbidity. Objective severity is
measured according to medical criteria using the biomedical model. The subjective view
of severity is based on the women’s perception of the seriousness of the condition which
is often influenced by local understandings of illness etiology as well as previous
experiences (Fortney JA and Smith JB 1996; Uzma A, Underwood P et al. 1999). In an
environment where home-based birth is the norm, women’s subjective perception is
critical to promote appropriate care seeking behaviors. There is some evidence that
women’s perceptions of severity of morbidities may act as a “trigger” to seek care
(Thaddeus S and Maine D 1994; Fronczak 1997; Nachbar N, Baume C et al. 1998; Uzma
A, Underwood P et al. 1999; Kalter HD, Salgado R et al. 2003; Yassin K, Laaser U et al.
2003). In this review, eight studies (30%) measured women’s perceptions of severity by
asking if the woman believed the condition was serious and/or life-threatening, while
67
another eight studies retrospectively classified morbidities into categories of lifethreatening, high risk, and other morbidities based on the medical literature. Sixty
percent of these studies reported subsequent care seeking behaviors.
Recommendations: Formative research will provide information on how women talk
about morbidity, as well as how they perceive the seriousness of specific signs and
symptoms. Perceived severity should be measured by programs aiming to improve care
seeking behaviors. These questions are best asked as a three- to five-point Likert scale or
other ranking method. In addition, care seeking behaviors are crucial outcome measures.
In formative research, different providers and preferred locations for care should be
identified. In Bangladesh and India, where home-based birth is the norm, the majority of
women first seek care at home. Questions that capture both home-based and facilitybased care should be included as appropriate.
Further research is needed to identify the validity of measuring perceived severity and
care seeking behaviors in quantitative surveys. Care seeking behaviors are complex and
do not always occur in a logical, sequential manner (Uzma A, Underwood P et al. 1999).
Thus, new methods that employ a combination of qualitative and quantitative techniques
need to be explored. Furthermore, there is a dearth of information on the burden of longterm chronic morbidities, such as uterus prolapse and fistula. Research is needed to
understand the impact of these conditions on women’s quality of life and ability to
perform daily work.
68
Although this literature review was extensive, it may not have been comprehensive.
Studies that measured and reported maternal morbidities may have been missed,
especially those in the gray literature. In addition, this review is limited to individuallevel reports of maternal morbidity and does not include estimates based on facility-level
data. Finally, this review focuses on India and Bangladesh, and findings may be different
for other regions.
5.6
Conclusion
Women perceive significant ill-health related to pregnancy and childbirth in Bangladesh
and India. In this cultural context, where home-based birth is the norm, safe motherhood
programs rely on prompt recognition of maternal morbidity to trigger appropriate care
seeking behaviors. This literature review includes specific recommendations for safe
motherhood programs that measure self-reports of maternal morbidity in an effort to
understand and improve care seeking behaviors.
69
Table 5.1: Description of community-based maternal morbidity studies in Bangladesh and India, 1965 to 2005 (n=27)
Author
Affonso
Publication
year
2000
Country
USA,
Guyana,
Italy,
Sweden,
Finland,
Korea,
Taiwan,
India,
Australia
Date data
collection
Method
Data Collection
Procedure
Not
specified by
country
Self
report;
Used
EPDS and
BDI
Interview:
PP: 4-6 wks and
10-12 wks
Interview:
Preg: 7th, 8th,
9th mths.
Delivery;
PP: 2nd, 3rd, 5th,
7th, 14th, 21st,
28th day;
physician visit
every 15 days to
verify
Bang
2004
Maharashtra
state, India
April 1995March 1996
Self
report;
assessed
by village
health
workers
Bangladesh
DHS 2004
2005
Bangladesh
Jan 2004 May 2004
Self report
Baqui
2003
2002
Bhatia
1996
Bangladesh
Karnataka
state,
Southern
India
Not
specified
Study
design
P
Type of
study
Quant.
P
Quant.
Interview
R
Quant.
Self report
Interview
R
Quant.
Self report
Interview
R
Quant.
70
Phase
Sample Population
PP
- PP women who
were 1) primiparous;
2) no major ob comp;
3) healthy baby at
first assessment
- Women with live or
stillbirth who
delivered in study
area and those from
other villages who
delivered in natal
All
home in study area
- Ever-married
women with live birth
five years before
CB
survey
- Women with live
birth or stillbirth 12
months prior to
All
survey
Mot– - Women < 35 yrs old
with at least one child
under 5 yrs of age
All
Sample
size
892 (All
countrie
s)
772
7,002
5,229
3,600
Author
Publication
year
Country
Date data
collection
Method
Data Collection
Procedure
Study
design
Type of
study
Phase
Sample Population
BIRPERHT
1994
Bangladesh
Nov 1992 –
Jan 1993
Self report
Interview
R
Quant.
All
BMMS
2001
2003
Bangladesh
Jan 2001 June 2001
Self report
R
Quant.
All
Chakraborty
2002
Bangladesh
Nov 1992 –
Jan 1993
Self report
Interview
Interview
monthly - in
pregnancy,
delivery, and 90
days preg. term.
or PP
P
Quant.
PP
P
Quant.
Preg
- Women with
abortion, live birth or
still birth in 2 years
prior to survey
- Woman with live or
still birth three years
prior to survey
- Pregnant married
women >6 mths
gestation in study
area
- At least one
postnatal visit
- Pregnant married
women in first or
second trimester at
time of baseline
survey
- At least one ANC
visit
Preg
- Pregnant women
with at least one
antenatal follow up
visit.
Chakraborty
Chakraborty
Chandran
2003a
2003b
2002
Bangladesh
Bangladesh
Tamil Nadu,
S. India
Nov 1992 –
Jan 1993
Nov 1992 –
Jan 1993
16 wk
period
Self report
Self report
Self
report;
used
Clinical
Interview
ScheduleR
Interview
monthly - in
pregnancy,
delivery, and 90
days preg. term.
or PP
Interview
monthly - in
pregnancy,
delivery, and 90
days preg. term.
or PP
Interview:
Preg: 34+ wks;
PP: 6 wks
71
P
P and R
Quant.
Quant.
ANC
and PP
- Pregnant women >
34 wks gestation
registered with ANC
clinics
- Expected to remain
in area 6 wks PP
Sample
size
6,493
40,657
1,006
993
993
384ANC;
359
ANC
and PP
Author
Publication
year
Country
Date data
collection
Chowdhury
2000
Bangladesh
Sept 1992 Oct 1992
ID; Oct
1992-Dec
1992 f/up
Fortney
1996
Bangladesh
Oct 1992 Dec 1992
Fronczak
Goodburn
Gordon
1997
Urban
slums,
Bangladesh
1994
Manikganj
district,
Bangladesh
1965
Punjab,
India
Nov 1993 May 1995
Dec 1991 June 1993
Not
specified
Method
Self report
Self report
Self report
with some
physician
Self report
with
communit
y health
worker
assessmen
t
Health
visitor
observatio
ns or
interview
Data Collection
Procedure
Interview:
Preg: Every 4
wks (up to 3
visits)
Interview
Interview:
preg; 27 wks
preg; 31 wks
preg; 72 hrs del;
1 wk pp; PP: 1422 days
Interview:
Preg: 28 wks;
PP: 48 hr; 2 wks;
6 wks; 12 wks
Interview
72
Study
design
Type of
study
Phase
Sample Population
Sample
size
P
Quant.
Preg
R
Quant.
All
- Married pregnant
women > 24 wks
gestation
- Married women
with pregnancy in last
two years (live,
stillbirth,
miscarriage/abortion)
All
- Women who
completed 7 mths of
pregnancy who lived
and delivered in
study area
1,506
Quant.
PP
- Pregnant women at
least 28 weeks
gestation delivering
in study area
1,540
Quant.
Not
specifi
ed
P
P
R
Quant.
Not specified
1,019
6,493
862
Author
Publication
year
Country
Islam
2004
Khan
2002
Bangladesh
Dewangonj,
Trishal subdistricts,
Bangladesh
Kumari
2000
North India
Kusiako
2000
Maine
1996
Mishra
2002
Mukhopadhyay
2002
Matlab,
Bangladesh
Matlab,
Bangladesh
West
Bengal,
India
West
Bengal,
India
Date data
collection
Method
Data Collection
Procedure
Study
design
Type of
study
Phase
Self report
Interview
monthly - in
pregnancy,
delivery, and 90
days preg. term.
or PP
P
Quant.
CB
Self report
Interview
R
Quant.
PP
Self report
Interview
R
Quant.
PP
Pictoral
cards;
facility
records
Pictoral
cards;
facility
records;
DSS;
Diagnosed by
midwife or as
noted in
maternity
register
Diagnosed by
midwife or as
noted in
maternity
register
Quant.
Preg
and
CB
1988-1989
Self report
Not
specified
Self report
Nov 1992 –
Jan 1993
2001
Jan 1996 Feb 1996
1987-93
1987-89
P
P
Quant.
All
Interview
R
Quant.
CB
Interview
R
Quant.
ANC
and PP
73
Sample Population
- Pregnant married
women >6 mths
gestation in study
area
- At least one ANC
follow up visit
- Postnatal women
- Married women >
15 yrs
- Pregnant women
>28 wks gestation
seen by a midwife for
ANC and childbirth
between 1987 and
1993
- Women diagnosed
with complication by
midwife based on
midwife cards
- Women with live
birth four years prior
to survey
- Women with live
birth 1 year prior to
survey
Sample
size
993
350
2,990
3,865
239
4,690
900
Author
Razzaque
Sibley
Uzma
Vanneste
Publication
year
Country
2005
Matlab,
Bangladesh
2005
Uttar
Pradesh,
India
1999
Urban
slums,
Bangladesh
2000
Matlab,
Bangladesh
Date data
collection
1996-2002
Method
Pictoral
cards
Data Collection
Procedure
Diagnosed by
midwife or as
noted in
maternity
register
Study
design
Type of
study
Phase
P
Quant.
Preg 3rd
ANC
visit
only
Bleeding
1998
Self report
Interview
R
Quant.
and
Qual.
July 1994 Dec 1994
Self report
with some
validation
Interview at 6
wks PP
R
Qual.
PP
1987-93
Pictoral
cards and
facility
records
Diagnosed by
midwife or as
noted in
maternity
register
P
Quant.
Preg
74
Sample Population
- Women who visited
health center during
3rd trimester of
pregnancy
- Women in study
area who planned a
home delivery and
whose pregnancy
ended in birth or
abortion
- Women with a live
or still birth 6 wks
prior to survey who
lived in study area
- Women seen by
midwife for ANC at
least once and
childbirth
- Complications
during or within 7
days of labor or
delivery
Sample
size
11,112
159
122
3,909
Table 5.2: Number of variables used to measure pre-eclampsia/eclampsia during
pregnancy, Bangladesh and India, 1965-2005 (all self report unless otherwise specified)
Variable
Number of
Reported
studies
prevalence (%)
Swelling of hands or face
6
4.30-22.90
Fits/convulsions
5
0.30-8.90
Convulsions/eclampsia
4
1.00-17.7
Pre-eclampsia1,2,2
3
1.50-2.70
Proteinuria1,2,2
3
1.00-9.00
Edema/pre-eclampsia
2
13.40-22.10
Tibial edema
2
11.10-19.50
Headache/blurry vision/high blood pressure
2
25.20-43.7
High blood pressure 1,2
2
3.30-4.20
Hypertension
2
3.60-3.62
Diastolic BP >= 90 mmHg2
1
9.10
Systolic BP >= 120 mmHg2
1
10.40
Hypertensive disorders of pregnancy3
1
9.00
Symptoms of pre-eclampsia, no convulsions4
1
9.00
Symptoms of pre-eclampsia, with convulsions5
1
1.00
All hypertension
1
3.80
1. Trained community-based health worker assessed (pre-eclampsia: two of the symptoms: high blood
pressure, proteinuria, pre-tibial pitting oedema)
2. Midwife assessed during antenatal care
3. Two symptoms: non-dependent oedema, headache, or dizziness where symptoms began in 3 rd
trimester
4. Two symptoms: non-dependent oedema, headache, or dizziness with no convulsions
5. Two symptom: non-dependent oedema, headache, or dizziness with symptoms of convulsions or
“fits” plus loss of consciousness
75
Table 5.3: Number of variables used to measure bleeding during pregnancy, childbirth,
and the postpartum period, Bangladesh and India, 1965-2005 (all self report unless
otherwise specified)
Variable
Number of
Reported
studies
prevalence (%)
Pregnancy
Antepartum bleeding
12
0.40-23.80
Excessive bleeding
3
1.60-12.50
Excessive bleeding
11
1.30-28.60
Severe intrapartum bleeding
2
2.70-5.00
Intra or immediate PPH
1
5.00
Intrapartum bleeding
1
25.00
Moderate intrapartum bleeding
1
21.00
Primary postpartum hemorrhage
1
3.20
Excessive bleeding
9
5.00-56.001
Shock/loss of consciousness
3
1.40-4.50
Postpartum bleeding
2
47.6-69.87
Secondary postpartum bleeding
2
15.2-30.00
Secondary postpartum hemorrhage at 2 weeks
1
16.00
Childbirth
Postpartum
postpartum
76
Variable
Secondary postpartum hemorrhage at 6 weeks
Number of
Reported
studies
prevalence (%)
1
5.60
1
3.10
postpartum
Secondary postpartum hemorrhage at 12 weeks
postpartum
Notes:
1. Not clear if from ANC, CB, or PP or all combined. Other highest percentage is 37.40%.
77
Table 5.4: Number of variables used to measure postpartum infection, Bangladesh and
India, 1965-2005 (all self report unless otherwise specified)
Variable
Number of
Reported
studies
prevalence (%)
Fever
6
3.30-32.10
Foul discharge
5
1.40-47.70
Pain in pelvic region
4
7.70- 49.00
Lower abdominal pain
3
11.60-49.00
Fever more than 3 days
2
16.60-18.30
Postpartum infection1,2
2
7.53-24.00
Postpartum infection during first two weeks after
1
26.00
Postpartum infection 2-6 weeks after delivery3
1
14.7
Lower abdominal pain at 2 weeks postpartum
1
32.00
Lower abdominal pain at 6 weeks postpartum
1
27.00
Pelvic infection4
1
14.00
Urinary tract infection5
1
37.00
Vaginal discharge (and associated symptoms)6
1
15.00
White discharge
1
2.30
Vaginal/pelvic infection7
1
1.10
Vaginal tract infection8
1
5.00
Genital tract infection9
1
10.2
Genital tract infection at 2 weeks postpartum10
1
26.40
delivery3
78
Variable
Number of
Reported
studies
prevalence (%)
Genital tract infection at 6 weeks postpartum10
1
14.70
Foul discharge at 2 weeks postpartum10
1
32.30
Foul discharge at 6 weeks10
1
13.70
High fever with foul smelling discharge
1
2.00
Fever 2 weeks postpartum10
1
32.40
Fever 6 weeks postpartum10
1
28.70
Notes:
1. Two reported symptoms: lower abdominal pain, foul smelling discharge, or fever
2. Midwife assessed
3. Assessed by trained community health workers– concurrently had two symptoms: fever, four
discharge, lower abdominal pain.
4. Two reported symptoms: abdominal tenderness, fever, or foul vaginal discharge three or more
days postpartum
5. Two reported symptoms: burning, frequency, urgency or foul odor.
6. Reported vaginal discharge– prompted on color, odor and quantity.
7. Three reported symptoms: foul discharge, fever, and pain.
8. One reported symptom: thick discolored or fold vaginal discharge
9. Assessed by trained female health workers and some physician validation.
10. Assessed by trained community health workers.
79
Table 5.5: Description of maternal morbidity studies by study characteristics, 1965 to 2005 (n=27)
Author
Morbidities reported
Type of
morbidity1
Affonso
Bang
Bangladesh
DHS 2004
Baqui
Bhatia
BIRPERHT
BMMS
Chakraborty
Chakraborty,
2003a
Chakraborty,
2003b
Depression
Life
threatening
and other
Life
threatening
and other
Life
threatening
Life
threatening
and other
Life
threatening
and other
Life
threatening
and other
Life
threatening
Life
threatening
and other
Life
threatening
and other
Openended
questions
Severity
Prompted
questions
Parameters
on symptoms2
Duration
Specified3
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Woman’s
perception4
On
general
health
Care
Seeking
Behaviors
On
performi
ng daily
activities
Classified
by
author5
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
80
Author
Morbidities reported
Type of
morbidity1
Chandran
Chowdhury
Fortney
Fronczak
Goodburn
Gordon
Islam
Khan
Kumari
Kusiako
Depression
Life
threatening
and other
Life
threatening
and other
Life
threatening
and other
Life
threatening
and other
Life
threatening
and other
Life
threatening
and other
Life
threatening
Uterus
prolapse
Life
threatening
(midwife
cards)
Openended
questions
Severity
Parameters
on symptoms2
Duration
Specified3
X
X
X
X
X
X
X
X
X
X
Woman’s
perception4
Prompted
questions
X
X
X
X
X
X
On
general
health
Care
Seeking
Behaviors
On
performi
ng daily
activities
Classified
by
author5
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
81
X
X
Author
Morbidities reported
Type of
morbidity1
Maine
Mishra
Mukhopadhyay
Razzaque
Sibley
Uzma
Life
threatening
(midwife
cards)
Life
threatening
and others
Life
threatening
and others
Life
threatening
(midwife
cards)
Life
threatening
and others
Life
threatening
and others
Life
threatening
(midwife
cards)
Openended
questions
Prompted
questions
Severity
Parameters
on symptoms2
Duration
Specified3
Woman’s
perception4
On
general
health
On
performi
ng daily
activities
Care
Seeking
Behaviors
Classified
by
author5
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Vanneste
Notes:
1. Life threatening refers to complications that lead to major direct obstetric causes of death including: (excessive) bleeding, high fever (with foul smelling
discharge), prolonged labor, hands/feet came first, and fits/convulsions.
2. Prompted symptoms include at least one specific definition of morbidity. For example, “bleeding so much that it wet your clothes and you feared it was
life-threatening” or “fever for more than three days with foul smelling vaginal discharge”.
82
Author
Morbidities reported
Type of
morbidity1
Openended
questions
Prompted
questions
Parameters
on symptoms2
Severity
Duration
Specified3
Woman’s
perception4
On
general
health
On
performi
ng daily
activities
Care
Seeking
Behaviors
Classified
by
author5
3. Duration of symptoms specified for at least one morbidity included as part of prompted questions.
4. Asked the woman if the complication(s) cited were serious and/or life threatening, based on her perception. If yes, the question specified if it was serious
for her general health and/or had an effect on her work or her ability to perform daily activities.
5. The authors retrospectively classified morbidities into groups based on medical definitions of “life-threatening” complications.
83
Study
84
99
6
99
oo
7
db
ur
n,
19
94
G
or
do
n,
19
65
Is
l
am
M
uk
,2
ho
00
pa
4
dh
ya
y,
20
02
Si
bl
ey
,2
00
5
U
zm
a,
19
99
k,
1
0
04
20
20
0
Childbirth
G
cz
a
3
00
2
ey
,1
S,
H
rtn
D
ry
,
or
ty
,2
M
S,
20
0
19
94
99
6
Percentage
Pregnancy
Fr
on
4
00
3
,1
T,
H
tia
dh
u
Fo
w
ho
kr
ab
ha
C
C
ER
BM
P
BI
R
Bh
a
ui
,2
Ba
q
g,
20
0
Ba
n
Figure 5.1: Percentage of women with at least one morbidity by timing of measurement and by study (n=16)
Postpartum
100
90
80
70
60
50
40
30
20
10
0
Figure 5.2: Number of variables reported by type of morbidity and timing of measurement (n=162)
Pregnancy
Childbirth
Postpartum
30
20
15
10
5
Reported Morbidity
85
th
er
O
ss
io
n
ep
re
D
Br
ea
st
pr
ob
le
m
s
U
rin
ar
y
pr
ob
le
m
s
An
em
ia
Pl
ac
en
ta
R
et
ai
ne
d
In
fe
ct
io
n
Bl
ee
edi
ec
ng
la
m
ps
ia
/E
cl
am
ps
ia
Pr
ol
on
ge
d
La
bo
r
0
Pr
Number of variables
25
Notes for Figure 5.2:
Pre-eclampsia/Eclampsia includes: headache; convulsions/fits; high blood pressure; blurry vision; and references to pre-eclampsia and/or eclampsia
Infection includes: fever; vaginal (foul smelling) discharge; lower abdominal pain; pelvic pain; backache; urinary tract infection; genital tract infection; pelvic
infection; postpartum infection
Breast problems include: painful nipples; abscesses; breast problems
Other (pregnancy): abortion (1); tuberculosis (1); weakness (1); rhematic heart disease (1); varicose veins (1); malaria (1); tetanus (2); vomiting (1); fundal height
>= 85 percentile (1); diarrhea (1); hypermesis (1); (n=43 total variables)
Other (childbirth): prolonged rupture of membranes (1); premature rupture membranes (3); infant malposition (2); loss of consciousness (1); ruptured uterus (1);
cesarean section (1); instrumental delivery (1); episiotomy (1); torn vagina/cervix (1); other direct (1); (n=36 total variables)
Other (postpartum): prolapse - uterine and genial (4); passage of stools (1); passage of gas (1); dyspareunia (1); weakness/fatigue (3); fistula (1); perineal tear (1);
hemorrhoids (1); shock/loss of consciousness (1); pain lower limbs (1); dysentery (1); jaundice (1); tetanus (1); palpitations (1); giddiness (1); leg weakness/pain
(1); non specific illness (1); indigestion with vomiting (1); (n=83 total variables)
86
CHAPTER 6: CARE SEEKING FOR MATERNAL HEALTH PROBLEMS IN
SYLHET DISTRICT, BANGLADESH
6.1
Abstract
6.1.1
Background
Maternal morbidity and mortality are substantial health problems in developing countries.
Between 5 to 50 percent of deaths to women of reproductive age are due to pregnancyrelated causes. These deaths can be prevented through timely treatment of complications
that contribute to maternal illness. In settings where home-based birth is the norm,
seeking appropriate care for complications is therefore the key intervention in safe
motherhood programs.
6.1.2
Methods
Twenty-four in-depth semi-structured interviews were conducted with women who had
recently given birth in Sylhet District, Bangladesh to elucidate care seeking patterns for
perceived maternal complications.
6.1.3
Results
Four different care seeking patterns were described: 1) seeking traditional remedies
available in or around the home, 2) bringing treatment/medicine to the home, 3) bringing
a health provider to the home, and 4) going to a health facility or provider for treatment.
Location of care inside or outside the household was the dominant theme from the
interviews. Perceived severity of the complication, local models of illness etiology,
decision-making about treatment and cost of treatment, perceived quality of care, and
women’s limited social mobility were key factors in shaping care seeking behaviors.
87
6.1.4
Conclusion
Perceived maternal morbidity is a large burden on women in rural Bangladesh. In this
setting, home-based birth is the norm, and safe motherhood programs aim to ensure that
women with potentially life-threatening complications receive skilled care. Women’s
understandings of complications as well as their definitions of care seeking are essential
in developing interventions to address care seeking behaviors at multiple levels.
88
6.2
Background
Women suffer needlessly from pregnancy-related morbidity and mortality in developing
countries; pregnancy-related deaths account for 5 to 50 percent of deaths to women of
reproductive age (World Health Organization, UNICEF et al. 2004). Life-threatening
complications that contribute to maternal illness and death cannot be predicted with
certainty by high risk pregnancy screening but can be managed with appropriate and
timely use of obstetric care (Starrs A 1997). The Safe Motherhood Initiative, launched in
1987, therefore recommends that all births are attended by a skilled provider to manage
complications if they occur (Starrs A 1997). In settings where the majority of women
give birth at home, timely care seeking for complications is a key intervention. These
life-saving interventions, such as Cesarean section and blood transfusions, require
facility-based care that cannot be provided at home.
There is an on-going debate within the safe motherhood community regarding the
medicalization of the birthing process. On the one hand, pregnancy is a normal
physiological process and only becomes an illness when a complication occurs.
Medicalization can have a deleterious effect on local capacity to manage the normal
birthing process that draws on local knowledge and involves birth attendants who often
acquire their skills through apprenticeship rather than formal training. In some settings,
over-medicalization of birth has resulted in high rates of episiotomy and Cesarean section
(Buekens P 2001). On the other hand, to reduce maternal death and illness, some
medicalization of the process is essential through improving the skills of providers who
attend home births to ensure clean delivery and that mothers who require life-saving
89
interventions (blood transfusion, Cesarean section for obstructed labor, intravenous
antibiotics) are referred to health facilities. This is especially critical in settings where
home-based births are the norm and social factors may inhibit women’s mobility outside
the household. Safe motherhood programs are currently struggling to define an
acceptable middle ground in this debate.
The Three Delays Model outlines the factors that contribute to maternal death and is used
extensively by safe motherhood programs. The first delay refers to recognizing the
problem and deciding to seek care, while the second delay includes the delay in
identifying and reaching a medical facility. The third delay refers to receiving
appropriate care in a medical facility (Thaddeus S and Maine D 1994). This definition of
care seeking is unidirectional and medical: “care” means medical care and “seeking”
means accessing a provider outside the home.
In Bangladesh, where home-based birth is the norm, few women access skilled care
during pregnancy and childbirth (National Institute of Population Research and Training
(NIPORT), Mitra and Associates et al. 2005). High economic costs, lack accessibility to
facilities and transportation, and poor quality of care contribute to low use of skilled care
(Goodburn EA, Gazi AR et al. 1995; Uzma A, Underwood P et al. 1999; Afsana K and
Rashid SF 2000; Haider SJ 2000; Afsana K and Rashid SF 2001; Schuler SR, Bates LM
et al. 2002; Rahman SA, Parkhurst JO et al. 2003). Safe motherhood programs use the
Three Delays Model to focus on early recognition of potentially life-threatening
complications, encouraging care seeking at health facilities and improving the availability
90
and quality of care. Programs disseminate messages on recognition of danger signs that
may indicate life-threatening complications, planning for transportation to a pre-selected
facility if a complication occurs, and saving money to pay for care. Unfortunately, there
is no evidence that these strategies work (Stanton CK 2004), and care is typically sought
too late or not at all (Uzma A, Underwood P et al. 1999; Fronczak N, Antelman G et al.
2005).
Sylhet District, Bangladesh has higher maternal mortality compared with the rest of the
country (471 per 100,000 live births) with only 11% of women giving birth with a skilled
provider (National Institute of Population Research and Training (NIPORT), ORC Macro
et al. 2003; National Institute of Population Research and Training (NIPORT), Mitra and
Associates et al. 2005). In a recent survey, 66% of women reported at least one lifethreatening complication during their most recent birth.13 Most women reported seeking
care at home (24.4%) or in places other than health facilities (20.1%) for these potentially
life-threatening conditions (Baqui A and Ahmed S 2004). To further explore care
seeking behaviors outside facilities, we conducted in-depth interviews with women who
had recently given birth (n=24). In this paper, we discuss women’s constructions of care
seeking behaviors and their implications for safe motherhood programs.
6.3
Methods
6.3.1
Study site
This qualitative study was nested within a larger research project to evaluate the effects
of community-based interventions on maternal morbidity and neonatal mortality in three
13
Complications included: excessive bleeding, high fever, foul smelling vaginal discharge, convulsions, prolonged
labor (more than 12 hours), and/or retained placenta.
91
sub-districts- Beanibazar, Zakiganj, and Kanaighat –of Sylhet District, Bangladesh.
Sylhet District was selected for this research project due to its higher rates of newborn
and maternal mortality compared with the rest of the country (National Institute of
Population Research and Training (NIPORT), ORC Macro et al. 2003; National Institute
of Population Research and Training (NIPORT), Mitra and Associates et al. 2005).
In Sylhet, as in the rest of Bangladesh, the health care system is highly pluralistic, with
availability of formal and informal providers (Parkhurst, Penn-Kekana et al. 2005). The
informal or traditional health sector is comprised of spiritual healers/leaders, village
doctors, homeopathic doctors, and traditional birth attendants, while the formal health
sector is quite diverse with a mixture of private facilities, government facilities, and
doctors’ offices. Pharmacy shops that sell medications and injections are also prevalent,
and account for a large proportion of care in this area (Winch PJ, Alam MA et al. 2005).
A description of health providers, their training and the location of care provided is
included in Table 6.1.
6.3.2
Data collection
This study included 24 in-depth semi-structured interviews with women who had recently
given birth. Women who reported a maternal health problem during their last pregnancy
were identified from a community-based survey for the parent project. Communities
were purposively sampled to ensure adequate representation of women living near and far
from health facilities as well as from the study area. Women who had given birth within
six to twelve months of the survey were randomly selected from these communities. The
in-depth semi-structured interview included questions about the woman’s birth
92
experience, health problems experienced, care seeking behaviors, decision-making, and
costs of treatments. Each respondent completed a free listing exercise on complications
during pregnancy, childbirth, and 40 days postpartum. For each complication mentioned
in the free listing, women were asked to rate the severity of that complication on their
general health (mild, neither mild or severe, or severe) as well as on their ability to
perform daily chores after birth (prevent you from working, restrict you to the home, or
require others to do your work). There were no refusals to participate in the study.
Two female Bangladeshi interviewers with masters-level training in medical
anthropology conducted the interviews. After interviewer training, ten pre-tests were
conducted in the study area. The interview instrument was finalized in Bangla with the
local research team. Each interview took between one and one-half hours to administer.
Data were collected over four weeks in 2005.
6.3.3
Data Analysis
The interviews were audio-recorded, and the interviewers also took extensive notes. The
notes and recordings were transcribed and translated into English by the interviewers.
The English versions were typed in Microsoft Word and reviewed by the research team.
Inconsistencies and questions were discussed and consensus was reached. Analysis
included manual coding of the transcripts by the female interviewers and the authors, as
well as discussions with the research team. Dominant themes were identified, and the
female interviewers used the constant comparative method to synthesize the data
(Boychuk Duchscher JE 2004). A list of key terms for maternal illnesses informed the
development of a quantitative instrument as well as qualitative analysis.
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Ethical approval for this study was obtained from Johns Hopkins University and
ICDDR,B: International Centre for Population and Health in Dhaka, Bangladesh. All
participants gave informed consent prior to enrollment.
6.4
Results
All women were currently married with a mean age of 26 years and an average of 3
children. With the exception of one woman who was Hindu, all women were Muslim.
Years of schooling varied from 0 to 12 years, with more than half of women (58%)
having no schooling. Twenty of the women gave birth at home (83%), while four of the
women gave birth in a health facility (17%).
In the interviews, women were asked about all health problems experienced during
pregnancy, childbirth, and in the first 40 days postpartum. Of the 90 problems reported,
50% occurred during pregnancy, 13% occurred during childbirth, and 36% took place
during the postpartum. If more than one complication was stated, women were asked to
identify the “most serious” complication in each phase. A total of 61 serious
complications were reported, and care was sought for 55 of these conditions (90%).
These problems were diverse and ranged the continuum of severity. Women reported
lower abdominal pain, fever, and body ache during pregnancy; prolonged labor and
uterus prolapse during childbirth; and fever, bleeding, and swollen legs during the
postpartum period (see Table 6.2). Thirty-two (58%) complications were first addressed
by seeking care at home and 23 (42%) were first addressed outside of the home. Care
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was sought at multiple places for 22 (40%) of the complications, and women tended to
consult doctors and pharmacy shops if the problem persisted. (Figure 6.1)
Four distinct care seeking patterns emerged from the interviews with place of care inside
or outside the home as the dominant theme. Based on these data, we adapted a
framework developed by Coreil, categorizing care seeking as occurring inside the home
(private domain) or outside the home (public domain) (Coreil J 1991). In this
framework, the private domain encompasses three types of care: 1) traditional remedies
available in or around the home, 2) sending a family member to purchase treatment to be
administered in the home, and 3) bringing a health provider into the home to administer
treatment. The public domain refers to care provided by health workers outside the home
in a health facility or a provider’s office/home.
6.4.1
Care seeking patterns
6.4.1.1 No care seeking
Of the 61 serious maternal health problems reported, six women did not seek any care.
The majority of these women (n=5) reported fever in the 40 days after delivery and didn’t
seek care due to the local perception that postpartum Taap [fever] is “normal” and “helps
to produce breast milk.”
The other reason why women did not seek care was lack of financial resources. One
woman who experienced uterus prolapse stated:
“[my uterus] it looks like an egg . . . I could not walk fast and also work fast. I put a
piece of cloth inside the mouth of the vagina to set uterus inside, but it is so difficult. . .
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for ten months I am suffering from this . . . I could not afford my meal daily so how could
I afford treatment at a facility.” (5 children, far from health facility)
Local understandings of illness causation and economic constraints may be barriers to
care seeking either inside or outside the household. These barriers have been noted in
other studies in Bangladesh (Blanchet 1984; Goodburn EA, Gazi AR et al. 1995; Afsana
K and Rashid SF 2000).
6.4.1.2 Private domain
More than half of families sought care within their own homes (58%), by using
traditional remedies available in or around the home, bringing treatment/medicine to the
home, or by bringing a provider to the home. Treatments varied by type of complication
and type of provider.
a) Traditional care:
Five women reported seeking traditional care at home. One woman with booke jolto,
gola jolto [a burning sensation in her chest and throat] ate panta bhaat which is boiled
rice that is put in fresh water and preserved for a future meal (4 children, near health
facility). Another woman with matha bedna [headache] poured cold water with mustard
oil on her head to alleviate the pain (3 children, near health facility). A third woman
reported a vaginal infection during pregnancy. She stated:
“Always water/fluid came out from that place [vagina]. . . . that place [vagina] was
infected and looked like rotten place . . . . so it was painful for me. I did not seek care
from anyone for this serious health problem . . . I felt shy to describe this problem to male
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doctor. My mother suggested me to wash that place regularly with dettol.” (3 children,
near health facility)
Even though these women lived relatively close to a health facility, they preferred to seek
care at home. In this environment, women have control over the type of treatment, its
cost, and do not need to discuss sensitive issues with male providers or male family
members.
b) Treatment at home:
The most prevalent pattern of care seeking in the private domain was receiving treatment
and/or medicine at home. Typically, a male family member was sent to a provider in the
informal or formal health sector, described the woman’s symptoms, and purchased
medicine or treatment. The treatments varied depending on the provider, but included
amulets to protect the woman from evil spirits, herbal remedies, and pharmaceuticals. By
administering these treatments at home, families had control over the type and cost of
treatment. The median cost of the treatments given in the home was 55 Taka (about
US$1– including medicine, transportation, and provider fees). These treatments were
usually sought from providers close to the home, thus decreasing or eliminating
transportation costs, and families often purchased only partial amounts of medications
based on their ability to pay.
One woman suffered from prolapsed uterus after delivery, so her husband visited a
homeopathic doctor. The woman stated:
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“My husband is very much religious person and as well as stubborn. He has no money
so that he cannot provide me any treatment and take me to any pass kora doctor [skilled
doctor] . . . he would not allow me to go to male doctor for treatment . . . so he was not
bothered by my sickness.” (5 children, near health facility)
Due to economic and social constraints, this woman received treatment for her problem at
home, with her husband acting as the mediator between private and public domains.
A second woman suffered from fever postpartum. She reported that she was cold and
had body pain because of the fever. She stated:
“I did not go to any doctor, my husband went to pharmacy and discuss with him
regarding my health problem. Then he gave my husband some medicine. He bought 10
to 20 Taka’s of medicine. I took this medicine only 3 to 4 days. Then I was cured.” (4
children, near health facility)
By purchasing treatment at the pharmacy, her husband was in control of how much
medicine to purchase and the overall cost of treatment. Even though the woman only
took the medicine for 3 to 4 days, she was cured, at a lower cost.
For many women, family members sought care from skilled providers and administered
treatment in the home. One woman with pain in her abdomen after delivery stated:
“It was so painful that I could not bear that along with this I felt so weak. . . At tenth day
after delivery my nephew went to Rowshon Ara [skilled doctor] and described my
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problems. Then she prescribed few medicines and then my nephew purchase that
medicine from medicine shop. . . My sister-in-law and also brother-in-law and dai
[traditional birth attendant] also insisted them to send.” (3 children, near health facility)
By sending male family members to the skilled doctor, this woman received some of the
putative benefits of skilled care without leaving her home.
Another woman who reported raw blood discharge for 20 to 25 days after delivery also
sought care from a skilled provider without leaving her home. She explained:
“During that time I felt that my head was spinning and I could not see things well. . .
Actually I was waiting for 20 days to see whether the bleeding was decreased or not. . . I
told my brother about my problem and requested him to bring some medicine from
Kalipada doctor [skilled medical officer]. After that my brother brought some medicine
from Kalipada doctor. . . My husband was at home during that time. But he does not
understand this kind of things.” (1 child, near health facility)
Women perceive bleeding postpartum to be cleansing and will often not seek care until
the problem is very serious (Blanchet 1984; Goodburn EA, Gazi AR et al. 1995; Afsana
K and Rashid SF 2000). Due to her weakness, this woman was able to receive skilled
care without leaving her home.
c) Health provider at home:
Few women reported receiving care from a health provider in the home. A spiritual
leader helped one woman with bleeding during pregnancy, while a pharmacy doctor
helped another woman with prolonged labor. The other three women reported that a
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skilled doctor came to their home to help with their problems. In this study, providers
were often brought to the home if the condition was perceived to be serious, and if
women were unable to easily travel to a health facility. For example, one woman was so
weak after giving birth and was having trouble eating, so her father brought a skilled
doctor to the home to examine her.
“My father brought her to the home [skilled doctor]. I was not able to even eat food, so
my father thought that if the doctor prescribe the medicine and after the medicine might
be I could able to food and then I got energy in my body.” (0 children, far from health
facility)
By receiving care at home, women are able to limit social and economic costs, and be
less of a burden on their families. Seeking care outside the home requires the husband’s
permission, as well as another family member to accompany the woman to the facility. If
the condition is serious, it is preferable to remain at home to avoid transport and waiting
time in facilities.
6.4.1.3 Public domain
A little less than half of the women (42%) sought care outside of the household from
providers in the informal or formal health sector. Seeking care outside the home was
influenced by the type of illness, reputation of the provider, the woman’s previous
experiences, and the family’s ability to pay. These factors seemed to propel women and
families to “break the boundary” between private and public domains and incur the
economic and social costs of seeking care outside the home. By seeking care in the
public domain, families were required to pay significantly more for treatment as well as
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for transport. The median cost of seeking care outside the home was 700 Taka (about
US$11 including provider fees, medication, and transportation costs).
One woman said:
“Everyone in this community used to go to Rowshon ara [MBBS doctor] for pregnancy
and delivery. She is good doctor and can identify disease properly. If the patient is not
capable to go to hospital then she comes to patient’s house by her and also if she could
not come in any reason they she sends a nurse. . . No other doctor does these things like
her.” (3 children, near health facility)
6.4.1.4 Care in both domains
Some women sought care in both the private and public domains. One woman with
diarrhea, head spinning, and lower abdominal pain during pregnancy reported that her
husband went to the pharmacy shop to get her medicine, and she also visited this same
shop three times. Reputation of the pharmacy doctor and closeness of the shop to the
home influenced these care seeking behaviors.
“Due to diarrhea my husband went to shop and bought medicine . . . the pharmacy shop
is near to Indian border. As we know him as a good doctor, we went to his shop. We had
known each other for years. I also went to pharmacy shop 3 times for my treatment. . . .
My husband knew them and he gave me permission to go over there alone. Every one is
busy with his or her own work, so I didn’t disturb anyone. Another thing is Pharmacy is
not far from my home so I can easily go there alone.” (7 children, near health facility)
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6.4.2
Case study
Care seeking patterns in the private and public domain varied greatly depending on the
perceived severity of the complication, access to informal and formal providers, ability to
pay, reputation of the provider, and social factors. We will discuss two case studies
which illustrate the dynamics of care seeking both inside and outside the household.
Fatima
Fatima is around 30 to 35 years old, lives in a more remote part of the study area, and has
no education. She has been pregnant 7 times and has 4 living children. Her last delivery
was at home with a dhonni/dhoroni (traditional birth attendant [TBA]). During
pregnancy, she reported suffering from amasha [dysentery] and sought care for this
condition.
To address dysentery, her husband went to a moulana [spiritual healer] and was given an
amulet to protect Fatima from upri [literally wind /spirits “from above”]. The dysentery
persisted, and her husband brought a pharmacy doctor to the home to give her
intravenous saline. Saline is widely used for different types of medical problems by both
traditional and skilled providers. The dysentery was not cured, so Fatima’s husband
accompanied her to a pharmacy doctor for further treatment. Fatima reported that this
pharmacy doctor was a relative, so this relationship may have mitigated her ability to
leave the household to seek care.
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During childbirth, Fatima reported kacha rocoto [raw blood discharge] three days before
delivery, and after the baby was born, her chal [uterus], auda [placenta], and nari vuri
[intestinal coil] came out together. Once the placenta was delivered, the dhonni [TBA]
told Fatima’s husband to bring medicine from the “doctor.” Her husband went to the
pharmacy doctor (the same one used to treat the dysentery), and bought medicine. The
dhonni replaced the uterus and intestinal coil, and the medicine helped with the pain.
Fatima didn’t report any specific problems during the postpartum period.
This story illustrates the magnitude of care seeking in the private domain. Fatima and her
family sought many different sources of care throughout her pregnancy and childbirth.
All treatment, with the exception of one trip to the pharmacy shop, took place at home
with Fatima’s husband acting as the mediator between the public and private domains.
Ayesha
Ayesha is 27 years old, lives in the central part of the study site, closer to the main road
and to health facilities, and has eight years of education. Her husband works in the
Middle East, and she returned to her natal home for childbirth. This was her first
pregnancy, and she gave birth at a private clinic in the town of Sylhet.
During pregnancy, Ayesha went to the health facility for regular antenatal care checkups. At seven months of pregnancy, she reported pete bedna [strong pain in her
abdomen]. Her family was concerned and took her to the government health facility. By
the time they arrived, her abdomen had swollen, and she was referred to a private clinic.
Ayesha’s sister accompanied her to the clinic by private car. Ayesha was examined by a
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female doctor and given saline and an injection. The next morning, the doctor suggested
a Cesarean section because Ayesha was seven months pregnant, but Ayesha and her
family refused. She stated:
“I thought that I have been carrying that child for seven months and went through a lots
of constraints. So depend on Allah I should try to carry two more months. Me and my
sister came back to home.”
Ayesha was concerned because her baby was overdue. Seven days past her due date,
Ayesha’s sister went to the government health facility and was told to wait two more
days. After two days, her sister approached the same provider at the government facility,
and the doctor suggested going to a private clinic. The female doctor at the private clinic
gave Ayesha saline and an injection, but labor did not start, and the doctor suggested a
Cesarean section. Her husband was contacted in the Middle East for permission, and the
surgery was conducted. Ayesha had no problems during the postpartum period. She
stated:
“We could go Government hospital but private clinic is good. The clinic doctor is
available and in any time if you call them they will attain you but in government hospital
you cannot communicate with doctor. . . . one of my sisters died in the government
hospital due to doctor’s ignorance. We actually don’t think about money. We prefer to
give importance to where we can get service.”
Ayesha’s story is very different from Fatima’s story, as Ayesha and her family sought
care exclusively in the public domain. These preferences for care seeking are shaped by
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Ayesha’s ability to pay (the C-section cost 35,000 Taka or about US$537), her personal
experiences (her sister had previously died during childbirth), it was her first pregnancy,
and her staying in her natal home. Ayesha also had eight years of education, which may
have facilitated her ability to decide to forgo the recommended cesarean section at seven
months gestation. The family had the economic means to go to a private clinic with good
quality of care and a female doctor.
6.5
Discussion
Pregnancy- and delivery-related complications are substantial health problems for women
in Sylhet District, Bangladesh. In the 24 in-depth interviews conducted in this study, 90
different complications were cited with 51% occurring during pregnancy, 13% occurring
during childbirth, and 36% occurring during the postpartum. Of these 90 complications,
61 were described as “very serious,” with women seeking care for 55 of these conditions
(90%). Four distinct care seeking patterns emerged from the interviews including: 1)
receiving traditional care in the home, 2) purchasing treatment and administering it in the
home, 3) bringing providers to the home to administer treatment, and 4) receiving care
from a provider in a private office, home, or facility. A framework was developed to
categorize care received at home (the private domain) versus care received outside the
home (the public domain). Overall, thirty-two complications were first addressed by
seeking care in the private domain (58%) while 23 were first addressed in the public
domain (42%). Care was sought at multiple places for 22 (40%) of the complications,
and women tended to consult doctors and pharmacy shops if the problem persisted.
These findings are similar to a recent national survey in Bangladesh, where 53.7% of
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women first sought home-based care for perceived complications, while 46.3% of women
first sought care outside the home (National Institute of Population Research and
Training (NIPORT), ORC Macro et al. 2003).
Why did the majority of women seek care inside the home for complications they
perceived to be “serious”? The interviews illustrated several advantages to seeking and
receiving care in the private domain where care is often brought to the home and the
woman remains out of view of the community. First, women/families retain decisionmaking power for type of treatment administered, type of provider consulted, as well as
costs of medicine/treatment. Local models of illness etiology also play a large role in
these considerations. If the complication is perceived to be caused by malevolent spirits
[upri, bhut], then the spiritual healer [moulana] is consulted, as in the case of Fatima.
For a condition such as postpartum fever, care is often not sought, as this condition is
perceived to help the production of breast milk. Economic costs can be minimized by
treating the woman in the home– both by purchasing medications/treatments within the
financial limits of the family and by limiting transportation costs to and from facilities.
Women can be treated in the comfort of the home, thus minimizing uncomfortable travel
over unpaved routes to health facilities. Finally, the reputation of the provider was an
important theme. Women reported deciding which provider to consult based on previous
experiences and family members’ experiences.
In addition to the factors cited above, there are a variety of social factors that inhibit
women’s ability to seek care in the public domain. In Bangladesh, women have limited
106
decision-making ability within the household power structure. When a woman is
married, she leaves her own household and becomes a part of her husband’s household.
This movement implies that she occupies a lower status with less decision-making power
until she becomes a mother-in-law herself (Rozario S 1992; Das Gupta M 1995).
According to Rozario (1992, p.45):
Married women are only residual members as far as their father’s gushti
(Central Bureau of Statistics, National Family Planning Coordinating
Board et al.) is concerned, and their membership of the husband’s gushti
(Central Bureau of Statistics, National Family Planning Coordinating
Board et al.) remains tenuous until they become mothers-in-law in their
old age. Their position changes somewhat as they become mothers, but
not significantly. They are made to feel outsiders as long as their
mothers-in-law are alive. Outsiderhood implies lack of power with the
paribar and gushti (Central Bureau of Statistics, National Family
Planning Coordinating Board et al.). Thus while in theory they are full
members of the husband’s gushti (Central Bureau of Statistics, National
Family Planning Coordinating Board et al.), in practice they occupy a
marginal position.
This lack of power has important implications for seeking care for maternal
complications. Although women can typically make decisions about using traditional
birth attendants and other local healers inside the home (Uzma A, Underwood P et al.
1999), husbands have the authority to decide whether or not women can seek care outside
of the home. Women are not typically allowed to seek care outside the home without
their husband’s or another elder male’s explicit permission. If permission is granted, they
are almost always accompanied to care by a family member (Blanchet 1984; Afsana K
and Rashid SF 2000). By leaving the woman at home in the care of female family
members, men can negotiate treatments with providers in the formal or informal sector
and bring the prescribed medicine/treatment to the home– thus eliminating the need to
accompany the woman to care. Men are able to vacillate between the public and private
107
domains. They are able to leave the household, go to the source of care, and bring
treatment back to the home. Thus, they are the mediators in this care seeking process.
Finally, pregnancy is seen as a vulnerable period in a variety of settings in Africa, Asia,
and Latin America (Winch PJ, Alam MA et al. 2005). Malevolent spirits [bhut, upri] can
possess pregnant women and cause ill health, and even death, to the woman and her
newborn (Blanchet 1984; Jeffrey PM, Jeffrey R et al. 1989; Afsana K and Rashid SF
2000; Van Hollen CC 2003; Winch PJ, Alam MA et al. 2005). Women’s movements
outside the home are thus restricted during pregnancy and childbirth to protect both the
woman and her baby.
During the postpartum period, women’s mobility is often limited due to impurity and
pollution. In Sylhet, the woman and her newborn are in a state of impurity or pollution
[opobitro, napak] that begins immediately after birth or other exposure to birth-related
fluids or to blood (Winch PJ, Alam MA et al. 2005). After birth, women are secluded
between seven and forty days to protect other family members from pollution, as well as
to protect the mother and child from possession by spirits and the evil eye (Winch PJ,
Alam MA et al. 2005). Limited social mobility restricts women’s movement outside the
household during the postpartum period and is an important barrier to seeking care
outside the home (Blanchet 1984; Goodburn EA, Gazi AR et al. 1995; Ensor T and
Cooper S 2004).
108
These factors of limited power within the household and restricted mobility during
pregnancy and the postpartum periods shape social barriers for seeking care outside the
household, and thus, may partially explain why care seeking in facilities is so low in
Sylhet District. In the private domain, families can minimize social barriers by
administering care in the home. In the public domain, on the other hand, families
relinquish decision-making power over all aspects of care and incur great social costs by
seeking care outside the household. Financial resources can mitigate these social costs,
as seen in the case of Ayesha. Her family was able to hire a private car to take her to a
health facility, thus keeping her out of public view. They also had the resources to pay
for a private female physician.
The results from this study have important implications for safe motherhood programs.
Care seeking is a complex and dynamic process (Uzma A, Underwood P et al. 1999), and
behaviors do not always proceed clearly from one step to the next, but consist of multiple
interventions and decisions occurring simultaneously. The medically-focused definition
of care seeking where “care” is medical and “seeking” is with a skilled provider outside
the home is unidirectional and may not capture the intricacies of the care seeking process.
The World Health Organization estimates that 15% of women will experience a
complication that requires medical interventions (UNICEF 1997). In settings like
Bangladesh where home-based birth is the norm, the challenge is correctly identifying
women who need facility-based care. This process requires multi-faceted interventions
simultaneously occurring at multiple levels.
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First, formative research is essential to identify perceptions of “serious” complications,
dominant care seeking patterns for those complications, as well as key providers in the
formal and informal sectors. The findings from the formative research need to be
translated into valid questionnaire items that aim to measure all patterns of care seeking
behaviors. As demonstrated in this study, there is a variety of care seeking patterns. If
only the medically-focused definition of care seeking was used, it would appear that
Fatima didn’t seek care for her health problems. This narrow definition greatly
underestimates care seeking behaviors on the part of Fatima and her family. Although
care was mainly sought in the home, Fatima and her husband went to great efforts to
address her health problems.
In this study, the majority of women relied on informal or “traditional” providers to treat
these “serious” complications. Family members sought advice from spiritual healers,
homeopathic doctors, pharmacy doctors, as well as skilled providers. Safe motherhood
program need to include these providers in program activities and interventions since
they are providing the majority of care in this area. Their ability to recognize a
potentially life-threatening condition may decrease the delay in attaining skilled care.
These providers have prestige in their communities and may be successful at persuading
male family members to seek skilled care. Relationships between providers in the
informal and formal sectors should be strengthened through team building and regular
meetings. These relationships are critical to ensuring timely referral to skilled care.
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Finally, in settings where home-based birth is the norm and social barriers inhibit use of
skilled care, community-based midwives can provide skilled care in the home. These
midwives can manage normal labor and are trained to identify life-threatening
complications, stabilize, and refer if necessary. This intervention can greatly increase
access to skilled care in the home, but raises issues of supervision, 24-hour availability,
and emergency referral linkages (World Health Organization 2005). Indonesia initiated a
community-based midwifery program in 1989 by ensuring that each of the approximately
68,000 villages had a community-based midwife (Shiffman 2003). This program has had
some success, as rates of use of trained nurses/midwives at delivery increased from
32.3% in 1984-1987 to 55.3% in 1999-2003 (Central Bureau of Statistics, National
Family Planning Coordinating Board et al. 1989; Badan Pusat Statistik-Statistics
Indonesia and ORC Macro 2003). The government of Bangladesh has recently begun to
train home-based skilled birth attendants.
6.6
Conclusion
Perceived maternal morbidity is a large burden on women in rural Bangladesh. In this
cultural context, home-based birth is the norm, and safe motherhood programs aim to
ensure that women with potentially life-threatening complications receive skilled care.
The challenge lies in identifying these women. Women’s understandings of
complications as well as their definitions of care seeking are essential in developing
interventions to address care seeking behaviors at multiple levels.
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Table 6.1: Description of health providers, by type of provider, training and type of care
provided, and location of care, Sylhet District, Bangladesh 2005
Provider
Training and type of care provided
Location
 May have some training in clean delivery
Woman’s
Traditional
Traditional birth
attendant
and newborn health
Home
 Attends home-based births
Homeopath
 Trained in government program1
Woman’s
 Provides medicines such as powdered
Home
sugar, sugar balls, and tonics
Homeopath
home
Spiritual healer
 Spiritual healer or leader
Woman’s
 Provides spiritual water, spiritual oil, and
Home
amulets to guard against evil spirits
Healer’s
home
Village doctor
 May have some training, often informal
Woman’s
 Provides allopathic medicines
home
Doctor’s
home
Pharmacy doctor
 Majority have no training2
Pharmacy
 Sells pharmaceuticals and injections
shop
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Provider
Training and type of care provided
Location
Certified as MBBS
Woman’s home
Skilled
Doctor
Office/Facility
Nurse
Certified as nurse
Woman’s home
Office/Facility
Midwife
Certified as midwife
Woman’s home
Office/Facility
Family Welfare
Certified as Family Welfare Visitor
Visitor
Woman’s home
Facility
Notes:
1. Governmental degree is similar to a Bachelor of Science, and takes three to four years to complete.
2. Training often consists of "apprenticeships". Some pharmacy doctors collect "false" certificates to
show as a proof of their degree or training.
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Table 6.2: Self-reported complications experienced during pregnancy, childbirth, and 40
days postpartum among recently delivered women, Sylhet District, Bangladesh 2005
(n=24)
Problem – Sylheti/Bangla
Problem - English
N
Pregnancy
Tol pete bedna
Lower abdominal pain
9
Taap/ Joor
Fever
5
Dasto bomi
Diarrhea with vomit
4
Bomi
Vomit
3
Jhapsha dekha
Head spin/hazy vision
3
Pa fuila gesilo
Legs swollen
2
Haat-paye fhula
Legs and hands swollen
2
Matha Ghurani
Dizziness
2
Khub matha batha
Severe headache
2
Roktto jay/Roktto gese
Bleeding
2
Komor bedna
Waist pain
1
Upri
Possessed by spirits
1
Bomi bomi bhab
Vomiting tendency or nausea
1
Shikay tan
Muscle pull in leg
1
Mokhe gha
Mouth ulcer
1
Hojome somossha
Indigestion
1
Amasha
Dysentery
1
Peshaber rastai gha
Burning sensation in the urinary tract
1
114
Problem – Sylheti/Bangla
Problem - English
N
Buk jala r gola jala korto
Burning sensation in the chest and throat
1
Sharire bish bedna
Body ache
1
Water break at 8 months
1
Aat masher shomoy pani
vangche
Sub-total1
45
Childbirth
Lombba bedna
Prolonged labor
5
Tol nise nami jay
Uterus comes out
2
Sharire bish bedna
Pain
1
Dasto
Diarrhea
1
Bacha howar din per hoiche
Overdue delivery
1
Roktto jay/Roktto gese
Bleeding
1
Behush/ Unconscious
Unconscious
1
Sub-total 1
12
Postpartum
Taap/ Joor
Fever
11
Pete bedna
(Severe) Abdominal pain
4
Roktto jay/Roktto gese
Bleeding
4
Pain in lower stomach after delivery of
placenta; feel like blood clot moving in
Aowdar bish
abdomen
3
Bacha howar jaygay batha
Vagina pain
2
115
Problem – Sylheti/Bangla
Problem - English
N
Sharire bish bedna
Body pain
2
Durbolota
Weakness
1
Tol nise nami jay
Uterus comes out
1
Upri
Possessed by spirit
1
Pa fuila gesilo
Legs swollen
1
Pitte/Kolizay patthor2
Gall bladder stone
1
Jhapsha dekha
Hazy vision
1
Ful/aowda na pora
Retained placenta
1
Sub-total1
33
Total complications1
90
Notes:
1. Women reported multiple complications in each phase of pregnancy.
2. Not included in analysis for “serious” complications since “gall bladder stone” is not directly related
to pregnancy and/or childbirth.
116
Figure 6.1: Care seeking patterns for “serious” complications, by first type of care
sought, Sylhet District, Bangladesh, 2005 (n=55)
Doctor
Spiritual
Homeopath
n=9
n=8
n=9
n=6
n=6
n=5
n=4
HOME
Doctor office
Spiritual
Health center
n=4
Traditional
Pharmacy
Pharmacy
n=2
n=1
Village doctor
n=1
n=32
Homeopath office
n=23
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CHAPTER 7: CARE SEEKING FOR PERCEIVED MATERNAL
COMPLICATIONS IN SYLHET DISTRICT, BANGLADESH: WHAT IS THE
ROLE OF KNOWLEDGE OF DANGER SIGNS?
7.1
Abstract
7.1.1
Background
Maternal mortality and morbidity are substantial health problems in developing countries.
Although the majority of maternal deaths are preventable through timely use of obstetric
care, less than half of women living in developing countries give birth with a skilled
provider. In Bangladesh, where home-based birth is the norm, safe motherhood
programs focus on recognition of danger signs, birth preparedness, and encouraging use
of skilled care if complications occur. However, of the 60% of women reporting health
problems during pregnancy, childbirth, and the postpartum period, only one-third of
women sought skilled care.
7.1.2
Methods
This study in Sylhet District, Bangladesh examined factors associated with care seeking
behaviors among women with perceived complications. Using multinomial logistic
regression with no care seeking as the reference category, factors associated with seeking
care from traditional providers, pharmacy shops, and/or skilled providers were examined
(n=3,689).
7.1.3
Results
Two in five (42.3%) women did not seek any care for complications, 22.2% sought care
from traditional providers or from other family members, 12.5% sought care from
pharmacy shops, and 23.1% of women sought skilled care either in the home or at a
118
health facility. Primary education versus no education, at least one antenatal care visit,
having a relative working overseas, and living in a more remote sub-district were
significantly associated with seeking care from traditional providers and/or family
members. At least one antenatal care visit and higher wealth status were significantly
associated with seeking care from a pharmacy shop. Use of skilled care was significantly
associated with primiparity, at least one antenatal care visit, a previous pregnancy loss,
higher wealth status, and living in the woman’s natal home during delivery. Knowledge
of danger signs was associated with use of skilled care, but the effect was moderated by
the number of antenatal care visits.
7.1.4
Conclusions
In Sylhet District, Bangladesh, women and families report seeking care from a variety of
sources, with few women seeking care from skilled providers. Knowledge of danger
signs may be associated with seeking skilled care, although this relationship was
moderated by the number of antenatal care visits. Additional research is needed to
further explore the mechanisms through which knowledge is translated into care seeking
behaviors to inform behavior change interventions that aim to improve maternal health
and survival.
119
7.2
Introduction
Maternal mortality and morbidity are substantial health problems in developing countries.
The World Health Organization (WHO) estimates that 529,000 women die each year
from maternal causes; 99% of these deaths occur in developing countries (World Health
Organization, UNICEF et al. 2004). Moreover, up to 300 million women suffer from
illness and long-term disability related to pregnancy and childbirth (World Health
Organization 1998). Improving maternal mortality has received recognition as a global
priority as evidenced by its inclusion in the Millennium Development Goals (United
Nations 2004).
The majority of maternal morbidity and mortality can be avoided by using appropriate
and timely obstetric care (Rosenfield A 1989). All pregnant women are at risk of
developing life-threatening complications that lead to maternal illness, long-term
disability, and death. Skilled providers such as doctors, nurses, and midwives are trained
to recognize and treat complications if they occur, and/or refer women to appropriate
care. Use of skilled care in developing countries remains low, with less than half of
women using a skilled provider at last birth (48%) (Demographic and Health Surveys
2004). South Asia has some of the lowest rates of skilled attendance at birth, and in
Bangladesh, only 13% of women used a skilled attendant at last delivery (National
Institute of Population Research and Training (NIPORT), Mitra and Associates et al.
2005).
120
Thaddeus and Maine (1994) outlined three factors that contribute to maternal morbidity
and mortality: 1) the delay in recognizing a complication and deciding to seek care, 2)
the delay in identifying and reaching a medical facility, and 3) the delay in receiving
treatment (Thaddeus S and Maine D 1994). This framework has been instrumental in the
design and implementation of safe motherhood programs.
In Bangladesh, where home-based birth is the norm, safe motherhood programs focus on
reducing the first delay by encouraging timely recognition of complications and decisions
to seek care from skilled providers. Interventions include improving knowledge of
women, family members, and traditional birth attendants to recognize danger signs that
indicate complications. These programs also emphasize birth preparedness, which is
comprised of pre-selecting a facility and/or provider if a complication occurs, planning
for transportation, and saving money to pay for services and supplies. There is little
evidence that these strategies are effective, and women continue to seek skilled care too
late or not at all (Uzma A, Underwood P et al. 1999; Koblinsky M 2003a; Koblinsky M
2003b; Stanton CK 2004; Fronczak N, Antelman G et al. 2005).
This paper examines care seeking behaviors among women with perceived complications
in Sylhet District, Bangladesh, focusing on knowledge of danger signs. The findings will
inform recommendations for safe motherhood programs in settings where the majority of
births take place at home.
121
7.3
Background
In Bangladesh, women report high levels of complications during pregnancy, childbirth,
and/or the postpartum period. In a recent national survey, 60.1% of women reported at
least one complication during their most recent pregnancy, childbirth, or postpartum
period (National Institute of Population Research and Training (NIPORT), ORC Macro et
al. 2003).14 Although more than half of women reported a complication, seeking skilled
care for these complications was low, even among women who perceived their
complication to be “potentially dangerous or life-threatening.” Among women with
perceived life-threatening conditions, 62% sought care but only 32% sought care from a
skilled provider. Of the women who perceived their complication to be non-lifethreatening, 42% sought care and 22% sought skilled care.
Seeking care for maternal health problems involves recourse to a combination of
traditional and modern providers and treatments. Studies have shown that women with
complications will seek care from a variety of providers in the formal and informal health
sectors depending on the complication, its severity, local knowledge about illness
etiology, access to providers and facilities, and perceptions about quality of care
(Blanchet 1984; Obermeyer CM and Potter JE 1991; Ahmed S, Khanum PA et al. 1998;
Uzma A, Underwood P et al. 1999; Afsana K and Rashid SF 2000; Fronczak N,
Antelman G et al. 2005). In Bangladesh, the most frequently cited barriers to using
facility-based skilled care were: lack of education and information about services,
14
Complications included headache/blurry vision/high blood pressure, edema/pre-eclampsia, excessive
bleeding, high fever with foul smelling discharge, convulsions/eclampsia, head/feet came first, prolonged
labor, tetanus, retained placenta, torn uterus, obstructed labor, abdominal pain, vomiting, diarrhea, general
weakness, premature rupture of membranes, other conditions.
122
“superstition”, fear of losing family prestige, costs of services, negligence of service
providers, lack of adequate drugs and medications, shortage of skilled doctors, and the
predominance of male doctors in government hospitals (Haider SJ 2000).
There are few theoretical models that explain women’s care-seeking behavior during
childbirth (Petterson KO, Christensson K et al. 2004). Some maintain that perceived
severity of the complication is the “trigger” that incites women and family to seek care
(Thaddeus S and Maine D 1994; Nachbar N, Baume C et al. 1998; Uzma A, Underwood
P et al. 1999; Roy SK 2000; Saving Newborn Lives Initiative 2002; Kalter HD, Salgado
R et al. 2003; Yassin K, Laaser U et al. 2003; Fronczak N, Antelman G et al. 2005). In a
study in the urban slums in Dhaka, Bangladesh, Fronczak et al. (2005) found that women
were more likely to seek care from skilled providers as severity of the condition
progressed. In a qualitative study in Karachi, Pakistan, care seeking patterns were based
on perceived severity and frequency of the condition. Women sought care from
traditional providers for conditions that were “frequent,” even if women also perceived
those conditions to be serious (Fikree FF, Ali T et al. 2004).
Yassin et al. (2003) developed an insightful model using qualitative and quantitative data
to predict care seeking behaviors for perceived obstetric complications in Upper Egypt.
Women tended to seek skilled care for less frequent complications perceived to be
serious where women felt low levels of personal responsibility. Conversely, frequent,
less serious complications where women felt high levels of personal responsibility were
123
perceived to be less important and care was typically sought from traditional providers
(Yassin K, Laaser U et al. 2003).
Although these models are helpful, they do not fully explain the decisions around care
seeking for complications in Sylhet District, Bangladesh, where women’s power and
social mobility are limited outside the household (Blanchet 1984; Rozario S 1992; Das
Gupta M 1995; Afsana K and Rashid SF 2000; Winch PJ, Alam MA et al. 2005). In this
setting, where home-based birth is the norm, understanding the factors associated with
care seeking patterns for maternal complications is crucial to develop effective safe
motherhood programs.
7.4
Methods
7.4.1
Study site
These data come from a cluster randomized controlled trial to assess the effectiveness of
community-based interventions on neonatal mortality and maternal morbidity in rural
Bangladesh. Three sub-districts of Sylhet division (Beanibazar, Zakiganj and Kanaighat)
were selected for this study due to their high levels of neonatal and maternal mortality
compared with the rest of the country (National Institute of Population Research and
Training (NIPORT), ORC Macro et al. 2003; National Institute of Population Research
and Training (NIPORT), Mitra and Associates et al. 2005). A quantitative baseline
household survey was conducted in 2003 to measure knowledge, attitudes, and coverage
of maternal and newborn care practices, reported maternal morbidity, as well as baseline
rates of neonatal mortality.
124
Sylhet District, similar to Bangladesh as a whole, is characterized by a pluralistic health
care system (Parkhurst, Penn-Kekana et al. 2005). There are a variety of traditional and
skilled providers who are consulted for maternal complications. The traditional or
informal sector is comprised of spiritual healers, village doctors, homeopathic doctors,
traditional birth attendants, and pharmacies where a variety of medications are sold.
These “pharmacy shops” can be staffed by trained or untrained providers. The formal
health system is also quite diverse, with a mixture of private facilities, government
facilities, and doctors’ offices. Although health and family planning services are fairly
accessible in Bangladesh, delivery services are less available. Ninety-five percent of
women reported having a clinic within one to two miles from their home; however, only
17.5% of these facilities offered delivery services (National Institute of Population
Research and Training (NIPORT), Mitra and Associates (MA) et al. 2001).
7.4.2
Eligibility
Communities or clusters were used as the unit of randomization, as it was not feasible to
randomly allocate individuals to the intervention package. Stratified random sampling
was used to identify women with a live or stillbirth in the 12 months prior to the survey
within the study area. A total of 85,625 households were enumerated. Of the 7,379
recently delivered women (RDW) randomly sampled for knowledge, practices, and
coverage modules of the survey, 6,050 (82%) were successfully interviewed, yielding
data for 5,625 women. No incentives were given to participate in the research, and the
major reason for the failure to interview women was their absence from the household
(Baqui A and Ahmed S 2004). Household heads were asked about socio-economic
125
information including household durable goods, water, and sanitation. Women were
asked about socio-demographic information (age, education level, religion, organization
membership), as well as knowledge of danger signs during pregnancy, childbirth, the
postpartum, and for the newborn. Reproductive history including parity, previous
pregnancy losses, deaths to other children, number of antenatal care visits, as well as
place of residence during last delivery were ascertained. Women were asked if they
experienced any health problems during last pregnancy, childbirth and/or postpartum
period as well as subsequent care seeking behaviors. Complications included six
potentially life-threatening complications: excessive bleeding; high fever; bad smelling
vaginal discharge; convulsions; prolonged labor (more than 12 hours); and/or retained
placenta. Data were collected by trained female health interviewers in 2003.
Ethical approval for this study was obtained from the Johns Hopkins University as well
as the ICDDR,B: Centre for Health and Population Research, in Dhaka, Bangladesh. All
women gave informed consent prior to study enrollment.
7.4.3
Analysis
Data were reviewed for accuracy, consistency, and completeness and entered into a
database designed using FoxPro version 9.0 (Microsoft, Redmond, WA, USA). Range
and consistency checks identified errors in data collection and entry. Bivariate analysis
measured associations between covariates and care seeking behaviors using the Pearson’s
chi-square statistic. Multinomial logistic regression was used to test for significant
associations with care seeking behaviors controlling for other covariates, with no care
seeking as the reference category (Hosmer D and Lemeshow S 2000; Long JS and Freese
126
J 2001). Models were adjusted for clustering at the union level using the generalized
estimating equation approach (Zeger SL, Liang KY et al. 1988). Missing responses for
the number of antenatal care visits were imputed using multiple imputation (Little RJA
and Rubin DB 1987). All data analysis was conducted using STATA software version
8.0 (Stata Corporation, College Station, TX, USA).
Covariates were coded as binary or categorical and were chosen for multivariate analyses
based on prior findings. Wald tests were used to determine which covariates were
significantly associated with the outcome, and covariates that did not contribute
significantly to care seeking behaviors were dropped from the model (Hosmer D and
Lemeshow S 2000).15 Forward and backward stepwise selection procedures were also
used to ensure parsimonious models.16 Woman’s age and parity were highly correlated
(r=0.6705), so only parity was included in the final model. Similarly, women’s education
level and husband’s education level were correlated (r=0.4165). Although husband’s
education level was highly significant at the bivariate level, it did not contribute
significantly to care seeking behavior based on the Wald test (p=0.1824). Women’s
education was also more strongly predictive of care seeking behavior, so only women’s
education was included in the final model. Having a child who had died as well as
religion were both significantly associated with care seeking behaviors in the bivariate
analysis; however, Wald tests for these variables in the multivariate model were not
15
Since data were adjusted for clustering at the union level, they are not based on log likelihood estimation.
Therefore, Wald tests were used to test for significance instead of likelihood ratio tests.
16
Stepwise selection procedures cannot be used with multinomial regression. Bivariate outcome variables
were created, and each was tested separately to estimate which covariates to include in the final model
(Hosmer D and Lemeshow S, 2000).
127
significant, and they were not included in the final model. Table 7.1 outlines selection
procedures for the final multivariate model.
Nine interaction terms based on the literature and study objectives were tested for
significance at the p<0.05 level using a Wald test.17 Significant interactions were further
tested by examining coefficients for differences across categories. An interaction term
for use of antenatal care and knowledge of danger signs was included in the final model.
Hosmer-Lemenshow Goodness of Fit was calculated to assess overall model fit (Hosmer
D and Lemeshow S 2000).18
7.4.4
Measures
Wealth index
A wealth index score was constructed using principal component analysis, based on
ownership of household durable goods and condition of the house (National Institute of
Population Research and Training (NIPORT), Mitra and Associates et al. 2005).
Sub-district
The three distinct sub-districts can be interpreted as a proxy for access to skilled care,
with Beanibazar as the reference category. Beanibazar is a more urban area with higher
access to both public and private services, while Zakiganj and Kanaighat are more remote
and rural. In these sub-districts, access to traditional care and pharmacy care is more
prevalent.
17
Interaction terms included knowledge X education; knowledge X ANC visits; education X ANC visits;
parity X ANC visits; ANC visits X wealth status; education X wealth status; ANC visits X pregnancy loss;
education X parity; and knowledge X parity.
18
Bivariate outcome variables were created, and goodness of fit was tested separately for each outcome.
The final model included covariates that maximized goodness of fit in each of the outcome categories
(Hosmer D and Lemeshow S, 2000).
128
Knowledge of danger signs
An additive index of the number of danger signs spontaneously cited during pregnancy,
childbirth, the postpartum period, and for the newborn was created to measure knowledge
of danger signs (4 items; Cronbach’s alpha=0.8913). This index was categorized into
quartiles for analysis.
Care seeking behavior
Care seeking behavior for perceived complications was defined as a four-category
dependent variable. Responses were categorized as no care seeking, care seeking from
traditional providers/family members, from pharmacy shops, or from skilled providers
(doctor, nurse/midwife, paramedic, family welfare visitor, medical assistant, or health
assistant). Traditional providers and family members were combined since few women
sought care from family members (2%). No care seeking was the reference category.
7.5
Results
7.5.1
Background characteristics
On average, women were 27.8 years of age, ranging from 14 to 52 years. Twenty percent
of women had one or no births, with 3.7 births on average. The majority of women had
no education (47.8%), with 28.1% having primary education and almost one-quarter
having secondary or higher education (24.1%). Husband’s education was similar, with
half of men having no education (50.0%), 30.7% having primary education, and only
19.3% having secondary or higher education. Most women gave birth while staying in
the shashurbari [husband’s family’s home] (86.6%), did not belong to any organizations
in their community (90.3%), and about two out of five women reported having a relative
129
working outside of Bangladesh (40.0%). One-third of women reported losing at least one
of their children (36.3%), and one-quarter of women reported a previous miscarriage or
abortion (25.4%). Half of women did not attend any antenatal care (ANC) visits (50.1%),
while almost one-third of women had one or two ANC visits (30.5%), and 19.5% had
three or more visits. Almost all women were Muslim (95.6%), with 43.1% living in
Beanibazar, 36.7% living in Zakiganj, and 20.2% living in Kanaighat sub-districts.
(Table 7.2)
7.5.2
Perceived complications
Women were prompted on six specific potentially life-threatening maternal
complications including excessive bleeding,19 high fever, foul smelling vaginal discharge,
convulsions, prolonged labor (more than 12 hours), and retained placenta. Women were
asked if they experienced any of these complications and were further prompted on
whether excessive bleeding, high fever, foul smelling discharge, and convulsions
occurred during pregnancy, childbirth, and/or the postpartum period. Overall, 65.7% of
women reported at least one complication, with 18.0% of women reporting a
complication during pregnancy. Thirty percent of women reported at least one
complication during delivery, and 51.8% of women reported at least one complication
during the postpartum period.
Of the 5,625 women, thirty-six percent reported excessive bleeding (36.5%), with
bleeding during the postpartum most prevalent (84.8%). About two in five women
reported high fever (39.6%), again with the majority of cases occurring during the
Women were asked if they experienced “Excessive bleeding was so much that it wet your clothes and
you feared it was life threatening?”
19
130
postpartum period (80.5%). Few women reported foul smelling vaginal discharge
(14.6%), but of those women, 87.6% reported discharge during the postpartum period. A
total of 14.1% of women reported convulsions, occurring equally during pregnancy and
the postpartum (59.3% and 50.6% respectively). About one-quarter of the women
experienced prolonged labor of more than 12 hours (24.0%), with only 6.6% of women
reporting retained placenta.
Of the women who reported at least one complication (n=3,697), 3,689 reported care
seeking behaviors by type of provider (99.9%). Of these women (n=3,689), about two in
five (42.3%) did not seek any care. Twenty-two percent of women sought care from
traditional providers or from family members, although few women turned to trained or
untrained traditional birth attendants or to family members for care. Almost thirteen
percent of women sought care from pharmacy shops, while 23.1% of women sought
skilled care either at the provider’s office or in a health facility. Women tended to seek
skilled care for bleeding during pregnancy (42.4%), for convulsions (28.9%), and for
prolonged labor (29.2%). Care from pharmacy shops was sought for high fever and for
vaginal discharge (16.2% and 13.9% respectively). (Table 7.3)
In the bivariate analysis, lower parity, higher education, having a child who died,
attending at least one antenatal care visit, and higher knowledge of danger signs were
significantly associated with seeking care for perceived complications. Household
factors of husband’s education level, Muslim religion, higher wealth, having a relative
working overseas, residing at natal home during delivery, and living in a more urban sub-
131
district were also significantly associated with seeking care. Belonging to an
organization and previous pregnancy loss were not significantly associated with care
seeking behaviors at the p=0.05 level. (Table 7.4)
In the multivariate analysis, care seeking behaviors among women with self-reported
complications were explored. The final multivariate model included women’s education,
parity, previous pregnancy loss, number of antenatal care visits, staying at natal home
during delivery, wealth status, having a relative working overseas, and sub-district. Table
7.5 outlines these associations.20
7.5.3
Care seeking from traditional providers/family members
Women who sought care from traditional providers and/or family members were more
likely to have primary education compared to no education, have a relative working
overseas, and to live in Zakiganj or Kanaighat (the more remote, rural sub-districts),
controlling for other covariates. Reproductive factors such as parity and number of
antenatal care visits, as well as wealth status were not associated with this type of care
seeking. Access to services is the strongest association. Women who lived in Zakiganj
or Kanaighat were 2.02 times and 2.26 times more likely to seek traditional care versus
no care compared with women in Beanibazar (the more urban sub-district) (95% CI:
1.459-2.801 and 1.553-3.329 respectively).
20
Multinomial logistic regression produces a ratio of relative risks (probability that Y=outcome divided by
probability that Y=reference category) for a one unit increase in X compared to the relative risk when X is
unchanged, holding the other Xs fixed. This is algebraically equivalent to a conditional odds ratio. In the
literature, studies that use multinomial logistic regression report odds ratios to facilitate interpretation of
findings.
132
7.5.4
Care Seeking from pharmacy shops
Thirteen percent of women reported seeking care from pharmacy shops for perceived
complications. These women were more likely to have had at least one antenatal care
visit and be from a household with higher wealth status. Women from Zakiganj (more
rural) were 43% less likely to seek care from pharmacy shops than women from
Beanibazar (more urban) (OR: 0.57; 95% CI: 0.376-0.877). The effect of knowledge of
danger signs was moderated by the number of antenatal care visits. For women with no
antenatal care, women with more knowledge of danger signs were 1.63 times more likely
to seek care from pharmacy shops than women with lower knowledge of danger signs
(95% CI: 1.093-2.419).
7.5.5
Care seeking from skilled providers
Individual, reproductive, and household level characteristics were significantly associated
with seeking skilled care for perceived complications. Using no care seeking as the
reference category, women with secondary or more education were 1.50 times more
likely to seek skilled care, while women with at least three antenatal care visits were 2.77
times more likely to seek skilled care (95% CI: 0.915-1.449 and 1.463-5.253
respectively). Primiparity, a previous pregnancy loss, living in the woman’s natal home
during delivery, and higher wealth status were also significantly associated with seeking
skilled care versus no care. Women who lived in the more remote sub-districts were no
less likely to seek skilled care than women who lived in the more urban sub-district.
Knowledge of danger signs also had a significant effect on seeking skilled care. For
women with one to two ANC visits, women with higher levels of knowledge were 1.65
times more likely to seek skilled care compared with women with lower levels of
133
knowledge (95% CI: 1.027-2.647). For women with three or more ANC visits, the
effects were stronger. Women who spontaneously cited seven to nine danger signs were
2.54 times more likely to seek skilled care compared with women who cited zero to three
danger signs, while women who cited 10 or more danger signs were 1.92 times more
likely to seek skilled care (95% CI: 1.33-4.853 and 1.103-3.356 respectively). (Table
7.6)
7.6
Discussion
This study demonstrated high levels of maternal morbidity in Sylhet District, Bangladesh.
Sixty-six percent of women reported at least one life-threatening complication during
pregnancy, childbirth, or the postpartum period, with more than half of the women
seeking treatment (58.0%). Seeking care from traditional providers, family members,
and pharmacy shops comprised the majority of care seeking behaviors with only 23.1%
of women seeking care from a skilled provider. These findings are consistent with other
studies in Bangladesh. A national survey conducted in 2001 found that 60.1% of women
reported at least one complication during pregnancy, childbirth, or the postpartum, and
62% of women who perceived their complication to be life-threatening sought treatment
(National Institute of Population Research and Training (NIPORT), ORC Macro et al.
2003). However, in the national survey, 32% of women who perceived their
complication to be life-threatening sought care from a skilled provider, while only
23.39% of women in this study sought skilled care for complications.
134
Care seeking behaviors differed by timing and by type of complication. Women with
excessive bleeding during pregnancy were more likely to seek skilled care than women
with excessive bleeding during childbirth and the postpartum period. This is also
consistent with the literature. Women are more likely to accurately recognize acute
illnesses, such as antepartum bleeding and convulsions, as compared with problems that
have a threshold after which the problem becomes life-threatening, such as postpartum
hemorrhage (Ronsmans C, Achadi E et al. 1997; Filippi V, Ronsmans C et al. 2000). In
addition, bleeding during childbirth and the postpartum period has important social
implications in Bangladesh. During this time, women are considered to be in a state of
ritual impurity, and it is perceived that bleeding is normal and cleanses polluting blood
from the body (Blanchet 1984; Jeffrey PM, Jeffrey R et al. 1989; Goodburn EA, Gazi AR
et al. 1995; Afsana K and Rashid SF 2000; Van Hollen CC 2003; Winch PJ, Alam MA et
al. 2005). As a result, women often seek care from traditional providers. This can delay
recognizing life-threatening conditions that require skilled care and may decrease the
woman’s chance of survival. The same is true of fever. In this study, few women sought
skilled care for high fever in any phase of the birthing process (pregnancy, childbirth, or
postpartum). Women and families tended to purchase treatment at pharmacy shops or
visit traditional providers, as postpartum fever is perceived to facilitate the production of
breast milk in Sylhet District (see Chapter 6).
In the multivariate analysis, factors associated with care seeking differed significantly
depending on the source of care– traditional providers/family members, pharmacy shops,
or skilled care. Primary education and access to services were significantly associated
135
with seeking care from traditional providers and/or family members. Women who lived
in Zakiganj and Kanaighat, the more remote sub-districts with less access to skilled care,
were more likely to go to traditional providers and/or family members for care. Seeking
care at pharmacy shops was also prevalent in the study area. At least one antenatal care
visit and higher wealth status were significantly associated with this type of care seeking.
Individual, reproductive, and household level factors were all associated with seeking
care from a skilled provider. With no care seeking as the reference category, women
with secondary or more education, of lower parity, with at least one antenatal care visit,
and of higher wealth status were significantly more likely to seek skilled care. These
findings are consistent with the literature (Graham WJ and Murray SR 1997; Graham W
and Bell J 2000; Gwatkin DR, Rustein R et al. 2000; Kunst AE and Houweling T 2001;
Bell J, Curtis SL et al. 2003). We also found that women with a previous pregnancy loss
and who were living at their natal home during delivery were significantly more likely to
seeking skilled care, while these factors were not associated with seeking care from
traditional providers or from pharmacy shops. Access to skilled care did not have a
significant effect on seeking skilled care. Women from more rural sub-districts (Zakiganj
and Kanaighat) were just as likely to seek skilled care as women from the more urban
sub-district (Beanibazar). This finding is consistent with other studies in Bangladesh.
Chakraborty et al. (2002) found that access (as measured by physical proximity to health
facilities) did not have a significant effect on seeking skilled care for perceived
complications during the postpartum period (Chakraborty, Islam et al. 2002).
136
The finding regarding knowledge of danger signs is one of the most interesting results in
this study. Safe Motherhood programs focus behavior change interventions on increasing
knowledge of danger signs that indicate potentially life-threatening complications in an
effort to improve care seeking behaviors, especially in countries like Bangladesh where
the majority of births take place at home. Although some programs have increased
knowledge of danger signs between the beginning and end of the program, there is no
consistent evidence that increased knowledge leads to recognizing complications or to
seeking skilled care (Ronsmans C, Achadi E et al. 1997; Perreira KM, Bailey PE et al.
2002; Ahluwalia IB, Schmid T et al. 2003; Koblinsky M 2003b; Thaddeus S and
Nangalia R 2004). In this study, knowledge of danger signs was significantly associated
with seeking skilled care, but the effects were moderated by the number of antenatal care
visits. Compared with no care seeking, women with more antenatal care visits and higher
knowledge were significantly more likely to seek skilled care than women with fewer
antenatal care visits and lower knowledge, controlling for other factors.
In the literature, knowledge about health and health risks is a prerequisite for behavior
change, but the process of translating knowledge into behavior is complex and requires
the presence of other factors (Rimal RN, Flora JA et al. 1999; Rimal RN 2000). Hornik
(1989) identified five classes of moderators (structural characteristics of communities,
structural characteristics of individuals, community social influences, learned
characteristics of individuals, and enduring characteristics of individuals) that influence
how knowledge affects behavior in developing countries (Hornik R 1989). If these
137
factors are appropriately situated, then knowledge is more likely to be translated into
behavior change.
In this study, the correlation between knowledge of danger signs and seeking skilled care
was low (r=0.1466).21 Contextual factors, such as structural characteristics of individuals
(i.e. education level, parity, previous use of the health system, previous pregnancy
losses), and community social influences (i.e. social norms surrounding use of skilled
care and perceived quality of services as learned from friends/family members) may have
moderated the effects of knowledge in relation to seeking skilled care. Due to the crosssectional retrospective nature of this baseline study, the source of “knowledge” is
unknown. Knowledge of danger signs may be a function of previous use of the health
care system, higher education, and/or information from friends and/or family members.
In addition, the temporal relationships are unclear thus limiting our ability to draw causal
inferences. We do not know which happened first– knowledge or use of skilled care.
Another issue to consider is the measurement of knowledge. In this study, knowledge
was measured as the number of danger signs women spontaneously cited for pregnancy,
childbirth, the postpartum period, and for the newborn. This measure may not accurately
capture “knowledge” as women with more education or with previous experiences with
complications may be able to recite these signs without comprehending the meaning of
the terms. The survey did not include measures of comprehension of knowledge of
danger signs.
21
The correlation between knowledge of danger signs and traditional providers was negative (r=-0.0216),
while the correlation with pharmacy shops was lower than with skilled care (r=0.0595)
138
Finally, individual knowledge may not adequately capture all aspects of “knowledge of
danger signs.” Women have limited decision-making ability when a life-threatening
complication occurs and thus rely on family members and traditional birth attendants.
The knowledge of these individuals may be more closely correlated with care seeking
behaviors. Even if women have individual knowledge, in settings where women have
limited decision-making power, such as Bangladesh (Rozario S 1992; Das Gupta M
1995), individuals may not be able to act on their individual knowledge. Community
social influences and knowledge of powerful others may be more influential in translating
knowledge into behavior than individual-level knowledge. Communication patterns, who
women turn to for maternal health information and advice on appropriate care seeking
behaviors, and the knowledge of these individuals, may more accurately measure
“knowledge” at the community-level.
These findings have important implications for safe motherhood programs which operate
under the assumption that knowledge about danger signs will lead to prompt recognition
of complications and subsequent care seeking behaviors thus decreasing the first delay.
Additional research is needed to more clearly understand how education, previous
experience, previous use of the health system, program activities, as well as the
characteristics identified by Hornik (1989) influence the acquisition of knowledge and
moderate the relationship between knowledge and use of skilled care. As knowledge
effects were significantly moderated by the number of antenatal care visits in this study,
women’s interaction with the health system may be the factor causing this relationship.
Use of antenatal care is strongly associated with using a skilled attendant at birth (Bell J,
139
Curtis SL et al. 2003; Curtis S, Bell J et al. 2003) and is also associated with seeking
skilled care for complications during the postpartum period (Chakraborty, Islam et al.
2002). A community-based trial that compares care seeking behaviors among women
who attend antenatal care and women who attend antenatal care and also receive
messages about knowledge of danger signs through community-based education could
provide evidence to disentangle these relationships. These findings will be crucial to
inform effective behavior change interventions for future safe motherhood programs.
This research has several strengths in its large sample size and quality assurance of data
management. There are also important limitations which may bias the findings. First,
the study was limited to recently delivered women. To more fully understand
community-based knowledge of danger signs and care seeking behaviors, it is crucial to
interview husbands, mothers-in-law, mothers, and both traditional and skilled providers.
Secondly, although the recall period was relatively short (12 months), women may be
able to more clearly recall complications and care seeking behaviors within a shorter
period (Stanton CK 2004). Research has shown that women’s self reports of obstetric
complications do not accurately correspond to medical diagnoses, and tend to over- or
under-estimate complications (Stewart MK and Festin M 1995; Danel I, Ponce de Leon R
et al. 1996; Ronsmans C, Achadi E et al. 1997; Seoane G, Castrillo M et al. 1998;
Fortney JA and Smith JB 2000; Sloan NL, Amoaful E et al. 2001). Nonetheless,
women’s perceptions of life-threatening problems are essential in relation to care seeking
behaviors (Fortney JA and Smith JB 2000; Yassin K, Laaser U et al. 2003), and these
140
findings indicate that although a majority of women perceive experiencing life
threatening complications, few seek care from a skilled provider.
Finally, this study focused solely on “demand side” variables, and we lacked information
on availability and quality of services. The literature indicates that these factors are
significantly associated with seeking and using skilled care (Chakraborty, Islam et al.
2002; Bell J, Curtis SL et al. 2003; Curtis S, Bell J et al. 2003; Rahman SA, Parkhurst JO
et al. 2003). Unfortunately, this data set didn’t include “supply side” variables. In
addition, due to the cross sectional nature of the study, we couldn’t explore reverse
causality in terms of the knowledge effects on care seeking behaviors.
7.7
Conclusion
In settings were home-based birth is the norm, safe motherhood programs rely on
women, families, and traditional birth attendants to recognize potentially life-threatening
complications and seek skilled care. In Sylhet District, Bangladesh, women and families
report seeking care from a variety of sources, with few women seeking care from skilled
providers. Seeking care in the traditional sector or at pharmacy shops may increase the
first delay, with women arriving at health facilities too late to receive life-saving care.
Knowledge of danger signs may be associated with seeking skilled care, although this
relationship was moderated by the number of antenatal care visits. Additional research is
needed to further explore the mechanisms through which knowledge is translated into
care seeking behaviors to inform behavior change interventions that aim to improve
maternal health and survival.
141
Table 7.1: Selection of Covariates, Sylhet District, Bangladesh 2003 (n=5,625)
Variable
Pearson’s
Unadjusted
Unadjusted
Wald
Forward/
Include
chi-
Coefficient
p-value
Test
backward
Final
p-value
selection1
Model?
square
p-value
Woman’s age2
0.300
Parity (Ref: 0-1)
0.000
2-4
5 or more
Education (Ref:
Y/N
NA
NA
NA
0.000
Trad: -0.230
Trad: 0.031
Pharm: 0.101
Pharm: 0.454
Skilled: -0.595
Skilled: 0.000
Trad: -0.201
Trad: 0.037
Pharm: 0.159
Pharm: 0.295
Skilled: -0.779
Skilled: 0.000
0.000
NA
N
None
Y
Skilled
None
0.0048
Y
none)
Primary
Secondary+
Belong to
0.059
organization
Knowledge of
Trad: 0.308
Trad: 0.005
Trad
Pharm: 0.417
Pharm: 0.002
Pharm
Skilled: 0.639
Skilled: 0.000
Trad: 0.267
Trad: 0.027
Skilled
Pharm: -0.286
Pharm: 0.101
Trad
Skilled: 0.1.49
Skilled: 0.000
Trad: -0.280
Trad: 0.071
Pharm: -0.322
Pharm: 0.074
Skilled: 0.309
Skilled: 0.035
0.000
danger signs
(Ref: 0-3)
142
0.3516
None
N
0.0158
None
Y
Variable
Pearson’s
Unadjusted
Unadjusted
Wald
Forward/
Include
chi-
Coefficient
p-value
Test
backward
Final
p-value
selection1
Model?
square
p-value
4-6
7-9
10 or more
Dead child
Pregnancy loss
ANC visits
0.000
0.261
Y/N
Trad: 0.0230
Trad: 0.800
Pharm: 0.275
Pharm: 0.156
Skilled: 0.415
Skilled: 0.000
Trad: -0.116
Trad: 0.334
Pharm: 0.484
Pharm: 0.029
Skilled: 0.660
Skilled: 0.000
Trad: -0.129
Trad: 0.368
Pharm: 0.406
Pharm: 0.083
Skilled: 0.880
Skilled: 0.000
Trad: -0.063
Trad: 0.461
Pharm: -0.152
Pharm: 0.212
Skilled: 0.399
Skilled: 0.000
Trad: 0.101
Trad: 0.135
Pharm: 0.225
Pharm: 0.092
Skilled: 0.051
Skilled: 0.481
0.000
None
None
None
0.4159
None
N
0.0302
Skilled
Y
Pharm
0.000
Y
(Ref: 0 visits)
1-2 visits
3 or more
Trad: 0.273
Trad: 0.020
Skilled
Pharm: 0.633
Pharm: 0.000
Trad
Skilled: 1.361
Skilled: 0.000
Pharm
Trad: 0.178
Trad: 0.298
Skilled
Pharm: 0.665
Pharm: 0.000
Pharm
Skilled: 2.249
Skilled: 0.000
143
Variable
Pearson’s
Unadjusted
Unadjusted
Wald
Forward/
Include
chi-
Coefficient
p-value
Test
backward
Final
p-value
selection1
Model?
square
p-value
Staying in natal
Trad: -0.168
Trad: 0.125
home for
Pharm: 0.128
Pharm: 0.425
delivery
Skilled: 0.517
Skilled: 0.000
Husband
0.000
Y/N
0.000
0.0160
Skilled
0.1824
Y
N
education (Ref:
none)
Primary
Trad: 0.126
Trad: 0.222
Pharm: -0.019
Pharm: 0.832
Skilled: 0.389
Skilled: 0.000
Trad: 0.255
Trad: 0.032
Pharm: 0.084
Pharm: 0.581
Skilled: 1.06
Skilled: 0.000
Trad: 0.331
Trad: 0.321
Pharm: 0.217
Pharm: 0.000
Skilled: 0.532
Skilled: 0.000
Trad: 0.324
Trad: 0.000
working
Pharm: 0.511
Pharm: 0.000
overseas
Skilled:0.883
Skilled: .000
Trad: -0.178
Trad: 0.315
Pharm: 0.870
Pharm: 0.004
Skilled: 0.633
Skilled: 0.059
Secondary+
Wealth index
Relative
Muslim
0.000
0.000
0.001
Religion
Sub-district
0.000
None
None
0.000
Beanibazar)
144
Y
Pharm
0.0398
Trad
Y
0.2640
None
N
0.000
(Ref:
Skilled
Y
Variable
Pearson’s
Unadjusted
Unadjusted
Wald
Forward/
Include
chi-
Coefficient
p-value
Test
backward
Final
p-value
selection1
Model?
square
p-value
Zakiganj
Kanaighat
Y/N
Trad: 0.553
Trad: 0.001
Trad
Pharm: -0.816
Pharm: 0.000
Pharm
Skilled: -0.853
Skilled: 0.000
Trad: 0.675
Trad: 0.000
Pharm: -0.119
Pharm: 0.703
Skilled: -0.720
Skilled: 0.002
Trad
Notes:
1. Bivariate variables created (skilled versus no care; pharmacy versus no care; traditional/family versus
no care)
2. Woman’s age not included in multivariate models due to high correlation with parity (r=0.6591).
145
Table 7.2: Percent distribution of background characteristics, Sylhet District,
Bangladesh 2003 (n=5,625)
Variable
Percentage (%)
Number
Individual
Woman’s age
14-19
4.71
265
20-24
24.53
1,380
25-29
31.06
1,747
30-34
22.28
1,253
35-39
13.16
740
4.27
240
0-1
20.28
1,141
2-4
46.38
2,609
5+
33.33
1,875
None
47.79
2,688
Primary
28.11
1,581
Secondary+
24.11
1,356
No
90.33
5,081
Yes
9.67
544
Lowest (0-3 signs)
24.84
1,397
Second (4-6 signs)
27.72
1,559
Third (7-9 signs)
27.61
1,553
Highest (10-27 signs)
19.84
1,116
40+
Parity
Woman’s Education
Belong to organization 1
Knowledge of danger signs
146
Variable
Percentage (%)
Number
Reproductive
Child death
No
63.75
3,586
Yes
36.25
2,039
No
74.60
4,196
Yes
25.40
1,429
0
50.10
2,818
1-2
30.45
1,713
3 or more
19.45
1,094
Marbari (natal home)
13.44
756
Shashurbari (in-law/husband’s
86.56
4,869
None
50.01
2,813
Primary
30.70
1,727
Secondary+
19.29
1,085
Lowest
19.13
1,076
Second
20.14
1,133
Middle
19.18
1,079
Fourth
20.05
1,128
Highest
21.49
1,209
Pregnancy loss
No. of ANC visits
Place of residence at delivery
family)
Household
Husband education
Wealth index
Relative working outside
147
Variable
Percentage (%)
Number
Bangladesh?
No
60.00
3,375
Yes
40.00
2,250
Islam
95.57
5,376
Hindu
4.43
249
Beanibazar
43.11
2,425
Zakiganj
36.73
2,066
Kanaighat
20.26
1,134
100.00
5,625
Religion
Community
Sub-district
Total
Notes:
1. Organizations include membership to at least one micro-credit or
Mother’s Club (Grameen Bank, BRAC, BRDB, Mother’s Club)
148
Table 7.3: Percentage of respondents with perceived complications during pregnancy, childbirth, and postpartum by type of care
sought, Sylhet District, Bangladesh, 2003 (n=5,625)
Type of complication
Type of care sought2
Percentage (No.)
reporting
No Care
Traditional/
complication1
Total
Pharmacy
Skilled
responses
family
Any complication
65.72 (3,697)
42.31
22.15
12.47
23.07
3,689
Excessive bleeding
36.48 (2,052)
43.48
21.62
12.98
21.91
2,049
Pregnancy
7.02 (144)
31.25
19.44
6.94
42.36
144
Childbirth
18.81 (386)
44.04
19.69
10.36
25.91
386
84.84 (1,741)
43.67
22.61
13.46
20.25
1,738
39.63 (2,229)
38.76
23.56
16.23
21.45
2,224
Pregnancy
24.59 (548)
35.90
22.71
12.09
29.30
546
Childbirth
6.95 (155)
42.58
20.65
12.90
23.87
155
80.48 (1,794)
37.93
24.86
17.37
19.83
1,790
14.56 (819)
42.77
22.30
13.85
21.08
816
Pregnancy
11.60 (95)
45.26
16.84
15.79
22.11
95
Childbirth
8.91 (73)
53.42
19.18
6.85
20.55
73
87.55 (717)
41.74
23.11
14.15
21.01
714
Postpartum
High fever
Postpartum
Vaginal discharge
Postpartum
149
Type of complication
Type of care sought2
Percentage (No.)
reporting
No Care
Traditional/
complication1
Total
Pharmacy
Skilled
responses
family
Convulsions
14.06 (791)
39.49
20.51
11.14
28.86
790
Pregnancy
59.29 (469)
41.36
17.91
11.09
29.64
469
Childbirth
15.68 (124)
39.52
27.42
7.26
25.81
124
Postpartum
50.57 (400)
36.34
24.81
12.03
26.82
399
24.04 (1,352)
38.70
24.31
7.78
29.21
1,349
6.56 (369)
46.07
24.12
10.03
19.78
369
Prolonged labor (>12 hrs)
Retained placenta
Notes:
1. Percentage of women reporting complication in pregnancy, childbirth, and postpartum may add up to more than 100%, since some women experienced the
complication in multiple phases.
2. Number of women who sought care may be less than number of women who experienced that complication. Not all women reported place of care for
complications reported.
150
Table 7.4: Percent distribution of women who sought care among women with any
complication, by socio-demographic characteristics, Sylhet District, Bangladesh 2003
(N=3,689)
Characteristic
Type of care sought
Statistic
No care
Traditional
Pharmacy
Skilled
Total
p-value
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
N
or %
or %
or %
or %
14-19
45.25
20.67
10.61
23.46
179
20-24
38.99
23.79
11.01
26.21
908
25-29
42.78
22.54
12.94
21.74
1,136
X2(15)=
30-34
42.70
22.01
13.64
21.65
836
17.32
35-39
44.44
18.87
13.00
23.69
477
p=0.300
40+
46.41
22.22
11.76
19.61
153
0-1
35.72
22.28
9.48
32.52
781
X2(6)=
2-4
43.65
21.62
12.81
21.92
1,670
60.23
5+
44.67
22.78
13.89
18.66
1,238
p=0.000
Individual
Woman’s age
Parity
Knowledge of danger signs
Lowest
47.80
26.16
10.39
15.65
818
Second
42.63
24.04
12.21
21.13
1,065
X2(9)=
Third
40.43
19.70
14.26
25.61
1,066
71.38
Highest
38.51
18.51
12.57
30.41
740
151
p=0.000
Characteristic
Type of care sought
Statistic
No care
Traditional
Pharmacy
Skilled
Total
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
N
or %
or %
or %
or %
p-value
Women’s No. Years School
None
49.86
22.78
12.34
15.02
1,791
X2(6)=
Primary
38.94
24.22
14.62
22.22
1,053
241.60
Secondary+
30.53
18.22
10.06
41.18
845
p=0.000
49.03
19.94
10.80
20.22
361
X2(3) =
Belong to
organization1
7.44
p=0.059
0.059
Reproductive
Child death
45.64
22.97
12.23
19.16
1,341
X2(3) =
20.15
p=0.000
Pregnancy loss
40.38
22.15
14.00
23.86
993
X2(3) =
4.00
p=0.261
No. ANC visits during pregnancy
0
53.25
25.13
11.54
10.07
1,767
X2(6)
1-2
36.14
22.42
14.77
26.67
1,151
=473.48
3 or more
26.46
14.92
11.15
47.47
771
p=0.000
Place of residence at delivery
Natal home
35.95
21.80
11.85
30.40
523
X2(3)=
In-laws
43.37
22.20
12.57
21.86
3,166
20.26
p=0.000
152
Characteristic
Type of care sought
Statistic
No care
Traditional
Pharmacy
Skilled
Total
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
N
or %
or %
or %
or %
p-value
Household
Husband’s No. Years School
None
46.31
22.36
13.56
17.77
1,829
X2(6)=
Primary
41.65
22.82
11.96
23.58
1,179
102.23
Secondary+
32.75
20.41
10.43
36.42
681
p=0.000
Lowest
55.44
26.04
8.86
9.66
745
Second
46.12
26.68
13.01
14.19
761
X2(12) =
Middle
43.89
20.74
14.77
20.60
704
324.86
Fourth
37.30
20.95
13.24
28.51
740
p=0.000
Highest
28.69
16.10
12.58
42.63
739
33.70
21.80
13.70
30.80
1,445
Wealth index
Relative
X2(3) =
working
106.15
outside
p=0.000
Bangladesh
Religion
Islam
42.04
21.81
12.73
23.42
3,544
X2(3) =
Hindu
48.30
29.93
6.80
14.97
147
15.73
p=0.001
Community
Sub-district
Beanibazar
38.72
13.55
15.56
32.17
1,542
X2(6)=
Zakiganj
46.73
28.43
8.31
16.54
1,481
220.07
Kanaighat
40.84
28.08
14.56
16.52
666
p=0.000
153
Characteristic
Total
Type of care sought
Statistic
No care
Traditional
Pharmacy
Skilled
Total
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
N
or %
or %
or %
or %
42.31
22.15
12.47
23.07
p-value
3,689
Notes:
1. Organizations include membership to at least one micro-credit or Mother’s Club (Grameen Bank,
BRAC, BRDB, Mother’s Club)
154
Table 7.5: Adjusted Odds Ratios of seeking care among women with any complication by type of care sought and socio-demographic
characteristics, Sylhet District, Bangladesh 2003 (n=3,689)
Variable
OR
p-value
95% CI
OR
Traditional Care (n= 817)
p-value
95% CI
OR
Pharmacy (n= 460)
p-value
95% CI
Skilled care (n= 851)
Women’s education (Ref: none)
Primary
1.34
0.006
1.088-1.654
1.31
0.061
0.987-1.750
1.15
0.229
0.915-1.449
Secondary+
1.23
0.144
0.932-1.621
0.93
0.692
0.668-1.307
1.50
0.009
1.110-2.039
2-4
0.86
0.188
0.688-1.076
1.11
0.448
0.852-1.437
0.647
0.001
0.505-0.829
5+
0.96
0.731
0.776-1.194
1.31
0.119
0.932-1.851
0.83
0.094
0.656-1.034
1.16
0.058
0.995-1.341
1.32
0.054
0.996-1.740
1.30
0.002
1.100-1.546
1-2
1.39
0.135
0.903-2.139
2.25
0.000
1.504-3.368
2.06
0.001
1.323-3.207
3 or more
1.18
0.604
0.635-2.184
1.18
0.689
0.526-2.640
2.77
0.002
1.463-5.253
Living in natal home at delivery
1.12
0.361
0.882-1.414
1.22
0.280
0.851-1.747
1.48
0.001
1.174-1.862
Wealth index
1.02
0.613
0.943-1.105
1.12
0.026
1.104-1.241
1.30
0.000
1.194-1.410
Relative living overseas
1.31
0.005
1.090-1.584
1.27
0.091
0.962-1.686
1.15
0.210
0.926-1.419
Parity (Ref: 0-1 births)
Pregnancy loss
No. ANC visits (Ref: 0 visits)
155
Variable
OR
p-value
95% CI
OR
Traditional Care (n= 817)
p-value
95% CI
OR
Pharmacy (n= 460)
p-value
95% CI
Skilled care (n= 851)
Sub-district (Ref: Beanibazar)
Zakiganj
2.02
0.000
1.459-2.801
0.57
0.010
0.376-0.877
0.88
0.418
0.649-1.196
Kanaighat
2.26
0.000
1.553-3.329
1.15
0.643
0.629-2.116
1.06
0.728
0.771-1.452
ANC visits X Knowledge of
See Table 7.6
See Table 7.6
See Table 7.6
danger signs
Reference category is no care seeking (n= 1,561); Standard errors adjusted for union; Log pseudo-likelihood = -4379.3814
156
Table 7.6: Interaction effects of knowledge of danger signs by number of antenatal care
visits, Sylhet District, Bangladesh 2003 (n=3,689)
Knowledge effects – Traditional/Family Care
Variable
OR
p-value
95% CI
Second vs. Lowest
1.03
0.867
0.733-1.44
Third vs. Lowest
1.12
0.329
0.893-1.404
Highest vs. Lowest
0.86
0.241
0.667-1.101
Second vs. Lowest
1.09
0.727
0.661-1.811
Third vs. Lowest
0.80
0.368
0.4915-1.3008
Highest vs. Lowest
1.31
0.383
0.7146-2.398
Second vs. Lowest
1.30
0.413
0.695-2.429
Third vs. Lowest
1.05
0.885
0.553-1.986
Highest vs. Lowest
0.98
0.951
0.443-2.148
ANC 0 (No visits)
ANC 1 (1-2 visits)
ANC 2 (3 or more visits)
Knowledge effects – Pharmacy Care
Variable
OR
p-value
95% CI
Second vs. Lowest
1.34
0.183
0.871-2.065
Third vs. Lowest
1.34
0.208
0.949-2.118
Highest vs. Lowest
1.63
0.016
1.093-2.419
Second vs. Lowest
0.88
0.626
0.5146-1.491
Third vs. Lowest
1.03
0.918
0.5779-1.838
ANC 0 (No visits)
ANC 1 (1-2 visits)
157
Variable
OR
p-value
95% CI
0.75
0.434
0.3643-1.543
Second vs. Lowest
1.63
0.254
0.703-3.791
Third vs. Lowest
2.08
0.139
0.7897-5.458
Highest vs. Lowest
1.48
0.528
0.4381-4.997
OR
p-value
95% CI
Second vs. Lowest
0.73
0.031
0.5458-0.971
Third vs. Lowest
0.97
0.879
0.634-1.476
Highest vs. Lowest
1.31
0.291
0.795-2.148
Second vs. Lowest
1.61
0.013
1.107-2.33
Third vs. Lowest
1.30
0.210
0.861-1.972
Highest vs. Lowest
1.65
0.039
1.027-2.647
Second vs. Lowest
1.59
0.189
0.7958-3.177
Third vs. Lowest
2.54
0.005
1.33-4.853
Highest vs. Lowest
1.92
0.021
1.103-3.356
Highest vs. Lowest
ANC 2 (3 or more visits)
Knowledge effects – Skilled Care
Variable
ANC 0 (No visits)
ANC 1 (1-2 visits)
ANC 2 (3 or more visits)
158
CHAPTER 8: DISCUSSION AND IMPLICATIONS
Maternal morbidity and mortality are significant health problems in Bangladesh. The
World Health Organization estimates that 16,000 women in Bangladesh die each year
due to causes related to pregnancy and childbirth (World Health Organization, UNICEF
et al. 2004). These deaths have consequences for children and families, and most
tragically, are avoidable through the timely use of obstetric care (Starrs A 1997). In
Bangladesh, 87% of births take place at home without skilled care. Safe Motherhood
programs focus on improving care seeking behaviors to ensure that women with
complications receive appropriate life-saving care.
This paper was based on six research questions:
1. What methods have been used to measure self-reports of maternal morbidity in
Bangladesh and India?
2. Are the community-based estimates of maternal morbidity consistent, and if not,
how can measurement be improved?
3. Do women seek care for these perceived complications, and if so, what type of
care do they seek?
4. What factors are associated with seeking care among women with perceived
complications at individual, household, and community levels?
5. Is knowledge of danger signs associated with care seeking behaviors?
6. How can safe motherhood programs improve measurement of morbidity as well
as programs that aim to improve care seeking behaviors?
159
Chapter 5 examined the first two research questions in regards to measurement methods
to document women’s self-reports of maternal morbidities and subsequent care seeking
behaviors in Bangladesh and India. In the 27 articles reviewed, we discovered a variety
of methods and a total of 162 different variables to measure maternal morbidities. These
morbidities ranged the continuum of severity with some indicating potentially lifethreatening complications, such as excessive bleeding, while others measured less serious
conditions such as diarrhea and vomiting. Definitions of maternal morbidity,
classification of morbidities, time points for measurement, and assessment by health
providers varied greatly among the studies. In addition, few studies measured perceived
severity of the condition or subsequent care seeking behaviors. These measurement
issues contribute to difficulty in documenting maternal morbidities and subsequent care
seeking behaviors to improve maternal outcomes.
Chapters 6 and 7 addressed research questions three, four, five, and six. These papers
used qualitative and quantitative methods to describe care seeking behaviors for
perceived maternal morbidities. Care seeking is a dynamic and multidimensional
process, where a multiple decisions may be made simultaneously, especially in the case
of an emergency. In Chapter 6, women were asked about health problems experienced
during their last pregnancy and subsequent care seeking behaviors using semi-structured
in-depth interviews. Overall, the 24 women cited a total of 90 complications, of which
61 were classified as “serious.” Women reported seeking care for 55 of these
complications with the majority of care taking place in the home. A framework was
presented that categorized care seeking as occurring in the private domain (at home) or in
160
the public domain (outside the home). There are many barriers to seeking skilled care in
Bangladesh cited in the literature. In a study conducted in 2000, the most frequently
cited barriers were: lack of education and information about services; superstition; fear of
losing family prestige; costs of services; negligence of service providers; lack of adequate
drugs and medications; shortage of skilled doctors; and the predominance of male doctors
in government hospitals (Haider SJ 2000). In this study, these factors were exacerbated
by social barriers, such as limited power within the household structure as well as
restrictions on social mobility. As a result, the majority of women sought care at home
with male family members acting as mediators between the private and public domains.
Families were able to retain power over treatments, costs of treatments, and providers
consulted in the private domain. Although this type of care seeking allowed families to
adhere to social traditions, it may have increased the first delay, meaning that women
arrive at health facilities too late for life-saving care.
In Chapter 7, specific hypotheses regarding relationships between knowledge of danger
signs, use of antenatal care, and previous pregnancy losses were tested. Women were
prompted on six potentially life-threatening complications overall and during pregnancy,
childbirth, and the postpartum period. If women reported at least one complication, she
was asked whether or not she sought care, and if so, the type of provider. A total of 58%
of women sought some type of care– with 22% seeking care from traditional providers or
other family members, 13% sought care from pharmacy shops, and 23% sought skilled
care. Although the location of care in terms of the private or public domain could not be
determined from these data, it is evident that few women sought skilled care.
161
In the multivariate multinomial logistic regression analysis, at least one antenatal care
visit was significantly associated with care seeking from pharmacy shops and from
skilled providers. Three or more antenatal care visits was significantly associated with
seeking skilled care. Primary education was significantly associated with seeking care
from traditional providers/family members, but was not significant for seeking skilled
care or care from pharmacy shops. Access to skilled care (as measured via sub-district)
was associated with seeking care from traditional providers/family members, but was not
associated with seeking skilled care. Higher family wealth, primiparity, having a
previous pregnancy loss, and living in natal home for delivery were all significantly
associated with seeking skilled care. There was some evidence that knowledge of danger
signs was significantly associated with seeking skilled care, but the effect was moderated
by number of antenatal care visits. Thus, hypotheses H1 and H2 regarding knowledge of
danger signs were not clearly demonstrated in this study, but did raise some interesting
questions for future research. On the other hand, H3 women regarding use of antenatal
care and H4 regarding previous pregnancy losses were both verified based on the results
of this study.
The results of this research have important implications for safe motherhood programs.
First, these studies have reiterated the importance of formative research as an integral part
of safe motherhood programs. In-depth interviews, focus groups, and other techniques
are crucial to understand how women talk about maternal morbidities, what they perceive
to be serious, where they seek care and from whom. The results of the formative research
are essential in designing valid and reliable quantitative research instruments. Terms
162
used to describe morbidities, providers and care seeking patterns as well as social norms
should be integrated into these questionnaires. Perceived severity of morbidities is an
essential component in understanding why and how families make decisions regarding
care seeking– a combination of qualitative and quantitative methods should be employed
to validly capture these perceptions as well as care seeking processes. Finally, providers
identified in the formative research need to be included in program activities. If the
majority of care takes place at home with assistance from traditional or informal
providers, programs should make every effort to include these stakeholders in program
activities as well as to better understand the social norms that encourage use of these
providers. In addition, interventions that create linkages between formal and informal
providers are crucial, especially if the informal providers will be referring women to
skilled care in the formal sector. Since three or more antenatal care visits was so strongly
associated with skilled care, programs should continue to improve and promote the
availability, quality, and use of antenatal care.
This paper also raised several important areas for future research. First, there is some
evidence that knowledge of danger signs has an effect on seeking skilled care. This
relationship requires further research to understand which comes first– knowledge or use
of the health system- and how education and previous experiences may influence this
relationship. In addition, innovative ways to measure knowledge at individual and
community levels need to be explored; social network analysis may be useful in this
endeavor. Finally, rigorous program evaluation is essential to more fully understand
163
which interventions are effective at improving care seeking behaviors in an effort to
improve maternal health and survival.
164
APPENDICES
Appendix 1: Three Delays Model
Phases of Delay
Factors Affecting
Utilization and Outcome
Phase I:
Deciding to Seek Care
Socio-economic/
Cultural Factors
Accessibility of Facilities
Phase II:
Identifying and Reaching
Medical Facility
Quality of Care
Phase III:
Receiving Adequate and
Appropriate Treatment
Source: Thaddeus & Maine, 1994
165
Appendix 2: Conceptual Model
Predisposing Factors
Need to
Seek Care
Enabling Factors
Using care
Outcome
Individual:
- Age
- Parity
- Education level
- Organization
Improved
maternal
morbidity &
mortality
Knowledge
- Knowledge of danger signs
Reproductive:
- Child loss
- Pregnancy loss
- Residence
during delivery
Household:
- Husband’s
education
- Religion
- Wealth status
- Relative overseas
Recognize a
complication
and decide to
seek care
Attending antenatal care
- Number of visits
Use of care
Availability and access of
quality services:
- Distance to health facility
- Cost of services
- Perceived quality of care
Improved
neonatal
mortality
Community:
- Sub-district
166
Appendix 3: Consent forms
Consent form for Qualitative Research
Protocol Title: Evaluation of the effects of community-based interventions on maternal
behaviors and morbidity during pregnancy, delivery and the early postpartum period in rural
Bangladesh
JHU Investigator’s name: Abdullah H. Baqui
ICCDR,B Investigator’S name: Shams El Arifeen
Organization: The Johns Hopkins University School of Hygiene and Public Health: Committee
on Human Research
ICDDR,B: Centre for Health and Population Research
Shimantik: A USAID-funded Bangladeshi NGO
Written Consent Form for In-depth Interviews for the Maternal Morbidity Survey
(Information sheet to obtain written consent from participants in the in-depth interviews for the
maternal morbidity survey)
Purpose of the Research:
We are doing a research study on the health of mothers and young children. This is a joint work
of Shimantik, the Johns Hopkins University, USA, the Ministry of Health and Family Welfare of
the Government of Bangladesh and ICDDR,B. We are asking you to participate in this study. The
purpose of this study is to learn about the problems experienced during childbirth, and where you
went for help if there was a problem in your community. The results of this study will be used to
develop delivery and newborn services. These services will be given by birth attendants and
community health workers to make sure that mothers and newborns have treatment for sickness.
Why selected:
Twenty-five women who had a baby in the last six to twelve months are being asked to take part
in this study. Project workers identified and listed all women who gave birth in the last six to
twelve months. You have been randomly selected from this list to be part of the study.
What is expected from the respondents?
If you agree to participate in this study, I will now ask you some questions about your household,
your experiences with problems during pregnancy and birth, and what type of care you had for
these problems. These questions will only be asked one time at your home, and the visit will take
about 45 minutes.
Risk and benefits:
There are no risks to you from taking part in the study. You can refuse to answer any question or
stop the interview at any time. There are no direct, embarrassing or sensitive questions. The
interview will take about 45 minutes. There are some benefits from being a part of this study.
You will learn about your feelings toward where to go for help if you have a problem during
pregnancy or childbirth in the future. You will also benefit by helping to improve health care in
Bangladesh.
THIS CONSENT FORM CONTINUES ON THE BACK OF THIS PAGE
167
Privacy, anonymity and confidentiality:
Your name will be kept confidential. The study forms will be kept for three years in the
ICDDR,B Dhaka office under lock and key. Only project staff and staff from the donor
organization will be able to see these forms.
Dr. Shams El Arifeen, ICDDR,B, Dhaka, Bangladesh and Dr. Abdullah H. Baqui, JHU, USA are
the Principal Investigators of this project. If you have questions about this study, you may call
Dr. Arifeen at 2-8810115.
If you feel that you have been treated unfairly or have been hurt by joining the study you may call
Dr. Arifeen. . You can also call the Office of Research and Ethics Review Committees of
ICDDR,B at 2-8810117.
Future use of information:
Only anonymous information will be used for this survey and if the information is used in the
future after this study. Your privacy, anonymity, and confidentiality will be maintained.
Right not to participate and withdraw:
Your participation in this study is voluntary. You have the right to withdraw from the study at
any time. Even if you do not want to join the study, or if you withdraw from the study, you will
still receive the same quality of medical care at Shimantik health facilities and the government
health centre.
Principle of compensation:
You will not be paid for your participation in this study.
If you agree to our proposal of enrolling you/your patient in our study, please indicate that by
putting your signature or your left thumb impression at the specified space below.
Thank you for your cooperation.
_______________________________________________
Signature or left thumb impression of subject
____________
Date
_______________________________________________
Signature or left thumb impression of the witness
______________
Date
________________________________________________
Signature of the PI or his/her representative
_____________
Date
Principal Investigators:
 Dr. Shams El Arifeen, ICDDR,B, Dhaka, Bangladesh.Tel: 2-8810115.
 Dr. Abdullah H. Baqui, JHU, USA
NOT VALID WITHOUT THE CHR
168
Consent form for Quantitative Research
The Johns Hopkins University School of Hygiene and Public Health: Committee on Human Research
ICDDR,B: Centre for Health and Population Research
Title of Research Project: Community-Based Interventions to Reduce Neonatal
Mortality in Bangladesh
(Information sheet to obtain verbal consent from participants in the baseline household survey)
ICDDR,B # 2000-037
CHR#: H.22.00.12.06.B
Explanation of Research Project:
We are from a local non-governmental organization (NGO) known as Shimantik. We are doing a
study on the health of young children. We are working with the Johns Hopkins University, USA,
the Ministry of Health and Family Welfare of the Government of Bangladesh and ICDDR,B. We
would like to ask for your permission to participate in this study. The purpose of this study is to
learn about the problems, perception and care seeking patterns for delivery and newborn care
services in your community. Based on that we plan to develop delivery and newborn care services
that can be provided by birth attendants and community health workers to ensure that the babies
are delivered as safely as possible and to provide proper treatment for babies in the first month of
life if they get sick. All mothers in your area are being requested to participate in this study. If
you agree to participate in this study, a field worker will visit your house once or twice and ask
you some questions about your household, how you or your family take care of delivering babies
and how you would take care of the baby after s/he is born. Each home visit will take about 30
minutes.
Your participation in this study is completely voluntary. You have the right to withdraw from the
study at any time. Even if you do not want to join the study, or if you withdraw from the study,
you will still receive the same quality of medical care available to you at Shimantik health
facilities and the thana health center.
Your identity will remain confidential. The study records/forms will be stored for three years in
ICDDR,B head office in Dhaka under lock and key. Only, project staff will have access to these
forms. In addition, staff members from organizations funding this study may also review the
forms. By giving consent, you agree to such inspection and disclosure.
If you want to talk to anyone about this research because you think you have not been treated
fairly or think you have been hurt by joining the study, or you have any other questions about the
study, you may call Dr. Shams El Arifeen, ICDDR,B, Dhaka, Bangladesh at 2-8810115 who is
the local Principal Investigator of this project or call the Office of Research and Ethics Review
Committees of ICDDR,B at 2-8810117.
Do you have any questions?
Yes
No
Do you agree to participate in this research project?
Yes
No
THIS CONSENT FORM CONTINUES ON THE BACK OF THIS PAGE
169
If this consent has been read and explained to you and you have been given the chance to ask any
questions now or at a later time, please sign and make your mark below.
Print Name of Subject:_____________________________________________________
_______________________________________________
_______________
Subject’s Mark or Signature
_______________________________________________
_______________
Signature of Person Obtaining Consent
_______________________________________________
_______________
Signature of Witness to Oral Presentation
(Must be different than the person obtaining consent.)
Date
Date
Date
Signed copies of this consent form must be 1) retained on file by the principle investigator,
2) given to the subject and 3) placed in the subject’s medical record (when applicable).
NOT VALID WITHOUT THE CHR
STAMP OF APPROVAL
170
Appendix 4: Questionnaire for Qualitative Research
Interviewer:
Name/ID No:
Location:
Religion:
Date:
Age
No. of Children:
Occupation:
Marital Status
Years of Education:
Most Recent Pregnancy
How many times have you been pregnant?
2. When was your last birth?
Months ago
Live birth ..........
Stillbirth ..........
2.a. Place of delivery....................................................
3. During your last pregnancy, did you experience any health problems/illnesses?
Yes ..........
No...........

IF NO, SKIP TO SECTION II (CHILDBIRTH)
3a. If yes, could you please describe this (ese) health problem(s)/illness (es)?
IN ONLY ONE PROBLEM, SKIP TO QUESTION 4
3b. If more than one health problem/illness was described, which of these health
problems/illnesses was most serious?
3c. Why was this health problem/illness the most serious?
4. Did you seek care from anyone for this serious health problem/illness?
Yes ...........
No..............
 IF NO, SKIP TO QUESTION 8.
5. Please tell me about your experience.
Probes:
Where did you go?
Why did you go there?
Who encouraged you to seek care?)
Who made the final decision to seek care?
171
How much money did you think you would have to spend for this problem/illness?
How much money did you actually spend for this health problem/illness?
How long did it take you to get to this place?
Who accompanied you to get to this place?
Did you go anywhere else to get help for this serious health problem/illness? and where?
6. Where would other people in your community go for serious health problem/illness during
pregnancy?
7. Why would they go there?
 SKIP TO SECTION II (CHILDBIRTH)
8. If no, why didn’t you seek care from anyone for this serious health problem/illness?
9. Who discouraged you from seeking care for this serious health problem/illness?
10. Who made the final decision to not seek care for this serious health problem/illness?
II. Labor and Childbirth
11. During your last labor and delivery, did you experience any health problems/illnesses?
Yes ..........
No ...........
 IF NO, SKIP TO SECTION III (POSTPARTUM)
12a. If yes, could you please describe this(ese) health problem(s)/illness(es)?
IF ONLY ONE HEALTH PROBLEM, SKIP TO QUESTION 13
12b. If more than one health problem/illness was described, which of these health
problems/illnesses was most serious?
12c. Why was this health problem/illness the most serious?
13. Did you seek care from anyone for this serious health problem/illness?
Yes ...........
No ...........
 IF NO, SKIP TO QUESTION 17
14. Please tell me about your experience.
172
Probes:
Where did you go?
Why did you go there?
Who encouraged you to seek care?)
Who made the final decision to seek care?
How much money did you think you would have to spend for this problem/illness?
How much money did you actually spend for this health problem/illness?
How long did it take you to get to this place?
Who accompanied you to get to this place?
Did you go anywhere else to get help for this serious health problem/illness? and where?
15. Where would other people in your community go for serious health problem/illness during
labor and child birth?
16. Why would they go there?
 SKIP TO SECTION II I (POSTPARTUM PERIOD)
17. If no, why didn’t you seek care from anyone for this serious health problem/illness?
18. Who discouraged you from seeking care for this serious health problem/illness?
19. Who made the final decision to not seek care for this serious health problem/illness?
III. Postpartum Period
20. During the first 40 days after giving birth, did you experience any health problems/illnesses?
Yes ............
No ............
 IF NO, SKIP TO SECTION IV (FREE LISTING ACTIVITY)
21. If yes, could you please describe this(ese) health problem(s)/illness(es)?
IF ONLY ONE HEALTH PROBLEM, SKIP TO QUESTION 24
22. If more than one health problem/illness was described, which of these health
problems/illnesses was most serious?
23. Why was this health problem/illness the most serious?
24. Did you seek care from anyone for this serious health problem/illness?
Yes ...........
No ...........
 IF NO, SKIP TO QUESTION 28
173
25. Please tell me about your experience.
Probes:
Where did you go?
Why did you go there?
Who encouraged you to seek care?)
Who made the final decision to seek care?
How much money did you think you would have to spend for this problem/illness?
How much money did you actually spend for this health problem/illness?
How long did it take you to get to this place?
Who accompanied you to get to this place?
Did you go anywhere else to get help for this serious health problem/illness? and where?
26. Where would other people in your community go for serious health problem/illness during the
first forty days after delivery?
27. Why would they go there?
 SKIP TO SECTION IV
28. If no, why didn’t you seek care from anyone for this serious health problem/illness?
29. Who discouraged you from seeking care for this serious health problem/illness?
30. Who made the final decision to not seek care for this serious health problem/illness?
174
Section IV: Free Listing of Women’s Health Problems during Pregnancy, Labor/Childbirth, and the
Postpartum
Interviewer:
Date:
Name/ID No:
Age
Location:
Religion:
No. of Children:
Marital Status
Years of Education:
Occupation:
READ TO RESPONDENT: Now, I will ask you some questions about health problems/illnesses in pregnancy, labor and childbirth, and the first 40 days after
giving birth in this community. (Go to Free Listing Activity)
Pregnancy:
A. What are the health problems/illnesses that women suffer from in (name of community/area) during pregnancy?
ILLNESSES:
SIGNS & SYMPTOMS:
CARE SEEKING:
OTHER’S CARESEEKING:
Probe to complete the list using
Fill in this column by asking the
Fill in this column by asking the
Fill in this column by asking the
the following question:
following question for each illness.
following question for each
following question for each
illness.
illness.
B. Are there other kinds of
C. What happens when you get
(illness type)?
(illness name)?
D. Where do you go for
E. Where do other people in this
treatment for (illness name)?
community go for treatment of
(illness name)?
Why do you go there?
1
2
3
4
5
175
Childbirth
A. What are the health problems/illnesses that women suffer from in (name of community/area) during labor/ childbirth?
ILLNESSES:
SIGNS & SYMPTOMS:
CARE SEEKING:
OTHER’S CARESEEKING:
Probe to complete the list using
Fill in this column by asking the
Fill in this column by asking the
Fill in this column by asking the
the following question:
following question for each illness.
following question for each
following question for each
illness.
illness.
B. Are there other kinds of
C. What happens when you get
(illness type)?
(illness name)?
D. Where do you go for
E. Where do other people in this
treatment for (illness name)?
community go for treatment of
(illness name)?
Why do you go there?
1
2
3
4
5
176
Postpartum period
A. What are the health problems/illnesses that women suffer from in (name of community/area) in the first 40 days after childbirth?
ILLNESSES:
SIGNS & SYMPTOMS:
CARE SEEKING:
OTHER’S CARESEEKING:
Probe to complete the list using
Fill in this column by asking the
Fill in this column by asking the
Fill in this column by asking the
the following question:
following question for each illness.
following question for each
following question for each
illness.
illness.
B. Are there other kinds of
C. What happens when you get
(illness type)?
(illness name)?
D. Where do you go for
E. Where do other people in this
treatment for (illness name)?
community go for treatment of
(illness name)?
Why do you go there?
1
2
3
4
5
177
Section V: Illness during Pregnancy, labor/Childbirth, and the
Postpartum – Rating of severity of impact on respondent’s health
Interviewer:
Date:
Name/ID No:
Age
Location:
Religion:
No. of Children:
Marital Status
Years of Education:
Occupation:
READ TO RESPONDENT: Now I am going to ask you about the seriousness/severity of each of the
health problems/illnesses that you listed earlier. Please tell me how serious this health problem/illness
is in terms of your overall health. We will first talk about pregnancy, then labor/childbirth, and then
the first 40 days after childbirth.
Pregnancy:
Severity Ratings in Terms of Woman’s Health
Illness Term
Pile 1 (Severe)
Pile 2
(Intermediate)
Pile 3 (Mild)
Why are these problems/illnesses (Pile 1) severe? ......................................................
Why are these problems/illnesses (Pile 2) neither mild nor severe? ................
Why are these problems/illnesses (Pile 3) mild? ....................................................
178
Labor/Childbirth:
Severity Ratings in Terms of Woman’s Health
Illness Term
Pile 1 (Severe)
Pile 2 (Intermediate)
Pile 3 (Mild)
Why are these problems/illnesses (Pile 1) severe? ......................................................
Why are these problems/illnesses (Pile 2) neither mild nor severe? ................
Why are these problems/illnesses (Pile 3) mild? ....................................................
179
Postpartum period: (first forty days after delivery)
Severity Ratings in Terms of Woman’s Health
Illness Term
Pile 1 (Severe)
Pile 2 (Intermediate)
Pile 3 (Mild)
Why are these problems/illnesses (Pile 1) severe? ......................................................
Why are these problems/illnesses (Pile 2) neither mild nor severe? ................
Why are these problems/illnesses (Pile 3) mild? ....................................................
180
Section VI: Illness during Pregnancy, labor/Childbirth, and the
Postpartum– Rating of severity of impact on respondent’s ability to
work
Interviewer:
Date:
Name/ID No:
Age
Location:
Religion:
No. of Children:
Marital Status
Years of Education:
Occupation:
READ TO RESPONDENT: Now I am going to ask you about how these health problems/illness(es)
affected your ability to work/perform daily tasks. Please tell me if these health problems/illnesses that
you listed earlier prevented you from being able to work, restricted you to the home, or required other
to do your work. We will first talk about pregnancy, then the time between the day of birth and the
noai, and then the time between noai and the end of chollish din.
Pregnancy
Severity Ratings in Terms of Woman’s Ability to Work
Illness Term
Pile 1 (Require other
Pile 2 (Restrict you to
to do your work)
the home)
Pile 3 (Prevent
from work/limit
your ability to do
all of your work)
Why do these health problems/illnesses (Pile 1) require others to do your work?
................................................................................
Why do these health problems/illness (Pile 2) restrict you to the home?
........................................................................
Why do these health problems/illnesses (Pile 3) prevent you from doing work/limit your ability to do
all of your work?)...............................................
181
Birth to noai:
Severity Ratings in Terms of Woman’s Ability to Work
Illness Term
Pile 1 (Require other
Pile 2 (Restrict you to
to do your work)
the home)
Pile 3 (Prevent
from work/limit
your ability to do
all of your work)
Why do these health problems/illnesses (Pile 1) require others to do your work?
................................................................................
Why do these health problems/illness (Pile 2) restrict you to the home?
........................................................................
Why do these health problems/illnesses (Pile 3) prevent you from doing work/limit your ability to do
all of your work?)...............................................
182
Noai to Chollish Din:
Severity Ratings in Terms of Woman’s Ability to Work
Illness Term
Pile 1 (Require other
Pile 2 (Restrict you to
to do your work)
the home)
Pile 3 (Prevent
from work/limit
your ability to
do all of your
work)
Why do these health problems/illnesses (Pile 1) require others to do your work?
................................................................................
Why do these health problems/illness (Pile 2) restrict you to the home?
........................................................................
Why do these health problems/illnesses (Pile 3) prevent you from doing work/limit your ability to do
all of your work?)...............................................
183
Appendix 5: Questionnaire for Quantitative Research
IDENTIFICATION
Code
Name
UPAZILA
UNION
(Category & Name)
Write down the ages
of RDWs if more
than 1 in this HH :
 

 
  
  
 -   - 
VILLAGE
BARI
HOUSEHOLD
Check# Bari # # #
HH # #
WOMAN
WOMAN
ETC.

of

RD Woman 1=
 
RD Woman 2=
 
RD Woman 3=
 
RD Woman 4=
 
RD Woman 5=
 
1=YOUNGEST, 2=NEXT,
Before begining, confirm that there is a recently delivered woman in this HH.
Depending on how long ago the village was visited to identify recently delivered
women, the delivery should have occurred no longer than approximately 15 months
ago. Ask the mother : “How long ago did your last pregnancy end ?”
Interviewer’s Visit and Status
Household
1
2
3
FINAL VISIT
DAY
DATE
___________
_____________
MONTH
_________
INTERVIEWER’S
NAME
RESULT*
NEXT
VISIT
_________
_____________
DATE
_________
_____________
TIME
_________
_____________
*RESULT CODES
01. Completed interview
02 No HH member at home OR no competent
respondent at home at time of interview
03. Entire HH absent for extended period of time
04.Postponed
05. Refused
06. Dwelling vacant OR address is not a dwelling
184
_____________
07
08
09
10
11
YEAR
INT.
CODE
RESULT
CODE
 
 
TOTAL
NUMBER

OF VISIT
Dweling destroyed
Dwelling not found
No women delivered in past 15
months
Woman who recently delivered
absent
Others_________________________
Specify
Reviewed by SFRA
Name/Code________________________
Date
Keyed by
Name/Code___________________
 
 
  /  / 
Date
  /  / 
CONSENT
We have provided you with necessary information about this survey. Are you agreed to
participate / be interviewed ?

Yes

No
Signature of Consent taker :___________________________
185
PROJAHNMO
FORM S1
RDWS: Socio-Economic Status
Upazillah ________________

  
Union_________
Name of Data Collector ___________________
LINE
USUAL
RELATIONSHIP
NO. RESIDENTS AND TO HEAD OF
VISITORS
HOUSEHOLD
Please give me the
names of the
persons who
usually live in your
household and
guests of the
household who
stayed here last
night, starting with
the head of the
household.
(1)
(2)
01
02
03
What is the
relationship of
(NAME) to the
head of the
household?*
 
SEX
Village___________
Household ID:
RESIDENCE
Is (NAME) Does
male or
(NAME)
female?
usually live
here?
How old is
(NAME)?
Record in
completed
years. 00 if
less than 1
year.
See CODE below
(3)
 
(4)
(5)
(6)
 -   - 
AGE
Did
(NAME)
sleep here
last night?
F YES
NO YES
1
2
1
2
1
2
 
1
2
1
2
1
2
 
1
2
1
2
1
2
 
Date
MARITAL
STATUS
(FOR ALL AGED
10 OR ABOVE)
What is the highest
level of school
(NAME) has
attended?***
IF AGED
LESS
THAN 25
YEARS
What is the highest
class (NAME)
completed at that
level?***
See CODE below
Is (NAME)
currently
attending
school?
(9)
(10)
NM YES NO LEVEL CLASS
(11)
YES NO
1
2
3
1
2
12

 
 
1
2
3
2
2
12

 
1
2
3
3
2
12

186
HUSBAND’S
LINE NUMBER
IF AGE 5 YEARS OR OLDER
See CODE below
(8)
FM
  /  /   
EDUCATION
Has
(NAME)
What is the current ever
marital status of
attended
(NAME)?**
school?
(7)
NO IN YEARS CM
M
  
WRITE THE
LINE NUMBER
OF THE
HUSBAND (from
column 1) IF A
MARRIED
WOMEN.
WRITE 00
OTHERWISE.
(12)
 
1
2
 
1
2
 
 
1
2
 
*Codes for Relationship to house hold head
01=Head
02=wife or husband
03=son or daughter
04=son-in-law or daughter-in-law
05=grandchild
06=parent
07=parent-in-law
08=brother or sister
09=other relative
10= adopted/step child
11= not related
**Codes for Education:
LEVEL
1=primary
2= Secondary
3=College/University/+
4= Don’t know
187
CLASS
00= less than 1 yr or none
98= Don’t know
***Notes on marital status:
CM= Currently Married
FM= Formerly Married
NM= Never Married
98=don’t know
Household ID:
 -   - 
check
bari
Name of HH Head:________________
house
Household Section: [Respondent: Household head or adult household member]
QUESTIONS
13 What is the main source of water your
household uses for dishwashing?
BE SURE OF THE SOURCE OF 'PIPED
WATER'. IF THE ANSWER IS 'PIPED
WATER', CHECK THE SOURCE AND
CIRCLE THE APPROPRIATE CODE.
14 What is the main source of drinking
water for members of your household?
BE SURE OF THE SOURCE OF 'PIPED
WATER'. IF THE ANSWER IS 'PIPED
WATER', CHECK THE SOURCE AND
CIRCLE THE APPROPRIATE CODE.
15 Do you usually boil this water before
you drink it?
16 What kind of toilet facility does your
household have?
17 Does your household have electricity?
CODING CATEGORIES
PIPED WATER
PIPED INSIDE DWELLING
PIPED OUTSIDE DWELLING
WELLWATER
TUBEWELL
DEEP TUBEWELL
SURFACE WELL/OTHER WELL
SURFACE WATER
POND/TANK/LAKE
RIVER/STREAM
RAINWATER
BOTTLED WATER
FILTERED WATER
OTHER_________________________
(SPECIFY)
PIPED WATER
PIPED INSIDE DWELLING
PIPED OUTSIDE DWELLING
WELLWATER
TUBEWELL
DEEP TUBEWELL
SURFACE WELL/OTHER WELL
SURFACE WATER
POND/TANK/LAKE
RIVER/STREAM
RAINWATER
BOTTLED WATER
FILTERED WATER
OTHER_________________________
(SPECIFY)
YES
NO
SKIP
11
12
21
22
23
31
32
41
51
61
98
11
12
21
22
23
31
32
41
51
61
98
1
2
SEPTIC TANK/MODERN TOILET
PIT TOILET/LATRINE
PIT LATRINE/WATER SEALED
PIT LATRINE/NOT WATER SEALED
OPEN LATRINE
HANGING LATRINE
NO FACILITY/BUSH/FIELD
OTHER____________________________
(SPECIFY)
YES
NO
11
21
22
23
24
31
98
1
2
188
18 How many (OBJECT) does your
household (or any member of you
household) have:
Almirah/Wardrobe?
table?
bench or chair?
watch or clock?
cot or bed?
radio that is working?
television that is working?
quilt (‘LEP’ or ‘KOMBOL’)?
mattress (‘TOSHOK’)?
refrigerator?
motorcycle?
sewing machine?
telephone that’s working?
mobile phone that’s working?
bicycle?
car / Microbus/ Van?
ricksaw?
boat?
ALMIRAH/WARDROBRE
 
TABLE
 
BENCH OR CHAIR
 
WATCH OR CLOCK
 
COT OR BED
 
RADIO
 
TELEVISION
 
‘LEP’ OR ‘KOMBOL’
 
‘TOSHOK’
 
REFRIGERATOR
 
MOTORCYCLE
 
SEWING MACHINE
 
TELEPHONE
 
MOBILE TELEPHONE
 
BICYCLE
 
CAR/MICROBUS/VAN
 
RICKSHAW
 
BOAT
 
IF DON’T KNOW ENTER ‘99’
IF NONE, ENTER ‘00’
189
19 How many of the following animals
are owned by your household?
Cow
Buffalo
Goats
Sheep
Chickens
Ducks
Pigeon
CATTLE
 
BUFFALO
 
GOATS
 
SHEEP
 
CHICKENS
 
DUCKS
 
PIGEON
 
IF DON’T KNOW ENTER ‘99’
IF NONE, ENTER ‘00’
20 How many rooms are in your
household?
21 Is the kitchen separated from the main
household structure?
22 Main material of the roof.
Record Observation.
23 Main material of the walls.
Record Observation
24 Main material of the floor.
Record Observation
 
yes
No
1
2
Natural Roof
Katcha (Bamboo/Thatch)
11
Rudimentary Roof
Tin
21
Finished Roof (Pukka)
Cement/Concrete/Tiled
31
Other___________________________ 98
(SPECIFY)
NATURAL WALLS
JUTE/BAMBOO/MUD (KATCHA)
11
RUDIMENTARY WALLS
WOOD
21
FINISHED WALLS
BRICK/CEMENT
31
TIN
32
OTHER___________________________ 98
(SPECIFY)
NATURAL FLOOR
EARTH/BAMBOO (KATCHA)
11
RUDIMENTARY FLOOR
WOOD
21
FINISHED FLOOR (PUKKA)
CEMENT/CONCRETE
31
OTHER___________________________ 98
(SPECIFY)
YES
1
NO
2
25 Does your household own any
homestead?
IF NO, PROBE:
Does your household own homestead any
other places?
YES
26 Does your household own any land
NO
(other than the homestead land)?
27 How much land does your household
own (other than the homestead land)?
AMOUNT __________________
SPECIFY UNIT
_______________
1
2
28
 
............... 2 
ACRE ........................... 1
DECIMLE
RECORD
(1 KIYAR = 30 DECIMEL)
00.00 IF NONE
190
28 Do you have a relative living/working
outside of Bangladesh?
29 What is the relationship between the
household head and this relative living
abroad?
(RECORD RELATIONSHIPS OF ALL IF
MORE THAN ONE)
YES
NO
1
2
WIFE OR HUSBAND
SON
DAUGHTER
SON-IN-LAW/DAUGHTER-IN-LAW
GRANDCHILD
FATHER/MOTHER
PARENTS IN LAW
BROTHER/SISTER
OTHER RELATIVES
ADOPTED OR STEP/CHILDREN
OTHER__________________________
DON’T REMEMBER/KNOW
A
B
C
D
E
F
G
H
I
J
Y
Z
30 How many are living in?
GREAT BRITAIN/LONDON
RECORD THE NUMBER OF
RELATIVES THEY HAVE IN EACH
NORTH AMERICA/USA
COUNTRY
How many live in GREAT BRITAIN/LONDON
 
 
 
/EUROPE
MIDDLE EAST
How many live in NORTH AMERICA/USA
How many live in MIDDLE EAST
How many live in
MALAYSIA/SINGAPORE/BRUNEI
MALAYSIA/SINGAPORE/BRUNEI
If none, record “00”
31 Do they send you money?
 
OTHER_____________________

(SPECIFY)
YES
NO
1
2
 
32 How many times have they sent you
money in the past year?
TIMES
RECORD ‘00’ if they never send
money.
33 Can you use or spend this money when YES
in need?
NO
34 Do you belong to any of the following
organizations?
Grameen Bank?
BRAC?
BRDB?
Mother's Club?
Any other organization (such as micro
credit)?
35 What is your religion?
34
1
2
GRAMEEN BANK
BRAC
BRDB
MOTHER’S CLUB
OTHER______________________
(SPECIFY)
DON’T BELONG TO ANY ORG.
A
B
C
D
E
Z
ISLAM
HINDUISM
BUDDHISM
CHRISTIANITY
OTHER___________________________
(SPECIFY)
191
1
2
3
4
8
34
36 What is the primary occupation of the
head of household?
(IF MORE THAN ONE OCCUPATION,
RECORD THE MAIN ONE)
Occupation:
________________________________
Write the occupation here and circle the
correct code in the next column
WORK ON OWN FARM OR AS A SHARE
CROPPER
DAY, UNSKILLED LABORER
DOMESTIC , AGRICULTURAL AND
MIGRANT
2
FISHERMAN
CONTRACTED LABORER
LONG TERM, ,
,CARPENTER
MASON
OWN BUSINESS
SHOPKEEPER, VENDOR,
RIKSAW/VAN PULLER, ARTISAN
PRIVATE SERVICE
SALARIED, SKILLED FACTORY
AND OFFICE WORKERS, SALESMEN
GOVERNMENT SERVICE
ALL GOB-PAID EMPLOYEES
HOUSEWIFE
JOBLESS
OTHER _________________________
(SPECIFY)
QUESTIONS AND FILTERS
1
3
4
5
6
7
8
9
0
CODING CATEGORIES
SKIP
100.................. Now I would like to ask about all the births you have had during your life.
YES
1
101Have you ever given birth?
NO
2
102 Do you have any sons or daughters to YES
whom you have given birth who are now
NO
living with you?
103 How many sons live with you?
And how many daughters live with you? Sons at home
IF NONE RECORD 00
104 Do you have any sons or daughters to
whom you have given birth who are still
alive but do not live with you?
105 How many sons are alive but do not
live with you?
And how many daughters are alive but
do not live
with you?
Daughters at home
YES
Daughters elsewhere
GIRLS DEAD
192
104
 
 
1
2
IF NONE RECORD 00
106 Have you ever given birth to a boy or YES
a girl who was born alive but later died?
NO
IF NO, PROBE: Any baby who cried or
showed any sign of life but only survived a
few hours or days?
107 In all, how many boys have died?
BOYS DEAD
And how many girls have died?
IF NONE RECORD 00
2
NO
Sons elsewhere
106
1
106
 
 
1
2
 
 
108
108 Some pregnancies end before full term YES
as miscarriage or an abortion, while others NO
may result in a stillbirth. Have you had
any pregnancies that did not result in live
births?
1
2
 
109 In all, how many pregnancies did not
Pregnancy Loss
result in a live birth?
110 SUM ANSWERS 103, 105, 107, AND
109 and ENTER TOTAL.
Total Outcomes
IF NONE RECORD 00
111 CHECK 110 Just to make sure that I
have this right: you have had
______children who are still living
(103+105)
______children who have died (107),
and
______pregnancies which did not
result in a live birth (109)?
Is that correct?
112
Proceed to Q. 113
110
 
YES
1
NO
2
IF NO PROBE AND CORRECT
AS NECESSARY
101 – 109
LAST PREGNANCY
113
PHIL
114
PHIL
115
PHIL
116
PHIL
117
PHIL
NOW I WOULD LIKE TO TALK TO YOU ABOUT YOUR LAST
PREGNANCY THAT IS COMPLETED, WHETHER THE CHILD WAS
BORN ALIVE, BORN DEAD, OR THE PREGNANCY WAS LOST
BEFORE FULL-TERM, THAT IS AS A MISCARRIAGE OR AN
ABORTION.
RECORD TWINS AND TRIPLETS ON FORMS SEPARATE COLUMN.
INFANT 1 INFANT 2 INFANT 3
Think back to the time of your
OUTCOME
last
pregnancy. (Do not include
pregnancies that delivered since
mapping and listing).
SINGLE
1
Was that a single or a multiple
MULTIPLE
2
pregnancy?
DON’T KNOW 9
Was the baby born alive, born
dead, or lost before full-term, that
is, as a miscarriage or an
abortion?
Did that baby cry, move, or
breathe when it was born?
118
PHIL
What name was given to that
child?
119
PHIL
Is/Was (NAME) a boy or a girl?
BORN ALIVE 1
BORN DEAD
2
LOST BEFORE
7 MONTHS
3
1
2
1
2
118
3
3
125
YES
1
1
1
NO
2
2
2
|____________|___________|_________
__|
BOY
1
1
1
GIRL
2
193
2
2
124
120
PHIL
121
PHIL
122
PHIL
In what month and year was
(NAME) born?
PROBE:
What is his/her birthday?
Ask: Where is he/she?
With intention of:
Is (NAME) still alive?
IF ALIVE:
How old is (NAME)?
RECORD IN MONTHS
__/__/____
dd
mm
yyyy
ALIVE
1
DEAD
2
1
1
2
2
 
Months
(NEXT INFANT OR IF NO MORE,
201)
123
PHIL
124
PHIL
IF DEAD:
How old was he/she when he/she
died?
IF “1 YR.”, PROBE: How many
months old was (NAME)?
IF “1 month”, PROBE: How
many days old was (NAME)?
RECORD DAYS IF LESS
THAN 1 MONTH,
OTHERWISE RECORD IN
MONTHS. IF AGE IS LESS
THAN 1 DAY, RECORD '00'.
Was that baby a boy or a girl?
125
PHIL
In what month and year did this
pregnancy end?
126
PHIL
How many months did the
pregnancy last?
127
PHIL
RECORD IN COMPLETED
MONTHS.
Did this pregnancy end by itself
or did you or someone else do
something to end it?
DAYS
 
 
 
MONTHS
 
 
 
(GO TO NEXT INFANT IF NO MORE, SKIP
TO 201)
BOY
GIRL
1
2
1
2
1
2
 
Month 

Year    
MONTHS  
Day
(IF 7 OR MORE, NEXT INFANT OR Go to
next question)
SPONTANEOUS
1
INDUCED
2
MENSTRUAL REGULATION 3
194
123
200
201
PAUL
202
PAUL
203
PAUL
MIGRATION
CODING CATEGORIES
QUESTIONS AND FILTERS
Now, I would like to ask you some questions about where you are from and
where you were when you were pregnant?
YES
1
Are you Sylheti? (permanent
NO
2
resident of this place ?)
1
Were you living in the Marbari or MARBARI/BAPENBARI
SHASHURBARI
2
Shashurbari when you found out
OTHER__________________________ 8
that you were pregnant with your
(SPECIFY)
most recent pregnancy?
What village and union is this in?
CURRENT VILLAGE
(IF THIS VILLAGE IS THE
SAME AS THE VILLAGE IN
UPAZILA
UNION
VILLAGE
WHICH THE INTERVIEW IS
BEING CONDUCTED, YOU
MAY SIMPLY TICK THE
BEANIBAZAR 1
ENTER NUMBER FROM
“CURRENT VILLAGE” BOX.)


 
  
Union ________________
ZAKIGANJ
2
APPENDIX F FOR
KANAIRGHAT 3
BEANIBAZAR,KANAIRGHAT
GOLAPGANJ
4
OR ZAKIGANJ
UPAZILLA
Village________________
OTHER__________________________ 8
(SPECIFY)
204
PAUL
Were you living in the Marbari or
Shashurbari when you delivered?
SAME AS 202
MARBARI/BAPENBARI
SHASHURBARI
OTHER__________________________
(SPECIFY)
205
PAUL
What village and union is this in?
(IF THIS VILLAGE IS THE
SAME AS THE VILLAGE IN
WHICH THE INTERVIEW IS
BEING CONDUCTED, YOU
MAY SIMPLY TICK THE
“CURRENT VILLAGE” BOX.)

Union ________________
Village________________
1
2
3
8
CURRENT VILLAGE
UPAZILA

UNION
VILLAGE
 
  
BEANIBAZAR 1
ENTER NUMBER FROM
ZAKIGANJ
2
APPENDIX F FOR
KANAIRGHAT 3
BEANIBAZAR,KANAIRGHAT
GOLAPGANJ
4
OR ZAKIGANJ
UPAZILLA
OTHER__________________________ 9
(SPECIFY)
206
PAUL
207
PAUL
How many weeks after moving
there did you deliver (or your
pregnancy ended)?
How long after delivery did you
remain at this location?
 
WEEKS
IF LESS THAN 1 WEEK –
RECORD “00”
WEEKS
 
 
DAYS
STILL THERE(RECORD 98 IN ALL BOXES)
195
207
RDWS: Knowledge, Practice and Coverage (KPC)
 -  
Check# Bari###
-

HH##
-- 
Woman#
PREGNANCY
300
301
BMMS
Now I would like to talk to you about some issues that arise before and
during pregnancy.
YES
1
When you were pregnant with
NO
2
(NAME) (last pregnancy), did
DON’T REMEMBER
9
you see anyone for a routine
medical checkup (not for
sickness) i.e., antenatal care for
this pregnancy?
196
309
309
302
BDHS
Where did you receive checkups?
Who did the checkup ?
Any other places?
PROBE FOR THE TYPE OF
FACILITY UNTIL NO
FURTHE RESPONE IS GIVEN,
AND RECORD ALL
FACILITIES SEEN.
AT HOME
QUALIFIED (MBBS) DOCTOR
NURSE/MIDWIFE
PARAMEDIC
FWV
MEDICAL ASSISTANT / SACMO
FWA / HEALTH ASSISTANT
AA
BA
CA
DA
EA
FA
OTHERS
HOMEOPATH
AYURVEDIC
TRAINED TBA (TTBA)
UNTRAINED TBA / DHORNI
QUACK DOCTOR
VILLAGE DOCTOR
SPIRITUAL
SHASHURI
RESPONDENT’S MOTHER
OTHER FAMILY MEMBERS
GA
HA
IA
JA
KA
LA
MA
NA
OA
PA
GOVT.
MEDICAL COLLEGE HOSPITAL
FAMILY WELFARE CENTRE
UPAZILA HEALTH COMPLEX
SATELLITE CLINIC / VACCINATION
CENTRE
MCWC
FWA / HA
QA
RA
SA
TA
UA
VA
NGO
NGO SATELLITE CLINIC
NGO FIXED CLINIC
NGO HOSPITAL
WA
XA
YA
NON-GOVT.
303
BMMS
304
How many times did you receive
medical checkups during this
pregnancy?
Did you go for antenatal care
each time just to check that
everything was fine or did you
ever go because you had a
problem?
NON-GOVT. HOSPITAL / CLINIC
QUALIFIED DOCTOR’S CHAMBER
NURSE/MIDWIFE’S HOME
PARAMEDIC’S HOME/CHAMBER
FWV’S HOME
MA/SACMO’S HOME/CHAMBER
QUACK/VILLAGE DOCTOR’S HOME/
CHAMBER
PHARMACY
ZA
AB
BB
CB
DB
EB
OTHERS
XX
DON’T KNOW / DON’T REMEMBER
ZZ
NUMBER OF TIMES
DON’T KNOW/DON’T REMEMBER
BECAUSE OF PROBLEM
TO CHECK ONLY
BOTH
DON'T KNOW/DON'T REMEMBER
197
FB
GB

99
1
2
3
9
305
BMMS
306
BMMS
REV
BCC
307
NEAR
BMMS
Now I would like to ask you
some questions about your
antenatal visits. When you were
pregnant with (NAME) (last
pregnancy), did you receive
advice on any of the following
during at least one of your
antenatal check-ups for this
pregnancy:
A. Advised to rest/avoid heavy
work?
B. Advice about diet?
C. Advised to breastfeed?
D. Advised about danger signs?
E. Advised to get TT injection?
F. Advised to take IFA tablets?
During any of your antenatal
visits while you were pregnant
with (NAME) (last pregnancy)
were you or your
husband/relatives told about any
of the following birth planning
items?
A. The location where you would
like to have the delivery
B. The person who will deliver
the baby
C. The hospital/clinic you can go
to if you have
Delivery complication
D. Arrangement for transport
E. Arrangement for money
F. Arrangement for delivery kit
G. Complications during
pregnancy and delivery
During any of your antenatal
visits while you were pregnant
with (NAME) (last pregnancy),
were you or your
husband/relatives told about safe
delivery including:
A. Delivery on a clean surface
B. Using of new boiled blade
C. Using clean boiled thread to
tie cord
D. Using a clean towel/cloth to
dry baby
E. Using a separate clean towel
to wrap baby
F. Keeping delivery kit at home
YES
NO
A. REST
B. DIET
1
1
2
2
9
9
C. BREASTFEED
D. DANGER SIGNS
1
1
2
2
9
9
E. TT INJECTION
F. IFA TABLETS
1
1
2
2
9
9
YES
NO
DK
1
1
1
1
1
1
1
2
2
2
2
2
2
2
9
9
9
9
9
9
9
YES
NO
DK
2
2
9
9
2
9
2
9
2
2
9
9
A.
B.
C.
D.
E.
F.
G.
DELIVERY PLACE
DELIVERY PERSON
HOSPITAL
TRANSPORT
MONEY
DELIVERY KIT
COMPLICATIONS
A. DELIVERY ON CLEAN
SURFACE
1
B. CLEAN BOILED BLADE 1
C. CLEANED BOILED
THREAD
1
D. CLEAN TOWEL/CLOT FOR
DRYING
1
E. CLEAN TOWEL WRAP FOR
WRAPPING
1
F. DELIVERY KIT
1
198
DK
308
BMMS
–
ITEM
S
309
BDHS
310
BDHS
311
BDHS
312
mod
BDHS
313
mod
BDHS
Did you have any of the
following performed at least once
during any of your antenatal
checkups for this pregnancy:
A. Blood Pressure Checked?
B. Urine Test?
C. Abdomen Exam?
D. Ultrasound?
Did you take any iron tablets or
iron syrup during this pregnancy?
SHOW TABLET/SYRUP
During the time that you were
pregnant with (NAME) did you
receive any TT injection?
How many TT injections did you
receive during the pregnancy
with (NAME)?
(ASK TO SEE CARD)
Now we will talk about possible
problems that a woman might
face when she is pregnant (going
to have a child). Please tell me
what are the complications
during pregnancy that need
medical treatment?
Anything else?
Now, please tell me what are the
complications in a woman during
childbirth that need medical
treatment?
Anything else?
Record all responses
314
mod
BDHS
Now, please tell me what are the
complications in a woman after
delivery that need medical
treatment?
Anything else?
Record all responses
A.
B.
C.
D.
YES
NO
DK
1
1
1
1
2
2
2
2
9
9
9
9
BLOOD PRESSURE
URINE TEST
ABDOMEN EXAMINED
ULTRASOUND
YES
NO
DON’T KNOW
1
2
9
YES
NO
DON’T KNOW
1
2
9

NUMBER BY HISTORY

NUMBER BY CARD
(9 IF CARD NOT AVAILABE)
SEVERE HEADACHE
A
BLURRY VISION
B
REDUCED OR ABSENT FETAL
MOVEMENT
C
HIGH BLOOD PRESSURE
D
EDEMA OF THE FACE
E
EDEMA OF THE HANDS
F
CONVULSIONS
G
EXCESSIVE VAGINAL BLEEDING
H
LOWER ABDOMINAL PAIN
I
NONE MENTIONED
Y
EXCESSIVE VAGINAL BLEEDING
FOUL-SMELLING DISCHARGE
HIGH FEVER
BABY’S HAND OR FEET COME FIRST
BABY IN BAD POSITION
PROLONGED LABOR (>12 HOURS)
RETAINED PLACENTA
TORN UTERUS
PROLAPSED CORD
CORD AROUND NECK
CONVULSIONS
NONE MENTIONED
A
B
C
D
E
F
G
H
I
J
K
Y
EXCESSIVE VAGINAL BLEEDING
FOUL-SMELLING DISCHARGE
HIGH FEVER
INVERTED NIPPLES
TETANUS
RETAINED PLACENTA
SEVERE ABDOMINAL PAIN
CONVULSIONS
ENGORGED BREASTS
NONE MENTIONED
A
B
C
D
E
F
G
H
I
Y
199
312
312
315
EDIT
What are the symptoms within
28 days after delivery indicating
the need to seek health care for
your newborn?
Anything else?
Record all responses
POOR FEEDING OR UNABLE TO SUCKLE?
INFANT DIARRHEA?
REDNESS OR DISCHARGE FROM AROUND
THE CORD?
RED/DISCHARGING EYES?
DIFFICULT BREATHING?
SKIN COLOR YELLOW (JAUNDICE)?
CONVULSIONS?
SKIN LESION (OR BLISTERS)?
BABY WON'T CRY?
FEVER?
UNCONSCIOUS?
FAST BREATHING/DIFFICULT
BREATHING?
SEVERE CHEST INDRAWING?
FAILURE TO PASS URINE
FAILURE TO PASS STOOL
NONE MENTIONED
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
Y
DELIVERY
400
401
Check the answer of Q.116 : Is
either of “1” or “2” circled ?
Now I would like to ask you
some questions about the time of
delivery of (NAME).
Who from your family delivered
the baby (NAME)?
Anyone else?
402
402A
RECORD THE
RELATIONSHIP OF EACH TO
THE RESPONDENT.
Did someone from outside of
your family assist with the
delivery of (NAME)?
From outside of your family Who assisted with the delivery ?
(Mention the main person who
helped)
Circle one answer only
402B
YES
NO
1
2
MOTHER-IN-LAW/SHASHURI
MOTHER/MA
SISTER/BOIN
SISTER-IN-LAW/NANURI/NONOD
HUSBAND/SHAMI
FATHER-IN-LAW/SHASHUR
OTHER MEMBER OF SHASHURBARI
OTHER MEMBER OF BAPERBARI
OTHER RELATIVES
NO ONE
DON’T REMEMBER
A
B
C
D
E
F
G
H
I
Y
Z
YES
No
Don’t remember / don’t know
1
2
9
HEALTH PROFESSIONAL
QUALIFIED DOCTOR
NURSE/MIDWIFE
PARAMEDIC
FAMILY WELFARE VISITOR
MA/SACMO
HEALTH ASST (HA)
FAMILY WELFARE ASST (FWA)
01
02
03
04
05
06
07
500
403
403
OTHER PERSON
TRAINED TRADITIONAL
BIRTH ATTENDANT (TTBA)
08
UNTRAINED TBA (DAI)
09
NEIGHBOUR OR FRIEND
10
UNQUALIFIED DOCTOR
11
OTHER_________________________98
(SPECIFY)
NO ONE
99
Check answer for 402A : if any of 08,09 or 10 is circled (that means If
the answer is “TBA” (Trained or untrained – whatever) OR “Neighbour or
Friend” ) – then ask the next Q. 402B; otherwise ask q. 403
YES
1
Does this person (whom you
NO
2
403
mentioned) regularly do the
DON’T KNOW
9
403
work of “Dhorni’?
200
402C
Please Check whether this Union is “A” or “B” (see on first page – Face
Sheet) – if this is “A” or “B” union – then please collect the name and
the address of the person; if it is “C” – then go to Q. 403
NAME :
Please tell me the name of the
person you mentioned for
assisting the delivery
ADDRESS :
BARI :
VILLAGE :
UNION :
UPAZILA :
DISTRICT :
403
404
BMMS
When (NAME) was born, was
your husband in the village?
Where did you give birth?
Circle only one answer
404A
Check answer of 404 : is` “1” is
circled
405
On what surface were you lying
on when you delivered?
406
Did you have a birth kit?
407
What did you use it for?
CIRCLE ALL RESPONSES
GIVEN
  
 

YES
NO
1
2
HOME
PUBLIC SECTOR
MEDICAL COLLEGE HOSPITAL02
01
FAMILY WELFARE CENTER (FWC)
UPAJILA HEALTH COMPLEX
MATERNAL AND CHILD WELFARE
CENTER (MCWC)
NGO SECTOR
NGO HOSPITAL
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC
QUALIFIED DOCTOR’S CHAMBER
TRADITIONAL DOCTOR’S
CHAMBER
OTHER_______________________
(SPECIFY)
DON’T KNOW/DON’T REMEMBER
03
04
05
06
07
08
09
98
99
YES
1
408
NO
2
PLASTIC SHEET
1
CLOTH
2
CHALA
3
COT
4
CHATAI ON FLOOR
5
ONLY FLOOR
6
OTHER____________________________8
(SPECIFY)
YES
1
NO
2
DON’T KNOW/DON’T REMEMBER
9
FOR PLASTIC SHEET TO
DELIVER ON
A
FOR SOAP FOR BIRTH
ATTENDENT TO WASH HANDS
B
FOR BLADE TO CUT CORD
C
FOR TIE TO TIE CORD
D
NOTHING
E
OTHER___________________________ Y
(SPECIFY)
201
408
408
408
BMMS
mod
Were any of the following
procedures performed at the
time of delivery?
A. The doctor used instruments
to get the baby out
(FORCEP)?
B. You had an abdominal
operation to get the baby
Out (C-SECTION)?
C. Received Blood Transfusion?
D. Received intravenous fluid?
E. Injection to speed delivery,
increase labor pain or stop
bleeding given with saline?
F. Episiotomy?
G. Baby’s position had to be
changed?
Y
N
1
2
1
2
1
2
1
2
1
2
1
2
1
2
DK
A. FORCEP
9
B. ABDOMINAL OPERATION/
C-SECTION
9
C. BLOOD TRANSFUSION
9
D. INTRAVENOUS
9
E. INJECTION TO SPEED LABOR
9
F. EPISIOTOMY
9
G. CHANGE BABY POSITION
9
202
409
MOD
BMMS
Did you experience any of the
following problems during the
pregnancy, delivery and/or after
delivery with (NAME)?
CIRCLE ALL
RESPONDENT MENTIONS.
FOR AFTER DELIVERY,
INCLUDE ONLY THINGS
THAT OCCURRED UP TO 1
MONTH AFTER.
A) Excessive bleeding was so
much that it wet your clothes
and you feared it was life
threatening?
B) A high fever
C) Bad smelling vaginal
discharge?
D) Convulsions?
E) Prolonged labor (>12 hours)?
F) Retained placenta?
PROBLEM
TIMING OF
PROBLEM
A. EXCESSIVE BLEEDING
YES ------1
DURING
PREGNANCY – 1
DURING
DELIVERY – 2
AFTER
DELIVERY – 3
NO--------2
B. HIGH FEVER
YES ------1
PREGNANCY – 1
DURING
DURING
DELIVERY – 2
AFTER
DELIVERY – 3
NO--------2
C.
BAD SMELLING VAGINAL
DISCHARGE
YES ------1
DURING
PREGNANCY – 1
DURING
DELIVERY – 2
AFTER
DELIVERY – 3
NO--------2
D. CONVULSION
YES ------1
PREGNANCY – 1
DURING
DURING
DELIVERY – 2
AFTER
DELIVERY – 3
NO--------2
E.
PROLONGED LABOUR (>12
HOURS)
YES ------1
NO--------2
F. RETAINED PLACENTA
YES ------1
NO--------2
203
IF
ALL N
501
409A
410
411
Check answer of Q. 409 : Is any
“Y” circled ?
Did you seek any care for any of
these/this complication?
Where did you receive treatment?
Who provided treatment ?
Any other places?
YES
NO
1
2
YES
NO
500
1
2
AT HOME
QUALIFIED (MBBS) DOCTOR
NURSE/MIDWIFE
PARAMEDIC
FWV
MEDICAL ASSISTANT / SACMO
FWA / HEALTH ASSISTANT
AA
BA
CA
DA
EA
FA
OTHERS
HOMEOPATH
AYURVEDIC
TRAINED TBA (TTBA)
UNTRAINED TBA / DHORNI
QUACK DOCTOR
VILLAGE DOCTOR
SPIRITUAL
SHASHURI
RESPONDENT’S MOTHER
OTHER FAMILY MEMBERS
GA
HA
IA
JA
KA
LA
MA
NA
OA
PA
GOVT.
MEDICAL COLLEGE HOSPITAL
FAMILY WELFARE CENTRE
UPAZILA HEALTH COMPLEX
SATELLITE CLINIC / VACCINATION
CENTRE
MCWC
FWA / HA
QA
RA
SA
TA
UA
VA
NGO
NGO SATELLITE CLINIC
NGO FIXED CLINIC
NGO HOSPITAL
WA
XA
YA
NON-GOVT.
NON-GOVT. HOSPITAL / CLINIC
QUALIFIED DOCTOR’S CHAMBER
NURSE/MIDWIFE’S HOME
PARAMEDIC’S HOME/CHAMBER
FWV’S HOME
MA/SACMO’S HOME/CHAMBER
QUACK/VILLAGE DOCTOR’S HOME/
CHAMBER
PHARMACY
ZA
AB
BB
CB
DB
EB
OTHERS
XX
DON’T KNOW / DON’T REMEMBER
ZZ
204
FB
GB
500
IMMEDIATE NEWBORN CARE
CHECK PREGNANCY HISTORY, SKIP TO 601 IF BABY
WAS STILL BORNE
500
501
Check answer of Q.116 : Is “1”
circled ?
Now I would like to ask you
some specific questions
pertaining to the baby
immediately following the
delivery.
What was the very first thing
done with the baby immediately
after delivery?
502
Was the baby dried before the
placenta was delivered?
503
Was the baby wrapped before the
placenta was delivered?
504
Who wrapped the baby?
Circle only one answer
YES
NO
1
2
CUT CORD
PLACED ON MOTHER'S ABDOMEN
LEFT ALONE
DRIED
WRAPPED
BATHED
LET SLEEP
BREAST FED
FED SUGAR WATER OR OTHER
OTHER___________________________
(SPECIFY)
DON’T KNOW
YES
1
NO
2
DON’T REMEMBER
9
YES
1
NO
2
DON’T REMEMBER
9
MOTHER
HEALTH PROFESSIONAL
QUALIFIED DOCTOR
NURSE/MIDWIFE
PARAMEDIC
FAMILY WELFARE VISITOR
MA/SACMO
HEALTH ASST (HA)
FAMILY WELFARE ASST (FWA)
OTHER PERSON
TRAINED TRADITIONAL
BIRTH ATTENDANT (TTBA)
UNTRAINED TBA (DORNI)
UNQUALIFIED DOCTOR
VILLAGE DOCTOR
SHASHURI
MA
OTHER FAMILY MEMBER
OTHER___________________________
(SPECIFY)
DON’T REMEMBER
505
PAUL
Was the baby put to breast before
the placenta was delivered?
506
PAUL
Where was the baby placed
before the placenta was
delivered?
507
GARY
Did your baby cry immediately
after birth?
508
GARY
Did your baby need help
breathing or crying shortly after
birth?
YES
NO
DON’T REMEMBER
ON THE FLOOR
ON THE COT
WITH THE MOTHER
WITH SOMEONE ELSE
DON’T REMEMBER
YES
NO
DON’T REMEMBER
YES
NO
DON’T REMEMBER
205
1
2
9
1
2
3
4
9
1
2
9
1
2
9
600
01
02
03
04
05
06
07
08
09
98
99
505
505
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
98
99
510
510
509
GARY
What was done to help the baby
cry or breath at the time of birth?
(DO NOT SUGGEST
ANSWERS)
510
What was used to cut the
umbilical cord?
511
Was the item used to cut the cord
boiled?
512
Who cut the umbilical cord?
NOTHING MENTIONED
A
DRIED THE BABY
B
RUBBED BACK OR FEET
C
RUBBED THE FEET
D
MOUTH TO MOUTH RESUSCITATION E
HEATED THE CORD
F
SLAPPED THE BABY
G
HELD THE BABY UPSIDE DOWN
H
OTHER___________________
Y
(SPECIFY)
BLADE
BAMBOO SLICE/BASHER TOL
SCISSOR/KACHI
OTHER___________________________
(SPECIFY)
DON’T REMEMBER
YES
1
NO
2
DON’T REMEMBER 9
MOTHER
HEALTH PROFESSIONAL
QUALIFIED DOCTOR
NURSE/MIDWIFE
PARAMEDIC
FAMILY WELFARE VISITOR
MA/SACMO
HEALTH ASST (HA)
FAMILY WELFARE ASST (FWA)
513
What was used to tie the cord?
514
Was the item used to tie the cord
boiled?
515
Was anything applied to the cord
immediately after cutting and
tying?
OTHER PERSON
TRAINED TRADITIONAL
BIRTH ATTENDANT (TTBA)
UNTRAINED TBA (DORNI)
UNQUALIFIED DOCTOR
VILLAGE DOCTOR
SHASHURI
RESPONDENT’S MOTHER
FAMILY MEMBER
OTHER___________________________
(SPECIFY)
DON’T REMEMBER
BOILED THREADS FROM BIRTH KIT
THREADS FROM HOME/SUTA
NYLON THREAD
JALA SUTA
OTHER__________________________
(SPECIFIC)
DON’T REMEMBER
YES
1
NO
2
DON’T REMEMBER 9
YES
1
NO
2
DON’T REMEMBER 9
206
1
2
3
8
9
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
98
99
1
2
3
4
8
9
517
517
516
517
What was applied to the cord just
after cutting the cord?
When was (NAME) bathed for
the first time? The first, second,
third day of life or later?
ANTIBIOTICS (POWDER / OINTMENT)
A
ANTISEPTIC
ALCOHOL/SPIRIT
MUSTARD OIL WITH GARLIC
CHAL CHIBANO
TUMERIC/HOLUDAR ROS/
HOLUDAR FUKY
GINGER/ADA ROS
SHIDUR
BORIC POWDER
GENTIAN VIOLET
TALCOM POWDER
OTHER___________________________
(specify)
DON’T KNOW
IMMEDIATELY AFTER BIRTH 0
FIRST DAY
1
SECOND DAY
2
THIRD DAY
3
LATER
4
DON’T REMEMBER
9
B
C
D
E
F
G
H
I
J
K
Y
Z
POSTPARTUM CARE
600
601
Check answer of Q.116 : Is “1”
circled ?
Now I would like to ask you
some questions about your health
after the time of delivery.
After (NAME) was born, did you
have a medical check-up?
YES
NO
1
2
YES
NO
1
2
207
STOP
700
602
Where did you receive this first
checkup?
Who checked at that time ?
If responded more than one
place, ask about the place where
she went first for check up.
AT HOME
QUALIFIED (MBBS) DOCTOR
NURSE/MIDWIFE
PARAMEDIC
FWV
MEDICAL ASSISTANT / SACMO
FWA / HEALTH ASSISTANT
01
02
03
04
05
06
OTHERS
CIRCLE ONLY ONE
RESPONSE
HOMEOPATH
AYURVEDIC
TRAINED TBA (TTBA)
UNTRAINED TBA / DHORNI
QUACK DOCTOR
VILLAGE DOCTOR
SPIRITUAL
SHASHURI
RESPONDENT’S MOTHER
OTHER FAMILY MEMBERS
08
09
10
11
12
13
14
15
16
17
GOVT.
MEDICAL COLLEGE HOSPITAL
FAMILY WELFARE CENTRE
UPAZILA HEALTH COMPLEX
SATELLITE CLINIC / VACCINATION
CENTRE
MCWC
FWA / HA
18
19
20
21
22
23
NGO
NGO SATELLITE CLINIC
NGO FIXED CLINIC
NGO HOSPITAL
24
25
26
NON-GOVT.
603
How many days or weeks after
the delivery did your first check
take place?
RECORD ‘00’ DAYS IF SAME
DAY
605
Did you have this check-up
because you were sick or was it a
routine check-up?
NON-GOVT. HOSPITAL / CLINIC
QUALIFIED DOCTOR’S CHAMBER
NURSE/MIDWIFE’S HOME
PARAMEDIC’S HOME/CHAMBER
FWV’S HOME
MA/SACMO’S HOME/CHAMBER
QUACK/VILLAGE DOCTOR’S HOME/
CHAMBER
PHARMACY
27
28
29
30
31
32
OTHERS
98
DON’T KNOW / DON’T REMEMBER
99
DAYS AFTER DELIVERY
1
 
WEEKS AFTER DELIVERY
2
 
33
34
IF DON’T KNOW/DON’T REMEMBER RECORD
“99” IN ALL BOXES
SICK
1
ROUTINE
2
DON’T REMEMBER
9
208
700
701
paul
702
paul
703
paul
NEWBORN CARE: FIRST
MONTH
Check answer of Q.116 : Is “1” is
circled ?
Now, I would like to ask you
some questions about what
happened during the first month
of (NAME’s) life. Was (NAME)
kept in a bedroom, kitchen or
other place during the first week
of life before the Noi?
Was (NAME) kept mainly with
mother, other family member or
alone during the first week of life
OR before the Noi?
Was (NAME) kept on a bed, on
the floor, or in a baby cot during
the first week of life OR before
the Noi?
YES
NO
1
2
STOP
KITCHEN
BEDROOM
OTHER _________________________
(SPECIFY)
DON’T REMEMBER
1
2
8
WITH MOTHER
BY THEMSELVES
WITH OTHER FAMILY MEMBER
OTHER________________________
DON’T REMEMBER
WITH MOTHER
1
2
3
8
9
ON FLOOR
ON BED
ON COT
11
12
13
OTHERS
9
18
(SPECIFY)
SEPARATE, NOT WITH MOTHER
ON FLOOR
ON BED
ON COT
21
22
23
OTHERS
28
(SPECIFY)
704
705
After (NAME) was born, did any
medical persons check your
child's health?
How many days or weeks after
the delivery did your child's first
check take place?
RECORD ‘00’ DAYS IS SAME
DAY
DON’T REMEMBER
99
YES
NO
DON’T REMEMBER
1
2
9
DAYS AFTER DELIVERY
1
 
WEEKS AFTER DELIVERY
2
 
IF DON’T KNOW/DON’T REMEMBER RECORD
“99” IN ALL BOXES
209
709
709
706
Who checked your child's health
at that time?
WHERE DID THE FIRST
CHECK UP TAKE PLACE ?
PROBE FOR THE MOST
QUALIFIED PERSON.
(Most qualified persons are listed
first)
AT HOME
QUALIFIED (MBBS) DOCTOR
NURSE/MIDWIFE
PARAMEDIC
FWV
MEDICAL ASSISTANT / SACMO
FWA / HEALTH ASSISTANT
01
02
03
04
05
06
OTHERS
HOMEOPATH
AYURVEDIC
TRAINED TBA (TTBA)
UNTRAINED TBA / DHORNI
QUACK DOCTOR
VILLAGE DOCTOR
SPIRITUAL
SHASHURI
RESPONDENT’S MOTHER
OTHER FAMILY MEMBERS
08
09
10
11
12
13
14
15
16
17
GOVT.
MEDICAL COLLEGE HOSPITAL
FAMILY WELFARE CENTRE
UPAZILA HEALTH COMPLEX
SATELLITE CLINIC / VACCINATION
CENTRE
MCWC
FWA / HA
18
19
20
21
22
23
NGO
NGO SATELLITE CLINIC
NGO FIXED CLINIC
NGO HOSPITAL
24
25
26
NON-GOVT.
708
Was this check because the baby
was sick or was it a routine
check-up?
NON-GOVT. HOSPITAL / CLINIC
QUALIFIED DOCTOR’S CHAMBER
NURSE/MIDWIFE’S HOME
PARAMEDIC’S HOME/CHAMBER
FWV’S HOME
MA/SACMO’S HOME/CHAMBER
QUACK/VILLAGE DOCTOR’S HOME/
CHAMBER
PHARMACY
27
28
29
30
31
32
OTHERS
98
DON’T KNOW / DON’T REMEMBER
99
SICK
ROUTINE
DON’T REMEMBER
210
1
2
9
33
34
709
710
During the first month of life did
(NAME) have any of the
following problems?
A. Fever?
B. Trouble breathing?
C. Jaundice?
D. Diarhea?
E. Umbilical infection or
discharge?
F. Convlusion?
Did you seek medical care for
any of these problems?
FEVER
TROUBLE BREATHING
JAUNDICE
DIARHEA
UMBILICAL INFECTION OR
DISCHARGE
CONVLUSION
NONE
YES
NO
1
2
211
A
B
C
D
E
F
Y
712
712
711
Where did you seek medical
care?
WHOI TREATED ?
Else where ?
Record all answers
AT HOME
QUALIFIED (MBBS) DOCTOR
NURSE/MIDWIFE
PARAMEDIC
FWV
MEDICAL ASSISTANT / SACMO
FWA / HEALTH ASSISTANT
AA
BA
CA
DA
EA
FA
OTHERS
HOMEOPATH
AYURVEDIC
TRAINED TBA (TTBA)
UNTRAINED TBA / DHORNI
QUACK DOCTOR
VILLAGE DOCTOR
SPIRITUAL
SHASHURI
RESPONDENT’S MOTHER
OTHER FAMILY MEMBERS
GA
HA
IA
JA
KA
LA
MA
NA
OA
PA
GOVT.
MEDICAL COLLEGE HOSPITAL
FAMILY WELFARE CENTRE
UPAZILA HEALTH COMPLEX
SATELLITE CLINIC / VACCINATION
CENTRE
MCWC
FWA / HA
QA
RA
SA
TA
UA
VA
NGO
NGO SATELLITE CLINIC
NGO FIXED CLINIC
NGO HOSPITAL
WA
XA
YA
NON-GOVT.
NON-GOVT. HOSPITAL / CLINIC
QUALIFIED DOCTOR’S CHAMBER
NURSE/MIDWIFE’S HOME
PARAMEDIC’S HOME/CHAMBER
FWV’S HOME
MA/SACMO’S HOME/CHAMBER
QUACK/VILLAGE DOCTOR’S HOME/
CHAMBER
PHARMACY
ZA
AB
BB
CB
DB
EB
OTHERS
XX
DON’T KNOW / DON’T REMEMBER
ZZ
212
FB
GB
712
Before the cord fell off, what was
applied to it in the days after
delivery?
Anything else?
ANTIBIOTICS
ANTISEPTIC
ALCOHOL
MUSTARD OIL WITH GARLIC
CHAL CHIBANO
TUMERIC/HOLUDAR ROS/
HOLUDAR FUKY
GINGER/ADA ROS
SHIDUR
BORIC POWDER
GENTIAN VIOLET
TALCOM POWDER
A
B
C
D
E
F
G
H
I
J
K
OTHER___________________________ Y
(specify)
DON’T KNOW
713
714
715
Did you ever breastfeed this
baby?
Did you feed (NAME) shaldudh,
or did you wait for your regular
milk to come in before starting to
breastfeed?
Before you breastfed (NAME)
for the first time, did you give
(NAME) anything else to eat or
drink?
Anything else?
RECORD ALL RESPONSES
716
How long after birth did you first
put (NAME) to the breast?
IF LESS THAN 1 HOUR,
RECORD ‘00’ HOURS.
IF LESS THAN 24 HOURS,
RECORD HOURS.
OTHERWISE, RECORD
DAYS.
Z
YES
NO
1
2
FED THE BABY SHALDUDH
DID NOT FEED BABY SHALDUDH
UNSURE
1
2
9
HONEY
PLAIN WATER
MISRIR PANI
KOLA
LEI
SUGAR WATER
JUICE
BABY OR INFANT FORMULA
COW’S OR GOAT’S MILK
OTHER LIQUIDS
PAPAYA/MANGO
GREEN LEAFY VEGETABLES
RICE, WHEAT, PORRIDGE
DAL
OTHER__________________________
(SPECIFY)
NOTHING
HOURS
1
 
DAYS
2
 
719
A
B
C
D
E
F
G
H
I
J
K
L
M
N
Y
Z
RECORD “99” IN ALL BOXES,
IF “DON’T KNOW”
213
717
After you starting breastfeeding,
what else did you give (NAME)
to eat or drink in the first month?
718
How many months did you
continue to breastfeed?
719
HONEY
PLAIN WATER
MISRIR PANI
KOLA
LEI
SUGAR WATER
JUICE
BABY OR INFANT FORMULA
COW’S OR GOAT’S MILK
OTHER LIQUIDS
PAPAYA/MANGO
GREEN LEAFY VEGETABLES
RICE, WHEAT, PORRIDGE
DAL
OTHER__________________________
(SPECIFY)
NOTHING
MONTH/CODE 
A
B
C
D
E
F
G
H
I
J
K
L
M
N
Y
Z

98=STILL BREASTFEEDING 99=DON’T
KNOW
CHECK THE ANSWER OF 718; IF RESPONDED LESS THAN 5 MONTHS – THEN ASK NEXT
QUESTION. IF ANSWER IS CODED AS “98” OR “99” – THEN STOP INTERVIEWING.
1
If breastfeeding lasted less than 5 COW’S MILK/GOAT MILK
FORMULA
2
months (OR the baby who was
3
never breastfed before as in 713), DAL
RICE,
WHEAT,
PORRIDGE
4
what was the baby’s main source
OTHER
_______________
8
of food after stopping breast
feeding?
214
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CURRICULUM VITAE
ALLISYN C. MORAN
1001 Saint Paul Street, #6G
Baltimore, MD 2120
(443) 527-5729
amoran@jhsph.edu
SUMMARY

Ten years professional experience in research, development, and evaluation of
international health programs.
 Long-term residence in Morocco; Short-term work in Bangladesh, Bolivia, Burkina Faso,
Indonesia, Ivory Coast, Kenya, Nepal, Senegal, Switzerland, Tanzania, Uganda, U.S.
 Fluent in French and English; proficient in Moroccan Arabic.
EDUCATION
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
expected May 2006
 Doctoral candidate Department of Health, Behavior and Society
Advisor: Professor Carl Latkin, Ph.D.
Thesis: Maternal Morbidity in rural Bangladesh: Women’s Perceptions and Care Seeking
Behaviors
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
February 2000
 Master of Health Science (MHS) in International Health
Focus: Reproductive Health/Program evaluation
Thesis: Improving maternal survival through behavior change interventions
Tufts University, College of Liberal Arts, Medford, MA
 Bachelor of Arts, cum laude
Majors: International Relations; Economics
Focus: International Development
May 1994
WORK EXPERIENCE
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Student Investigator, Department of International Health
2004-present
 Manage research study to measure maternal outcomes of three-arm cluster randomized
community intervention trial in rural Bangladesh in collaboration with US-based and incountry partners.
 Develop research proposals, including sample size, study design, instrument
development, interviewer training, data management, and ethical approvals.
Institute of Reproductive Health, Georgetown University, Washington, D.C.
Consultant
2004
 Developed Interviewer and Supervisor Manuals for a study to introduce natural family
planning methods in three countries.
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ALLISYN C. MORAN (page 2 of 5)
Johnson and Johnson Community Healthcare Program, Baltimore, MD
Evaluation Scholar
2003-2005
 Provided technical assistance to monitor and evaluate infant immunization program in
Newark, New Jersey.
 Developed project framework, monitoring forms, questionnaires, and data analysis.
 Conducted training in EpiInfo for project coordinator and outreach workers.
 Completed social network data analysis to measure cohesion of immunization network.
JHPIEGO (An affiliate of Johns Hopkins University) Baltimore, MD
Evaluation Advisor
2000-2004
 Implemented monitoring, evaluation and applied research activities in reproductive health,
maternal health, family planning, and malaria during pregnancy interventions in developing
countries.
 Responsible for study design, instrument development, data collector training, quality
assurance, and data analysis for research to measure provider performance and behavior
change interventions.
 Conducted pilot test of facility-based indicators to monitor and evaluate malaria during
pregnancy in three African countries as a technical liaison with World Health
Organization/Roll Back Malaria.
Technical Development Officer
1999-2000
 Developed and implemented monitoring and evaluation frameworks for Maternal and
Neonatal Health Program (MNH) country programs in collaboration with Baltimore-based
MNH staff, partners and in-country offices.
 Collaborated with JHPIEGO research and evaluation office in modifying existing
computer-based monitoring system.
Technical Assistant for Behavior Change Communication/Community Mobilization
1999
 Conducted literature review to identify primary sources of demand generation activities in
maternal and neonatal health.
 Collaborated with technical directors to draft a position paper on behavior change/
communication to inform Maternal and Neonatal Health Program.
The World Bank, Washington, D.C.
Knowledge Management Intern
1999
 Reviewed information, education and communication (IEC) activities implemented by
World Bank funded health programs in Africa.
 Drafted summary report for the Division of External Affairs on effectiveness of these IEC
activities.
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Research Assistant, Department of International Health
1998-1999
 Researched micro-nutrient supplementation and its impact on immunity to malaria.
 Drafted meta-analysis on impact of iron supplementation on malaria in pregnant women.
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ALLISYN C. MORAN (page 3 of 5)
U.S. Peace Corps, Morocco, North Africa
Health Extentionist
1995-1997
 Implemented health education projects for family planning, clean birthing practices,
nutrition, and basic hygiene in a rural desert village.
 Provided education during pre- and postnatal consultations, including clean birthing kits.
 Introduced appropriate technologies to conserve scarce resources and improve quality of
life in collaboration with Near East Foundation, a local non-governmental organization.
PEER REVIEWED PUBLICATIONS
Sirima SB, Hoppe A, Konaté A, Moran AC, Asamoa K, Bougouma EC, Diarra A, Ouédraogo A,
Parise ME, Newman RD. Malaria Prevention During Pregnancy: Assessing the Disease Burden
One Year After Implementing a Program of Intermittent Preventive Treatment (IPTp) in Koupéla
District, Burkina Faso (accepted to American Journal of Tropical Medicine and Hygiene).
Newman RD, Moran AC, Kayentao K, Benga-De E, Yameogo M, Gaye O, Faye O, Lo Y,
Moreira PM, Doumbo O, Parise ME, Steketee RW (2006). Prevention of malaria during
pregnancy in West Africa: policy change and the power of subregional action. Tropical Medicine
and International Health. 11(4): 462-469.
Fronczak N, Antelman G, Moran AC, Caulfield LE, Baqui AH. (2005). Delivery-related
complications and early postpartum morbidity in Dhaka, Bangladesh. International Journal of
Gynecology and Obstetrics. Oct 20 [Epub ahead of print].
Singer LM, Newman RD, Diarra A, Moran AC, Huber CS, Stennies G, Sirima SB, Konate A,
Yameogo M, Sawadogo R, Barnwell JW, Parise ME. (2004). Evaluation of a Malaria Rapid
Diagnostic Test for Assessing the Burden of Malaria during Pregnancy. American Journal of
Tropical Medicine and Hygiene. 70(5): 481-485.
Sirima SB, Sawadogo R, Moran AC, Konate A, Diarra A, Yaméogo M, Parise ME, Newman
RD. (2003) Failure of a chloroquine chemoprophylaxis program to adequately prevent malaria
during pregnancy in Koupéla district, Burkina Faso. Clinical Infectious Diseases. 36: 13741382.
PAPERS/REPORTS/HANDBOOKS
JHPIEGO/MNH Program. Developing regional experts in essential maternal and newborn care:
The MNH Program Experience. Baltimore, Maryland: JHPIEGO. 2004.
Bicaba A, Moran A, Dineen R. Acceptability and Feasibility of Introducing the Standard Days
Method (SDM) of Family Planning in Reproductive Health Clinics in Burkina Faso, West Africa:
Mid-term Evaluation (May to December 2003). Baltimore, Maryland: JHPIEGO. January 2004.
JHPIEGO/MNH Program. Guidelines for assessment of skilled providers after training in
maternal and newborn healthcare. Baltimore, Maryland: JHPIEGO. 2004.
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ALLISYN C. MORAN (page 4 of 5)
Moran AC, Newman RD. Prevention and Control of Malaria during Pregnancy in Africa:
From Research to Policy Change. Shaping Policy for Maternal and Newborn Health: A
Compendium of Case Studies. Baltimore, Maryland: JHPIEGO. 2003.
Baya B, Sangli G, Moran AC. Analyse de l’enquête de base Burkina Faso, Rapport Final
[Analysis of Baseline data in Burkina Faso, Final Report]. Baltimore, Maryland: JHPIEGO.
January 2003.
JHPIEGO/MNH Program. A Summary of Findings from Baseline Surveys in Three Maternal and
Neonatal Health Program Countries. Baltimore, Maryland: JHPIEGO. December 2002.
Nthani R, Namatovu P, Jonazi M, Moran A, Kinzie B. Developing Regional Experts in
Maternal and Neonatal Health. Paper accepted to International Confederation of
Midwives 26th Triennial Congress. April 2001.
PRESENTATIONS
Moran AC, Nighat Sultana, Nahid Kalim, Marge Koblinsky, Peter J. Winch, Abdullah H. Baqui
et al. Careseeking for maternal health problems in Sylhet District, Bangladesh. Presentation at
the American Anthropological Association. Washington, DC. December 2005.
Moran AC, Rimal RN. Testing the Risk Perception Attitude (RPA) Framework to Promote
Maternal Health: Findings from Burkina Faso. Presentation at International Communication
Association. New York, NY. May 2005.
Moran AC. Pilot of Facility-based Indicators to Monitor and Evaluate Malaria during
Pregnancy: Final Evaluation Methodology. Presentation at World Health Organization/ Roll
Back Malaria. Geneva, Switzerland. September 6-8, 2004.
Yaméogo M, Moran AC, Sirima SB, Jesencky K, Parise ME, Newman RD. Malaria in
pregnancy: Process of advocating policy change in West Africa. Multilateral Initiative on
Malaria (MIM), Arusha, Tanzania. November 2002.
Sirima SB, Sawadogo R, Moran AC, Konate A, Diarra A, Yameogo M, Parise ME, Newman
RD. Failure of a chloroquine chemoprophylaxis program to adequately prevent adverse
outcomes associated with malaria during pregnancy in Koupéla district, Burkina Faso.
Multilateral Initiative on Malaria (MIM), Arusha, Tanzania. November 2002.
Moran AC. Framework for monitoring and evaluation of malaria during pregnancy. Informal
Consultation of the Draft Strategic Framework for Malaria Prevention and Control during
Pregnancy in the WHO Africa Region. World Health Organization/Roll Back Malaria. July
24-25, 2002.
Moran AC. Coalition for Malaria Prevention and Control of East and Southern Africa.
Presentation to Malaria in Pregnancy Working Group. Washington, DC. June 26, 2002.
Moran AC, Newman RD. Regional Workshop on Prevention of Malaria during Pregnancy in
Francophone West Africa. Presentation to Malaria in Pregnancy Working Group.
Washington, DC. April 3, 2002.
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ALLISYN C. MORAN (page 5 of 5)
Newman RD, Moran AC. Draft framework for monitoring and evaluation of malaria during
pregnancy. Presentation to Malaria in Pregnancy Working Group. Washington, DC. April
3, 2002.
POSTERS
Moran A, Sarwin S. Expanding Immunization Coverage for Children Under Two in Irvington,
New Jersey. American Public Health Association Conference, Washington, DC. November
2004.
Moran A, Bicaba A, Dineen R, Blair C. The Acceptability and Feasibility of Introducing the
Standard Days MethodTM of Family Planning into Reproductive Health Clinics in Burkina Faso,
West Africa. American Public Health Association Conference, Washington, DC. November
2004.
Diarra A, Stennies GM, Newman RD, Sirima SB, Moran AC, Sawadogo R, Barnwell J.
Diagnosis of Plasmodium falciparum Placental Malaria using Histidine-rich Protein 2 Rapid
Diagnostic Tests, Burkina Faso, 2001. Multilateral Initiative on Malaria (MIM), Arusha,
Tanzania. November 2002.
SKILLS
Languages: French; Moroccan Arabic.
Computer Skills: Microsoft Office; STATA; SPSS; EpiInfo; EndNotes; AnthroPac; UciNet;
NetDraw
ASSOCIATION MEMBERSHIPS
 American Public Health Association, 2004-present.
 International Communication Association, 2004-present.
AWARDS
 Johnson and Johnson Community Healthcare Program Evaluation Scholar, 2003-2005.
 Scholarship Foundation of Santa Barbara Recipient, 2003-2006.
 National Collegiate Broadcasting Association Finalist for “Best Documentary” Category,
1994.
 Golden Key National Honor Society, 1994.
 Fulbright Scholarship Finalist, 1994.
 Tufts University Alumni Senior Award, 1994.
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