Md. Mosiur Rahman¹, Md. Golam Mostafa¹ and Dr. Md. Nurul Islam²

Institutions

1. Department of Population Science and Human Resource Development, University of Rajshahi, Rajshahi-6205, Bangladesh.
2. Department of Statistics, University of Rajshahi, Rajshahi-6205, Bangladesh.
   

 

ABSTRACT Maternal health, especially in the pregnancy period, is a worthy researchtopic. Less developed countries like Bangladesh give little attention to the utilization of mother’s health care services. This study investigates the utilization of maternal and child health care in Bangladesh, using data from the 2004 Bangladesh Demographic and Health survey (BDHS, 2004) vover 2 eperiod spaning 1990-1999 and 2000-2004. The analysis reveals that a vast majority of women do not take any care (i.e., antenatal. natal and postnatal care services) and of those women who take antenatal care most of them received care from doctors and the same result is obtained for the time span 1990-1999 and 2000-2004. Well-trained personnel can reduce mother and child mortality at the time of the delivery. This study also found that very few women in Bangladesh are found to receive delivery assistance from medically trained personnel and most of them took assistance from untrained persons. It is also observed from the study that around nineteen percent of mother’s place of delivery is their own homes or other homes and only a few of them were found to go to the government or private hospital for delivery cases. This study also elucidates that only 12 percent of babies receive a postnatal checkup by trained health providers within the first two days of delivery. Although it is found that in the time span 1990-1999 and 2000-2004 a vast portion of the children aged 12-23 months receive all the recommended vaccination before their first birthday but still many of them did not receive the recommended vaccination. Key words: Ante natal care, Natal care, Post natal care, Pregnancy complications, Delivery assistance.

Maternal health services have been given highest priority in the health system and it deserves high priority and special importance in a nation’s development. In any community, mothers constitute not only a relatively large and primary group, but also a vulnerable or special risk group. The risk is connected especially with child bearing and delivery. Globally, over half a million women die of pregnancy related complications each year and 99 percent of these deaths occur in developing countries (ICPD, 1994; UNICEF, 1996). UNFPA has estimated lifetime risk of dying from pregnancy and child birth related causes in Bangladesh as 1 woman in 21, which compares to 1 woman in over 4,000 in industrialized countries (UNFPA, 2002). The situation in South Asia is more precarious and accounts for about half of maternal deaths, globally (WHO, 1991). In Bangladesh, the current level of maternal mortality is very high, even by the standard of other developing countries (Mtra al., 1994). Much of the maternal mortality and morbidity is largely preventable and improvement of maternal health considerably contributes to the health of general population. These considerations have led to the formulation of special health care services for mothers all over the world. The term ‘Maternal Health Care’ encompasses the promotive, preventive, curative and rehabilitative health care for mothers especially during and after the pregnancy and delivery. The provision of maternal health care services is of utmost importance for the survival as well as for a better health and better quality of life of both mother and child.

The state of maternal health in a nation can be characterized by numerous factors, such as outcome measures like maternal mortality and morbidity rates, or maternal nutrition status, as well as process indicators of service availability and use. These indicators include: the levels of antenatal and postnatal care, contraceptive prevalence rate (CPR), coverage of tetanus toxoid (TT) vaccination, proportion of deliveries conducted in health facilities by trained birth attendants, or proportion of unwanted pregnancies. Unfortunately, according to many of these measures, the maternal health situation in Bangladesh appears to be poor. Antenatal care is essential to promote, protect and maintain the health of both mother and child The risk of maternal mortality and morbidity as well as neonatal deaths and infant mortality and morbidity can be reduced substantially through proper antenatal care, such as timely regular antenatal check-ups to trained health personal during pregnancy and delivery under safe and hygienic condition (Moller et al., 1989; Joseph, 1989). Three visits should be covered during the entire pregnancy a) 1^st visit at 20 weeks or as soon as the pregnancy is known, b) 2^nd visit at 32 weeks and c) 3^rd visits at 36 weeks. (Park, 1997).

In Bangladesh, lack of proper medical attention and hygienic conditions during delivery leads to the risk of complications and infections that cause death or serious illness for the mother or the newborn or both. Although Government health facilities are available down to union level, more than 90% of deliveries are conducted at home (BDHS, 1999-2000).

Despite the presence of a well-established service delivery infrastructure in Bangladesh and various measures taken so far, the utilization of essential obstetric care (EmOC) services is still poor. Women in rural Bangladesh are not fully aware of the complications that they may encounter during pregnancy and childbirth, and even those who are aware do not know where to go for help. They also face certain barriers (cultural, geographic and economic) in accessing obstetric care. Although the problem is not exclusively medical, the role of the health system is most crucial to the saving of lives. A large percentage of women with obstetric complications fail to get the care they need in time and die at home or on the way to the hospital. This is because referral linkage in the country is weak and there is a need to strengthen it from the grassroots level to the upper tiers of service delivery (Ahmed S et al., 1998).

Although Bangladesh has made significant progress in child survival initiatives and has cut the infant mortality rate by half, every year 150,000 babies are lost within the first 28 days of their lives. Added to this loss, another 100,000 babies are stillborn in late pregnancy bringing the total perinatal (still births and early neonatal) and neonatal deaths to 250,000 annually.

Hence from the forgoing analysis it appears that although Maternal and Child Health (MCH) services have been given highest priority in the health sector the maternal health situation in Bangladesh appears to be poor and the facilities available for these services is not sufficient enough to fulfill these needs adequately.

Maternal Health Care Delivery System in Bangladesh

The MCWCs established mainly at the district level (with some also at the Upazila level) provide only the maternal and child health services under the direct control of the Directorate of Family Planning. These facilities are expected to be equipped to provide basic EOC and obstetric first aid (Ahmed et al., 1995). The District Hospitals (DHs) in the district headquarters provide maternal services through an outpatient consultation centre and a labour ward. Between 25-40% hospital beds are reserved for maternal patients in every hospital.

The immunization and other related programmes such as health laboratory; epidemiological surveillance/health information system will be further expanded and strengthened to assist in controlling communicable and non-communicable diseases effectively. A typical THC is a two-story building and is headed by a Thana Health and Family Planning Officer (TH&FPO). Under TH&FPO there are 8 doctors (the medical officers) working in each THC. The THC covers on average a population of around 200,000 people. The lowest level of static health facilities is located at Union level.

In Bangladesh, for women in reproductive age, getting proper maternal health care services was found to be beyond their reach, which is mainly due to their poverty, illiteracy, general backwardness and adherence to superstitious beliefs, and inadequate facilities. With a view to understanding the utilization of Maternal and Child Health care Services (MCH) and its determinants, this study has been carried out. This study utilizes the data extracted from 2004 Bangladesh Demographic and Health Survey (BDHS), which were conducted under the authority of the National Institute of Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare.

The BDHS survey was implemented by Mitra and Associates, a private research firm located in Dhaka. Macro International Inc. of Calverton, Maryland provided technical assistance to the project as a part of its international Demographic and Health Survey (DHS) program, while financial assistance was provided by United States Agency for International Development (USAID) Bangladesh.

Previously, BDHS surveys were carried out in 1993-1994, 1996-1997 and 1999-2000.The objectives of the BDHS was to provide up to date information on fertility, childhood mortality, fertility preference, awareness, approval and use of family planning method, breastfeeding practices, nutrition levels, maternal and child health and so forth. This information is intended to assist in evaluating and designing programmers’ strategies for improving health and family planning services in Bangladesh.

The BDHS 2004 is a nationally representative survey from 11,440 ever married women of age 10-49 and 4297 men age 15-54 from 10,500 households covering 361 sample points (clusters) throughout Bangladesh, 122 urban areas and 239 in the rural areas. The data was collected from six administrative divisions of the country - Barisal, Chittagong, Dhaka, Khulna, Rajshahi and Sylhet. Data collection took place over a five-month period from 1 January to 25 May 2004. Out of 11,440 ever-married sample, data was taken from8860 women who have at least one child (live or dead) under consideration the time interval 1990-2004 and divided the sample according to the two time spans 1990-1999 and 2000-20004 in order to achieve our objectives. In the time span 1990-1999, 3987 samples were identified and in 2000-2004, 4873 were identified. The data were analyzed using SPSS (Version 11.5). Percentage distribution and the average value are used to investigate the overall situation of maternal and child health care utilization in Bangladesh.

Findings

Background of the Respondents

The socio-economic and demographic background of the women is presented in terms of their educational status, occupational status, place of residence, region of residence; mother’s earning status and number of children surviving.

We have utilized respondents’ place of residence as a proxy to control for the differing levels of service access seen between urban and rural areas. It is found that 26.5 percent are in urban area and 73.5 percent live in rural areas. The biggest percent of mothers live in rural areas. The results in Table 2 provides that Dhaka division contains the highest proportion of mothers (31.9 percent), and more than one-quarter lives in Rajshahi division compared to the other division.

Another structural variable included here is religion. Religion is represented by a dummy variable for Muslims and Non-Muslims. Muslim women are expected to differ in receiving health care services due to their restricted movement and cultural norm than the Non-Muslim. The analysis reveals that of a total group of mothers 91.9 percent are Muslims.

The educational attainment of the women was grouped into three categories (no education, primary, secondary and higher education) so as to capture critical educational transitions, which are directly related to employment prospects, and socioeconomic status. A large proportion of mothers (36.5 percent) of the children are illiterate. 27.6 percent completed secondary education and only a few (5.5 percent) are higher educated. Mothers are further distinguished according to their work status.

A majority of the Bangladeshi women are housewife (82.1 percent) and 14.8 percent are involved in working with cash. Men with higher educational attainment may play a more important role in decisions affectng children than men with less schooling (Caldwell, 1990). Our present study represents that 39.2 percent women’s husbands are illiterate and 9.9 percent are higher educated. Regarding child survival status overall 95.4 percent are alive.

Ante Natal Care

Ante natal aspects such as, Antenatal care (ANC) received Sources of Antenatal care Number of months pregnant at time of first visits, Number of antenatal visits,Tetanus toxoid injection received; Delivery assistance; are covered in the study.

^a. Received at least three antenatal car visits with first visit during the first three months of pregnancy from medically trained personnel (i.e. doctor, nurse & family welfare visitors).

^b. Received antenatal care from other persons (i.e. trained & untrained TBA, other).

^c. Not receiving antenatal care.

^d. Assistance from doctor, nurse & family welfare visitor

^e. Assistance from trained & untrained traditional birth attendant

^f. Assistance from  relative/other persons or no one.

Antenatal care is the most important care for a pregnant mother and her child in maternal health services. Here in our maternal health care services, we have categorized antenatal care into three groups (groups are: Sufficient, Insufficient & No care) depending on the extent of care received by mothers. The mothers who received the antenatal care visits from medically trained personal (i.e. doctor, nurse & family welfare visitor) are treated as sufficient antenatal care. The mothers who didn’t receive antenatal care from medically trained personal are treated as insufficient antenatal care and the mothers who didn’t receive any type of antenatal care are considering in the none category or No care. Representing in this way we see from Table 2, that 45.3 percent of mothers take sufficient antennal care and only 7.4 percent of mothers take insufficient antenatal care and the rest of the 47.3 percent women did not have any care during 1990-1999. On the other side during 2000-2004, sufficient antenatal care was taken by 49.1 percent of mothers and only 7.2 percent of mothers had taken insufficient and the rest of 43.8 percent mother dud not have any type of care.

Table 2 represents mothers who have sufficient antenatal care, 27.2 percent have care from doctor, and 18.1 percent from nurses or trained midwifes and family welfare visitors and 47.3 percent did not have any care from any persons in 1990-1999 (Figure-1). On the other side, from 2000-2004, the rate of antenatal care from doctors has increased than in 1990-1999, where 31.6 percent mothers had gone to the doctor and 19.5 percent to nurse/trained midwife and  family welfare visitors and 43.8 percent did not have any care (Figure-2). Antenatal visits should be taken in the specific months during pregnancy. It can also be seen from Table 2 it is clear that most of the mothers (81.4 percent) had the first visit within six months, 12.6 percent of mothers visitedwithin six to seven months and only 6.0 percent mother had care in eight months or after (1990-1999). In 2000-2004, 78.4 percent and 11.7 percent mothers had a visit less than six months, and six to seven months respectively. Only a few, 9.8 percent of mother had it in eight months or after eight months during pregnancy.

We can see that Table 2 represents that 14.7 percent, 24.3 percent and 13.7 percent of mothers had taken one, 2-3 or  more than 4 antenatal visits and 47.3 percent of mothers did not have any visits, respectively in 1990-1999. On the other hand in 2000-2004 16.2 percent, 23.8 percent and 16.2 percent mothers made visits for one, two or three times and more than four times respectively.

In the case of tetanus toxoid (TT) injection, the mothers’ who have received two or more dose of TT injections are considered in one group. The other categories are those who have received just one dose and the rest is those who haven’t received any dose of TT injection. On this view 17.3 percent of mothers did not take any dose, 22.6 percent mother had taken only one dose and 60.1 percent mother had taken two or more doses of tetanus toxoid (TT) injections in 1990-1999. Besides these 26.0 percent of mothers had taken one dose, 55.6 percent had taken two or more doses and 18.4 percent of mothers did not take any dose in 2000-2004.

Well-trained personnel can reduce a Mother’s and child’s mortality at the time of delivery. For assistance during delivery, the mothers who received assistance from doctor nurse/trained midwife and family welfare visitor are considered as mother having received assistance from a “Health professional”. If the mother was assisted by more than one type of provider, only the most qualified person is recorded. The mothers who received assistance from trained and untrained traditional birth attendants (TBA) are considered “TBA” category and in the “Others” category the mothers’ had received assistance from a relative, other, don’t know, or from no-one. 15.4 percent of mother’s delivery assistance was a medically trained personal in the year 1990-1999. 44.4 percent of mothers took assistance during delivery form a TBA and 40.2 percent took assistance form other persons. In 2000-2004, 25.1 percent and 40.9 percent of mother’s delivery assistance was medically trained personnel and TBA respectively and the rest 34.0 percent took assistance from others. Vitamin A capsules may be regarded as a preventive management. Table 2 shows that 85.6 percent mothers took vitamin A in 1990-1999 where the rate is low in 2000-2004 (67.1 percent).

Natal Care

Home deliveries are widely reported by women in the study .Assistance during delivery is an important element of delivery care in reducing health risks for both mothers and child. Proper health facilities and adequate medical supervision along with safe, hygienic conditions during delivery can reduce significantly the risk of infections, and facilities management of delivery related complications that may lead to maternal or neonatal morbidity and/or mortality. Developed countries are fully dependant on doctors and nurses in the maternity hospitals for delivery care. Bangladesh is a poor developing country and maternity hospitals are quite inadequate. Most of our pregnant mothers are mainly accustomed to deliver births traditionally taking help from their relatives or neighbors. The high perinatal mortality and maternal mortality in Bangladesh may be attributed to the low prevalence of delivery care and assistance. Table 3 represents that, about nineteen percent of mother’s place of delivery is their own homes or other home and 8.1 percent of mothers had gone to the government or private hospitals for delivery cases in 1990-1999. This situation has somewhat improved in 2000-2004 where 14 percent mothers choose government or private hospital and 85.4 percent in their own homes or others home for delivery. On the other hand those that have assistance, among them 5.6 percent go to the doctor and 9.8 percent go to a nurse/midwife and  family welfare visitors, in 1990-1999. In 2000-2004, 9.5 percent mothers go to a doctor and 15.6 percent go to a nurse/midwife and family welfare visitors. Besides these 40.2 percent mothers have assistance from others in 1990-1999, whereas the rate is somewhat low in 2000-2004 (34 percent).

It is an important factor that mothers can inform about their pregnancy complications. But generally this is a rare case. Table 3 shows that about one-quarter mothers can tell their pregnancy complications in 1990-1999 and 31.0 percent in 2000-2004. The rest of the mothers are unable to inform of any complications about their pregnancy. In response to a question whether mothers suffer from any problem, about 21.9 percent of mothers reported that they suffered from many types of hazards in 1990-1999 and 26.1 percent in 2000-2004 (Table 3). The major delivery hazards as experienced by the women in Bangladesh, include prolonged labor (i.e. duration of true labor or regular, rhythmic uterine contraction lasting for more than 12 hours); excessive bleeding which may be life threatening; high fever with bad smelling vaginal discharge and convulsions not cause by fever. 14.9 percent mothers suffered from prolonged labor and 7.9 percent excessive bleeding in 1990-1999 whereas the rate is slightly higher (17.3 percent and 11.2 percent respectively) in 2000-2004. 3.5 percent of mothers suffered from high fever and 3.3 percent from convulsions in 1990-1999 where the rate is 4.8 percent and 3.3 percent in 2000-2004 respectively.

Post Natal Care

A crucial component of safe motherhood is postnatal care. Postnatal care is important for mothers for treatment of complications arising from delivery, especially for births that occur at home. Postnatal checkups provide an opportunity to assess and treat delivery complications and to counsel mothers on how to care for themselves and their newborns. In order to assess the extent of postnatal care utilization, women whose most recent live birth in the five years preceding the survey was delivered outside a health facility were asked whether they and/or the child received a postnatal checkup from a health provider and within how many days of delivery the checkup was received. It is assumed that deliveries in any health facility will receive a postnatal checkup for the mother and the child within the first two days of delivery, as a part of routine institutional delivery care.

Table 4 shows that very few mothers in Bangladesh receive postnatal care. Only 14 percent of mothers received a postnatal checkup from a trained health service provider within 42 days of delivery during the year 1990-1999 and the corresponding figure for the year 2000-2004 is 17.8 percent. In Bangladesh, newborns are as likely as their mothers to have received postnatal care from a medically trained provider. During the year 2000-2004 less than one in five newborns is checked by a health professional within six weeks of delivery. The timing of postnatal care for newborns is important since most neonatal deaths occur within two days of delivery. The data indicates that during the year 2000-2004 only 12 percent of babies received a postnatal checkup by a trained health provider within the first two days of delivery.

Vitamin A capsules may be regarded as preventive management. It is also effective in child morbidity especially it is the leading factor to prevent childhood blindness. Table 4 shows that 11.8 percent children took vitamin A in 1990-1999 where the rate is 14.9 percent in 2000-2004 (67.1 percent).

Universal immunization of children under one year of age against the six vaccine-preventable diseases (tuberculosis; diphtheria, pertussis, and tetanus [DPT]; poliomyelitis; and measles) is one of the most cost-effective programs in reducing infant and child morbidity and mortality. The Expanded Program on Immunization (EPI) is a priority program for the government of Bangladesh. It follows the international guidelines recommended by the World Health Organization (WHO). WHO recommends that children receive all of these vaccines before their first birthday. Overall, 68 percent of children age 12-23 months had received all the recommended vaccinations before their first birthday during the time span 2000-2004 and 60.2 percent during 1990-1999.

Bangladesh has achieved important health gains over the last decade. However, equivalent progress has not been realized in the area of maternal health. The main focus of this study is to analyze the patterns and determinants of maternal and child health care services utilization in Bangladesh with particular attention to the utilization of maternal health care facilities for effective antenatal care (ANC), tetanus toxoid injection, delivery care, and delivery related complications. The result shows that 47.3 percent women did not take any ANC during pregnancy in the time span 1990-1999 and 43.8 percent in 2000-2004. It is a positive notation that mothers neglecting ANC has decreased in 2000-2004 than 1990-1999.

Of those who receive some ANC, the majority of them (27.2 percent) receive care from a qualified doctor, 18.1 percent from nurse/trained midwives and family welfare visitors and 7.2 percent are from others, in 1990-1999. But these rates are positively high and low in 2000-2004, whereas 31.6 percent go to a doctor, 19.5 percent go to a nurse/trained midwife and family welfare visitor and 4.8 percent haves ANC from others in 2000-2004.

Out of them 45.3 percent of mothers have sufficient antenatal care and only 7.4 percent of mothers had insufficient antenatal care during 1990-1999. On the other side during 2000-2004, sufficient antenatal care has   increased (49.1 percent of mothers) and only 7.2 percent of mothers had insufficient ANC during pregnancy. It is a well-known fact that antenatal visits should be taken in the specific months during pregnancy.

Our study shows that most of the mothers (81.4 percent) had the first visit within six months, 12.6 percent of mothers had one at six to seven months and only 6.0 percent of mother had care at eight months or after in 1990-1999. But in 2000-2004, 78.4 percent and 11.7 percent of mothers had a visit less than six months and six to seven months respectively.

Only a few, 9.8 percent of mothers had it at eight months or after eight months during pregnancy. On the other hand 4.7 percent, 24.3 percent and 13.7 percent of mothers has attended once, 2-3 times and more than 4 antenatal visits, and 47.3 percent mother did not take any visits respectively in 1990-1999. In 2000-2004 16.2 percent, 23.8 percent and 16.2 percent mother made visits for once, two or three times and more than four times respectively.

The proportion receiving tetanus (TT) injections in the time span 2000-2004 has decreased than in the time span 1990-1999. 17.3 percent mothers did not take any dose, 22.6 percent of mother had had only one dose and 60.1 percent of mothers had two or more doses of tetanus toxoid (TT) injections in 1990-1999. Besides these 26.0 percent of mother had one dose, 55.6 percent had two or more doses and 18.4 percent of mother had not had any dose in 2000-2004.

The utilization of health facilities for delivery assistance shows a clear picture; 15.4 percent of mother’s delivery assistance was by medically trained personal in the time span 1990-1999. 44.4 percent of mothers had assistance during delivery form TBAs and 40.2 percent had assistance from other persons. In 2000-2004, 25.1 percent and 40.9 percent of mother’s delivery assistance was by medically trained personnel and TBAs respectively and the rest, 34.0 percent form others.

Regarding Natal care services,home deliveries are widely reported by women in the study.This study also reveals that about one-quarter of mothers can relatetheir pregnancy complications in 1990-1999 and 31.0 percent in 2000-2004.

The rest of mothers are unable to relate any complications about their pregnancy. In response to a question whether mothers suffer from any problem, about 21.9 percent of mothers reported that they suffered from many types of hazards in 1990-1999 and 26.1 percent in 2000-2004. 14.9 percent mothers suffered from prolonged labor and 7.9 percent from excessive bleeding in 1990-1999 whereas the rate is slightly higher (17.3 percent and 11.2 percent respectively) in 2000-2004. 3.5 percent of mothers suffered from high fever and 3.3 percent from convulsions in 1990-1999 whereas the rate is 4.8 percent and 3.3 percent in 2000-2004 respectively. With respect to postnatal care services it was found that very few mothers in Bangladesh receive postnatal care.

Only 14 percent of mothers received a postnatal checkup from a trained health service provider within 42 days of delivery during the year 1990-1999 and the corresponding figure for the year 2000-2004 is 17.8 percent.

In Bangladesh, newborns are as likely as their mothers to have received postnatal care from a medically trained provider. During the years 2000-2004 less than one in five newborns is checked by a health professional within six weeks of delivery. The timing of postnatal care for newborns is important since most neonatal deaths occur within two days of delivery.

The data indicates that during the year 2000-2004 only 12 percent of babies received a postnatal checkup by a trained health provider within the first two days of delivery. It is also found that 11.8 percent if children took vitamin A in 1990-1999 whereas the rate is 14.9 percent in 2000-2004 (67.1 percent). The study also identified that during the time span 2000-2004 and 1990-1999 68.4 and 60.2 percent of children age 12-23 months had received all the recommended vaccinations before their first birthday.

Based on the discussion some recommendations have been suggested that would help the government to take initiatives to promote maternal and child health care facilities.

1. The results of this study indicate that there is a strong need to focus strategic measures upon the increase of health facilities, such as the THC, health clinic and FWC. Emphasis should be given to the IEC activities of the national health programme that communities, particularly the poor and uneducated women become aware of the need for regular antenatal care check up and safe deliveries by competent health personnel. Trained TBAs should be linked with the health service facility-delivery system at different levels to ensure their utilization.
2. There is a further need to investigate with regard to the efforts of Programmatic (e.g., accessibility and cost of antenatal services) on the antenatal care seeking behavior of Bangladeshi women.
3. As most people go to TBAs and village doctors they should be given proper training and integrated into the main stream of government health intervention programmes, which should upgrade the poor maternal and child health care status existing in Bangladesh to a greater extent.
4. Policies to expand educational opportunities, particularly for girls, would increase the access to information and health services and improve their ability to make good use of it in order to lead healthier lives.

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