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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 socio-demographic/reproductive factors and care seeking behaviors.
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.
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
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 pregnancy- and 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. 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 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.
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.
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
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
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
LIST OF TABLES
Table 2.1: Barriers and facilitators to use of skilled care 23
Table 4.1: Description and measurement of variables 42
Table 5.1: Description of community-based maternal morbidity studies 68
Table 5.2: Number of variables to measure pre-eclampsia/eclampsia 72
Table 5.3: Number of variables to measure bleeding 73
Table 5.4: Number of variables to measure postpartum infection 75
Table 5.5: Description of maternal morbidity studies by study characteristics 77
Table 6.1: Description of health providers 108
Table 6.2: Self-reported complications 110
Table 7.1: Selection of covariates 138
Table 7.2: Percent distribution of background characteristics 142
Table 7.3: Percentage of respondents with perceived complications 145
Table 7.4: 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
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
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 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).
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, 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;
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?
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.
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 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.
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).
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).
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 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).
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, 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 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 “patron-client” 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 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 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 (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 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).
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 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).
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 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.
Table 2.1 Barriers and Facilitators to Use of Skilled Care for Normal or Complicated Births at Various Levels
|Barriers |Facilitators |
|Facility/Provider |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 characteristics: |Facility characteristics: |
|Discomfort with male health providers2,3 |Confidence in the technical competence of skilled birth |
|Predominance of male doctors in government hospitals20 |attendants; in the better equipped facilities to manage |
|Long delays once in facility for emergency care2 |complications4,12,13 |
|Poor quality of services13,14,15,17 |Babies can get injections, eye treatment, new clothes at a |
|Lack of blood banks17 |facility4 |
|Limitations of medical equipment and technical capacity of health| |
|personnel13,17,20 | |
| | |
|Birthing care: | |
|Poor-quality, inhuman, or cold treatment at health facility 2,13 |Birthing care: |
|Information about procedures not given or not clear 3 |Being accompanied to skilled care by a TBA improved |
|No respect for ‘our’ customs (e.g. birthing position, clothing, |acceptance and reduced delay in receipt of care4 |
|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,|Concerns and fears of users: |
|want to avoid episiotomy or c-section, fear bad experience in |Fear of dying, of vesico-vaginal fistula/recto-vaginal |
|hospital14 |fistula4 |
|Fear of death in a hospital, lack of confidence in staff17 |Want to get antenatal card as ‘passport’ to skilled care, |
|If can’t manage complications, should not be advised to go there3|especially if emergency4,12 |
|During ANC providers say that pregnancy is “normal”, so women |Previous experience in health clinic and previous delivery |
|perceive that they are OK to birth at home12 |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 | |
| | |
| | |
| |Access: |
| |Living near a facility4 |
|Community |Community |
|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 |Household |
|Knowledge: |Knowledge: |
|Do not recognize danger signs of complications9 in a timely way10|Educate husband and influential others, including traditional|
|Lack of knowledge and understanding of childbirth, unpreparedness|birth attendants, on complications and birth plan6,7 |
|for childbirth13 | |
|Lack of knowledge about services20 | |
| | |
|Social status: |Social status: |
|Husbands/influential others are decision makers when travel16, |Support of husband/close friends and relatives, shared |
|referral, funds are involved6,11,12,13,15,22 |workload13 |
|Less empowered situation in family; less decision-making |Freedom of woman’s movement18 |
|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 | |
|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: | |
|Time, funds needed to purchase ‘birth supply kits’ for hospital | |
|delivery,4 to find and pay for transportation5,16 | |
|Labor starting at night or unexpectedly so no time to go to |Access/logistics: |
|health units12 |Access to family budget13 |
|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)
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 relative working overseas were measured. Location of residence (sub-district) was used as a proxy variable for access to services.
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 cluster-randomized 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 non-governmental 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 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 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.
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.
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 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.
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).
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 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)
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.
Nine interaction terms[5] 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 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 sub-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.
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 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 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 life-threatening 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).
Table 4.1: Description and measurement of variables in quantitative study
|Measure |Definition |Level of Measurement |
|Dependent Variable |
|Care seeking for reported |Care seeking for a reported maternal complications (0=no care, |Categorical |
|complication |1=traditional/family, 2=pharmacy, 3=skilled care at home, facility, | |
| |or office). No care is reference category. | |
|Covariates |
|Individual level | | |
|Woman’s age |Woman’s age at time of interview (1=14-19, 2=20-24, 3=25-29, 4=30-34,|Ordinal |
| |5=35-39, 6=40+) | |
|Parity |Number of births in lifetime (1=0-1, 2=2-4, 3=5+) |Categorical |
|Knowledge |Knowledge of danger signs spontaneously cited during pregnancy, |Categorical |
| |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+) | |
|Organization |Woman belongs to at least one micro-credit organization or Mother’s |Binary |
| |Club (Grameen Bank, BRAC, BRDB, etc.) | |
| |(0=no, 1=yes) | |
|Education level of woman |No. of years of schooling completed by woman (0=none, 1=primary, |Categorical |
| |2=secondary or more) | |
|Reproductive | | |
|Child death |Woman had at least one child die (0=no, 1=yes) |Binary |
|Pregnancy loss |Woman had at least one pregnancy loss (miscarriage, abortion, |Binary |
| |stillbirth) (0=no, 1=yes) | |
|No. ANC visits |Number of ANC visits with skilled provider during last pregnancy (0=0|Categorical |
| |visits, 1=1-2visits, 3=3 or more visits) | |
|Place of residence during |Woman’s location when she gave birth |Binary |
|delivery |(0=in-laws house, 1=natal home) | |
|Household | | |
|Education level of husband |No. of years of schooling completed by husband (0=none, 1=primary, |Categorical |
| |2=secondary or more) | |
|Wealth index |Wealth index based on Demographic and Health Surveys (5 quintiles, |Ordinal |
| |1=lowest, 5=highest) | |
|Relatives working overseas |At least one relative working overseas |Binary |
| |(0=no, 1=yes) | |
|Religion |Religion of household (0=Hindu, 1=Islam) |Binary |
|Community | | |
|Sub-district |Sub-district (0=Beanibazar, 1=Zakiganj, 2=Kanaighat) |Categorical |
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, 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.
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 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, 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).
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 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.
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 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. 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 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 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 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 pre-eclampsia/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” (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 pre-eclampsia/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%), 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%), “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 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 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 life-threatening, 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, pre-eclampsia/eclampsia, ectopic pregnancy, and ruptured uterus (UNICEF/WHO/UNFPA 1997). Anemia, malaria, tuberculosis and other pre-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 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 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 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 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).
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 another eight studies retrospectively classified morbidities into categories of life-threatening, 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 facility-based 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 long-term 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.
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 individual-level 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.
Table 5.1: Description of community-based maternal morbidity studies in Bangladesh and India, 1965 to 2005 (n=27)
|Author |Publi- |Country |
| |cation year | |
|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 |
|Trained community-based health worker assessed (pre-eclampsia: two of the symptoms: high blood pressure, proteinuria, |
|pre-tibial pitting oedema) |
|Midwife assessed during antenatal care |
|Two symptoms: non-dependent oedema, headache, or dizziness where symptoms began in 3rd trimester |
|Two symptoms: non-dependent oedema, headache, or dizziness with no convulsions |
|Two symptom: non-dependent oedema, headache, or dizziness with symptoms of convulsions or “fits” plus loss of consciousness |
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 studies |Reported prevalence (%) |
|Pregnancy |
|Antepartum bleeding |12 |0.40-23.80 |
|Excessive bleeding |3 |1.60-12.50 |
|Childbirth |
|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 |
|Postpartum |
|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 postpartum |1 |16.00 |
|Secondary postpartum hemorrhage at 6 weeks postpartum |1 |5.60 |
|Secondary postpartum hemorrhage at 12 weeks postpartum |1 |3.10 |
|Notes: |
|1. Not clear if from ANC, CB, or PP or all combined. Other highest percentage is 37.40%. |
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 studies |Reported 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 delivery3 |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 |
|Variable |Number of studies |Reported 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: |
|Two reported symptoms: lower abdominal pain, foul smelling discharge, or fever |
|Midwife assessed |
|Assessed by trained community health workers– concurrently had two symptoms: fever, four discharge, lower abdominal pain. |
|Two reported symptoms: abdominal tenderness, fever, or foul vaginal discharge three or more days postpartum |
|Two reported symptoms: burning, frequency, urgency or foul odor. |
|Reported vaginal discharge– prompted on color, odor and quantity. |
|Three reported symptoms: foul discharge, fever, and pain. |
|One reported symptom: thick discolored or fold vaginal discharge |
|Assessed by trained female health workers and some physician validation. |
|Assessed by trained community health workers. |
Table 5.5: Description of maternal morbidity studies by study characteristics, 1965 to 2005 (n=27)
|Author |Morbidities reported |Severity |Care Seeking |
| | | |Behaviors |
| |
Figure 5.1: Percentage of women with at least one morbidity by timing of measurement and by study (n=16)
[pic]
Figure 5.2: Number of variables reported by type of morbidity and timing of measurement (n=162)
[pic]
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)
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 pregnancy-related 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.
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.
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 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 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 life-threatening 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 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 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.
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 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. . . 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 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:
“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 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 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 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)
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.
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 check-ups. 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 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 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 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 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 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 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 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).
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.
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.
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.
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 |
|Traditional |
|Traditional birth attendant |May have some training in clean delivery and newborn health |Woman’s Home |
| |Attends home-based births | |
|Homeopath |Trained in government program1 |Woman’s Home |
| |Provides medicines such as powdered sugar, sugar balls, and tonics |Homeopath home |
|Spiritual healer |Spiritual healer or leader |Woman’s Home |
| |Provides spiritual water, spiritual oil, and amulets to guard against|Healer’s home |
| |evil spirits | |
|Village doctor |May have some training, often informal |Woman’s home |
| |Provides allopathic medicines |Doctor’s home |
|Pharmacy doctor |Majority have no training2 |Pharmacy shop |
| |Sells pharmaceuticals and injections | |
|Provider |Training and type of care provided |Location |
|Skilled |
|Doctor |Certified as MBBS |Woman’s home |
| | |Office/Facility |
|Nurse |Certified as nurse |Woman’s home |
| | |Office/Facility |
|Midwife |Certified as midwife |Woman’s home |
| | |Office/Facility |
|Family Welfare Visitor |Certified as Family Welfare 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. |
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 |
|Buk jala r gola jala korto |Burning sensation in the chest and throat |1 |
|Sharire bish bedna |Body ache |1 |
|Aat masher shomoy pani vangche |Water break at 8 months |1 |
|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 |
|Aowdar bish |Pain in lower stomach after delivery of placenta; feel like blood |3 |
| |clot moving in abdomen | |
|Bacha howar jaygay batha |Vagina pain |2 |
|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. |
Figure 6.1: Care seeking patterns for “serious” complications, by first type of care sought, Sylhet District, Bangladesh, 2005 (n=55)
[pic]
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 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.
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).
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.
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-life-threatening, 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, “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 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.
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 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 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 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 p12 hrs) |24.04 (1,352) |38.70 |24.31 |7.78 |29.21 |1,349 |
|Retained placenta |6.56 (369) |46.07 |24.12 |10.03 |19.78 |369 |
|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. |
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 |
| | |p-value |
| |No care |Traditional |Pharmacy |Skilled |Total | |
| |Mean (SD) or % |Mean (SD) or % |Mean (SD) or % |Mean (SD) or % |N | |
|Individual |
|Woman’s age |
| 14-19 |45.25 |20.67 |10.61 |23.46 |179 | |
| | | | | | | |
| | | | | | |X2(15)= 17.32 |
| | | | | | |p=0.300 |
| 20-24 |38.99 |23.79 |11.01 |26.21 |908 | |
| 25-29 |42.78 |22.54 |12.94 |21.74 |1,136 | |
| 30-34 |42.70 |22.01 |13.64 |21.65 |836 | |
| 35-39 |44.44 |18.87 |13.00 |23.69 |477 | |
| 40+ |46.41 |22.22 |11.76 |19.61 |153 | |
|Parity |
| 0-1 |35.72 |22.28 |9.48 |32.52 |781 |X2(6)= 60.23 |
| | | | | | |p=0.000 |
| 2-4 |43.65 |21.62 |12.81 |21.92 |1,670 | |
| 5+ |44.67 |22.78 |13.89 |18.66 |1,238 | |
|Knowledge of danger signs |
| Lowest |47.80 |26.16 |10.39 |15.65 |818 | |
| | | | | | |X2(9)= 71.38 |
| | | | | | |p=0.000 |
| Second |42.63 |24.04 |12.21 |21.13 |1,065 | |
| Third |40.43 |19.70 |14.26 |25.61 |1,066 | |
| Highest |38.51 |18.51 |12.57 |30.41 |740 | |
| | | | | | | |
| | | | | | | |
|Women’s No. Years School |
| None |49.86 |22.78 |12.34 |15.02 |1,791 |X2(6)= 241.60 |
| | | | | | |p=0.000 |
| Primary |38.94 |24.22 |14.62 |22.22 |1,053 | |
| Secondary+ |30.53 |18.22 |10.06 |41.18 |845 | |
|Belong to |49.03 |19.94 |10.80 |20.22 |361 |X2(3) = 7.44 |
|organization1 | | | | | |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) =473.48 |
| | | | | | |p=0.000 |
| 1-2 |36.14 |22.42 |14.77 |26.67 |1,151 | |
| 3 or more |26.46 |14.92 |11.15 |47.47 |771 | |
|Place of residence at delivery |
| Natal home |35.95 |21.80 |11.85 |30.40 |523 |X2(3)= 20.26 |
| | | | | | |p=0.000 |
| In-laws |43.37 |22.20 |12.57 |21.86 |3,166 | |
| |
|Household |
|Husband’s No. Years School |
| None |46.31 |22.36 |13.56 |17.77 |1,829 |X2(6)= 102.23 |
| | | | | | |p=0.000 |
| Primary |41.65 |22.82 |11.96 |23.58 |1,179 | |
| Secondary+ |32.75 |20.41 |10.43 |36.42 |681 | |
|Wealth index |
| Lowest |55.44 |26.04 |8.86 |9.66 |745 | |
| | | | | | |X2(12) = 324.86|
| | | | | | |p=0.000 |
| Second |46.12 |26.68 |13.01 |14.19 |761 | |
| Middle |43.89 |20.74 |14.77 |20.60 |704 | |
| Fourth |37.30 |20.95 |13.24 |28.51 |740 | |
| Highest |28.69 |16.10 |12.58 |42.63 |739 | |
|Relative working |33.70 |21.80 |13.70 |30.80 |1,445 |X2(3) = 106.15 |
|outside Bangladesh | | | | | |p=0.000 |
|Religion |
| Islam |42.04 |21.81 |12.73 |23.42 |3,544 |X2(3) = 15.73 |
| | | | | | |p=0.001 |
| Hindu |48.30 |29.93 |6.80 |14.97 |147 | |
|Community |
|Sub-district |
| Beanibazar |38.72 |13.55 |15.56 |32.17 |1,542 |X2(6)= 220.07 |
| | | | | | |p=0.000 |
| Zakiganj |46.73 |28.43 |8.31 |16.54 |1,481 | |
| Kanaighat |40.84 |28.08 |14.56 |16.52 |666 | |
| | | | | | | |
|Total |42.31 |22.15 |12.47 |23.07 |3,689 | |
|Notes: |
|1. Organizations include membership to at least one micro-credit or Mother’s Club (Grameen Bank, BRAC, BRDB, Mother’s Club) |
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 |
|Women’s education (Ref: none) | | | |
|Sub-district (Ref: Beanibazar) | | | |
Reference category is no care seeking (n= 1,561); Standard errors adjusted for union; Log pseudo-likelihood = -4379.3814
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 |
|ANC 0 (No visits) | | | |
| 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 |
|ANC 1 (1-2 visits) | | | |
| 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 |
|ANC 2 (3 or more visits) | | | |
| 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 |
Knowledge effects – Pharmacy Care
|Variable |OR |p-value |95% CI |
|ANC 0 (No visits) | | | |
| 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 |
|ANC 1 (1-2 visits) | | | |
| Second vs. Lowest |0.88 |0.626 |0.5146-1.491 |
| Third vs. Lowest |1.03 |0.918 |0.5779-1.838 |
| Highest vs. Lowest |0.75 |0.434 |0.3643-1.543 |
|ANC 2 (3 or more visits) | | | |
| 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 |
Knowledge effects – Skilled Care
|Variable |OR |p-value |95% CI |
|ANC 0 (No visits) | | | |
| 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 |
|ANC 1 (1-2 visits) | | | |
| 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 |
|ANC 2 (3 or more visits) | | | |
| 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 |
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?
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 life-threatening 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 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.
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 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 which interventions are effective at improving care seeking behaviors in an effort to improve maternal health and survival.
APPENDICES
Appendix 1: Three Delays Model
Appendix 2: Conceptual Model
[pic]
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
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
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
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 Date
_______________________________________________ _______________
Signature of Person Obtaining Consent Date
_______________________________________________ _______________
Signature of Witness to Oral Presentation Date
(Must be different than the person obtaining consent.)
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
Appendix 4: Questionnaire for Qualitative Research
Interviewer: Date:
|Name/ID No: |Age |Marital Status |
|Location: |No. of Children: |Years of Education: |
|Religion: |Occupation: | |
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?
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.
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
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?
Section IV: Free Listing of Women’s Health Problems during Pregnancy, Labor/Childbirth, and the Postpartum
Interviewer: Date:
|Name/ID No: |Age |Marital Status |
|Location: |No. of Children: |Years of Education: |
|Religion: |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 the following|Fill in this column by asking the following |Fill in this column by asking the following |Fill in this column by asking the following |
|question: |question for each illness. |question for each illness. |question for each illness. |
| | | | |
|B. Are there other kinds of (illness type)? |C. What happens when you get (illness name)? |D. Where do you go for treatment for |E. Where do other people in this |
| | |(illness name)? |community go for treatment of |
| | | |(illness name)? |
| | |Why do you go there? | |
|1 | | | |
|2 | | | |
|3 | | | |
|4 | | | |
|5 | | | |
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 the following|Fill in this column by asking the following |Fill in this column by asking the following |Fill in this column by asking the following |
|question: |question for each illness. |question for each illness. |question for each illness. |
| | | | |
|B. Are there other kinds of (illness type)? |C. What happens when you get (illness name)? |D. Where do you go for treatment for |E. Where do other people in this |
| | |(illness name)? |community go for treatment of |
| | | |(illness name)? |
| | |Why do you go there? | |
|1 | | | |
|2 | | | |
|3 | | | |
|4 | | | |
|5 | | | |
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 the following|Fill in this column by asking the following |Fill in this column by asking the following |Fill in this column by asking the following |
|question: |question for each illness. |question for each illness. |question for each illness. |
| | | | |
|B. Are there other kinds of (illness type)? |C. What happens when you get (illness name)? |D. Where do you go for treatment for |E. Where do other people in this |
| | |(illness name)? |community go for treatment of |
| | | |(illness name)? |
| | |Why do you go there? | |
|1 | | | |
|2 | | | |
|3 | | | |
|4 | | | |
|5 | | | |
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 |Marital Status |
|Location: |No. of Children: |Years of Education: |
|Religion: |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? ....................................................
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? ....................................................
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? ....................................................
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 |Marital Status |
|Location: |No. of Children: |Years of Education: |
|Religion: |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 to do |Pile 2 (Restrict you to the |Pile 3 (Prevent from |
| |your work) |home) |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?)...............................................
Birth to noai:
|Severity Ratings in Terms of Woman’s Ability to Work |
|Illness Term |Pile 1 (Require other to do |Pile 2 (Restrict you to the |Pile 3 (Prevent from |
| |your work) |home) |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?)...............................................
Noai to Chollish Din:
|Severity Ratings in Terms of Woman’s Ability to Work |
|Illness Term |Pile 1 (Require other to do |Pile 2 (Restrict you to the |Pile 3 (Prevent from |
| |your work) |home) |work/limit your ability |
| | | |to do all of your work) |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
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| | | | |
| | | | |
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?)...............................................
Appendix 5: Questionnaire for Quantitative Research
|IDENTIFICATION |
| |Name | Code |
|UPAZILA | | |Write down the ages of RDWs |
| | | |if more than 1 in this HH : |
| | | |RD Woman 1= |
| | | |RD Woman 2= |
| | | |RD Woman 3= |
| | | |RD Woman 4= |
| | | |RD Woman 5= |
|UNION (Category & Name) | | | |
|VILLAGE | | | |
|BARI | | | |
|HOUSEHOLD | |-- | |
| | |Check# Bari # # # HH # # | |
|WOMAN | |WOMAN of 1=YOUNGEST, 2=NEXT, ETC. |
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 |
|DATE |_________ |___________ |_____________ |DAY | |
| | | | | | |
| | | | |MONTH | |
| | | | | | |
| | | | |YEAR | |
|INTERVIEWER’S NAME | | | |INT. CODE | |
|RESULT* |_________ |_____________ |_____________ |RESULT CODE | |
|NEXT VISIT |DATE |
| | |
|Reviewed by SFRA |Keyed by |
|Name/Code________________________ |Name/Code___________________ |
| | |
|Date // |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 :___________________________
| PROJAHNMO FORM S1 |
|RDWS: Socio-Economic Status |
|Upazillah ________________ Union_________ Village___________ |
|Name of Data Collector ___________________ Household ID: -- Date // |
|LINE NO. |USUAL RESIDENTS AND |RELATIONSHIP TO HEAD OF HOUSEHOLD |SEX |
| |VISITORS | | |
| | |LEVEL |CLASS | |
| | |1=primary |00= less than 1 yr or none | |
| | |2= Secondary |98= Don’t know | |
| | |3=College/University/+ | | |
| | |4= Don’t know | | |
Household ID: -- Name of HH Head:________________
check bari house
Household Section: [Respondent: Household head or adult household member]
| | | |
|QUESTIONS |CODING CATEGORIES |SKIP |
|What is the main source of water your household uses |PIPED WATER | |
|for dishwashing? |PIPED INSIDE DWELLING 11 | |
| |PIPED OUTSIDE DWELLING 12 | |
|BE SURE OF THE SOURCE OF 'PIPED WATER'. IF THE ANSWER|WELLWATER | |
|IS 'PIPED WATER', CHECK THE SOURCE AND CIRCLE THE |TUBEWELL 21 | |
|APPROPRIATE CODE. |DEEP TUBEWELL 22 | |
| |SURFACE WELL/OTHER WELL 23 | |
| |SURFACE WATER | |
| |POND/TANK/LAKE 31 | |
| |RIVER/STREAM 32 | |
| |RAINWATER 41 | |
| |BOTTLED WATER 51 | |
| |filtered water 61 | |
| |OTHER_________________________ 98 | |
| |(SPECIFY) | |
|14 What is the main source of drinking water for |PIPED WATER | |
|members of your household? |PIPED INSIDE DWELLING 11 | |
| |PIPED OUTSIDE DWELLING 12 | |
|BE SURE OF THE SOURCE OF 'PIPED WATER'. IF THE ANSWER|WELLWATER | |
|IS 'PIPED WATER', CHECK THE SOURCE AND CIRCLE THE |TUBEWELL 21 | |
|APPROPRIATE CODE. |DEEP TUBEWELL 22 | |
| |SURFACE WELL/OTHER WELL 23 | |
| |SURFACE WATER | |
| |POND/TANK/LAKE 31 | |
| |RIVER/STREAM 32 | |
| |RAINWATER 41 | |
| |BOTTLED WATER 51 | |
| |filtered water 61 | |
| |OTHER_________________________ 98 | |
| |(SPECIFY) | |
|15 Do you usually boil this water before you drink |YES 1 | |
|it? |NO 2 | |
|16 What kind of toilet facility does your household |SEPTIC TANK/MODERN TOILET 11 | |
|have? |PIT TOILET/LATRINE | |
| |Pit Latrine/WATER SEALED 21 | |
| |PIT LATRINE/not water sealed 22 | |
| |OPEN LATRINE 23 | |
| |HANGING LATRINE 24 | |
| |NO FACILITY/BUSH/FIELD 31 | |
| |OTHER____________________________ 98 | |
| |(SPECIFY) | |
|17 Does your household have electricity? |YES 1 | |
| |NO 2 | |
|18 How many (OBJECT) does your household (or any |Almirah/Wardrobre | |
|member of you household) have: |Table | |
| |Bench or chair | |
|Almirah/Wardrobe? |Watch or Clock | |
|table? |Cot or Bed | |
|bench or chair? |Radio | |
|watch or clock? |Television | |
|cot or bed? |‘LEP’ or ‘KOMBOL’ | |
|radio that is working? |‘TOSHOK’ | |
|television that is working? |Refrigerator | |
|quilt (‘LEP’ or ‘KOMBOL’)? |Motorcycle | |
|mattress (‘TOSHOK’)? |Sewing machine | |
|refrigerator? |Telephone | |
|motorcycle? |Mobile telephone | |
|sewing machine? |Bicycle | |
|telephone that’s working? |Car/Microbus/Van | |
|mobile phone that’s working? |Rickshaw | |
|bicycle? |Boat | |
|car / Microbus/ Van? |If Don’t Know Enter ‘99’ | |
|ricksaw? |If None, Enter ‘00’ | |
|boat? | | |
| | | |
|19 How many of the following animals are owned by |Cattle | |
|your household? |Buffalo | |
|Cow |Goats | |
|Buffalo |Sheep | |
|Goats |Chickens | |
|Sheep |Ducks | |
|Chickens |pigeon | |
|Ducks |If Don’t Know Enter ‘99’ | |
|Pigeon |If None, Enter ‘00’ | |
|20 How many rooms are in your household? | | |
|21 Is the kitchen separated from the main household |yes 1 | |
|structure? |No 2 | |
|22 Main material of the roof. |Natural Roof | |
| |Katcha (Bamboo/Thatch) 11 | |
|Record Observation. |Rudimentary Roof | |
| |Tin 21 | |
| |Finished Roof (Pukka) | |
| |Cement/Concrete/Tiled 31 | |
| |Other___________________________ 98 | |
| |(Specify) | |
|23 Main material of the walls. |Natural Walls | |
| |Jute/Bamboo/Mud (Katcha) 11 | |
|Record Observation |Rudimentary Walls | |
| |Wood 21 | |
| |Finished Walls | |
| |Brick/Cement 31 | |
| |Tin 32 | |
| |Other___________________________ 98 | |
| |(Specify) | |
|24 Main material of the floor. |Natural Floor | |
| |Earth/Bamboo (Katcha) 11 | |
|Record Observation |Rudimentary Floor | |
| |Wood 21 | |
| |Finished Floor (Pukka) | |
| |Cement/Concrete 31 | |
| |Other___________________________ 98 | |
| |(Specify) | |
|25 Does your household own any homestead? |YES 1 | |
|IF NO, PROBE: |NO 2 | |
|Does your household own homestead any other places? | | |
|26 Does your household own any land (other than the |YES 1 | |
|homestead land)? |NO 2 |(28 |
|27 How much land does your household own (other than| Acre 1 | |
|the homestead land)? |Decimle 2 | |
|AMOUNT __________________ |(1 kiyar = 30 Decimel) | |
|SPECIFY UNIT _______________ |RECORD 00.00 IF NONE | |
|28 Do you have a relative living/working outside of |YES 1 | |
|Bangladesh? |NO 2 |(34 |
|29 What is the relationship between the household |wife or husband A | |
|head and this relative living abroad? |son B | |
| |daughter C | |
|(RECORD RELATIONSHIPS OF ALL IF MORE THAN ONE) |son-in-law/daughter-in-law D | |
| |grandchild E | |
| |father/mother F | |
| |Parents in law G | |
| |brother/sister H | |
| |other relatives I | |
| |adopted or step/children J | |
| |OTHER__________________________ Y | |
| |DON’T REMEMBER/Know Z | |
|30 How many are living in? |Great Britain/London | |
|RECORD THE NUMBER OF RELATIVES THEY HAVE IN EACH |North America/USA | |
|COUNTRY |Middle East | |
|How many live in Great Britain/London /europe |Malaysia/Singapore/Brunei | |
|How many live in North America/USA |Other_____________________ | |
|How many live in Middle East |(Specify) | |
|How many live in Malaysia/Singapore/Brunei | | |
|If none, record “00” | | |
|31 Do they send you money? |YES 1 | |
| |NO 2 |(34 |
|32 How many times have they sent you money in the | times | |
|past year? | | |
| |RECORD ‘00’ if they never send money. | |
|33 Can you use or spend this money when in need? | | |
| |YES 1 | |
| |NO 2 | |
|34 Do you belong to any of the following | | |
|organizations? |GRAMEEN BANK A | |
|Grameen Bank? |BRAC B | |
|BRAC? |BRDB C | |
|BRDB? |Mother’s Club D | |
|Mother's Club? |Other______________________ E | |
|Any other organization (such as micro credit)? |(Specify) | |
| |Don’t belong to any org. Z | |
|35 What is your religion? |Islam 1 | |
| |Hinduism 2 | |
| |Buddhism 3 | |
| |Christianity 4 | |
| |Other___________________________ 8 | |
| |(Specify) | |
|36 What is the primary occupation of the head of |WORK ON OWN FARM OR AS A SHARE | |
|household? |CROPPER 1 | |
| |DAY, UNSKILLED LABORER | |
|(IF MORE THAN ONE OCCUPATION, RECORD THE MAIN ONE) |DOMESTIC , AGRICULTURAL AND MIGRANT 2 | |
| |FISHERMAN 3 | |
|Occupation: ________________________________ |CONTRACTED LABORER | |
| |LONG TERM, , | |
|Write the occupation here and circle the correct code|,carpenter | |
|in the next column |mason 4 | |
| |OWN BUSINESS | |
| |SHOPKEEPER, VENDOR, | |
| |RIKSAW/VAN PULLER, ARTISAN 5 | |
| |PRIVATE SERVICE | |
| |SALARIED, SKILLED FACTORY | |
| |AND OFFICE WORKERS, SALESMEN 6 | |
| |GOVERNMENT SERVICE | |
| |ALL GOB-PAID EMPLOYEES 7 | |
| |housewife 8 | |
| |jobless 9 | |
| |OTHER _________________________ 0 | |
| |(Specify) | |
| | | |
|QUESTIONS And Filters |CODING CATEGORIES |SKIP |
|100 Now I would like to ask about all the births you have had during your life. |
|101Have you ever given birth? |YES 1 | |
| | | |
| |NO 2 |(106 |
|102 Do you have any sons or daughters to whom you |YES 1 | |
|have given birth who are now living with you? | | |
| |NO 2 |(104 |
|103 How many sons live with you? |Sons at home | |
|And how many daughters live with you? | | |
|IF NONE RECORD 00 |Daughters at home | |
|104 Do you have any sons or daughters to whom you |YES 1 | |
|have given birth who are still alive but do not live | | |
|with you? |NO 2 |(106 |
|105 How many sons are alive but do not live with you?|Sons elsewhere | |
|And how many daughters are alive but do not live | | |
|with you? |Daughters elsewhere | |
| | | |
|IF NONE RECORD 00 | | |
|106 Have you ever given birth to a boy or a girl who |YES 1 | |
|was born alive but later died? IF NO, PROBE: Any | | |
|baby who cried or showed any sign of life but only |NO 2 |(108 |
|survived a few hours or days? | | |
|107 In all, how many boys have died? |BOYS DEAD | |
|And how many girls have died? | | |
| |GIRLS DEAD | |
|IF NONE RECORD 00 | | |
|108 Some pregnancies end before full term as |YES 1 | |
|miscarriage or an abortion, while others may result | | |
|in a stillbirth. Have you had any pregnancies that |NO 2 |(110 |
|did not result in live births? | | |
|109 In all, how many pregnancies did not result in a |Pregnancy Loss | |
|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 |YES 1 | |
|right: you have had | | |
|______children who are still living (103+105) |NO 2 | |
|______children who have died (107), and | | |
|______pregnancies which did not result in a live |IF NO PROBE AND CORRECT 101 – 109 | |
|birth (109)? |AS NECESSARY | |
|Is that correct? | | |
|112 | |
|Proceed to Q. 113 | |
| | |
| |LAST PREGNANCY | | |
|113 |Now I would like to talk to you about your LAST pregnancY that is completed, whether the child | |
|PHIL |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. | |
|114 |Think back to the time of your last | Infant 1 Infant 2 Infant 3 | |
|PHIL |pregnancy. (Do not include pregnancies |Outcome | |
| |that delivered since mapping and listing). | | |
|115 |Was that a single or a multiple pregnancy? |Single 1 | |
|PHIL | |Multiple 2 | |
| | |Don’t know 9 | |
|116 |Was the baby born alive, born dead, or lost|BORN ALIVE 1 1 1 |(118 |
|PHIL |before full-term, that is, as a miscarriage|BORN DEAD 2 2 2 | |
| |or an abortion? |LOST BEFORE | |
| | |7 MONTHS 3 3 3 |(125 |
|117 |Did that baby cry, move, or breathe when it|Yes 1 1 1 | |
|PHIL |was born? | | |
| | |No 2 2 2 |(124 |
|118 |What name was given to that child? | | |
|PHIL | ||____________|___________|___________| | |
|119 |Is/Was (NAME) a boy or a girl? |Boy 1 1 1 | |
|PHIL | | | |
| | |Girl 2 2 2 | |
|120 |In what month and year was (NAME) born? |__/__/____ | |
|PHIL |PROBE: |dd mm yyyy | |
| |What is his/her birthday? | | |
|121 |Ask: Where is he/she? |Alive 1 1 1 | |
|PHIL |With intention of: | | |
| |Is (NAME) still alive? |Dead 2 2 2 |(123 |
|122 |IF ALIVE: | | |
|PHIL |How old is (NAME)? | Months | |
| |RECORD IN MONTHS |(NEXT INFANT OR IF NO MORE, 201) | |
|123 |IF DEAD: |DAYS | |
|PHIL |How old was he/she when he/she died? | | |
| |IF “1 YR.”, PROBE: How many months old was|MONTHS | |
| |(NAME)? | | |
| |IF “1 month”, PROBE: How many days old was|(GO TO NEXT INFANT IF NO MORE, SKIP TO 201) | |
| |(NAME)? | | |
| | | | |
| |RECORD DAYS IF LESS THAN 1 MONTH, OTHERWISE| | |
| |RECORD IN MONTHS. IF AGE IS LESS THAN 1 | | |
| |DAY, RECORD '00'. | | |
|124 |Was that baby a boy or a girl? |BOY 1 1 1 | |
|PHIL | |GIRL 2 2 2 | |
|125 |In what month and year did this pregnancy |Day | |
|PHIL |end? |Month | |
| | |Year | |
|126 |How many months did the pregnancy last? |MONTHS | |
|PHIL | |(IF 7 OR MORE, NEXT INFANT OR Go to next question) | |
| |RECORD IN COMPLETED MONTHS. | | |
|127 |Did this pregnancy end by itself or did you|SPONTANEOUS 1 | |
|PHIL |or someone else do something to end it? |INDUCED 2 | |
| | |MENSTRUAL REGULATION 3 | |
| |MIGRATION | | |
| |QUESTIONS AND FILTERS |CODING CATEGORIES | |
|200 |Now, I would like to ask you some questions about where you are from and where you were when you | |
| |were pregnant? | |
|201 |Are you Sylheti? (permanent resident of |Yes 1 | |
|PAUL |this place ?) |no 2 | |
|202 |Were you living in the Marbari or |Marbari/bapenbari 1 | |
|PAUL |Shashurbari when you found out that you |Shashurbari 2 | |
| |were pregnant with your most recent |Other__________________________ 8 | |
| |pregnancy? |(Specify) | |
|203 |What village and union is this in? |Current Village | |
|PAUL |(If this village is the same as the village| | |
| |in which the interview is being conducted, |UPAZILA Union Village | |
| |you may simply tick the “Current Village” | | |
| |box.) | | |
| | |Beanibazar 1 ENTER NUMBER FROM | |
| |Union ________________ |Zakiganj 2 APPENDIX F FOR | |
| | |Kanairghat 3 BEANIBAZAR,KANAIRGHAT | |
| |Village________________ |Golapganj 4 OR ZAKIGANJ upazilla | |
| | | | |
| | |Other__________________________ 8 | |
| | |(Specify) | |
|204 |Were you living in the Marbari or |same as 202 1 |(207 |
|PAUL |Shashurbari when you delivered? |Marbari/bapenbari 2 | |
| | |Shashurbari 3 | |
| | |Other__________________________ 8 | |
| | |(Specify) | |
|205 |What village and union is this in? |Current Village | |
|PAUL |(If this village is the same as the village| | |
| |in which the interview is being conducted, |UPAZILA Union Village | |
| |you may simply tick the “Current Village” | | |
| |box.) | | |
| | |Beanibazar 1 ENTER NUMBER FROM | |
| |Union ________________ |Zakiganj 2 APPENDIX F FOR | |
| | |Kanairghat 3 BEANIBAZAR,KANAIRGHAT | |
| |Village________________ |Golapganj 4 OR ZAKIGANJ upazilla | |
| | | | |
| | |Other__________________________ 9 | |
| | |(Specify) | |
|206 |How many weeks after moving there did you |weeks | |
|PAUL |deliver (or your pregnancy ended)? |If LESS THAN 1 WEEK – RECORD “00” | |
|207 |How long after delivery did you remain at |WEEKS | |
|PAUL |this location? |Days | |
| | |Still there(record 98 in all boxes) | |
RDWS: Knowledge, Practice and Coverage (KPC)
- - --
Check# Bari### HH## Woman#
| |PREGNANCY | | |
|300 |Now I would like to talk to you about some issues that arise before and during pregnancy. | |
|301 |When you were pregnant with (NAME) (last |Yes 1 | |
|BMMS |pregnancy), did you see anyone for a |No 2 |(309 |
| |routine medical checkup (not for sickness) |Don’t remember 9 |(309 |
| |i.e., antenatal care for this pregnancy? | | |
|302 |Where did you receive checkups? Who did the|At HOME | |
|BDHS |checkup ? | | |
| | |Qualified (MBBS) doctor AA | |
| |Any other places? |Nurse/Midwife BA | |
| | |Paramedic CA | |
| |PROBE FOR THE TYPE OF FACILITY UNTIL NO |FWV DA | |
| |FURTHE RESPONE IS GIVEN, AND RECORD ALL |Medical assistant / SACMO EA | |
| |FACILITIES SEEN. |FWA / Health Assistant FA | |
| | | | |
| | |Others | |
| | | | |
| | |Homeopath GA | |
| | |Ayurvedic HA | |
| | |Trained TBA (TTBA) IA | |
| | |Untrained TBA / Dhorni JA | |
| | |Quack Doctor KA | |
| | |Village doctor LA | |
| | |SPIRITUAL mA | |
| | |SHASHURI NA | |
| | |RESPONDENT’S MOTHER OA | |
| | |OTHER FAMILY MEMBERS PA | |
| | | | |
| | |GOVT. | |
| | | | |
| | |MEDICAL COLLEGE HOSPITAL QA | |
| | |FAMILY WELFARE CENTRE RA | |
| | |UPAZILA HEALTH COMPLEX SA | |
| | |SATELLITE CLINIC / VACCINATION | |
| | |CENTRE TA | |
| | |MCWC UA | |
| | |FWA / HA VA | |
| | | | |
| | |NGO | |
| | | | |
| | |NGO SATELLITE CLINIC WA | |
| | |NGO FIXED CLINIC XA | |
| | |NGO HOSPITAL YA | |
| | | | |
| | |NON-GOVT. | |
| | | | |
| | |NON-GOVT. HOSPITAL / CLINIC ZA | |
| | |QUALIFIED DOCTOR’S CHAMBER AB | |
| | |NURSE/MIDWIFE’S HOME BB | |
| | |PARAMEDIC’S HOME/CHAMBER CB | |
| | |FWV’S HOME DB | |
| | |MA/SACMO’S HOME/CHAMBER EB | |
| | |QUACK/VILLAGE DOCTOR’S HOME/ | |
| | |CHAMBER FB | |
| | |PHARMACY GB | |
| | | | |
| | |OTHERS XX | |
| | | | |
| | |DON’T KNOW / DON’T REMEMBER ZZ | |
| | | | |
|303 |How many times did you receive medical |Number of times | |
|BMMS |checkups during this pregnancy? |Don’t know/Don’t remember 99 | |
|304 |Did you go for antenatal care each time |Because of Problem 1 | |
| |just to check that everything was fine or |To Check Only 2 | |
| |did you ever go because you had a problem? |BOTH 3 | |
| | |Don't know/don't remember 9 | |
|305 |Now I would like to ask you some questions | | |
|BMMS |about your antenatal visits. When you were | | |
| |pregnant with (NAME) (last pregnancy), did | | |
| |you receive advice on any of the following |YES NO DK | |
| |during at least one of your antenatal | | |
| |check-ups for this pregnancy: |a. rest 1 2 9 | |
| | |b. DIET 1 2 9 | |
| |A. Advised to rest/avoid heavy work? |c. Breastfeed 1 2 9 | |
| |B. Advice about diet? |d. DANGER SIGNS 1 2 9 | |
| |C. Advised to breastfeed? |e. tt injection 1 2 9 | |
| |D. Advised about danger signs? |f. ifa tablets 1 2 9 | |
| |E. Advised to get TT injection? | | |
| |F. Advised to take IFA tablets? | | |
|306 |During any of your antenatal visits while | | |
|BMMS |you were pregnant with (NAME) (last | | |
| |pregnancy) were you or your | | |
|REV BCC |husband/relatives told about any of the | | |
| |following birth planning items? | | |
| | | | |
| |A. The location where you would like to | | |
| |have the delivery |YES NO DK | |
| |B. The person who will deliver the baby | | |
| |C. The hospital/clinic you can go to if you|A. DELIVERY PLACE 1 2 9 | |
| |have |B. DELIVERY PERSON 1 2 9 | |
| |Delivery complication |C. HOSPITAL 1 2 9 | |
| |D. Arrangement for transport |D. TRANSPORT 1 2 9 | |
| |E. Arrangement for money |E. MONEY 1 2 9 | |
| |F. Arrangement for delivery kit |F. DELIVERY KIT 1 2 9 | |
| |G. Complications during pregnancy and |G. Complications 1 2 9 | |
| |delivery | | |
|307 |During any of your antenatal visits while | | |
|NEAR BMMS|you were pregnant with (NAME) (last |Yes No DK | |
| |pregnancy), were you or your | | |
| |husband/relatives told about safe delivery |A. delivery on clean | |
| |including: |surface 1 2 9 | |
| | |B. CLEAN BOILED BLADE 1 2 9 | |
| |A. Delivery on a clean surface |C. CLEANED BOILED | |
| |B. Using of new boiled blade |THREAD 1 2 9 | |
| |C. Using clean boiled thread to tie cord |D. clean towel/clot for | |
| |D. Using a clean towel/cloth to dry baby |dryING 1 2 9 | |
| |E. Using a separate clean towel to wrap |E. clean towel WRAP for | |
| |baby |wrapPING 1 2 9 | |
| |F. Keeping delivery kit at home |F. DELIVERY KIT 1 2 9 | |
|308 |Did you have any of the following performed| | |
|BMMS |at least once during any of your antenatal |yes no dk | |
|–ITEMS |checkups for this pregnancy: | | |
| | | | |
| |A. Blood Pressure Checked? | | |
| |B. Urine Test? |A. blood pressure 1 2 9 | |
| |C. Abdomen Exam? |B. urine test 1 2 9 | |
| |D. Ultrasound? |C. abdomen examined 1 2 9 | |
| | |d. ultrasound 1 2 9 | |
|309 |Did you take any iron tablets or iron syrup|Yes 1 | |
|BDHS |during this pregnancy? |No 2 | |
| | |Don’t Know 9 | |
| |SHOW TABLET/SYRUP | | |
|310 |During the time that you were pregnant with|Yes 1 | |
|BDHS |(NAME) did you receive any TT injection? |No 2 |(312 |
| | |Don’t Know 9 |(312 |
|311 |How many TT injections did you receive |Number BY HISTORY | |
|BDHS |during the pregnancy with (NAME)? |Number BY cARD | |
| |(ASK TO SEE CARD) |(9 if card not availabe) | |
|312 |Now we will talk about possible problems |Severe Headache A | |
|mod |that a woman might face when she is |Blurry Vision B | |
|BDHS |pregnant (going to have a child). Please |Reduced or absent fetal | |
| |tell me what are the complications during |movement C | |
| |pregnancy that need medical treatment? |High Blood Pressure D | |
| | |Edema of the face E | |
| |Anything else? |Edema of the hands F | |
| | |Convulsions G | |
| | |Excessive Vaginal Bleeding H | |
| | |Lower abdominal pain I | |
| | |none mentioned y | |
|313 |Now, please tell me what are the |Excessive Vaginal Bleeding a | |
|mod |complications in a woman during childbirth |Foul-Smelling Discharge b | |
|BDHS |that need medical treatment? |High Fever c | |
| | |Baby’s Hand or Feet Come First d | |
| | |Baby in Bad Position e | |
| |Anything else? |Prolonged Labor (>12 hours) f | |
| | |Retained Placenta g | |
| |Record all responses |Torn Uterus h | |
| | |Prolapsed Cord i | |
| | |cord around neck j | |
| | |Convulsions k | |
| | |none mentioned y | |
|314 |Now, please tell me what are the |Excessive Vaginal Bleeding a | |
|mod |complications in a woman after delivery |Foul-Smelling Discharge b | |
|BDHS |that need medical treatment? |High Fever c | |
| | |Inverted nipples d | |
| |Anything else? |Tetanus e | |
| | |Retained Placenta f | |
| |Record all responses |severe Abdominal pain g | |
| | |Convulsions h | |
| | |Engorged breasts i | |
| | |none mentioned y | |
|315 |What are the symptoms within 28 days after|Poor feeding or unable to suckle? a | |
|EDIT |delivery indicating the need to seek |Infant diarrhea? b | |
| |health care for your newborn? |Redness or discharge from around | |
| | |the cord? c | |
| | |Red/discharging eyes? d | |
| |Anything else? |Difficult breathing? e | |
| | |Skin color yellow (jaundice)? f | |
| |Record all responses |Convulsions? g | |
| | |Skin lesion (or blisters)? h | |
| | |Baby won't cry? i | |
| | |Fever? j | |
| | |Unconscious? k | |
| | |Fast breathing/difficult | |
| | |breathing? l | |
| | |severe Chest indrawing? m | |
| | |failure to pass urine n | |
| | |failure to pass stool o | |
| | |NONE MENTIONED y | |
| |DELIVERY | | |
|400 |Check the answer of Q.116 : Is either of |Yes 1 | |
| |“1” or “2” circled ? |No 2 |(500 |
|401 |Now I would like to ask you some questions|Mother-in-law/shashuri A mother/ma | |
| |about the time of delivery of (NAME). |b | |
| | |Sister/boin c | |
| |Who from your family delivered the baby |Sister-in-law/nanuri/nonod d | |
| |(NAME)? |Husband/shami e | |
| | |father-in-law/shashur f | |
| |Anyone else? |Other member of shashurbari g | |
| | |Other member of baperbari h | |
| |RECORD THE RELATIONSHIP OF EACH TO THE |Other Relatives i | |
| |RESPONDENT. |no One y | |
| | |don’t remember z | |
|402 |Did someone from outside of your family |Yes 1 | |
| |assist with the delivery of (NAME)? |No |(403 |
| | |2 |(403 |
| | |Don’t remember / don’t know 9| |
|402A |From outside of your family - Who assisted|HEALTH PROFESSIONAl | |
| |with the delivery ? (Mention the main |QUALIFIED DOCTOR 01 | |
| |person who helped) |NURSE/MIDWIFE 02 | |
| | |paramedic 03 | |
| |Circle one answer only |FAMILY WELFARE VISITOR 04 | |
| | |ma/sacmo 05 | |
| | |health asst (Ha) 06 | |
| | |FAMILY WELFARE ASST (FWA) 07 | |
| | | | |
| | |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 |
|402B |Does this person (whom you mentioned) |Yes 1 | |
| |regularly do the work of “Dhorni’? |No 2 |(403 |
| | |Don’t know 9 |(403 |
| |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 |
|402C |Please tell me the name of the person you |Name : | |
| |mentioned for assisting the delivery | | |
| | |address : | |
| | |Bari : | |
| | |Village : | |
| | |Union : | |
| | |Upazila : | |
| | |District : | |
|403 |When (NAME) was born, was your husband in |Yes 1 | |
| |the village? |No 2 | |
|404 |Where did you give birth? |HOME 01 | |
|BMMS | |PUBLIC SECTOR | |
| |Circle only one answer |MEDICAL COLLEGE HOSPITAL02 | |
| | | | |
| | |FAMILY WELFARE CENTER (FWC) 03 | |
| | |UPAJILA HEALTH COMPLEX 04 | |
| | |MATERNAL AND CHILD WELFARE | |
| | |CENTER (MCWC) 05 | |
| | |NGO SECTOR | |
| | |NGO HOSPITAL 06 | |
| | |PRIVATE MEDICAL SECTOR | |
| | |PRIVATE HOSPITAL/CLINIC 07 | |
| | |QUALIFIED DOCTOR’S CHAMBER 08 | |
| | |TRADITIONAL DOCTOR’S | |
| | |CHAMBER 09 | |
| | |OTHER_______________________ 98 | |
| | |(SPECIFY) | |
| | |DON’T KNOW/Don’t remember 99 | |
|404A |Check answer of 404 : is` “1” is circled |Yes 1 | |
| | |No 2 |(408 |
|405 |On what surface were you lying on when you|plastic sheet 1 | |
| |delivered? |cloth 2 | |
| | |chala 3 | |
| | |cot 4 | |
| | |chatai on floor 5 | |
| | |only floor 6 | |
| | |other____________________________8 | |
| | |(specify) | |
|406 |Did you have a birth kit? |Yes 1 | |
| | |No 2 |(408 |
| | |Don’t Know/Don’t Remember 9 |(408 |
|407 |What did you use it for? |for plastic sheet to | |
| | |deliver on A | |
| |CIRCLE ALL RESPONSES GIVEN |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) | |
|408 |Were any of the following procedures | | |
|BMMS mod |performed at the time of delivery? |Y N DK | |
| | | | |
| |A. The doctor used instruments to get the | | |
| |baby out |A. FORCEP 1 2 9 | |
| |(FORCEP)? |B. ABDOMINAL OPERATION/ | |
| |B. You had an abdominal operation to get |C-SECTION 1 2 9 | |
| |the baby |C. BLOOD TRANSFUSION 1 2 9 | |
| |Out (C-SECTION)? |D. INTRAVENOUS 1 2 9 | |
| |C. Received Blood Transfusion? |E. injection to speed labor 1 2 9 | |
| |D. Received intravenous fluid? |F. EPISIOTOMY 1 2 9 | |
| |E. Injection to speed delivery, increase |G. Change baby position 1 2 9 | |
| |labor pain or stop bleeding given with | | |
| |saline? | | |
| |F. Episiotomy? | | |
| |G. Baby’s position had to be changed? | | |
|409 |Did you experience any of the following |Problem Timing of Problem |IF ALL N |
|MOD |problems during the pregnancy, delivery |Excessive Bleeding |(501 |
|BMMS |and/or after delivery with (NAME)? |Yes ------1 During Pregnancy – 1 | |
| |CIRCLE ALL RESPONDENT MENTIONS. |During Delivery – 2 | |
| |FOR AFTER DELIVERY, INCLUDE ONLY THINGS |After Delivery – 3 | |
| |THAT OCCURRED UP TO 1 MONTH AFTER. | | |
| | |NO--------2 | |
| |A) Excessive bleeding was so much that it | | |
| |wet your clothes and you feared it was |High Fever | |
| |life threatening? |Yes ------1 During Pregnancy – 1 | |
| |B) A high fever |During Delivery – 2 | |
| |C) Bad smelling vaginal discharge? |After Delivery – 3 | |
| |D) Convulsions? | | |
| |E) Prolonged labor (>12 hours)? |NO--------2 | |
| |F) Retained placenta? | | |
| | |Bad smelling vaginal discharge | |
| | |Yes ------1 During Pregnancy – 1 | |
| | |During Delivery – 2 | |
| | |After Delivery – 3 | |
| | |NO--------2 | |
| | | | |
| | |Convulsion | |
| | |Yes ------1 During Pregnancy – 1 | |
| | |During Delivery – 2 | |
| | |After Delivery – 3 | |
| | |NO--------2 | |
| | | | |
| | |prolonged labour (>12 hours) | |
| | |Yes ------1 | |
| | |NO--------2 | |
| | | | |
| | |retained placenta | |
| | |Yes ------1 | |
| | |NO--------2 | |
| | | | |
|409A |Check answer of Q. 409 : Is any “Y” circled|Yes 1 | |
| |? |No 2 |(500 |
|410 |Did you seek any care for any of these/this|yes 1 | |
| |complication? |no 2 |(500 |
|411 |Where did you receive treatment? Who |At HOME | |
| |provided treatment ? | | |
| | |Qualified (MBBS) doctor AA | |
| |Any other places? |Nurse/Midwife BA | |
| | |Paramedic CA | |
| | |FWV DA | |
| | |Medical assistant / SACMO EA | |
| | |FWA / Health Assistant FA | |
| | | | |
| | |Others | |
| | | | |
| | |Homeopath GA | |
| | |Ayurvedic HA | |
| | |Trained TBA (TTBA) IA | |
| | |Untrained TBA / Dhorni JA | |
| | |Quack Doctor KA | |
| | |Village doctor LA | |
| | |SPIRITUAL mA | |
| | |SHASHURI NA | |
| | |RESPONDENT’S MOTHER OA | |
| | |OTHER FAMILY MEMBERS PA | |
| | | | |
| | |GOVT. | |
| | | | |
| | |MEDICAL COLLEGE HOSPITAL QA | |
| | |FAMILY WELFARE CENTRE RA | |
| | |UPAZILA HEALTH COMPLEX SA | |
| | |SATELLITE CLINIC / VACCINATION | |
| | |CENTRE TA | |
| | |MCWC UA | |
| | |FWA / HA VA | |
| | | | |
| | |NGO | |
| | | | |
| | |NGO SATELLITE CLINIC WA | |
| | |NGO FIXED CLINIC XA | |
| | |NGO HOSPITAL YA | |
| | | | |
| | |NON-GOVT. | |
| | | | |
| | |NON-GOVT. HOSPITAL / CLINIC ZA | |
| | |QUALIFIED DOCTOR’S CHAMBER AB | |
| | |NURSE/MIDWIFE’S HOME BB | |
| | |PARAMEDIC’S HOME/CHAMBER CB | |
| | |FWV’S HOME DB | |
| | |MA/SACMO’S HOME/CHAMBER EB | |
| | |QUACK/VILLAGE DOCTOR’S HOME/ | |
| | |CHAMBER FB | |
| | |PHARMACY GB | |
| | | | |
| | |OTHERS XX | |
| | | | |
| | |DON’T KNOW / DON’T REMEMBER ZZ | |
| | | | |
| |IMMEDIATE NEWBORN CARE | |
| |CHECK PREGNANCY HISTORY, SKIP TO 601 IF BABY WAS STILL BORNE | |
|500 |Check answer of Q.116 : Is “1” circled ? |Yes 1 | |
| | |No 2 |(600 |
|501 |Now I would like to ask you some specific |cut cord 01 | |
| |questions pertaining to the baby |placed on mother's abdomen 02 | |
| |immediately following the delivery. |left alone 03 | |
| |What was the very first thing done with the|dried 04 | |
| |baby immediately after delivery? |wrapped 05 | |
| | |bathed 06 | |
| | |let sleep 07 | |
| | |breast fed 08 | |
| | |fed sugar water or other 09 | |
| | |other___________________________ 98 | |
| | |(specify) | |
| | |DON’T KNOW 99 | |
|502 |Was the baby dried before the placenta was |Yes 1 | |
| |delivered? |no 2 | |
| | |don’t remember 9 | |
|503 |Was the baby wrapped before the placenta |Yes 1 | |
| |was delivered? |no 2 |(505 |
| | |don’t remember 9 |(505 |
|504 |Who wrapped the baby? |mother 01 | |
| | | | |
| |Circle only one answer |HEALTH PROFESSIONAl | |
| | |QUALIFIED DOCTOR 02 | |
| | |NURSE/MIDWIFE 03 | |
| | |paramedic 04 | |
| | |FAMILY WELFARE VISITOR 05 | |
| | |ma/sacmo 06 | |
| | |health asst (Ha) 07 | |
| | |FAMILY WELFARE ASST (FWA) 08 | |
| | | | |
| | |OTHER PERSON | |
| | |TRAINED TRADITIONAL | |
| | |BIRTH ATTENDANT (TTBA) 09 | |
| | |UNTRAINED TBA (Dorni) 10 | |
| | |UNQUALIFIED DOCTOR 11 | |
| | |Village Doctor 12 | |
| | |shashuri 13 | |
| | |ma 14 | |
| | |other family member 15 | |
| | |OTHER___________________________ 98 | |
| | |(SPECIFY) | |
| | |don’t remember 99 | |
|505 |Was the baby put to breast before the |Yes 1 | |
|PAUL |placenta was delivered? |no 2 | |
| | |DON’T REMEMBER 9 | |
|506 |Where was the baby placed before the |on the floor 1 | |
|PAUL |placenta was delivered? |on the cot 2 | |
| | |with the mother 3 | |
| | |with someone else 4 | |
| | |DON’T REMEMBER 9 | |
|507 |Did your baby cry immediately after birth? |Yes 1 | |
|GARY | |No 2 | |
| | |DON’T REMEMBER 9 | |
|508 |Did your baby need help breathing or crying|Yes 1 | |
|GARY |shortly after birth? |No 2 |(510 |
| | |DON’T REMEMBER 9 |(510 |
|509 |What was done to help the baby cry or |nothing mentioned A | |
|GARY |breath at the time of birth? |dried the baby B | |
| |(DO NOT SUGGEST ANSWERS) |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) | |
|510 |What was used to cut the umbilical cord? |blade 1 | |
| | |Bamboo slice/basher tol 2 | |
| | |Scissor/Kachi 3 | |
| | |other___________________________ 8 | |
| | |(specify) | |
| | |don’t remember 9 | |
|511 |Was the item used to cut the cord boiled? |Yes 1 | |
| | |no 2 | |
| | |don’t remember 9 | |
|512 |Who cut the umbilical cord? |mother 01 | |
| | | | |
| | |HEALTH PROFESSIONAl | |
| | |QUALIFIED DOCTOR 02 | |
| | |NURSE/MIDWIFE 03 | |
| | |paramedic 04 | |
| | |FAMILY WELFARE VISITOR 05 | |
| | |ma/sacmo 06 | |
| | |health asst (Ha) 07 | |
| | |FAMILY WELFARE ASST (FWA) 08 | |
| | | | |
| | |OTHER PERSON | |
| | |TRAINED TRADITIONAL | |
| | |BIRTH ATTENDANT (TTBA) 09 | |
| | |UNTRAINED TBA (Dorni) 10 | |
| | |UNQUALIFIED DOCTOR 11 | |
| | |Village doctor 12 | |
| | |Shashuri 13 | |
| | |Respondent’s Mother 14 | |
| | |family member 15 | |
| | |OTHER___________________________ 98 | |
| | |(SPECIFY) | |
| | |don’t remember 99 | |
|513 |What was used to tie the cord? |boiled threads from birth kit 1 | |
| | |threads from home/suta 2 | |
| | |nylon thread 3 | |
| | |jala suta 4 | |
| | |other__________________________ 8 | |
| | |(specific) | |
| | |don’t remember 9 | |
|514 |Was the item used to tie the cord boiled? |yes 1 | |
| | |No 2 | |
| | |don’t remember 9 | |
|515 |Was anything applied to the cord |yes 1 | |
| |immediately after cutting and tying? |No 2 |(517 |
| | |don’t remember 9 |(517 |
|516 |What was applied to the cord just after |antibiotics (Powder / Ointment) A | |
| |cutting the cord? |antiseptic B | |
| | |alcohol/SPIRIT C | |
| | |mustard oil with garlic D | |
| | |chal chibano E | |
| | |tumeric/Holudar ros/ | |
| | |holudar fuky F | |
| | |ginger/ada ros G | |
| | |shidur H | |
| | |boric powder i | |
| | |gentian violet J | |
| | |Talcom Powder K | |
| | |other___________________________ y | |
| | |(specify) | |
| | |don’t know z | |
|517 |When was (NAME) bathed for the first time? |immediately after birth 0 | |
| |The first, second, third day of life or |First day 1 | |
| |later? |second day 2 | |
| | |third day 3 | |
| | |later 4 | |
| | |don’t remember 9 | |
| |POSTPARTUM CARE | | |
|600 |Check answer of Q.116 : Is “1” circled ? |Yes 1 | |
| | |No 2 |(STOP |
|601 |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 |Yes 1 | |
| |medical check-up? |No 2 |(700 |
|602 |Where did you receive this first checkup? |At HOME | |
| |Who checked at that time ? | | |
| | |Qualified (MBBS) doctor 01 | |
| |If responded more than one place, ask about|Nurse/Midwife 02 | |
| |the place where she went first for check |Paramedic 03 | |
| |up. |FWV 04 | |
| | |Medical assistant / SACMO 05 | |
| |CIRCLE ONLY ONE RESPONSE |FWA / Health Assistant 06 | |
| | | | |
| | |Others | |
| | | | |
| | |Homeopath 08 | |
| | |Ayurvedic 09 | |
| | |Trained TBA (TTBA) 10 | |
| | |Untrained TBA / Dhorni 11 | |
| | |Quack Doctor 12 | |
| | |Village doctor 13 | |
| | |SPIRITUAL 14 | |
| | |SHASHURI 15 | |
| | |RESPONDENT’S MOTHER 16 | |
| | |OTHER FAMILY MEMBERS 17 | |
| | | | |
| | |GOVT. | |
| | | | |
| | |MEDICAL COLLEGE HOSPITAL 18 | |
| | |FAMILY WELFARE CENTRE 19 | |
| | |UPAZILA HEALTH COMPLEX 20 | |
| | |SATELLITE CLINIC / VACCINATION | |
| | |CENTRE 21 | |
| | |MCWC 22 | |
| | |FWA / HA 23 | |
| | | | |
| | |NGO | |
| | | | |
| | |NGO SATELLITE CLINIC 24 | |
| | |NGO FIXED CLINIC 25 | |
| | |NGO HOSPITAL 26 | |
| | | | |
| | |NON-GOVT. | |
| | | | |
| | |NON-GOVT. HOSPITAL / CLINIC 27 | |
| | |QUALIFIED DOCTOR’S CHAMBER 28 | |
| | |NURSE/MIDWIFE’S HOME 29 | |
| | |PARAMEDIC’S HOME/CHAMBER 30 | |
| | |FWV’S HOME 31 | |
| | |MA/SACMO’S HOME/CHAMBER 32 | |
| | |QUACK/VILLAGE DOCTOR’S HOME/ | |
| | |CHAMBER 33 | |
| | |PHARMACY 34 | |
| | | | |
| | |OTHERS 98 | |
| | | | |
| | |DON’T KNOW / DON’T REMEMBER 99 | |
| | | | |
|603 |How many days or weeks after the delivery |Days after delivery 1 | |
| |did your first check take place? | | |
| | |Weeks after delivery 2 | |
| |RECORD ‘00’ DAYS IF SAME DAY | | |
| | | | |
| | |iF DON’T KNOW/DON’T REMEMBER RECORD “99” IN ALL BOXES| |
|605 |Did you have this check-up because you were|Sick 1 | |
| |sick or was it a routine check-up? |Routine 2 | |
| | |don’t remember 9 | |
| |NEWBORN CARE: FIRST MONTH | | |
|700 |Check answer of Q.116 : Is “1” is circled ?|Yes 1 | |
| | |No 2 |(STOP |
|701 |Now, I would like to ask you some questions|kitchen 1 | |
|paul |about what happened during the first month |bedroom 2 | |
| |of (NAME’s) life. Was (NAME) kept in a |Other _________________________ 8 | |
| |bedroom, kitchen or other place during the|(specify) | |
| |first week of life before the Noi? |don’t remember 9 | |
|702 |Was (NAME) kept mainly with mother, other |With MOther 1 | |
|paul |family member or alone during the first |by themselves 2 | |
| |week of life OR before the Noi? |with other family member 3 | |
| | |other________________________ 8 | |
| | |don’t remember 9 | |
|703 |Was (NAME) kept on a bed, on the floor, or |wITH MOTHER | |
|paul |in a baby cot during the first week of life| | |
| |OR before the Noi? |ON FLOOR 11 | |
| | |ON BED 12 | |
| | |ON COT 13 | |
| | | | |
| | |OTHERS 18 | |
| | |(SPECIFY) | |
| | | | |
| | |Separate, NOT WITH MOTHER | |
| | | | |
| | |ON FLOOR 21 | |
| | |ON BED 22 | |
| | |ON COT 23 | |
| | | | |
| | |OTHERS 28 | |
| | |(SPECIFY) | |
| | | | |
| | | | |
| | |dON’T REMEMBER 99 | |
| | | | |
|704 |After (NAME) was born, did any medical |Yes 1 | |
| |persons check your child's health? |No 2 |(709 |
| | |don’t remember 9 |(709 |
|705 |How many days or weeks after the delivery |Days after delivery 1 | |
| |did your child's first check take place? | | |
| | |Weeks after delivery 2 | |
| |RECORD ‘00’ DAYS IS SAME DAY | | |
| | |iF dON’T KNOW/DON’T REMEMBER RECORD “99” IN ALL BOXES| |
|706 |Who checked your child's health at that |At HOME | |
| |time? | | |
| |WHERE DID THE FIRST CHECK UP TAKE PLACE ? |Qualified (MBBS) doctor 01 | |
| | |Nurse/Midwife 02 | |
| | |Paramedic 03 | |
| |PROBE FOR THE MOST QUALIFIED PERSON. |FWV 04 | |
| | |Medical assistant / SACMO 05 | |
| |(Most qualified persons are listed first) |FWA / Health Assistant 06 | |
| | | | |
| | |Others | |
| | | | |
| | |Homeopath 08 | |
| | |Ayurvedic 09 | |
| | |Trained TBA (TTBA) 10 | |
| | |Untrained TBA / Dhorni 11 | |
| | |Quack Doctor 12 | |
| | |Village doctor 13 | |
| | |SPIRITUAL 14 | |
| | |SHASHURI 15 | |
| | |RESPONDENT’S MOTHER 16 | |
| | |OTHER FAMILY MEMBERS 17 | |
| | | | |
| | |GOVT. | |
| | | | |
| | |MEDICAL COLLEGE HOSPITAL 18 | |
| | |FAMILY WELFARE CENTRE 19 | |
| | |UPAZILA HEALTH COMPLEX 20 | |
| | |SATELLITE CLINIC / VACCINATION | |
| | |CENTRE 21 | |
| | |MCWC 22 | |
| | |FWA / HA 23 | |
| | | | |
| | |NGO | |
| | | | |
| | |NGO SATELLITE CLINIC 24 | |
| | |NGO FIXED CLINIC 25 | |
| | |NGO HOSPITAL 26 | |
| | | | |
| | |NON-GOVT. | |
| | | | |
| | |NON-GOVT. HOSPITAL / CLINIC 27 | |
| | |QUALIFIED DOCTOR’S CHAMBER 28 | |
| | |NURSE/MIDWIFE’S HOME 29 | |
| | |PARAMEDIC’S HOME/CHAMBER 30 | |
| | |FWV’S HOME 31 | |
| | |MA/SACMO’S HOME/CHAMBER 32 | |
| | |QUACK/VILLAGE DOCTOR’S HOME/ | |
| | |CHAMBER 33 | |
| | |PHARMACY 34 | |
| | | | |
| | |OTHERS 98 | |
| | | | |
| | |DON’T KNOW / DON’T REMEMBER 99 | |
| | | | |
|708 |Was this check because the baby was sick or|Sick 1 | |
| |was it a routine check-up? |routine 2 | |
| | |don’t remember 9 | |
|709 |During the first month of life did (NAME) | | |
| |have any of the following problems? |Fever a | |
| |Fever? |Trouble breathing b | |
| |Trouble breathing? |Jaundice c | |
| |Jaundice? |Diarhea d | |
| |Diarhea? |Umbilical infection or | |
| |Umbilical infection or discharge? |discharge e | |
| |Convlusion? |Convlusion f | |
| | |none y |(712 |
|710 |Did you seek medical care for any of these |Yes 1 | |
| |problems? |NO 2 |(712 |
|711 |Where did you seek medical care? |At HOME | |
| |WHOI TREATED ? | | |
| | |Qualified (MBBS) doctor AA | |
| |Else where ? |Nurse/Midwife BA | |
| | |Paramedic CA | |
| |Record all answers |FWV DA | |
| | |Medical assistant / SACMO EA | |
| | |FWA / Health Assistant FA | |
| | | | |
| | |Others | |
| | | | |
| | |Homeopath GA | |
| | |Ayurvedic HA | |
| | |Trained TBA (TTBA) IA | |
| | |Untrained TBA / Dhorni JA | |
| | |Quack Doctor KA | |
| | |Village doctor LA | |
| | |SPIRITUAL mA | |
| | |SHASHURI NA | |
| | |RESPONDENT’S MOTHER OA | |
| | |OTHER FAMILY MEMBERS PA | |
| | | | |
| | |GOVT. | |
| | | | |
| | |MEDICAL COLLEGE HOSPITAL QA | |
| | |FAMILY WELFARE CENTRE RA | |
| | |UPAZILA HEALTH COMPLEX SA | |
| | |SATELLITE CLINIC / VACCINATION | |
| | |CENTRE TA | |
| | |MCWC UA | |
| | |FWA / HA VA | |
| | | | |
| | |NGO | |
| | | | |
| | |NGO SATELLITE CLINIC WA | |
| | |NGO FIXED CLINIC XA | |
| | |NGO HOSPITAL YA | |
| | | | |
| | |NON-GOVT. | |
| | | | |
| | |NON-GOVT. HOSPITAL / CLINIC ZA | |
| | |QUALIFIED DOCTOR’S CHAMBER AB | |
| | |NURSE/MIDWIFE’S HOME BB | |
| | |PARAMEDIC’S HOME/CHAMBER CB | |
| | |FWV’S HOME DB | |
| | |MA/SACMO’S HOME/CHAMBER EB | |
| | |QUACK/VILLAGE DOCTOR’S HOME/ | |
| | |CHAMBER FB | |
| | |PHARMACY GB | |
| | | | |
| | |OTHERS XX | |
| | | | |
| | |DON’T KNOW / DON’T REMEMBER ZZ | |
| | | | |
|712 |Before the cord fell off, what was applied |antibiotics A | |
| |to it in the days after delivery? |antiseptic B | |
| | |alcohol C | |
| |Anything else? |mustard oil with garlic D | |
| | |chal chibano E | |
| | |tumeric/Holudar ros/ | |
| | |holudar fuky F | |
| | |ginger/ada ros G | |
| | |shidur H | |
| | |boric powder i | |
| | |gentian violet J | |
| | |tALCOM pOWDER k | |
| | | | |
| | |other___________________________ Y | |
| | |(specify) | |
| | | | |
| | | | |
| | |don’t know Z | |
|713 |Did you ever breastfeed this baby? |Yes 1 | |
| | |No 2 |(719 |
|714 |Did you feed (NAME) shaldudh, or did you |Fed the baby shaldudh 1 | |
| |wait for your regular milk to come in |did not feed baby shaldudh 2 | |
| |before starting to breastfeed? |Unsure 9 | |
|715 |Before you breastfed (NAME) for the first |honey A | |
| |time, did you give (NAME) anything else to |Plain water B | |
| |eat or drink? |misrir pani C | |
| | |kola D | |
| |Anything else? |lei E | |
| | |sugar water f | |
| |RECORD ALL RESPONSES |juice g | |
| | |Baby or infant formula h | |
| | |Cow’s or goat’s milk i | |
| | |Other liquids j | |
| | |papaya/mango k | |
| | |Green leafy vegetables l | |
| | |Rice, wheat, porridge m | |
| | |Dal n | |
| | |Other__________________________ Y | |
| | |(Specify) | |
| | |nOTHING Z | |
|716 |How long after birth did you first put | | |
| |(NAME) to the breast? | | |
| |IF LESS THAN 1 HOUR, RECORD ‘00’ HOURS. |Hours 1 | |
| |IF LESS THAN 24 HOURS, RECORD HOURS. |Days 2 | |
| |OTHERWISE, RECORD DAYS. |RECORD “99” IN ALL BOXES, IF “DON’T kNOW” | |
|717 |After you starting breastfeeding, what else|honey A | |
| |did you give (NAME) to eat or drink in the |Plain water B | |
| |first month? |misrir pani C | |
| | |kola D | |
| | |lei E | |
| | |sugar water f | |
| | |juice g | |
| | |Baby or infant formula h | |
| | |Cow’s or goat’s milk i | |
| | |Other liquids j | |
| | |papaya/mango k | |
| | |Green leafy vegetables l | |
| | |Rice, wheat, porridge m | |
| | |Dal n | |
| | |Other__________________________ Y | |
| | |(Specify) | |
| | |nOTHING Z | |
|718 |How many months did you continue to |mONTH/CODE | |
| |breastfeed? |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. |
|719 |If breastfeeding lasted less than 5 months |cow’s milk/goat milk 1 | |
| |(OR the baby who was never breastfed before|formula 2 | |
| |as in 713), what was the baby’s main source|dal 3 | |
| |of food after stopping breast feeding? |rice, wheat, porridge 4 | |
| | |other _______________ 8 | |
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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 May 1994
• Bachelor of Arts, cum laude
Majors: International Relations; Economics
Focus: International Development
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 in-country 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.
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.
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: 1374-1382.
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.
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.
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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[1] Includes Europe, Canada, the United States of America, Japan, Australia and New Zealand.
[2] Direct obstetric causes of maternal death include: post-partum hemorrhage; puerperal sepsis; pre-eclampsia and eclampsia; obstructed labor; and abortion.
[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.
[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.
[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).
[7] Direct obstetric causes of maternal death include: post-partum hemorrhage, puerperal sepsis, pre-eclampsia 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.
[9] Other articles may have specified parameters for symptoms. Questionnaires were not available for all papers included in the review.
[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.
[11] There was some discussion on including morbidities due to accidental or incidental causes.
[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).
[13] Complications included: excessive bleeding, high fever, foul smelling vaginal discharge, convulsions, prolonged labor (more than 12 hours), and/or retained placenta.
[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.
[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).
[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).
[19] Women were asked if they experienced “Excessive bleeding was so much that it wet your clothes and you feared it was life threatening?”
[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.
[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)
-----------------------
Socio-economic/
Cultural Factors
Phase I:
Deciding to Seek Care
Phase II:
Identifying and Reaching Medical Facility
Phase III:
Receiving Adequate and Appropriate Treatment
Quality of Care
Accessibility of Facilities
Phases of Delay
Factors Affecting Utilization and Outcome
Source: Thaddeus & Maine, 1994
Improved neonatal mortality
Improved maternal morbidity & mortality
Using care
Need to
Seek Care
Enabling Factors
Outcome
Predisposing Factors
Individual:
- Age
- Parity
- Education level
- Organization
Household:
- Husband’s education
- Religion
- Wealth status
- Relative overseas
Community:
- Sub-district
Reproductive:
- Child loss
- Pregnancy loss
- Residence during delivery
Knowledge
- Knowledge of danger signs
Attending antenatal care
- Number of visits
Availability and access of quality services:
- Distance to health facility
- Cost of services
- Perceived quality of care
Recognize a complication and decide to seek care
Use of care
................
................
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