Utilization of Reproductive Health Care in Relation to Socio Demographic Status (Part-2)

Reproductive Health Care in Bangladesh

Host of the deliveries take place at the hands of untrained birth attendants. Even fewer women receive prenatal care. This is partly due to inadequacies in provision. Developing countries spend about two percent of the gross national product on health services, with the result that many millions of people live beyond the reach of modern medicine. But it is also due to the fact that the services that do exist are not reaching women, as they effective when they are service can only be truthly based firstly on their needs and secondly on an appreciation of the complex social, cultural and economic factors that effects use of health facilities.

At least 90% of maternal deaths are due to direct obstetric causes. Obstructed labour can be preventable by prompt surgical delivery of the fetus, yet thousands of women continue to labour for days without relief. In their classic paper “too far to walk Maternal mortality in context,” Thaddeus and Maine analyzed the numerous factors that contribute to the delayed treatment of obstetric complications in the developing world. They grouped these factors into three broad categories that they called “The Three phases of delay”: (1) delay on the part of the pregnant woman, her family, or both in deciding to seek care; (2) delay in reaching an adequate health-care facility; (3) delay in receiving an adequate care once the facility has been reached. All of these factors are present in Bangladesh. The determination that a woman has a serious problem requiring hospital care is a male responsibility. Unfortunately, given their position in the social hierarchy, pregnant women must have male permission to seek medical care, and usually they must be accompanied by their husbands or by a male relative. In addition to these family dynamics, the status of woman, the distance from the health care facilities, financial costs, opportunity, previous experience with the system of health care and the perceived quality of the available care, all influence the decision to seek care. When labour starts a women turn most readily to the traditional midwife, whose face is familiar and comforting, but whom may use unhygienic methods that pose threat to her health and life even.

Methodology

Type of study

Descriptive type of cross sectional study.

Place of study

Mallick Ban and Sadar Union of Bhaluka Upazila under Mymensingh District.

Study Population

All married women in reproductive age (15-49 years) who delivered their last child within 12 months.

Study period

The study will conducted for a period from June 2011 to December 2011.

Sample size:

Calculation of sample size by using the following formula

n=z² pq/d²

Here:

n=the desired sample size

z=standard normal deviation, usually set 1 .96.which corresponds to 95% CL

Since there is no ready reference on the married women in reproductive age who delivered their last child within 12 months, we can assume p = 12% to be adequate.

So, p= 0.12,

q=1- 0.12=0.88

d= Degree of precision and in this study it will set at 5%

So sample size

n= (1.96)² x (0.88) (0.12) I (.05)²

= 162.24

Due to allocation of data collection time, the feasible sample size was 150.

Sampling technique

Purposive according to the willingness of the respondents.

Data collection tool

Structured questionnaire

Data Collection procedure

Data was collected through structured questionnaire by face to face interview which was pre-tested earlier in an area similar to study area before finalizing the same.

Data Processing and Analysis

After collection of data, checked and remove error and finalized for analysis. Statistical Package for Social Science (SPSS) used for data analysis. A series of cross tabulation had done. Data presented in tabular and graphical formats.

Tables and Results

Age Distribution of the respondent                                                         

n=150

Mean: 24.99, SD = ±4.4

Majority 55(36.7%) were in 23-27 age group and 50(33.3%) were in 18-22 yrs of age group. Mean age of the respondents was 24.99 yrs with SD of ± 4.4. All respondents were within 18-36 yrs of age group and their in highly fertile and active reproductive age.

Distribution of the respondents by religion                                                         

n=150

Almost all 145 (96.7%) out of 150 of total respondents were Muslim only a few 5 (3.3%) were other religious status. 

Distribution of the respondents by Educational Status                                                         

n=150

Data shows out of 150 respondents 62(4l.3%) were illiterate, 56(37.3%) had only primary education. Less than one third 32(21.33) of the total respondents had academic qualifications only. Educational information of the respondents almost similar to national coverage of the educational status.

Distribution of the respondents by Main Occupation                                                         

n=150

Almost all (146) 97.3% respondents were housewife in terms of their main occupation which is common scenario of rural Bangladesh. Only 4 (2.7°/o), were in other occupation like service and business. Information reflects the less empowerment of women in rural Bangladesh.

Distribution of the respondents by Family Member                                                         

n=150

Mean family member is 5.49  SD ± 3.580

Table showed that 106 (70.7) respondents had family member within 3-5, which is almost similar to the national statistics of family member. Others had family member 6 and more than 6. Mean family member is 5.49 with, SD ± 3.580.

Distribution of the respondents by monthly family income                                                         

                                                                                                                         n=150

Table shows that 30 (20%) had their total monthly family income less than 1500.00 and 61 (40.7%) had their monthly family income within 3,500.00 which indicates all most of the respondents were in under poverty line in terms of their monthly family income. 37(24.7%) respondents had their monthly family income were within 6,000/- and only 22(14.7%) had their monthly family income more than 6,000/.

Distribution of the respondents by dwelling house

                                                                                                               n=150

Table shows that out of 150 respondents 10 (6.6%) were homeless and 96 (64.0%) had katcha house for their dwelling which reflects the low socio economic condition of the respondents. 29 (19.3) had Tin shade house; 8 (5.3%) had semi-pacca house and 7 (4.7%) had pacca housing for their dwelling house.

Distribution of the respondents by Sanitation

                                                                                                               n=150

Table shows 143 (95.3%) of the respondents used sanitary latrine which is very near to national target (100%). Only 4.7% used non-sanitary latrine.

Distribution of the respondents by during of Marital Life                                                         

                                                                                                        n=150

Table shows 43(28.7%) had within 4 years of marriage life, 46(30.7%) had within 8 years of marriage life. 36(24.0%) had within 12 years marriage life, 15(10.0%) had within 16 years marriage life and 10(6.7%) had more than 17 years marriage life. The mean duration of marriage life of the respondents was 7.94 years with SD± 4.86 years. All the respondents were married and had short duration of married life and within active reproductive age.

Distribution of the respondents by their number of pregnancy                                                         

                                                                                                        n=150

Mean number of pregnancy = 2.21 with SD±1.239

Data shows that 106(70.66) had two pregnancies, 36(24.0) had more than two pregnancy and 8(5.3%) were multi-gravid. The mean number of pregnancy was 2.21 with SD±1.239

Distribution of the respondents by the age of their last child                                                         

                                                                                                        n=150

Mean age of last child 6.12 months with SD± 3.409 months,

All the respondents were recent mother because age of their last child were within 1-12 months. 84 (56%) respondents delivered their last child within 6 months. Rest 66 (44%) were within 7-12 months. The mean age of the last child was 6.12 with SD± 3.4. Fact is that all the respondents are very recent mother. They had very recent experience regarding reproductive health care i e. ANC, INC, PNC. So there less chance of recall bias and data should be more accurate and authentic.

Distribution of the respondents by taking additional

food during their last pregnancy                                                         

                                                                                                        n=150

Table shows that 94 (62.7%) had taken additional food and 56 (37.3%) not taking additional food during the last pregnancy. Taking additional food during pregnancy is most important determining factor for healthy child and reducing maternal complications during pregnancy, delivery and after child birth. Though the socio economic condition of the respondents not up to the mark, but at least two third of total respondents taking additional food during their last pregnancy due to their knowledge about importance additional food during pregnancy.

Distribution of the respondents by reason for not taking additional food                                                         

                                                                                                        n=150

Data shows out of 150 respondents 56 (37.3%) respondents who had not taking additional food during the last pregnancy. Reasons for not taking additional food 56 respondents had 95 responses. Out of these 95 responses 43 (45.26%) responses were lack of knowledge about additional food, 30 (3l.57%) responses were due to poverty and 22 (23.15°/o) responses were for social constraints and superstition.

Distribution of the respondents by the knowledge

about danger signs of pregnancy                                                         

                                                                                                        n=150

Table shows that 120 (80%) of the respondents had knowledge about danger signs of pregnancy. But 30 (20%) respondents had no knowledge about danger signs of pregnancy.

Distribution of the respondents by the level of knowledge

about 5 danger signs of pregnancy                                                         

                                                                                                        n=150

Table shows out of 120 respondents who had knowledge about danger sign of pregnancy. 15(12.5) know one danger sign, 33(27.5%) know two danger signs, 44(36.7%) know three danger signs, 25(20.8%) know four danger, signs and 3(2.5%) know 5 danger signs. From the above information we can say the knowledge of respondents regarding danger signs of pregnancy is remarkable.

Distribution of the respondents by TT vaccine

during their last pregnancy                                                         

                                                                                                        n=150

Data shows 146 (97.3%) out of 150 respondents received TT vaccine during their last pregnancy. But 4(2.7%) not received TT Vaccine. Information reflects the successful EPI Programme utilization by the respondents in the, study area.

Distribution of the respondents by Reasons for not receiving

TT vaccine during their last pregnancy                                                         

                                                                                                        n=150

Table shows very negligible respondent only 4 (2.7%) of total respondents not received TT vaccine were 1(25%) due to social restriction and 3(75%) were non availability of service due to long distance of service centre.

Distribution of the respondents by receiving ANC

during their last pregnancy                                                         

                                                                                                        n=150

This table shows 98(65.3%) received ANC during their last pregnancy which is almost double of national ANC (34.7%) coverage. Because according WHO guideline (ANC) at least 3 visits should be performed. But in this information WHO guideline could not strictly followed. On the other hand in my study area including all other Reproductive Health Care service Bangladesh Integrated Nutrition Programme and EOC Programme ongoing,. So ANC coverage trends, is increasing in the study area.

Distribution of the respondents by the service centre for ANC                                                         

                                                                                                        n=150

Table shows that utilization of Upazila Health Complex and Satellite Clinic almost same 38.77% and 32.65% respectively. But utilization of FWC is very low. Though all manpower and logistics for ANC is available in this service centers.

Distribution of the respondents by referral for ANC                                                         

                                                                                                        n=150

Data shows 50(51%) were referred by+ Health Workers 40(40.8%), received ANC by their own (Self, Husband, and Relatives) decision which is very, encouraging positive information. That reflects increasing trends of decision making by themselves, for reproductive health care. This increasing trends can help to reduce at least one delay out of three delay for getting service. Rest 8(8.2%) were referred by TBA.

Distribution of the respondents by reasons for not receiving ANC                                                         

                                                                                                        n=150

Out of 52 respondents who did not receive ANC during last pregnancy 18(34.61) for poverty, 16(30.76%) for lack of knowledge about ANC, 12(23.07%) for non-availability of service due to long distance service centre and rest 6(11.53%) due to social constraint and lack of accompany. All the reasons for not receiving ANC by the respondents during their last pregnancy, related to their socio-demographic status.

Distribution of the respondents by the

place of last delivery                                                         

                                                                                                        n=150

Data shows out of 150 respondents 29(19.3%) delivered their last child, in hospital private or govt. It indicates that high rising trends of institutional delivery. 121, (80.7%), were delivered their last child at home which is similar to the other area of rural Bangladesh. Percentage is, near to the national” home delivery coverage.

Distribution of the respondents by referral for institutional delivery                                                         

                                                                                                        n=29

Out of 29 respondents who delivered their last child at hospital Govt. or Private 15 (51.73%) has taken service by their own initiative and 14 (48.27%) were referred the Health workers. Own decision making for service is very significant and encourage information. Because the availability of decision making regarding services will reflect positive impact in reducing maternal morbidity and mortality.

Distribution of the respondents by person conducting delivery at home                                                         

                                                                                                        n=121

Table shows that out of 121 respondents who delivered their last child at home conducting persons ‘were 82(67.76%) by TBA, 37(30.57%) by relatives and 2 (1.65%) were delivered by trained personnel. Majority of delivery were conducted by the persons who had no any institutional training regarding Intra-natal Care and, its complications management, Post Natal Care and newborn management.

Distribution of the respondents by complications

during their last delivery                                                         

                                                                                                        n=84

N.B: Number of response increased due to multiple response were allowed.

Data shows out of 150 respondents 82(54.66%) not facing any complication, 68(45.33%) facing one or more dangerous complications during their last delivery. 68 respondents had 84 responses about their complication. These were 29(34.52%) had obstructed/prolong labour, 26(30.95%) had post partum hemorrhage, 15(17.85) had convulsion 8(9.52%) had perennial tear and 6(7.14%) had retained placenta. All the complication are leading cause of maternal mortality and morbidity and most similar to the national data of cause of maternal mortality.

Distribution of the respondents by receiving service for

 their complications                                                         

                                                                                                        n=40

Out of these 68 respondents who facing complications during the last delivery only 40 had taken measure for management of their, problem at different Govt. and non-govt. health service centre. Majority of the respondents i.e. 24(60%) had taken their service from Upazila health complex and 9(22.5%) taking their service from Govt. or Non-govt. hospital other than Upazila Health Complex and 7(17.5%) were taken service from non-qualified (Village Doctor) Health Personnel.

Distribution of the respondents by reasons for not taking service for their complications                                                         

                                                                                                        n=72

Rest 28 respondent who did not take any measure for their complications. Though they had developed serious maternal complications. Reasons for not taking services for their complications were 72 responses of 28 respondents these were 27(25.0%) for nobody accompany them, 21 (29.16%) for poverty, l7(23.6l%) percent for their negligence or lack of awareness and 7(9.72%) for non availability of service due to long distance of service centre.

Distribution of the respondents by facing complications after

delivery of their last child                                                         

                                                                                                        n=197

Out of 150 respondents 34(14.71%) had no complications after their last child birth, 116 respondents had one or more complication after their last child birth. Complications were 45.68% had lower abdominal pain, 18.78% breast swelling, 14.72% foul smelling vaginal discharge, 11.67°/o high fever and 9.l3% were post partum hemorrhage. All the complications are common cause of maternal morbidity in Bangladesh like other developing countries.

Distribution of the respondents by receiving service for their complications after their last child birth                                                         

                                                                                                        n=83

Out of these 116 respondents who had develop complications after their last child birth. Only 67 had taken services from different govt/non-govt. health service centre. 30(36.14%) had taken services from Upazila Health Complex, 13(15.66%) from satellite clinic, 9(10.84%) from Union Health &. family welfare centre, 10(12 O4%) private clinic, 2(2.40%) district/medical college hospital. Rest 19(22.89%) from unqualified medial personnel (village doctors.) which is not hopeful information. It is due to their negligence or lack of knowledge. Above data reflects the utilization of upazila health complex is encouraging and utilization of Union Health and Family Welfare Centre, is very poor. Though setup of manpower is satisfactory.

Distribution of the respondents by referral for service after

delivery of their last child                                                         

                                                                                                        n=83

Regarding referral of the respondents who taken services 55(66.26%) were referred by their own initiative (self, husband and relatives) which is significant sign for decision making for taking services that health positively for reducing maternal mortality and morbidity. Health worker also done well they offered 24(28.91%) respondents and 4 (4.81%) by TBA. 

Distribution of the respondents by reasons for not taking institutional service for complications after delivery of their last child                                                         

                                                                                                        n=80

Out of 116 83 had taken services rest 33 not taken service though they had developed complication reason were 33 respondents had 80 responses. These were 19 (23.75%) for poverty, 33(41.25%) for not accompany, 14(17.5%) for lack of knowledge and 14(17.50) due to long distance.

Distribution of the respondents by receiving Postnatal Care                                                         

                                                                                                        n=150

Out of all respondents only 17 (11.3%) had received Postnatal Care after their last child birth. Majority of the respondents i.e. 133 (88.7%) had not received PNC. The PNC coverage of the respondents is almost similar to the national coverage of PNC.

Distribution of the respondents by Reason for not taking PNC                                                         

                                                                                                        n=244

Number of respondents increased because multiple answer was allowed.

Out of 150 respondents 133 had not taken PNC reasons for not taking PNC 133 respondents had 244 responses. These were 53 (21.72%) they had not any complications, 123 (5O.40%) Lack of knowledge about PNC, 47(19.26%) for poverty, 18(7.37%) and rest 3(1.22%) for social constraint. 

Distribution of the respondents by receiving contraceptive

 methods after their last child birth                                                         

                                                                                                        n=150

Among all (150) respondents 67(44.7%) not received any contraceptive method after their last child birth. 83 (55.33%) respondents received any one of the different contraceptive methods which are provided by family planning services. Use of oral pill 64(42.7%) is very high which is not hopeful information. Because dropout rate of oral pill user is very high. Otherwise, methods mix is similar to the national coverage of different contraceptive methods.

Distribution of the respondents by source of contraceptive methods receiving by the respondents                                                         

                                                                                                        n=83

Regarding sources of contraceptive methods information is to some extend satisfactory. Use of method from market 16(10.7%) indicates less utilization of ongoing domically and other family planning services or much awareness of the respondent about contraceptive method used.

Distribution of the respondents by reason for not

 receiving contraceptive methods                                                          

                                                                                                n=67

Regarding reasons for not receiving contraceptives methods by the respondents after their last child birth. 55(36.7%) respondents not receiving contraceptive methods due to their lactation amenorrhea. Their conception is that without menstruation pregnancy will not occur. It is very signification, information for the service providers and national planners. Due to lack of correct conception many unwanted pregnancy occur which increased prevalence of MR and abortion may leads to maternal mortality and morbidity. Other reason for not receiving contraceptive method is common causes for not receiving contraceptive methods in rural community.

Scoring and Rating for Construction of Composite Variable in terms of Socio-Demographic Indicators of the respondents

<7 Poor     8-9 = Middle Class         10-12 = Affluent         >12 = Very affluent

Table shows the socio-demographic status of the respondents according to self rating and scoring method by construct a composite variable considering the following status of the respondents.

(1) Educational status, (2) Monthly family income, (3) Sanitary Condition

(4), Housing Condition, (5) Main Occupation

According to the above guideline respondents are categorized into 4 category those who had rating score was <7 = Poor Class, (2) Those who had rating score 7 – 8 = Middle Class, (3) Those who had rating score 9-12 = affluent class, (4) Those who had rating score >12 = Very affluent.

Distribution of the respondents by their socio demographic status                                                         

                                                                                                n=150

According to self rating of socio-demographic status out of 150 respondents 54 (36.00%) were poor 39 (26.0%) were middle class, 46(30.7%) affluent and only11(7.3%) very affluent.

Cross Tabulation of Receive ANC during last pregnancy with their socio demographic status                                                                                n=150                                                                                         

Cross tabulation between socio demographic status and ANC received by the respondents during their last pregnancy. Data shows 50% poor, 59% middle class, 80.4% affluent and 100% very affluent class utilizes ANC during their last Pregnancy. Data Shows ANC utilization rate increases when their social, demographic status increases. There were a clear relation between ANC utilization and social demographic status of the respondents which is statistically proved. In this cross table ~2=16.770 df = 3, the value of calculated x2 is greater than tabulated x2. So, P. Value is less than .05, test is statistically significant. Therefore, null hypothesis is rejected. Alternative hypothesis is accepted. So there is significant relation between ANC utilization arid the socio-demographic status of the respondents.

Cross Tabulation of Receive PNC during last pregnancy with their socio demographic status                                                                                n=150                                                                                        

Cross Tabulation between social demographic status and PNC utilization by the respondents after their last delivery. Data shows 1.9% poor, 10.3 Middle class, 2l.7% affluent and l8.2% very affluent class respondents received PNC after their last delivery. There is no significant relation between socio demographic status of the respondents and PNC utilization of the respondents during after their last delivery. In this cross table x²=10.346 df = 3, the value of calculated x² is less than tabulated x². So, P Value is greater than 0.05, test is not statistically significant. Therefore, null hypothesis is accepted. So there is no significant relation between PNC utilization and soda-demographic status of the respondents.

Cross Tabulation of Take additional food during last pregnancy with their socio demographic status                                                              n=150                                      

Cross tabulation between socio demographic status and taking additional food during their last pregnancy of the respondents. Table shows who had taken additional food were 33.3% Poor, 71.8% were middle class, 82.6% affluent and 90.9% very affluent class. Cross table shows a significant relation between Socio demographic statuses of the respondents with additional food taken during the last pregnancy. In this cross table x²=32.819 df = 3, the value of calculated x² is greater than tabulated x². So, P. Value is less than .05, test is statistically significant. Therefore, null hypothesis is rejected. Alternative hypothesis is accepted. So there is significant relation between taking additional food during last pregnancy and socio-demographic status of the respondents.

Cross Tabulation of Place of delivery with their socio demographic status                                                                                                        n=150                                      

Cross tabulation between socio demographic statuses of the respondent with the place of delivery of their last child. Data shows higher trends of utilization hospital as the place of delivery when their socio demographic status increases. 7.4% Poor, 15.4% Middle class, 26.1% affluent class, 63.6% very affluent class, utilizes hospital as their place of delivery during their last pregnancy. So there is significant relation between hospital service utilization and socio demographic status of the respondent. In this cross table /2=20.504 df = 3, the value of calculated x² is greater than tabulated x². So, P. Value is less than .05, test is statistically significant. Therefore, null hypothesis is rejected. Alternative hypothesis is accepted. So there is significant relation between institutional delivery during last pregnancy and socio-demographic status of the respondents.

DISCUSSION 

A Descriptive cross sectional study was conducted among 150 married women of Reproductive age who delivered their last child within 12 month at Mallikbari and Sadar Union of Bhaluka Upazila under Mymensingh district with the mean age of the respondents was 24.99 and SD± 4.4. All the respondent was within 18-36 years age group and there in highly fertile and active reproductive age.

In this study population almost 96 7% (145) were Muslim only a few 3.3% (5) were other religious status. Only one third 50(37.39/o) had only primary education. 62.0 (41.3%) were illiterate, rest of the respondents had academic qualification. 146 (97.3%) respondents were housewife in terms of their main occupation only 4(2.7%) were in other occupation. Within regard to monthly family income of the respondents 20.0% had their monthly income below taka 1500 and 40.6% had monthly income within Tk. 1500-3500. Among all the respondents 95.3% used sanitary latrine.

Majority of the respondents (64%) of their housing condition were found katcha house and 29.3°/o had good housing for their dwelling which reflects the low socio economic condition of the respondents. In this study all the indicators of socio demographic status of the respondents were all most similar to the national data. Since there was no study with the same title conducted but some study were conducted with different component of Reproductive Health Care. In this study, knowledge about danger signs of the pregnancy (120) 80% respondents had knowledge at least one danger sign.

Study shows that out of 150 respondent 62.7% had taken additional food and 37.3% did not take any additional food during their last pregnancy, which almost similar to the study conducted by Associates for Community and + Population Research (ACPR) where they found 40°/o of the women did not take additional food during pregnancy.⁹ Reasons for not taking additional food that’s lack of knowledge, poverty, and social constraints which are related to socio-demographic status of the respondents (P<0.05).

With regard to receiving ANC during last pregnancy among 150 respondents 65.3% were received Antenatal care which almost double of national coverage (34.7%) as because EOC program and Bangladesh Integrated Nutrition Program (BINP) are implementing in this study area in ANC coverage shows increasing trends. On the other hand the study, was conducted by Akther H H found that about 72% of the pregnant women were taken Antenatal Care during pregnancy, which almost similar to the present study.⁸

The study findings shows that 19.3% delivered their last child in Govt. Hospital or Private Institution which higher than national coverage due to have the EOC program at the study area. In this study it was found that as the barriers for not taking institutional service for the different components of Reproductive Health were considered due to poverty, not accompany and long distance of service centre which are the findings of Demographic Health Survey, 2003 also.¹⁵

Out of 150 respondents only 11.3% had received postnatal care after last child birth. The reasons for not taking PNC it was found that 50.40% of respondents had no knowledge about PNC, 19.26% for poverty, rest of all for non availability of services and social constraints.

With regard to receiving contraceptive method after last child birth, the study shows that among all respondents, 44.7% did not receive, any contraceptive method 55.33%, received any one of the different contraceptive methods. Where 42.7% were pill users considering the method mix it are similar to the national coverage. Those who did not receive any contraceptive method among them 82.1% respondents after their last child birth due to lactatiorial amenorrhea. The conception is that without menstruation pregnancy will not occur.