Determinants of the use of skilled birth

attendants at delivery by pregnant

women in Bangladesh

Author

S. M. Abul Bashar

Master Student

Department of Public Health and Clinical Medicine

Epidemiology and Global Health

Umeå International School of Public Health

Umeå University – Sweden

2012

Supervisors:

Kjerstin Dahlblom

Hans Stenlund

i

PROLOGUE

Before starting my Master’s Program in Public Health, I worked as a Rehabilitation Officer in

a non-governmental organization. I worked both in urban and rural areas in Bangladesh

during the period of 2007 to 2009 in order to implement a rehabilitation program for

children with disabilities. While working in the actual setting where the children lived, I

observed several maternal deaths. There are health facilities and health personnel in the

community, though, an insufficient amount, yet mothers are not using these facilities and

health personnel adequately. Witnessing this situation, I asked myself the following

questions: Why are the mothers from different family backgrounds dying? Why do mothers

not give birth at a health facility? Why do not family members call trained health personnel

for delivery at home? These questions motivated me to search for the underlying factors

behind this situation. Now, as a public health student, I have the opportunity to look into

these factors. Therefore, the purpose of this thesis is to estimate the determining factors that

influence the use of skilled birth attendants at delivery in Bangladesh by using secondary

data accessed from the 2007 Bangladesh Demographic and Health Survey.

ii

ACKNOWLEDGEMENT

Foremost, I would like to thank following organizations for their effort to the dataset

available and allow me to use the data to conduct this study:

National Institute of Population Research and Training

Mitra and Associates

Measure Demographic and Health Survey

Macro International Inc.

U. S. Agency for International Development

I would like to thank many people who made this thesis possible. I would like to pass my

heartfelt gratitude and appreciation to my supervisors Kjerstin Dahlblom and Hans Stenlund

for their continuing and constructive assistance in all matters related to this thesis. I would

also like to thank all my teachers and administration workers especially for Sabina Bergsten

and Karin Johansson for their unconditional support.

I am indebted to my friends Negin Yekkalam, Laith Hussain, and Gilbonce Betson for helping

me throughout data analysis. I am deeply grateful to my friend Niha for emotional support,

camaraderie, entertainment, and caring she provided me.

Last but not least, I would like to thank my father and mother who have invested all their life

to support me. My parent, I thank you very much for your sweet words on the telephone

every weekend that gave me hope. To them I dedicated this thesis.

iii

ABSTRACT

Background: Bangladesh has made a significant progress towards Millennium

Development Goal (MDG) 5, which specifies a 75% reduction in the maternal

mortality ratio (MMR) between 1990 and 2015. In 1990 the MMR was 570 per

100,000 live births and declined to 194 per 100,000 live births in 2010. Progress

on the indicator of MDG 5 for example, the use of antenatal care has been

remarkable. However, progress on the use skilled assistance at delivery is still far-

below any acceptable standard. Roughly 26% of the women use delivery assistance

from medically-trained personnel either at home or at a health facility. Many

factors are associated with this low use of skilled assistance at delivery.

Objective: The study aimed to estimate the magnitude of the use of skilled birth

attendants at delivery and the effects of predisposing and enabling factors on the

use of skilled assistance at delivery by pregnant women of Bangladesh

Methods: The study was a cross sectional analysis of the 2007 Bangladesh

Demographic and Health Survey, which is a nationally representative survey of

women in the 15-49 years age groups. Women who had at least one birth in the five

years preceding the survey were included in this study. To estimate the effects of

demographic and socio-economic factors on the use of skilled assistance at

delivery, logistic regression analyses were carried out.

Results: A total of 6,132 women fulfilled the study eligibility criteria and were

included in the analysis. Only 20.80% of births were attended by skilled birth

attendants either at home or at a health facility. Over 36% of urban women

delivered with skilled assistance compared to 12.42% of rural women. In logistic

regression analyses parental education, birth order, place of residence, husbands’

occupation, and wealth index were found to be significantly associated with the use

of skilled assistance at delivery. Muslim women and women those who were from

male-headed household were less likely to use skilled assistance at delivery.

Women’s age was not found to be significantly associated with the use of skilled

delivery assistance.

Conclusion: The study identified that the use of skilled attendants at delivery was

very low in Bangladesh. Parental education and birth order were strong predictors

for the use of skilled assistance at delivery. Rural women and women from Muslim

religion were at greater disadvantage in the use of skilled assistance at delivery. To

improve maternal health and reduce maternal mortality, special efforts and

attention to improve both formal and informal education of the girls and boys are

needed. Moreover, to explore cultural factors and traditional beliefs related with

the use of skilled assistance at delivery, qualitative study needs to be conducted.

Extra effort should be given to rural areas so that the rural women can easily access

to maternal health services.

Key Words: maternal health; skilled birth attendants; delivery practice;

Bangladesh

iv

TABLE OF CONTENTS

PROLOGUE……………………………………………………………………………………………………………………. i ACKNOWLEDGEMENT…………………………………………………………………………………………………… ii ABSTRACT…………………………………………………………………………………………………………………….. iii TABLE OF CONTENTS ……………………………………………………………………………………………………. iv LIST OF ABBREVIATIONS….……………………………………………………………………………………………. V LIST OF FIGURES AND TABLES..……………………………………………………………………………………… Vi 1. INTRODUCTION……………………………………………………………………………………………………….

1.1. Background Review……………………………………………………………………………………….. 1 1

1.1.1. Global Overview of Maternal Health……………………………………………………… 1.1.2. International Initiatives on Maternal Health…………………………………………… 1.1.3. Country Profile of Bangladesh....................................................................

1.1.3.1. Geography and Demography............................................................. 1.1.3.2. Economy and Health Financing.......................................................... 1.1.3.3. Health Care Delivery System.............................................................. 1.1.3.4. Maternal Health Status………………………………………………………………….. 1.1.3.5. Delivery Care Services……………………………………………………………………..

1.2. Review of Literature………………………………………………………………………………………. 1.2.1. Skilled Birth Attendants at Delivery………………………………………………………… 1.2.2. Delivery Practice in Developing Regions…………………………………………………. 1.2.3. Delivery Practice of Pregnant Women in Bangladesh…………………………….. 1.2.4. Determinants of the Use of Skilled Birth Attendants……………………………….

1.3. Conceptual Framework…………………………………………………………………………………. 1.4. Rationale of the Study.………………………………………………………………………………….. 1.5. Research Question………………………………………………………………………………………… 1.6. Aim of the study……………………………………………………………………………………………..

1.6.1. Specific Objectives………………………………………………………………………………….

1 2 3 3 4 4 5 6

7 7 8 8 9 11 12 13 13 13

2. METHODS……………………………………………………………………………………………………………… 2.1. Study Design……………………………………………………............................................. 2.2. Data Source………………………………………………………………………………………………. 2.3. Sampling Method and Sample of 2007 BDHS……………………………………………… 2.4. Study Participants…………………………………………………………………………………….. 2.5. Variable Specification and Selection……………………………………………………………

2.5.1. Dependent Variable…………………………………………………………………………….. 2.5.2. Independent Variables…………………………………………………………………………

2.6. Data Collection…………………………………………………………………………………………. 2.7. Ethical Consideration…………………………………………………………………………………. 2.8. Data Analysis……………………………………………………………………………………………….

14 14 14 15 16 16 16 16 18 18 18

3. RESULTS…………..…………………………………………………………………………………………………….. 3.1. Characteristics of the Women……………………………………………………………………… 3.2. Usage Patterns of Skilled Birth Attendants at Delivery………………………………… 3.3. Logistic Regression Analyses…………………………………………………………………………

19 19 20 22

4. DISCUSSION……..……………………………………………………………………………………………………. 4.1. Discussion of the Main Findings…………………………………………………………………… 4.2. Limitations of the Study……………………………………………………………………………….

26 26 30

5. CONCLUSION…………………….……………………………………………………………………………………. 32 6. REFERENCES…………………………………………………………………………………………………………… 33

v

LIST OF ABBREVIATIONS

AIDS Acquired Immune Deficiency Syndrome

ANC Antenatal Care

BBS Bangladesh Bureau of Statistics

BDHS Bangladesh Demographic and Health Survey

BEOC Basic Emergency Obstetric Care

CEmOC Comprehensive Emergency Obstetric Care

CI Confidence Interval

CSBA Community Skilled Birth Attendant

DGFP Directorate General of Family Planning

DGHS Directorate General of Health Services

DHS Demographic and Health Survey

DSF Demand Side Financing

EOC Emergency Obstetric Care

FIGO International Federation of Gynecology and Obstetrics

GDP Gross Domestic Product

ICM International Confederation of Midwives

MDG Millennium Development Goal

MMR Maternal Mortality Ratio

MOHFW Ministry of Health & Family Welfare

NGO Non-Governmental Organization

NIPROT National Institute of Population Research and Training

OPD Out Patient Department

OR Odds Ratio

PSU Primary Sampling Unit

p-value Probability-Value

SBA Skilled Birth Attendant

TBA Traditional Birth Attendant

UNDP United Nations Development Program

WHO World Health Organization

vi

LIST OF FIGURES AND TABLES

Figure 1: Maternal mortality ratio by country....................................................................... 1

Figure 2: Map o Bangladesh…………………………………………………………………………………………….. 3

Figure 3: Causes of maternal death in Bangladesh……………………………………………………………. 6

Figure 4: Andersen’s behavioral model of use of health services……………………………………… 12

Table 1: Demographic characteristics of Bangladesh………………………………………………………… 3

Table 2: Different levels of public health care facilities in Bangladesh………………………………. 5

Table 3: Emergency obstetric care (EOC) services by type of facilities………………………………. 7

Table 4: Independent variables used in the study: definitions and categories………………… 17

Table 5: Background characteristics of the women who had at least one birth in the five years preceding the survey, Bangladesh 2007…………………………………………………………………..

19

Table 6: Percent distribution of women who had at least one birth in the five years preceding the survey according to the use of SBAs by different background characteristics, Bangladesh 2007………………………………………………………………………….

21

Table 7: Logistic regression results with OR and 95% CI for the use of SBAs by the pregnant women who had at least one birth in the five years preceding the survey, Bangladesh 2007……………………………………………………………………………………………………………….

23

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1. INTRODUCTION

1.1. Background Review

1.1.1. Global Overview of Maternal Health

Every day, pregnancy- and childbirth-related complications account for approximately 1,000

maternal deaths1 around the world [1]. In 2008, the World Health Organization (WHO)

estimates that 358,000 women of reproductive age die during and following pregnancy and

childbirth [2]. Nearly all (99%) of these deaths occur in developing regions. Developing

regions, like South Asia, alone account for more than one third of the global maternal deaths

[2]. The maternal mortality ratio (MMR) – number of maternal deaths per 100,000 live

births – is 280 maternal deaths per 100,000 live births in this region, which is in stark

contrast to developed regions where the figure is only 14 deaths per 100,000 live births [2].

Figure 1 below displays the MMR in varies countries in 2008. Explanations for these deaths

in developing regions are the inadequate access to modern health care services and the poor

use of these services [3].

Figure 1: Maternal mortality ratio by country (Adapted from WHO trends in maternal mortality: 1990 to 2008, 2010).

1Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy,

irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes [4].

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Maternal death has a large impact on the baby the mother is carrying, the health and well-

being of the family, the community, and on the society in general. Each year, more than one

million children lose their mothers due to maternal mortality [5]. Evidence shows that

children up to 10 years of age whose mothers die, have a 3 to 10 times higher risk of dying

within two years than children who live with their mothers [5]. The WHO estimates that each

year US $15.5 billion is lost in potential productivity due to maternal and child death [6].

Maternal death is the most extreme consequence of poor maternal health. However, due to

inadequate care during pregnancy and delivery or the first critical hours after birth, more

than 30 million women in developing regions suffer from serious diseases and disabilities.

These diseases and disabilities include uterine prolapse, pelvic inflammatory disease, fistula,

incontinence, infertility, and pain during sexual intercourse [6]. The majority of these deaths

and complications could be avoided by access to basic maternity care and improved delivery

care, which is supported by adequate medical and surgical care [7].

1.1.2. International Initiatives on Maternal Health

Globally, several initiatives have been taken to reduce maternal deaths and improve maternal

health, in particular, the Nairobi Safe Motherhood Conference of 1987 [8]. The Nairobi

conference led to the establishment of Safe Motherhood Initiative. The specific activities of

this initiative include: provision of antenatal care (ANC)2, skilled assistance for normal

deliveries, appropriate referral for women with obstetric complications, postnatal care, family

planning and other reproductive health services [8-10]. Maternal health is further

emphasized in the International Conference on Population and Development in 1994 [8, 11]

and Fourth World Conference on Women in 1995 [12]. Finally, maternal health is reinforced

in the United Nations Millennium Summit of 2000, when it was included as one of the

Millennium Development Goal (MDG) [8]. The goal, which has the aim to improve maternal

health, includes two targets: reduce maternal mortality ratio by three quarters between 1990

and 2015 and achieve universal access to reproductive health by 2015. Proportion of births

attended by skilled birth attendants (SBAs) and coverage of ANC are the two main indictors

to measure these targets [8, 13]. The presence of a SBA at delivery, either at home or at a

health facility has been strongly emphasized throughout the international initiatives on

maternal health.

2 ANC – care during pregnancy – is the key entry point for a pregnant woman to receive a wide range of preventive

interventions and information which fosters their health, well-being and survival, and that of their infants [14].

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1.1.3. Country Profile of Bangladesh

1.1.3.1. Geography and Demography

The People’s Republic of Bangladesh – one of

the largest delta of the world – emerged on

the world map as an independent and

sovereign country in 1971 following a nine-

month war of liberation. It is a low-lying

country with a total land area of 147,570 sq.

km, which lies in the north eastern part of

South Asia. On three sides, Bangladesh

borders with India [Figure 2]. In the

southeast, only a small strip is bordered by

Myanmar, and the Bay of Bengal lies to the

south. The country is covered with a network

of more than 230 rivers and canals with a

total length of 24,140 km and Bangladesh has

a coastline of about 580 km along the Bay of

Bengal. The majority of the people are Muslim followed by Hindu, Buddhist, and Christian;

the figures are 89.35%, 9.64%, 0.5%, and 0.27%, respectively. Table 1 below represents a

summary of the basic demographic characteristics of Bangladesh [15, 16, 17].

Table 1: Demographic characteristics of Bangladesh

Characteristics Number

Population in thousand (male/female) (2011 census) 142,319 (71,255/71,064)

Population density (inhabitants per sq km) 964

Urban population (in %) 25.4

Rural population (in %) 74.6

Total fertility rate (birth per woman, 15-49 years) 2.40

Average household size (persons per household) 4.4

Mean age at first marriage male/female (years) 25.04/20.31

Life expectancy male/female (years) 65.61/67.96

Adult literacy rate (in %) 59.07

Source: Directorate General of Health Services [DGHS], 2010; Bangladesh Bureau of Statistics [BBS], 2011.

Figure 2: Map of Bangladesh

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1.1.3.2. Economy and Health Financing

Bangladesh is mainly an agricultural country. Agriculture, the single largest-producing

sector, contributes about 22% to the total Gross Domestic Product (GDP) and accommodates

approximately 48% of the country’s labor force [15]. According to the BBS, in 2008 the per

capita GDP was US $ 621 [15]. Until now, roughly one half of the total population had been

living under poverty, where around 36% of people lived with a per capita income of less than

US $ 1 a day [18]. Regarding health financing, a combination of several methods exists

including: households-out-of-pocket money, government revenue, and community financing

through non-governmental organizations (NGOs) and donors. In 2007-2008 fiscal years, the

government spending on health was 7% of the total country’s national budget, which

accounts for only 3.4% of the GDP. Out-of-pocket expenditure was the major source of health

financing. In 2007, approximately 64% of the total health expenditure came from

household’s out-of-pocket money. Household’s out-of-pocket contribution continues to be

two thirds of the total health expenditure, which was 57% of the total health expenditure in

1996-97, and rose to 64% in 2006-07. People often do not want to go to the doctor because

paying for such a visit greatly increases the household expenditure. Rather, individuals prefer

to go a seller of medicine in order to buy drugs without having any formal prescription.

Hence, people suffer from chronic poor health, which leads to morbidity and mortality [16,

19].

1.1.3.3. Health Care Delivery System

The Ministry of Health & Family Welfare (MOHFW) is responsible for developing policies,

planning, and decision-making for the total health care services in the country.

Implementation of these decisions and policies are then executed by various executing

authorities. The Directorate General of Health Services (DGHS) and the Directorate General

of Family Planning (DGFP) are the two largest branches of MOHFW. Health care services are

provided by a mix of public and private institutions, and NGOs. The public sector provides

both curative and preventive care, while the private sector mainly provides curative care.

Contrary, NGOs provide mainly preventive and basic care. Some of the government’s services

are provided in collaboration with NGOs, which include immunization, nutrition, and

tuberculosis control program. The delivery of public sector services is performed through

different tires including national, divisional, district, upazila (sub-district), union, and the

ward and village levels. In rural areas, public facilities are the main source of modern care;

however, private hospital and clinics outnumber public facilities in the urban areas. Table 2

on the following page displays information of different levels of health care facilities in

Bangladesh [16, 18].

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Table 2: Different levels of public health care facilities in Bangladesh

Levels of health care

Administrative units

Types of facilities Number

Primary Ward/Village

Community Clinics

Satellite Clinic per month (under DGFP)

9722

30,000

Union

Union Health and Family Welfare Centers 3806

Rural Health Centers (10-20 beds) 27

Union Sub-Center (OPD* only) 1362

Maternal and Child Welfare Center (under DGFP) 24

Upazila Upazila Health Complex 424

Other Hospitals 36

Maternal and Child Health-Family Planning clinic

(under DGFP)

407

Maternal and Child Welfare Center (under DGFP) 12

Secondary District District hospitals 59

Maternal and Child Health-Family Planning clinic

(under DGFP)

64

Maternal and Child Welfare Center (under DGFP) 61

Tertiary Division or

District

Medical College Hospitals 18

Specialized Hospitals and other Hospitals 40

Postgraduate Institutions 7

Source: DGHS, 2010 *OPD: Out Patient Department

1.1.3.4. Maternal Health Status

Due to inadequate access to modern health care services and poor use of services, the

situation of maternal health is worse in Bangladesh than other developing countries [3]. The

country faces what is considered to be a high number of maternal mortality and morbidity.

Estimates vary, but the official figure of maternal mortality is 194 maternal deaths per

100,000 live births [20], whereas the estimate of the United Nations Development Program

(UNDP) is 348 maternal deaths per 100,000 live births [21]. The major contributing factors

behind these high rates of maternal deaths are a very low use of assistance from skilled

personnel at delivery, poor facilities for delivery, and insufficient ANC services [20].

However, women die from a wide range of both direct and indirect causes. Indirect causes,

which are not the complications of pregnancy, complicate pregnancy or are aggravated by it.

Direct causes of death include hemorrhage, infections, eclampsia, obstructed labor, and

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unsafe abortion [20]. Among other causes, hemorrhage and eclampsia together comprise

more than half of the maternal deaths in the country (Figure 3).

Figure 3: Causes of maternal death in Bangladesh

Source: Bangladesh maternal mortality and health care survey 2010 – Summary of key findings and implications.

1.1.3.5. Delivery Care Services

Achieving MDG5, Bangladesh with assistance from international agencies is continuing to

implement different strategies and services for delivery services. The country conducts

facility based Emergency Obstetric Care (EOC) program in all districts. The EOC service

provision is in two forms: Comprehensive Emergency Obstetric Care (CEmOC), and the Basic

Emergency Obstetric Care (BEOC). Table 3 on the following page demonstrates a summary of

EOC services by type of facilities in the country. A number of private clinics or hospital and

NGOs also provide similar services in different districts. Furthermore, special emphasis has

been given to increase the number of skilled health personnel as the shortage of skilled

personnel is thought to be a major barrier in improving delivery care. With 77,011 numbers of

existing doctors and nurses, the country has 23,472 and 5,179 numbers of mid-wives and

community skilled birth attendants (CSBAs), respectively [16].

Undetermined 1%

Hemorrhage 31%

Eclampsia 20%

Indirect Causes 35%

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Table 3: Emergency obstetric care (EOC) services by type of facilities in Bangladesh

Types of EOC Types of facilities Number

Comprehensive Emergency Obstetric Care

(CEmOC)

Medical College Hospital 18

District Hospital 22

Upazila Health Complex 269

24-hour CEmOC Maternal and Child Welfare Center 60

Basic Emergency Obstetric Care (BEOC) District Hospital 59

24- hour BEOC Upazila Health Complex

Maternal and Child Welfare Center

132

29

Source: Maternal, neonatal and child health program in Bangladesh – review of good practices and lessons learned, 2007 [22]; DGHS, 2010.

Additionally, the government conducts an innovative program, which is known as Demand

Side Financing (DSF). The aim of the program is to encourage pregnant women to seek ANC

service, delivery care, and postnatal care from skilled medical personnel. The pregnant

women receive a reimbursable maternal health voucher if she takes any other form of

pregnancy-related health care from a skilled medical personnel or health facilities in the

program area. The maternal health care package consists of three antenatal check-ups, safe

delivery, and a postnatal care within six weeks of delivery and services for obstetric

complications. Women receive a financial benefit for a normal delivery, a delivery with

complication, management of eclampsia, and a case that requires cesarean section.

Moreover, these women receive costs for travel to the health facility and to the district

hospital. Even after the baby is born in the health facility, the mother receives hygienic

toiletries and toys for newborns. In 2009, DSF covered 33 upazilas of Bangladesh; now the

program is continuing 53 upazilas. Beside the government facilities, there are NGOs and

private practitioners, including medical doctors and traditional healers, who also provide

maternal health care services across the country [16].

1.2. Review of the Literature

1.2.1. Skilled Birth Attendants at Delivery

In 2004, the WHO, International Confederation of Midwives (ICM) and the International

Federation of Gynecology and Obstetrics (FIGO) jointly define SBA as an accredited health

professional such as a midwife, doctor or nurse who has been educated and trained to

proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth

and the immediate postnatal period, and in the identification, management and referral of

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complications in women and newborns [23]. According to the definition of SBA, traditional

birth attendants (TBAs), either trained or not, are excluded from the category of SBAs. SBAs

can administer interventions to prevent and manage life-threatening complications or refer

the mother to the higher level of care if required. However, the definition of SBA is context

based. In Bangladesh doctor, nurse, midwife, CSBA, and Family Welfare Visitor (FWV) are

considered as SBA [24]. For this study the later definition of SBA is used.

The presence of SBAs during delivery is crucial. Research findings suggest that although all

women and babies need pregnancy care, care at childbirth is most important for the survival

of pregnant women and their babies [25]. Evidence also establishes a strong association

between having a SBA at delivery and reducing maternal mortality. For example, by

providing professional midwifery care at child birth, industrialized countries halved their

maternal mortality ratios in the early 20th century [6]. Similarly, in the 1950s and 1960s,

Malaysia, Sri Lanka, and Thailand halved their maternal mortality ratios within 10 years by

increasing the number of midwives [6]. International community agreed at the special

session of the United Nations General Assembly in 1999, that globally 80%, 85% and 90% of

all births should be assisted by SBA by 2005, 2010 and 2015, respectively [26]. The WHO

strongly advocates for skilled care at every birth to reduce the global burden of 358,000

maternal deaths, 3 million stillbirths and 3.7 million newborn deaths each year [2, 27].

Through extended coverage of SBAs at delivery, it is possible to reduce maternal mortality.

1.2.2. Delivery Practice in Developing Regions

Worldwide, around 60 million deliveries take place annually where the woman is cared for by

only a family member, an untrained TBA, or no one at all [28]. Although nearly all (99%)

births are assisted by SBAs in developed countries, the proportion is only 35.3% in the least

developed countries [26]. More than half of all births in South Asia still occur at home or in

other non-health facility settings [29]. Of the total, around 48% of deliveries are conducted

by SBAs in this region, while the remaining are conducted by an unskilled person [29].

However, the global target of using an SBA at delivery is 90% by the year 2015 [26]. In

developing regions, women often give birth at home because it is the cheapest option, but it is

also associated with the risk of infection and complication [30].

1.2.3. Delivery Practice of Pregnant Women in Bangladesh

Bangladesh Maternal Mortality and Health Care Survey 2010 reveal that almost 2.4 million

births take place at home annually, especially in rural areas. Of this, only 4.3% of women use

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an SBA to attend deliveries [20]. The survey also reveals that approximately 26% of women

in the country receive assistance from SBAs at delivery either at home or at a health facility

[20], however, the percentage is 32% according to the preliminary report of the Bangladesh

Demographic and Health Survey (BDHS) conducted in 2011 [24]. Despite using assistance

from SBAs, the vast majority of births in the country are delivered by TBAs. TBAs, who are

called dais, are usually family members, relatives, or neighbors with no or very little

knowledge of modern delivery practice. TBAs perform all the tasks related to child delivery

without having any formal training. They use unsterile razor blades to cut the umbilical cord

and uncleaned thread to tie the cord. Sometime they even use cow dung for dressing the

cord. These factors are thought to be the primary sources of childbirth complication, which in

turn leads to what is considered to be a high number of maternal mortality and morbidity in

the country [31]. The tragic consequence of poor maternal health is not only on maternal

mortality and morbidity but also on the babies who are born. The percentage of the babies

born to these women are likely to die within the first week of their life is around 75% [22].

1.2.4. Determinants of the Use of Skilled Birth Attendants

The use of health services is influenced by the characteristics of the health delivery system for

example, accessibility, quality, and cost of the services [3]. However, even where there is a

good supply of services, those services may not be fully used. Even under the same

circumstances of availability, some women are more likely to use services than others.

Therefore, a health delivery system is not the only factor that determines the level of use of

health care services. Other factors such as social characteristics and structure influence the

use of health care services [32]. Several studies emphasize factors like cultural beliefs, socio-

demographic characteristics, economic conditions, and physical and financial accessibility to

be important determinants of the use of maternal health care services [33, 34].

It is well-recognized that parental education, especially mother’s education, plays an

important role in the use of skilled assistance at delivery. Association between women’s

education and the use of maternal health care services is evident [32, 33, 35, 36, 37]. The

mother’s education emerged as an independent factor in determining the choice of delivery

under skilled supervision in a study from Tanzania [38]. Like women’s education, a study

from India points out the husband’s education as a significant predictor of the use of an SBA

at delivery [35]. Educated families have better knowledge on current health practices, as they

are more accessible to resources than their less educated counterparts [31]. This, in turn, may

influence educated families to use proper medical care whenever they perceive it to be

necessary. A study of analysis of choice of delivery location reveals that parental education is

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a predisposing factor in determining the choice of facility for delivery with skilled attendants

[30].

Additionally, women’s age is an important factor which may influence the use of maternal

health care services. The association between a woman’s age and the use of medical services

has been found to be inconsistent across studies. Because of greater exposure to and

knowledge of modern health care, younger women may make more use of modern health

care facilities than older women. Several studies indicate older women are less likely to use

skilled delivery assistance [30, 37, 38]. A women’s age, however, may act as a proxy for the

woman’s accumulated knowledge of health care services. Moreover, women acquire

experience and skills with age. Therefore, older women may use more health care services

than their younger counterpart. A study in Bangladesh suggests a U-shaped relationship

between mother’s age and use of skilled assistance [3].

Similarly, several studies indicate a negative association between higher birth order and the

use of maternal health care services [36, 39, 40]. A study from India affirms that women with

more than two children are less likely to deliver at health facilities [30]. A study from Nigeria

also indicates that women with three or more children are less likely to use SBAs at delivery

[36]. An analysis of the 1993 Turkish Demographic Health Survey shows that women having

their first childbirth are significantly more likely to use professional delivery assistance from

skilled personnel than women in the higher birth order [37]. One explanation for this may be

the perceived risk associated with first pregnancy which influences women to seek for skilled

assistance at delivery for the first birth more than higher birth order [3].

Place of residence is also a well-recognized factor that can affect a woman’s use of health care

service. Living in urban areas increases the probability of pregnant women using skilled

assistance at delivery [37]. A systematic review of inequalities in the use of maternal health

care in developing countries states that urban women are more likely to deliver with

assistance from skilled health personnel than rural women [41]. Similarly, a study in

Bangladesh suggests that the use of SBAs is higher among urban women compared to rural

women [42]. Likewise, a national survey in India highlights that urban women are less likely

to deliver at home compared to rural women [30]. Urban women tend to be more educated

than rural women, which broadens their knowledge about the benefits of modern health care

services [3, 41, 42]. Thus, the urban women may make use of more health care facilities

compared to their rural counterpart.

- 11 -

Furthermore, studies find a positive association between economic status and the use of

skilled assistance at delivery [32, 36, 39]. A study from India indicates that low use of

maternal health care services is due to low level of household income [35]. A similar study in

Nigeria points out a significant association between household socio-economic status and the

use of skilled assistance at delivery. The study affirms that the use of skilled assistance at

delivery is more than four times higher among women from rich and very rich households

compared to the women from very poor households [36]. Likewise, evidence from Nepal

indicates that household economic status is an important factor associated with the use of

professional assistance at delivery [32]. However, some studies argue the association between

economic status and the use of skilled assistance at delivery [43, 44].

Additionally, the occupation of the husband also plays an important role in the use of

maternal health care services by the pregnant women. The occupation of the husband may

also serve as a proxy for family income and status. The husband’s occupation appears as a

significant enabling factor in the use of skilled assistance at delivery [3]. In addition with the

above mentioned factors, religion and the gender of the household head influence the

pregnant women in using services to treat and prevent maternal morbidity and mortality. A

study from Bangladesh reveals that the use of skilled attendants at birth is higher among

women from Hindu religion compared to women from Muslim religion [42]. On the other

hand, studies in India claim that Muslim women are more likely to deliver with skilled

assistance compared to women from Hindu religion [30, 45]. Study from Nepal [32] and

Tanzania [38] show that women from female-headed households are more likely to use

skilled assistance at delivery than women from male-headed households [32, 38].

In summary, the above studies identify several factors that determine the use of SBAs at

delivery including: parental education, women’s age, birth order, religion, gender of the head

of the household, place of residence, household economic status, and the husband’s

occupation. It is also evident that the determinants are not consistent in different regions and

countries; they vary within and between regions and countries.

1.3. Conceptual Framework

The conceptual framework of the use of delivery care services used in this study was based on

Andersen’s Behavioral Model of Health Services Use [46]. This model has been widely used

to understand the factors that determine an individual’s use of health care services [29]. The

model describes that the use of health care services are influenced by three sets of individual

characteristics: predisposing characteristics, enabling resources, and need (Figure 4).

- 12 -

Predisposing factors are the combination of demographic characteristics, social structure,

and health beliefs. Demographic characteristics are the tendency of the individual to use

services which include: age, gender, family size, number of previous pregnancies and marital

status. Social structure such as education, occupation and religion or ethnicity measures the

coping ability of the individual with the problem and availability of the resources. Health

beliefs are the knowledge about health and health care system; for example, attitudes towards

disease and medical care [46]. Enabling factors are factors that make the individual able to

obtain health care services, such as income, health insurance, travel, waiting time, and

availability of the health care providers [46]. Need factors – which are considered to be the

most immediate cause of health service use – are the perception of one’s own health status

and expectation of benefit from the treatment [46]. For this study, the selected independent

variables were in the categories of predisposing and enabling factors.

Figure 4: Andersen’s behavioral model of use of health services (adopted from Andersen RM, 1995).

1.4. Rationale of the Study

In Bangladesh there are services for delivery care which may be insufficient amount, but they

are not adequately used. Studies have been done to identify the determining factors of the use

of SBAs at delivery by the pregnant women in Bangladesh. However, few studies have been

done with country representative data on the use of SBAs. The 2007 BDHS – a national

representative survey – reported the frequency of the use of SBAs at delivery by the pregnant

women of Bangladesh based on different background characteristics. The survey report did

not cover some important factors such as sex of the household head, religion, and husband’s

education and occupation. These factors play an important role in the use of SBAs at delivery.

It is needed to identify these factors in the use of SBAs at delivery. Additionally, the 2007

BDHS did not identify any association between the use of SBAs at delivery and background

characteristics. Therefore, the purpose of this study is to identify those factors that are not

- 13 -

reported in the 2007 BDHS and to determine the factors hindering the use of SBAs at

delivery in Bangladesh by using country representative data.

1.5. Research Question

What are the major factors determining the use of SBAs at delivery by pregnant women of

Bangladesh?

1.6. Aim of the Study

The aim of this study was to estimate the factors related to the use of SBAs at delivery by

pregnant women of Bangladesh.

1.6.1. Specific Objectives

To examine the patterns of the use of SBAs at delivery by pregnant women of

Bangladesh by different background characteristics.

To investigate the determinants of the use of SBAs at delivery by pregnant women of

Bangladesh.

- 14 -

2. METHODS

2.1. Study Design

The study was a cross sectional analysis of the 2007 Bangladesh Demographic and Health

Survey (BDHS) dataset.

2.2. Data Source

Data for this study were collected from the 2007 BDHS, which is part of the global

Demographic and Health Surveys (DHS) program. Under the Ministry of Health and Family

Welfare (MOHFW) of Bangladesh, the 2007 BDHS was conducted by the authority of the

National Institute for Population Research and Training (NIPORT). The survey was

implemented by Mitra and Associates, a Bangladeshi research firm located in the capital city.

To conduct the survey, technical assistance was provided by Macro International Inc. as a

part of its international DHS program and the financial support was provided by the U.S.

Agency for International Development. The 2007 BDHS obtained detailed information on

basic national indicators including: fertility, childhood mortality, contraceptive knowledge

and use, maternal and child health, nutritional status of mothers and children, knowledge

and attitudes of AIDS and other sexually transmitted diseases, and domestic violence. To

obtain detailed information on the above mentioned areas, the 2007 BDHS used five

questionnaires: a Household Questionnaire, a Women’s Questionnaire, a Men’s

Questionnaire, a Community Questionnaire, and a Facility Questionnaire [47].

The Household Questionnaire was used to obtain household level information such as age,

sex, education etc., along with information on the household’s socioeconomic status. The

2007 BDHS did not include the question of household income. However, it collected

information on the source of water, type of toilet facilities, construction material used for the

floor and roof, and ownership of various durable goods such as radio, television, mobile

phone, refrigerator, table, chair, bicycle etc. The Women’s Questionnaire collected

information from ever-married women aged 10-49 on the following topics:

Background characteristics such as age, residential history, education, religion, and

media exposure

Reproductive history

Knowledge and use of family planning methods

Antenatal, delivery, postnatal, and newborn care

Breastfeeding and infant feeding practices

Vaccinations and childhood illnesses

- 15 -

Marriage

Fertility preferences

Husbands’ background and respondent’s work

Awareness of AIDS and other sexually transmitted diseases

Knowledge of tuberculosis

Domestic violence

The Men’s questionnaire collected information from ever-married men aged 15-54 on

background characteristics including respondent’s work, marriage, fertility preferences,

participation in reproductive health care, awareness of AIDS and other sexually transmitted

diseases, knowledge of tuberculosis, injuries, and tobacco consumption, and domestic

violence. The Community and Facility Questionnaires collected information on the existence

of development organizations in the community and the availability and accessibility of

health services and other facilities. These were administered in each selected cluster during

listing. The information obtained by these questionnaires was also used to verify information

gathered in the Women’s and Men’s Questionnaires on the type of facilities respondents

accessed and the health service personnel who saw [47].

To administer the Community and Facility Questionnaires and listing households, 42 field

staffs were trained and organized. The Household, Women’s, and Men’s Questionnaires were

pre-tested by 14 interviewers. Based on the suggestions of the interviewers, revisions were

made in the wording and translation of the questionnaires. Finally, 128 staffs were recruited

and trained to conduct the main survey. Fieldwork was conducted from March 24 to August

24, 2007. A team of quality controllers monitored the quality of the data. Data processing was

started shortly after fieldwork commenced using six microcomputers. Data processing began

on April 16 and ended on August 31, 2007 by ten data entry operators and two data entry

supervisors. Data were entered using CSPro, a program developed jointly by the U.S. Census

Bureau, Macro International, and Serpro S.A [47].

2.3. Sampling Method and Sample of 2007 BDHS

The 2007 BDHS used the sampling frame of the 2001 Population Census of Bangladesh,

which consists of a list of census enumeration areas with population and household

information. The 2007 BDHS was based on a two-stage stratified sample of households. The

proportions of the population of the country were not the same in urban and rural areas.

Thus, the country was divided into strata to achieve statistical precision. At the first stage of

sampling, 361 Primary Sampling Units (PSUs) were selected from the strata. Of the total

PSUs, 134 were from urban areas and 227 were from rural areas. At the second stage of

- 16 -

sampling, lists of households were used as the sampling frame for the selection of

households. On average, 30 households were selected from each PSU, using an equal

probability systematic sampling technique. Finally, 10,400 households were interviewed with

a representative sample of 3,771 ever-married men age 15-54 and 11,051 ever-married women

age 10-49. However, there were very few ever-married women age 10-15. These women have

been removed from the dataset. Therefore, the 2007 BDHS dataset constituted of a

representative sample of 10,996 ever-married women [47].

2.4. Study Participants

In the 2007 BDHS, 10,996 women age 15-49 were interviewed. For this study, the analysis

was limited to the women within the age group of 15-49 who had had at least one birth in the

five years prior to the survey. If the woman had more than one child in the five years

preceding the survey, information on the use of delivery assistance was collected for the last

birth. The total number of women who had had at least one birth in the five years before the

survey was 6,150. There were 18 cases in which information on assistance at delivery was

missing, and these cases were excluded from the analysis. At the end 6,132 cases were

included in the analysis.

2.5. Variable Specification and Selection

2.5.1. Dependent Variable

Assistance at delivery: In the 2007 BDHS, the respondents (ever-married women age 15-49)

were asked, with respect to the last birth occurring in the five years preceding the survey, who

assisted with the delivery. From this specific question, dichotomous variable was created for

this study. It was coded as 1 if the woman received assistance at delivery from SBAs

including: qualified Doctor, Nurse or Midwife, Family welfare visitor (FWV), and Community

skilled birth attendant (CSBA) either at home or at a health facility and 0 if otherwise.

2.5.2. Independent Variables

Based on the Andersen’s behavioral model of the use of health services, nine independent

variables were included in this study. Six variables were from predisposing factors and three

were from enabling factors. Definition and coding of the independent variables which

employed in this study are presented in the Table 4 on the following page.

- 17 -

Table 4: Independent variables used in the study: definitions and categories

Variables Description

Predisposing factors: Women’s age In the survey, women’s age was ranging from 15-49. In this study, women were

classified into three age groups. These were code as 0, 1, and 2 for the age groups of 15-19, 20-34, and 35-49, respectively.

Women’s education

This referred to the highest levels of education of the women. In the survey, women were classified into four levels of education including: no education, primary, secondary, and higher education. In this study, women were categorized into three categories and were coded as 0, 1, and 2 for the level of education of no education, primary education, and more than primary education, respectively. The number of women in the higher education group was too small to be treated under separate category; thus, such women were included in secondary category, and this category was than recoded as more than primary education.

Husband’s education

Similar to the level of education of women.

Birth order This was the order in which a woman’s children were born ranging from 1-12 births. In this study, birth order was categorized into 4 categories including: 1 birth, 2-3 births, 4-5 births, and 6 or more births and were coded as 0, 1, 2, and 3, respectively.

Religion This variable was derived from the type of religion that the women had at the time of the survey. In the survey, women were classified into five different religions namely Muslim, Hinduism, Buddhism, Christianity, and others. In this study, women were classified into two categories as Muslim and Other religions and were coded as 0 for Muslim and 1 for Other religions. The number of women in the Buddhism, Christianity, and others religions were too small to be treated under separate categories; thus, such women were included in the Hinduism category, and this category was then recoded as Other religions.

Sex of household head

This variable was created on the basis of the sex of the household head at the time of the survey. In this study, sex of the head of the household was coded as 1 for female and 0 for male.

Enabling factors: Husband’s occupation

This was based on the question of the type of work that the respondent’s husband does primarily. In this study, husband’s occupations were categorized into two categories including: unskilled work and skilled work, and were coded as 0 and 1, respectively. Husbands who worked in agriculture, unskilled manual work, and who never worked were classified as unskilled work and those who were involved in business, services, and skilled manual work were classified as skilled work.

Place of residence

This variable was based on where the respondent was interviewed, either urban or rural. This was not respondent’s own categorization, but was created based on whether the cluster or sample point number was defined as urban or rural. Urban areas were classified into large cities (capital cities and cities with over 1 million people), small cities (population over 50,000), and towns (other urban areas) and all rural areas were assumed to be countryside. In this study, the women’s type of place of residence was coded as 1 for rural and 0 for urban.

- 18 -

Table 4: Independent variables used in the study: definitions and categories (Continued)

Variables Description

Wealth index In the 2007 BDHS, wealth index was constructed from data on household possession. This was based on the questions about whether a household had items such as radios, televisions, and bicycles, and facilities such as type of floor, piped water, toilets, and electricity. Each asset was assigned a weight, and each household was then assigned a score for each asset, and the scores were summed for the particular household. Individuals were then ranked according to the total score. The higher the score, the higher the economic status of the household. This variable was coded as 0, 1, 2, 3, and 4 for poorest, poorer, middle, richer, and richest, respectively.

2.6. Data Collection

In the primary survey, data were collected using five questionnaires: a Household

Questionnaire, a Women’s Questionnaire, a Men’s Questionnaire, a Community

Questionnaire, and a Facility Questionnaire. For this study, only selected data collected using

the Household Questionnaire and the Women’s Questionnaire were used. Data were directly

downloaded from the MEASURE DHS website after proper permission was obtained

(http://legacy.measuredhs.com/login.cfm) [48].

2.7. Ethical Consideration

To get access to the dataset of the 2007 BDHS, a written request was sent to the MEASURE

DHS and permission was granted to use the data for this study.

2.8. Data Analysis

The unit of analysis in this study was an ever-married woman, who had had at least one birth

in the five years preceding the survey. Data cleaning and analysis were carried out using

STATA SE, Version 10.1. Variables were re-coded to meet the desired classification.

Descriptive statistics (frequencies and percentages) were carried out to describe the data and

to estimate the patterns of the use of SBAs at delivery. The dependent variable being

dichotomous, logistic regression analysis was carried out by taking each independent variable

against the outcome variable to estimate the effect of the indicator variables on the outcome

variable. Odds ratio (OR) and 95% confidence interval (CI) were calculated. The significance

level of this study was p-value <0.05. Multivariate analysis was not used in this study because

some of the independent variables were highly correlated.

- 19 -

3. RESULTS

3.1. Characteristics of the Women

A total of 6,132 women fulfilled the study eligibility criteria and were included in the

analyses. Table 5 below represents the background characteristics of the women. Of the total

respondents, slightly more than 91% were from Muslim religion and over 90% were from

male-headed household. With the median age of 25, approximately 75% of women were in

the age group of 20-34. The majority (65.79%) of women lived in rural areas, while the

remaining 34.21% lived in urban areas. Among the respondents, with the median of 2

children, 42.68% had 2-3 children. Socioeconomic variables showed that 31.34% of women

were from primary level of education and 41.42% were from more than primary level of

education. The percentage of women who had no education was 27.23%. Regarding wealth

index, the percentages of women from different wealth categories were almost the same.

Among husbands, over 34% had no education, while more than 37% had more than primary

level of education and 28.47% had primary level of education. More than half (55.63%) of

husbands were involved in unskilled work, while around 43% worked in skilled work.

Table 5: Background characteristics of the women who had at least one birth in the five years preceding the survey, Bangladesh 2007

Characteristics % Number

Demographic characteristics: Women’s age (years) 15-19 20-34 35-49

14.38 75.18 10.44

882

4610 640

Birth order 1 2-3 4-5 ≥6

33.19 42.68 16.47 7.66

2035 2617 1010 470

Religion Muslim Other religions

91.21 8.79

5593 539

Place of residence Urban Rural

34.21 65.79

2098 4034

Sex of the household head Male Female

90.83 9.17

5570 562

Socio-economic characteristics: Women’s education No education Primary More than primary

27.23 31.34 41.42

1670 1922 2540

Husband’s education No education Primary More than primary

34.07 28.47 37.46

2089 1746 2297

- 20 -

Table 5: Background characteristics of the women who had at least one birth in the five years preceding survey, Bangladesh 2007 (Continued)

Characteristics % Number

Husband’s occupation Unskilled work Skilled work

55.63 44.37

3411 2721

Wealth index Poorest Poorer Middle Richer Richest

19.85 20.84 18.79 18.69 21.84

1217 1278 1152 1146 1339

Total 100 6132

3.2. Usage Patterns of Skilled Birth Attendants at Delivery

Of the total 6,132 births, only 20.80% were attended by SBAs either at home or at a health

facility, while the remaining 79.20% were conducted by TBAs and family member or

relatives. Table 6 on the following page represents the distribution of women according to the

use of assistance at delivery by different predisposing and enabling factors.

Predisposing Factors

Table 6 shows that the type of assistance used at delivery did not differ notably among

women from different age groups. Differences are evident among women with different levels

of education. The percentage of women who received assistance from SBAs at delivery

increased from 4.79% among women with no education to 38.66% among women with more

than primary education. Likewise, slightly more than 11% of women with primary education

used assistance from SBAs at delivery (Table 6). A similar trend was seen between the

husband’s level of education and the use of skilled delivery assistance. More than 39% of

women whose husbands had more than primary education received assistance from SBAs at

delivery compared to 6.41% of women whose husbands had no education. Similarly, 13.17%

of women whose husbands had primary education received skilled assistance at delivery

(Table 6). The percentage of women who received assistance from SBAs gradually decreased

with increasing number of births. Among women who had had one birth, the percentage of

those who received assistance at delivery from SBAs was 32.04%, while the percentage

declined substantially to 4.04% for those who had had six or more births. Around 19% of

women with 2-3 births used SBAs at delivery compared to 8.91% of women with 4-5 births

(Table 6). More than 26% of women from other religions received assistance from SBAs at

delivery compared to slightly over 20% among Muslim women (Table 6). Compared to male-

headed households, 4.34% more women from female-headed households used SBAs at

delivery (Table 6).

- 21 -

Table 6: Percent distribution of women who had at least one birth in the five years preceding the survey according to the use of SBAs by different background characteristics, Bangladesh 2007

Variables Skilled assistance at delivery Number Used (%) Not used (%)

Predisposing factors: Women’s age (year) 15-19 20-34 35-49

171 (19.39) 993 (21.54) 111 (17.34)

711 (80.61)

3617 (78.46) 539 (82.66)

882

4610 640

Women’s education No education Primary More than primary

80 (4.79)

213 (11.08) 982 (38.66)

1590 (95.21) 1709 (88.92) 1558 (61.34)

1670 1922 2540

Birth order 1 2-3 4-5 ≥6

652 (32.04) 514 (19.64)

90 (8.91) 19 (4.04)

1383 (67.96) 2103 (80.36) 920 (91.09) 451 (95.96)

2035 2617 1010 470

Religion Muslim Other religions

1132 (20.24) 143 (26.53)

4461 (79.76) 396 (73.47)

5593 539

Sex of household head Male Female

1136 (20.39) 139 (24.73)

4434 (79.61) 423 (75.27)

5570 562

Husband’s education No education Primary More than primary

134 (6.41)

230 (13.17) 911 (39.66)

1955 (93.59) 1516 (86.83) 1386 (60.34)

2089 1746 2297

Enabling factors: Husband’s occupation Unskilled work Skilled work

418 (12.25) 857 (31.50)

2993 (87.75) 1864 (68.50)

3411 2721

Place of residence Urban Rural

774 (36.89) 501 (12.42)

1324 (63.11) 3533 (87.58)

2098 4034

Wealth index Poorest Poorer Middle Richer Richest

65 (5.34) 81 (6.34)

140 (12.15) 296 (23.47) 720 (53.77)

1152 (94.66) 1197 (93.66) 877 (87.85) 882 (76.53) 619 (46.23)

1217 1278 1152 1146 1339

Total 1275 (20.80) 4857 (79.20) 6132

Enabling Factors

Table 6 shows that more than 31% of women whose husbands worked in skilled work

received skilled assistance at delivery compared to 12.25% of women whose husbands were

involved in unskilled work. Nearly 37% of urban women delivered with professional

assistance compared to 12.42% of rural women (Table 6). The percentage of women who

received assistance from SBAs gradually increased as the household economic status

increased. The percentage of women who received assistance from medically trained

- 22 -

personnel increased from 5.34% among women who were in poorest category to 53.77%

among women who were in richest category (Table 6).

3.3. Logistic Regression Analyses

The outcome variable being dichotomous, logistic regression analysis was carried out by

taking each independent variable against the outcome variable to estimate the effect of the

indicator variables on the outcome variable. Since the rural and urban women were different

in most of the characteristics, separate logistic regression analyses were carried out for urban

and rural women to get the precise results. Table 7 on the following page represents the

results derived from logistic regression analyses for use of assistance at delivery.

Predisposing factors

Women’s age

Table 7 shows that the odds of using SBAs at delivery did not differ significantly among

women from 20-34 years age group (OR=1.14, CI: 0.95-1.37) and 35-40 years age group

(OR= 0.87 CI: 0.67-1.14) in the total sample (Table 7). The difference of odds ratio of using

SBAs at delivery between urban women from 35-49 years age group (OR= 0.99, CI: 0.68-

1.44) and rural women from the same age group (OR= 0.58, CI: 0.37-0.89) was 0.41 (Table

7).

Women’s education

The results showed that the odds of delivering with assistance from SBAs significantly

increased as the level of education of the women increased. Women with primary education

(OR=2.48, CI: 1.90-3.23) had 2.48 times higher odds of delivering with assistance from SBAs

compared to women with no education (Table 7). Similarly, women with more than primary

education (OR=12.53, CI: 9.87-15.90) had 12.53 times higher odds of using SBAs at delivery

compared to women with no education (Table 7). When compared urban women with more

than primary education (OR= 17.81, CI: 12.29-25.82) to rural women from the same level of

education (OR= 8.12, CI: 5.91-11.16), the difference of odds ratio of using SBAs at delivery

was 9.69 (Table 7). The odds of delivering with SBAs were 2.01 for the rural women with

primary education (OR= 2.01, CI: 1.40-2.89), while the odds was 2.85 for the urban women

with the same level of education (OR= 2.85, CI: 1.90-4.27) (Table 7).

Birth order

The results showed a significant negative association between the use of SBAs at delivery and

higher birth order. Women with 2-3 births (OR=0.52, CI: 0.45-0.59) had 48% lower odds of

- 23 -

using assistance from SBAs at delivery compared to the women with only one birth (Table 7).

Likewise, women with 4-5 births (OR=0.21, CI: 0.16-0.26) and ≥6 births (OR=0.09, CI: 0.06-

0.14) had 79% and 91%, respectively, lower odds of delivering with assistance from SBAs

compared to the women with one birth (Table 7). The differences of odds of using SBAs at

delivery among rural and urban women with different number of births were not noticeable

(Table 7).

Table 7: Logistic regression results with OR and 95% CI for the use of SBAs by the pregnant women who had at least one birth in the five years preceding the survey, Bangladesh 2007

Variables Total Rural Urban Odds Ratio (95% CI) Odds Ratio (95% CI) Odds Ratio (95% CI)

Predisposing factors: Women’s age (year) 15-19 20-34 35-49

1

1.14 (0.95-1.37) 0.87 (0.67-1.14)

1

1.08 (0.83-1.39) 0.58 (0.37-0.89)*

1

0.98 (0.74-1.29) 0.99 (0.68-1.44)

Women’s education No education Primary More than primary

1

2.48 (1.90-3.23)** 12.53 (9.87-15.90)**

1

2.01 (1.40-2.89)** 8.12 (5.91-11.16)**

1

2.85 (1.90-4.27)** 17.81 (12.29-25.82)**

Birth order 1 2-3 4-5 ≥6

1

0.52 (0.45-0.59)** 0.21 (0.16-0.26)** 0.09 (0.06-0.14)**

1

0.41 (0.33-0.50)** 0.21 (0.15-0.29)** 0.11 (0.06-0.21)**

1

0.56 (0.47-0.96)** 0.22 (0.16-0.31)** 0.08 (0.04-0.18)**

Religion Muslim Other religions

1

1.42 (1.16-1.74)**

1

1.56 (1.17-2.07)**

1

1.60 (1.16-2.20)** Sex of household head Male Female

1

1.28 (1.05-1.57)*

1

1.36 (1.01-1.82)*

1

1.38 (1.01-1.87)* Husband’s education No education Primary More than primary

1

2.21 (1.77-2.77)** 9.59 (7.90-11.64)**

1

2.27 (1.67-3.09)** 7.13 (5.42-9.36)**

1

1.98 (1.42-2.75)** 9.98 (7.49-13.30)**

Enabling factors: Husband’s occupation Unskilled work Skilled work

1

3.29 (2.89-3.75)**

1

2.04 (1.69-2.46)**

1

3.56 (2.91-4.34)** Place of residence Urban Rural

1

0.24 (0.21-0.28)** -- --

Wealth index Poorest Poorer Middle Richer Richest

1

1.20 (0.86-1.68) 2.45 (1.81-3.33)** 5.44 (4.09-7.23)**

20.61 (15.71-27.06)**

1

1.16 (0.79-1.69) 2.30 (1.63-3.24)** 4.98 (3.59-6.89)**

12.19 (8.63-17.21)**

1

1.18 (0.54-2.61) 2.42 (1.18-4.97)*

4.94 (2.51-9.72)** 18.86 (9.79-36.31)**

[*=p<0.05; **=p<0.01; CI=Confidence Interval]

- 24 -

Religion

Women from other religions were significantly more likely to use skilled assistance at

delivery. These women (OR= 1.42, CI: 1.16-1.74) had 42% higher odds of delivering with

assistance from SBAs at delivery compared to the women from Muslim religion (Table 7).

The odds of using SBAs were almost the same among women from Muslim religion and other

religions when compared urban women to rural women (Table 7).

Sex of household head

Women whose household head was female (OR=1.28, CI: 1.05-1.57) had 28% higher odds of

using SBAs at delivery compared to the women whose household head was male (Table 7).

The odds of delivering with SBAs were almost the same among urban and rural women with

different sex of household head (Table 7).

Husband’s education

Similar women’s education, husband’s education also had a significant influence on the use

of SBAs at delivery. Women whose husbands had primary education (OR=2.21, CI: 1.77-2.77)

and more than primary education (OR=9.59 CI: 7.90-11.64) had 2 times and 9.59 times,

respectively, higher odds of delivering with skilled assistance compared to the women whose

husbands had no education (Table 7). When compared urban women whose husbands had

more than primary education (OR= 9.98, CI: 7.49-13.30) to rural women with husbands from

the same level of education (OR= 7.13, CI: 5.42-9.36), the difference of odds ratio of using

SBAs at delivery was 2.85 (Table 7). Similarly, rural women whose husbands had primary

level of education (OR= 2.27, CI: 1.67-3.09) were more likely to receive SBAs at delivery

compared to their urban counterpart with husbands from the same level of education (OR=

1.98, CI: 1.42-2.75) (Table 7).

Enabling factors

Husband’s occupation

Table 7 shows that, women whose husbands worked in skilled work were significantly more

likely to receive assistance from SBAs at delivery. The odds of using delivery assistance from

SBAs were 3.29 times higher among women whose husbands involved in skilled work (OR=

3.29, CI: 2.89-3.75) compared to the women whose husbands worked in unskilled work

(Table 7). When compared urban women whose husbands were involved in skilled work

(OR= 3.56, CI: 2.91-4.34) to rural women with husbands from the same occupational group

(OR= 2.04, CI: 1.69-2.46), the difference of odds ratio of using SBAs at delivery was 1.52

(Table 7).

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Place of residence

The logistic regression analysis of place of residence showed that the urban women were

more likely to receive assistance from SBAs at delivery compared to their rural counterpart.

Women from rural areas (OR=0.24, CI: 0.21-0.28) had 76% lower odds of using SBAs at

delivery compared to the urban women (Table 7).

Wealth index

Women who were classified as belonging to poorest and poorer categories were more likely to

receive assistance from unskilled attendants compared to their richest and richer

counterparts. Women from middle wealth group (OR=2.45, CI: 1.81-3.33) had 2.4 times

higher odds of using SBAs at delivery compared to the women from poorest wealth group

(Table 7).The odds of delivering with assistance from SBAs among women from richer

(OR=5.44, CI: 4.09-7.23) and richest wealth group (OR=20.61, CI: 15.71-27.06) were 5.4

times and 20.6 times, respectively, higher compared to the poorest women (Table 7).The

result for poorer group was not significant. The difference of odds ratio between urban

women from richest wealth group (OR= 18.86, CI: 9.79-36.31) and rural women from the

same wealth group (OR= 12.19 CI: 8.63-17.21) was 6.67 (Table 7). The differences among

urban and rural women from other wealth groups were almost the same.

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4. DISCUSSION

4.1. Discussion of the Main Findings

This study was based on the 2007 BDHS data, which involved a nationally representative

sample. A total of 6,132 women were included in this study to examine the patterns of the use

of SBAs at delivery and to determine the factors that influence the use of skilled assistance at

delivery. Among rural women, the percentage of using SBAs at delivery was only 12.42%,

while the percentage was more than 36% for the urban women. Our results show that the

level of use of skilled assistance at delivery among women in Bangladesh is low. Indeed the

use of skilled assistance at delivery is lower in Bangladesh than in many other countries in

South East Asia. In our study we found that 20.80% of Bangladeshi mothers used SBAs at

delivery for their last birth, however, the 2011 BDHS-preliminary report reveals that the use

of SBAs at delivery in Bangladesh is 32% [24]. Still the percentage is low compared to other

countries in South East Asia. For example the comparative figures are 47% for India (2007

National Family Health Survey), 39% for Pakistan (2006-7 DHS), 73% for Indonesia (2007

DHS), and 95% for Maldives (2009 DHS) [49-52]. This low use of SBAs at delivery in

Bangladesh is for several reasons. First, unexpected user fee is one of the reasons. Pitchforth

et al observed that, although EOC is normally free of charge in Bangladesh, families face

considerable out-of-pocket expense. In their study no women reported to give money to any

doctors or nurses, but the women made payment to other staffs such as wardboys and ayas

(female workers responsible for cleaning). The payments were demanded for the staff’s

scheduled job such as moving the patient between wards and taking them to the toilets [53].

Second, local culture and religious believes play an important role is using SBAs at delivery.

Parkhurst and Rahman observed that it is common for family members to visit some kind of

spiritualists before delivery. Family members collect spiritual remedy such as protective

amulet or items and oil or holy water for the laboring women [54]. In Bangladesh women

especially from Muslim religion do not speak to males who are unknown to them even with

doctors; instead, husbands or sons explain women’s health condition to the doctor. Because

of greater comfort, women prefer female service provider. Most of the SBAs in Bangladesh

are males and from outside of the locality, while TBAs are usually females and are locally

available. Therefore, these women receive assistance at delivery from TBAs and relatives or

neighbors [31, 55]. Third, distance to health facility is also an important barrier in using SBAs

at delivery. Most of the health facilities are situated in the urban areas. Additionally, all

specialized hospitals and medical college hospitals are located only in the urban areas

whereas around 74% of the population lives in the rural areas. In contrast, TBAs are locally

available and are highly affordable [54, 55]. Finally, the poor quality of the available services

and inattentive or discourteous behavior of the providers are also a major concern to not use

skilled assistance at delivery [53, 54, 55].

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The analyses showed that among the predisposing factors, parental education appeared as a

strong predictor of the use of skilled assistance at delivery. Similarly, birth order was seen to

be strongly associated with the use of SBAs at delivery; however, the association was

negative. Women’s age did not appear as a significant influencing factor in the use of SBAs at

delivery. We found that mothers other than those of Muslim were more likely to use SBAs at

delivery. The analyses also showed that female household heads significantly influenced the

use of SBAs at delivery. Among the enabling factors, husband’s occupation and place of

residence found to be strong predictors of the use of SBAs at delivery.

In our study, we found a negative relationship between age and the use of SBAs at delivery,

however; the finding was not significant. This finding accepts some previous studies, which

indicate that older women are less likely to use skilled delivery assistance [37, 38]. This can

be explained by the fact that with age women gain more experience regarding childbirth,

which influences them to not use skilled assistance at delivery.

As have many other studies, our study showed a significant positive association between

education of the women and the use of skilled assistance at delivery for both urban and rural

women [3, 31, 36, 37, 38]. Education serves as proxy for information and knowledge of

available health care services [36]. Education also serves as proxy for women’s higher socio-

economic status that improves the ability of educated women to afford the cost of health care

services [3]. It is also likely that education enhances level of autonomy and increases female

decision-making power that results in improved freedom to make decisions including

maternal health care services [37, 56]. Moreover, educated women are considered to have

better knowledge and information on modern health care services [36]. These factors,

therefore, enable women to seek for safer childbirth under the supervision of skilled

attendants. A Tanzanian study reported that educated women were more likely to make a

decision to use assistance from medical personnel at delivery compared to their uneducated

counterpart [38]. Women’s education was found by Chakraborty et al in Bangladesh [3],

Navaneetham et al in India [45], and Celik et al in Turkey [37], to be a strong determinant of

the use of skilled assistance at delivery. Similar women’s education, our study also found

husband’s education as an important predictor of the use of SBAs at delivery. This finding

conforms with some previous studies [30, 31, 42]. It is likely that an educated family will

have a better understanding and knowledge of modern health care services. Education also

leads to better awareness of available services [31, 36]. These, in turn, sensitize the educated

family to make use of available services including maternal health services whenever they

perceive it to be necessary. Studies by both Thind et al in India [30] and Paul et al in

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Bangladesh [31] reported that husband’s education is a strong influencing factor for using

professional assistance at delivery.

Whereas a previous study from rural Bangladesh find a U-shaped relationship between

higher birth order and the use of professional assistance at delivery [3], we found a

significant negative association between higher birth order and the use of SBAs at delivery for

both rural and urban women. Our finding agrees with several other studies that find negative

association between higher birth order and the use of skilled delivery assistance [30, 37, 45,

57]. This finding can be explained by a reason that fear of complication or lack of confidence

is of women who experience first birth and thus, are more likely to use SBAs at delivery than

women with higher birth order [3, 57]. Conversely, women with more children believe

themselves to be more experienced in childbirth, hence, are less likely to use skilled

assistance at delivery [57]. The low use of SBAs at delivery among women of higher number

of children can also be due to the resource constraints in the family as there are many

demands in the family [3]. Another reason that can be ascribed that women with lower birth

order were more educated then were women from higher birth order; in this study nearly half

of the women with more than primary education had a birth order less than two.

In this study, we found that women who are not Muslim are more likely to use skilled

assistance at delivery compared to their counterpart of Muslim women. Our finding conforms

with a study by Anwar et al indicating that Muslim women are less likely to use skilled

assistance at delivery compared to women from other religions [42]. A possible reason for

this finding may be the local tradition and culture that influence Muslim women not to use

SBAs at delivery. This is supported by Paul’s observation cited in Paul et al [31], indicating

that the rural people in Bangladesh believe that pregnancy is a gift of God and childbirth is a

natural event. Therefore, they do not expect any complications and do not use skilled

assistance at delivery. Moreover, rural Muslim women do not usually talk to males unknown

to themselves. However, most of the deliveries at rural health centers are attended by

assistance from males [31, 42]. This presence of males, in turn, may act as an important

barrier to the use of SBAs at delivery by the Muslim women in Bangladesh. The other reason

may be the women from other religions were from families who have a higher level of

education. In this study around 3% more women from other religions than women from

Muslim religion had more than a primary education. Similarly, about 8% more women whose

husbands had more than a primary education were from other religions.

This study shows that women from female-headed households were more likely to use SBAs

at delivery than were women from male-headed households. Similar findings from a study in

- 29 -

Nepal [32] and Tanzania [38] affirm the present study’s result. This result can be due to

several reasons. For example, one reason is that being female, the household heads are more

aware of delivery complications. Another reason may be that the women can talk more easily

with the female head about their fear of complications and other problems. Therefore, the

female household head encouraged women and make the decision to use SBAs at delivery.

Usually the head of the household has the overall control over the household resources.

Therefore, the head irrespective of sex, can make a decision regarding the use of resources.

The female household heads use more resources to afford maternal health care services; this

is supported by research finding from India which indicates that a woman's control over

household resources has a significant positive effect on the use of antenatal care and

professional delivery assistance [58].

In this study, urban women were significantly associated with increased odds of delivering

with skilled assistance. This finding reflects the finding of several previous studies which

have reported a significantly higher use of skilled assistance at delivery by urban women

compared to rural women in Bangladesh [42] and elsewhere [30, 37, 41]. A reason for this

may be the availability of health facilities, because health facilities are much more convenient

in urban areas than rural areas in developing countries like Bangladesh. This close proximity

allows urban women greater access to information and knowledge regarding modern health

care facilities, which influences them to use these facilities. This is supported by Anwar et al

indicating that women who live more than five km from the health facility are significantly

less likely to receive skilled assistance at delivery [42]. Other reasons may be that the urban

women are from the families who have a higher level of education and have a higher level of

household economic status. In this study, nearly half (49.62%) of urban women had more

than primary education, while the percentage was 37.16% for the rural women. Similarly, the

percentage of urban women whose husbands had more than primary education was

approximately 49%, while it was 31.46% for the rural women. The majority (67.83%) of the

urban women were classified within richer and richest categories, while roughly 26% of rural

women were classified similarly. This finding is consistent with previous studies in Turkey

and Ethiopia among others [37, 57].

This study’s finding regarding the positive association between economic status of the

household and the use of SBAs at delivery concurs with previous reports in Bangladesh [42]

and elsewhere [32, 35, 36]. The study in Bangladesh that aimed to assess the inequity in

maternal health care services, have reported that women with the highest asset quintile were

almost three times higher than the lowest quintile women to use skilled assistance at delivery

[42]. We found that the odds of using SBAs at delivery consistently increased as the

- 30 -

household economic status increased. A reason for this finding may be that the family

members from higher level of household economic status are more aware of existing modern

health care services and can afford those services easily. The costs of seeking skilled

assistance at delivery may act as an important barrier to women from poorer households.

Another reason may be that the women who were classified as belonging to the richer and

richest wealth index had a higher level of education. In this study, around 72% and more than

56% of women from richest and ricer wealth index, respectively, had more than a primary

education.

In this study, women whose husbands worked in skilled work such as business and services

were more likely to use SBAs at delivery compared to the women whose husbands were

involved in unskilled work. This finding consistent with a study by Chakraborty et al in

Bangladesh indicating husband’s occupation as a significant predictor to use skilled

assistance at delivery [3]. Husband’s occupation also serves as proxy for household economic

status. As it is discussed earlier, the more the household economic status the more likely to

use skilled assistance at delivery.

4.2. Limitations of the Study

There are several limitations in the interpretation of the results of this study. First, the

logistic regression results are not adjusted for other independent variables because of some

variables which were highly correlated. Therefore, the findings may be imprecise in

estimation. Second, this study was based on the analyses of the 2007 BDHS data set.

Recently, the 2011 BDHS preliminary report has been published. Thus, the findings of this

study are not up to date. As yet, the 2011 BDHS data set are not publicly available. Therefore,

the present study cannot include the analyses of the 2011 BDHS data set and the study

started before this recent survey. Third, because of the cross-sectional nature of the data, the

analysis can only provide evidence of statistical association between independent variables

and the use of SBAs at delivery and cannot show cause-effect relationship. Fourth, the 2007

BDHS did not collect information about many of the other recognized factors such as the

quality of services, cultural influences, the attitude of health care providers towards

clients, and psychosocial factors. Therefore, the study cannot provide additional

information about these factors, which are considered to be related to the use of maternal

health services. Finally, because data on distance to the health facilities were not collected, a

proxy measure of place of residence was taken for this study. Thus, it is not possible to

directly assess the effects of other factors on the accessibility to the health facilities.

Nevertheless, as the 2007 BDHS uses a well-established methodology that is used in

- 31 -

many countries and subject to good quality assurance procedures, the information

collected on the studied variables is valid and important.

- 32 -

5. CONCLUSION

This study has identified a number of important factors that influence the use of skilled

assistance at delivery by pregnant women of Bangladesh. The use of skilled attendants at

delivery was found to be very low and unequally distributed. The distribution of the use of

SBA varied among women with different demographic and socio-economic characteristics.

The logistic regression analysis indicated parental education as the most significant

predictive factors for the use of skilled assistance at delivery. Therefore, informal adult

education for women and men can be employed as an immediate intervention to provide

basic education and to increase awareness about basic maternity care. Besides, special efforts

and attention to improve formal education of the girls and boys are needed in a long run.

Higher birth order appeared as a strong predictor to not use of professional assistance at

delivery. Therefore, raising awareness about the use of SBAs among women and men through

mass media and local human resources (religious leader, political leader, school teacher,

village headman, and singer) may be an immediate intervention accompanied by improving

access to family planning as a long term strategy. Women from Muslim religion were less

likely to use SBAs at delivery. Further qualitative study needs to be conducted to explore the

insights of the women. However, as the religious leaders are considered influential persons

especially in the rural areas, meetings or seminars with them can be a way of short term

intervention to discuss the consequences of not using skilled assistance at delivery. Women

from rural areas, women whose husbands were involved in unskilled work, and women from

lower wealth index were at a greater disadvantage in using SBAs. Informal education and

vocational training for those groups of women may serve as an immediate strategy to

improve the use of SBAs at delivery. Informal education and vocational training will enable

the women to acquire skills and be engaged in income generating activities. These skills and

activities will empower the women and improve their access and the use of health care

services and SBAs at delivery in particular. Additionally, special attempts of delivery care

services should be prepared for those groups of women as a long term strategy. For example,

more services should be offered to the rural areas with mass awareness program to use those

services and a reimbursable maternal health voucher by the government facilities can be

introduced.

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