Research Reports (2002): Health Studies, Vol - XXXII

Permanent URI for this collectionhttps://hdl.handle.net/10361/13051

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Skilled attendance at delivery in Bangladesh: a strategy development tool
(BRAC Research and Evaluation Division (RED), 2002-11) Chowdhury, AMR; Mahbub, Amina; Chowdhury, Anita Sharif; Kamal, Faiza Ela; Ahmed, Syed Masud
SAFE study aimed to provide new knowledge on the identification, implementation and evaluation of effective, affordable and equitable strategies to increase Skilled Attendance at delivery in developing countries. It was a multi country research and five countries .. including Bangladesh were involved in this study. The main purpose of SAFE study was to develop a Strategy Development Tool (SDT), which would enable the policy makers and programme planners to systematically gather and interpret information on skilled attendance at delivery. The SDT contained five components, which revealed the collection, analysis and synthesis of existing and new data on skilled attendance. The five modules were: problem identification, situation analysis, needs assessment, quality of clinical care and synthesis. The cost of the application of the SDT was also examined during SAFE study as part of the field test to consider the affordability. In Bangladesh under SAFE study using the SDT, certain strategy options to promote skilled attendance at delivery were developed. The key findings in SAFE study and the strategy options are given in the following. A review of existing literature showed that in Bangladesh only 7% of deliveries were assisted by qualified medical practitioners, while 22% by relatives and almost half by traditional birth attendants (TBAs). At community level where home delivery was almost universal certain factors were related to skilled attendance at delivery: mother's age and education, religion, residence poverty status and child's birth order. It was found that proportion of deliveries done at health facilities were highly inequitable. Whereas the proportion of well-to-do women delivering in a facility was 17.3 percent, it was less than one percent for the poorest women. DHS 1 data (1999-'00) revealed that women who had used health facilities for other health services like immunisation, contraception, and antenatal care (ANC) in the past used health facilities for deliveries more frequently compared to others. DHS data also showed that the proportion delivered at a Govt. Hospital increased by four times who had 4+ ANC visits, but the need assessment study reve~led that ANC during pregnancy was not that considered important by the women for the purpose of delivery; The need assessment study also identitied a number of barriers at different levels which hindered women's access to fomlal deiivery care. At individual level women were not , willing to deliver in the hospital due to shame, fear of caesarean and death. At family level it was noted that the major decision makers i.e. mothers-in-law, husbands were the least knowledgeable about different level of obstetric services, which eventually increased the expenditure of delivery care. In the need assessment study, the villagers pointed out that in emergencies the neighbours extended their cooperation. However, as most of them were poor, often it was difficult for them to provide financial support or loans. Thus, economic constraints were noted as one of the major hindrances in accessing fonnal delivery care services. At community level it was found that neighbours discouraged to go to the health facilities for delivery care and over dependence on TBAs was also noted. The key informants pointed out that although many NGOs in Bangladesh had motivational activities at community level, but those were not adequate for promoting skilled attendance. The study revealed that at facility level unfriendly behaviour of the healthcare providers, lack of female doctors and problems in the system of referral prevented people's access to formal delivery care The study indicated that doctors at Upazila (sub district) level mostly did not have specialised obs & gynae training, which limited service provision. The qualified health care providers were found to be concentrated in the urban areas and few female doctors could be found in rural areas. Most of the key informants opined that lack of professional commitment was a major problem in promoting skilled attendance in Bangladesh. The doctors posted at the Upazilas were mostly found not to reside in the campus and were more interested in private practice.
Neonatal death: any role for development interventions?
(BRAC Research and Evaluation Division (RED), 2002-09) Hashima-e-Nasreen
Objective: The study aimed to explore whether or not the women focused development interventions have any effect on neonatal death. Methods: The qualitative research method was used. Case study of cases (died within 28 days) and controls (live children and taken from the nearest door of cases) who born during the year 1999-2000 was the main method employed. lCDDR, B surveillance database provided the sampling frame. Results: The antenatal care of mothers and maternal nutrition carried out an important role in reducing neonatal death. On the other hand, physical abuse and emotional stress, and congenital anomalies are associated with increased risk of neonatal death. It is noted that women who were members of any government and non-government organization including BRAC were better exposed to antenatal care and nutrition as well as have had less physical abuse or emotional stress. Nevertheless, the study did not find any effect of mother's reproductive history, and birthing and newborn care on neonatal death. Conclusion: Regular medical check-up, following rules and regulations of antenatal care as well as the development intervention may have an influence over reduced trend of neonatal death over the year. In order to prove this hypothesis, a quantitative study, such as, a nested case-control study can be performed. To address whether or not BRAC's interventions have any influence, the study may, therefore, be performed in both BRAC and non-BRAC area.
Level and determinants of pregnancy care in developing countries: the case of Bangladesh, 1999 - 2000
(BRAC Research and Evaluation Division (RED), 2002-11) Ahmed, Syed Masud; Mahbub, Amina
This study explored the current state of pregnancy care in Bangladesh using data from the Bangladesh Demographic and Health survey (1999-2000), based on a nation-wide representative sample. Data were collected from women with reference to the most recent live birth occurring in the preceding five years. Findings revealed that 72% of the pregnant women did not have any ANC visit while only 8% completed 4 visits. Of those who visited, 77% were attended by health professionals (doctors, nurses, mid-wives). Most of the deliveries (92%) took place at home while only 4% took place in govt. health facilities. Untrained TBAs delivered more than half of the babies while only 7% of the deliveries were attended by qualified medical practitioners and 22% by relatives or other non-professionals. Deliveries by health professionals increased from 10% in 1993-94 to 14% in 1999-2000 (p<O.OOI), due largely to increase in the proportion of delivery attended by doctors from 4.4% to 8.8% during this period. Logistic regression identified mother's age, education, religion, residence, ANC visits and wealth quintiles to be important predictors of the presence of skilled attendants at delivery. The programme implications of these findings are discussed.
Changing health-seeking behaviour in the context of development interventions: experiences from Matlab, Bangladesh
(BRAC Research and Evaluation Division (RED), 2002) Ahmed, Syed Masud; Adams, Alayne M; Chowdhury, Mushtaque; Bhuiya, Abbas
It is generally assumed that socioeconomic development interventions will enhance the-material and social capacities of the poor who are disenfranchised to prevent ill health, and to seek appropriate and timely care. Using cross-sectional data from surveys undertaken in 1995 and 1999 as part of the BRAC-ICDDR, B Joint Research Project in Matlab, Bangladesh, this paper explores patterns of health-seeking behaviour over time, with the hypothesis that exposure to integrated socioeconomic development activities will enhance gender equity in care-seeking, and the use of qualified medical care. While there is tentative evidence of greater gender equity in treatment choice among households benefiting from development interventions, a preference for qualified medical care is not apparent. Findings reveal a striking and generalized rise in selftreatment over the four year period that is attributed to the repercussions of a major flood in 1998, and greater heath awareness due to the density of community health workers in Matlab. Also noteworthy is the substantial reliance on informal and often unqualified practitioners (over 20%) such as pharmacists and itinerant drug sellers. Factors associated with the type of health care sought were identified using logistic regression. Self-care is associated with female gender, the absence of low cost health services, and illnesses of relatively short duration. Medical care, on the other hand, is positively predicted by male gender, geographic location, greater socioeconomic status, and serious illness of long duration. The paper concludes by emphasizing the importance of enhancing local capacities to determine whether self-treatment is indicated, to self-treat appropriately, or in cases where health care is sought, to judge provider competence and evaluate whether treatment costs are justified. The provision of training on the rational and informed use of allopathic drugs to the full spectrum of informal health care providers is also recommended.
Socioeconomic and regional disparity in the utilization of reproductive health services in Bangladesh
(BRAC Research and Evaluation Division (RED), 2002) Hadi, Abdullahel; Gani, Md. Showkat
Although the health care system has significantly expanded in Bangladesh during the last two decades, the health status of the population has remained very poor because .of the uneven distribution of health services. Inequality in health exists in many forms and multiple dimensions such as age, gender, economic, ethnicity, class, etc. Using data from a nationally re'presentative sample, this study attempts to improve our understanding about the socioeconomic and regional disparity in the utilization of reproductive health services in Bangladesh. Data for this study came from the demographic and health surveillance system of BRAe which provided the updated information of the ownership of household asset. Socioeconomic disparity was measured by constructing a wealth index using compound assets and possessions of a set of household assets based on which the households were classified into wealth quintiles. The surveillance areas were categorized into four regions as urban, rural under-served, other rural and the hill tracts. The utilization of reproductive health services was measured by the access to ante and postnatal care, maternal immunization, and safe delivery. A total of 1,182 women were interviewed who gave birth in 200 I were selected at random. Findings revealed significant household and regional differentials in the use of reproductive health services. The use of health services was much lower among the extreme poor than the non-poor and among the ethnic minorities in the hill and under-served than the other regions. While socioeconomic differentials in the utilization of health services by age, education, land ownership were noticeable, the use of services among women involved in NGO program was found significantly higher than those not similarly involved. Multivariate analysis identifies that older and illiterate women from the extreme poor households who lived in the traditionally under-served region and not involved in NGO-Ied development program were the most deprived and vulnerable groups in receiving reproductive health services. The probability to receive services. however, is likely to significantly increase after involving in NGO-Ied program. The study argues that targeted development intervention has the potential to significantly reduce both the socioeconomic and regional inequality in the utilization of reproductive health services in Bangladesh.
Promoting knowledge of sexual illnesses among women in Bangladesh: can non-governmental organizations play a role?
(BRAC Research and Evaluation Division (RED), 2002) Hadi, Abdullahel; Parveen, Roxana
Integrating ARI prevention with micro credit programme: experience of BRAC, Bangladesh
(BRAC Research and Evaluation Division (RED), 2002) Hadi, Abdullahel
The contribution of ARI control project within the framework of micro credit-based development intervention in promoting maternal knowledge of acute respiratory infections (ARIs) in children was assessed. Data came from a cross-sectional survey of 2,814 mothers of under 5 year-old children residing in 200 randomly selected villages in five districts in Bangladesh. Findings revealed that the ARI control project had significant positive effects in raising knowledge of clinical signs and preventive measures. When ARI control project activities were integrated with the credit-based development initiative, maternal knowledge improved even further. The study concludes that the micro-credit programme can be a catalytic agent in raising health knowledge among the poor women in developing countries.
Fighting arsenic at the grassroots: experience of BRAC's community awareness initiative in Bangladesh
(BRAC Research and Evaluation Division (RED), 2002) Hadi, Abdullahel
The study evaluates the arsenic mitigation project of BRAC in raising awareness of arsenic poisoning in rural communities in Bangladesh. Data came from selected project villages in south-western Bangladesh. Comparison villages were also selected from the same region. A total of 1240 randomly selected adults were interviewed in May 2000. Findings reveal that the mitigation project played a significant, positive role in raising awareness of the safe water options, signs of arsenicosis, mode of transmission and the type of treatment. Testing tube-well water for arsenic created curiosity, innovation and interest in the community, and the water treatment plant became a symbol of the arsenic campaign. The study concludes that the behavioral change aspects of the arsenic mitigation project have the potential to significantly improve the level of understanding about arsenic contamination in the traditional communities.
An approach to reaching the poor and disadvantaged to promote health equity in rural Bangladesh
(BRAC Research and Evaluation Division (RED), 2002) Hadi, Abdullahel
Although the health care system has significantly expanded in the rural areas of Bangladesh duri!lg the . last two decades, the overall health status of the population has remai~ed very poor because of the uneven distribution of health and other basic services. The study asse~sed the contribution of micro credit-based health interventions in reducing the differentials in the access to arid utilization of health services and identified the specific interventions that might promote health equity. Data for this study carne from the demographic and health surveillance system of BRAC covering 70 villages in I 0 regions of the country. The surveillance system provided updated sampling frame from where a total of 3,208 households were selected at random for the survey. One adult woman from each sampled household was selected for the interviews. The survey provided basic socioeconomic information of the households, health status and access to health care and their participation in microcredit program. In-depth interviews were also conducted with key informants such as community health volunteers, local health care providers and the vulnerable individuals to assess the needs and availability of the health care services for the poor. Data were collected in September 200 I. Findings revealed significant socioeconomic differentials in the access to and the utilization of health care in the study communities. Education and landownership were strong predictors of the health service use. Gender differential in health care wa,s not significant. The access to and use of health care were much higher among the micro-credit program participants than non-participants. The health care for the poor should not only be subsidized but the mode of services must be appropriate to reach them. Subsidized treatment and medicines for the extreme poor, targeted and appropriate health services, and closer monitoring of the performance of health service providers was identified as prioritized interventions for the poor. Health services promotion at the grassroots level was costly when it was one-dimensional program. The credit-based health promotion was cost-effective since other components such as income generating activities, adult literacy and basic curative services were added to the package. The study concludes that expanded health services, integrated with poverty-focus development program, can significantly improve the access to and the utilization of health services among the poor in developing countries.

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