Utilization of health facilities and trained birth attendants for childbirth in rural Bangladesh: an empirical study

Abstract

The majority of births in rural Bangladesh are carried out in unhygienic conditions by relatives and traditional birth attendants (TBAs). This results in a high incidence of maternal and infant mortality that could be reduced if childbirth were to occur in health centers or under the supervision of trained TBAs (TTBAs). In this paper, we examined factors associated with utilization of modern health resources for childbirth in 39 villages of Bangladesh. We followed a retrospective survey research design to collect relevant information from couples who experienced childbirth during a two-year period from July 1, 1995 to June 1997. The data indicate that slightly over 11% of the deliveries were performed by trained personnel with the rest attended by TBAs. Multivariate analysis clearly shows that delivery complications was the most significant factor determining the use of modern health care resources for childbirth, followed by parental education, and pre-natal care. We conclude that quick response to delivery complications and improved access to hospitals and TTBAs can reduce the risk of infant and maternal mortality and morbidity in rural Bangladesh.

Introduction

Most births in rural Bangladesh occur at home. The vast majority of these births are delivered by traditional birth attendants (TBAs) called dais, who are usually family members, relatives, or neighbors with little or no knowledge of modern delivery practices. The tasks TBAs usually perform include: delivering the baby, cutting and tying the umbilical cord, extraction and disposal of the placenta, and cleaning of the newborn and mother (see Paul, 1991a). Unsanitary and harmful practices of these TBAs—such as cutting the umbilical cord with unsterile razor blades, tying the cord with an uncleaned thread, or dressing the cord with cow dung—are thought to be the primary sources of infection leading to a high infant death rate in Bangladesh (Paul, 1991a; Shuaib, 1995). In addition, many maternal mortalities and morbidities result from obstructed and prolonged labor, delivery complications, and mishandling on the part of TBAs at delivery.

Available literature suggests that 80% of maternal deaths in developing countries result from direct obstetric complications (e.g., Khan, Jahan, & Begum, 1986; Fauveau, Koenig, Chakraborty, & Chowdhury, 1988; WHO, 1994; Maine, Akalin, Chakraborty, deFrancisco, & Strong, 1996). In Bangladesh, some 20,000 women die every year from birth-related complications (Haq, 1999). A considerable proportion of these deaths (15–25%) result from conditions which also threaten the new-born's life (see Akalin, Maine, deFrancisco, & Vaughan (1991), Loudon (1992); Akalin, Maine, deFrancisco, & Vaughan, 1997). A study in Bangladesh found that only 12% of infants whose mother had died in childbirth survived for two months, and only one in twenty survived for one year (Koenig, Phillips, Campbell, & D’Souza, 1990).

The tragedy of maternal mortality is further compounded by a high incidence of morbidity among women who survive delivery (Paul, 1993). Worldwide, some 62 million women suffer from pregnancy and delivery-related problems annually. A considerable number of these are disabled or permanently crippled by infertility, urinary incontinence, and uterine prolapse. Reproductive morbidity is often debilitating and can cause a reduction in productivity. Not only does it adversely affect the quality of life, but it may also compromise the quality of care these afflicted women provide to their children (Starrs & Measham, 1990).

Health risks of mothers and infants can be significantly reduced if delivery occurs in medical centers and/or at homes under the supervision of TTBAs or nurses. Proper medical attention and hygienic conditions during delivery can reduce the risk of infection and facilitate the management of serious complications that might arise for the mother and/or the newborn (Mitra, et al., 1997).

Realizing the benefits of bio-medical childbirth, the government of Bangladesh has pursued policies to increase the proportion of babies born under the supervision of medically trained attendants. Despite this government emphasis, no in-depth study has been conducted on childbirth in rural Bangladesh to date. However, the Bangladesh Demographic Health Survey (BDHS) collected data on child delivery and other demographic information in 1993–1994 and 1996–1997 (Mitra, Ali, Islam, Cross, & Saha, 1994; Mitra, Al-Sabir, Cross, & Jamil, 1997). These data have been analyzed in an uni-variate manner using cross tabulations providing only limited value in formulating effective policies to reduce infant and maternal mortality and morbidity. Applying a multi-variate approach, an attempt is made in this paper to identify determinants of use of medical center and TTBAs for delivery purposes in a rural area of Bangladesh.

The remainder of this paper is divided into five sections. The next section outlines government policies directed toward improving health conditions for mothers and children in Bangladesh. A conceptual framework is then presented to study determinants of use of medically trained birth attendants. The subsequent section discusses the research design followed by the results of the empirical analysis. Conclusions of this study are presented in the last section.