Respondent's profile
The majority (15 out of 20 respondents) of the women were in their twenties, two were below 20 years of age while three were in their thirties. Most of the interviewees were Muslim. Non-farming labour, like rickshaw pulling, was one of the most common occupations of the household heads. Most of them lived in poor hygienic condition as revealed by the use of proper sanitation (with or without water seal latrine or pit latrine), water access, and overall household condition. At the time of data collection, all the respondents were in their initial phase of the CFPR-II programme.
Pregnancy care
Almost all the women reported about becoming aware of their pregnancy when they experienced amenorrhoea, nausea and vomiting, loss of appetite and weakness. Most of them could identify their pregnancy within the first 2-3 months. According to them, pregnancy identification and its subsequent care was seen as a normal event which did not require any additional medical intervention unless significant complications arose during this period. Two women were found to have had no menstruation history after delivery of the last baby till conception of the next one.
Antenatal care
Confirmation of pregnancy was considered by the women as the most important part of antenatal care and eight out of 20 women went to the nearby health facilities for pregnancy tests. Reportedly, the most common service that a pregnant woman received in ante-natal clinics was iron supplementation. However, most of them did not take all the tablets dispensed because they perceived the tablets to be tasteless (or have bad taste) and made the stool black. None of them took iron tablets for more than two months during their last pregnancy. Most of these women opined that antenatal care provided no benefit to them or their child. Monetary constraints, absence of knowledge about the need of services, and restrictions on the movement of women were also cited as reasons for not accessing antenatal care.
Social exclusion
The following finding is not unique but typical of the broad experience of ultra poor women living in the rural areas of Bangladesh:
"I was avoiding health worker because she would scold me if she would have heard about my 4
th
pregnancy. She used to give me birth control pills. So, I did not meet her and inform her." (A lactating mother of 27 years old)
In two cases, the women reported that the respective health worker came to their house to give birth control pills. However, neither of them came out of their respective houses. The use of harsh words and low tolerance level of the health workers discouraged the women to use the services provided by these health facilities for antenatal care. These women perceived that they were treated in such a manner by the health worker because of their low socioeconomic status.
"I heard that health service from government facility is free of charge but when I went to the health facility I was asked to make a card for Tk. 20.Which services are then considered to be free of charge?" (A pregnant woman of 21 years old)
Nutrition during pregnancy
Women reported that the reasons for decreasing consumption of food during pregnancy were mostly related to aversion to specific food, followed by lack of monetary power to purchase specific food that extremely poor households usually consumed (like rice, potato, and small fish). However, few women also reported increasing consumption of food during pregnancy. The reasons given for this varied from those given for decreasing consumption. The most frequently cited reason was 'feel like eating more.' 'Craving for a specific food 'was also cited as a reason for increased consumption of some food such as molasses-made drink, rice with green chilies, and milk. Two of the women mentioned that the increased food intake was directly related to improved health of the mother or the baby. This tended to be where husbands and other family members were helpful and better informed.
"I know that eating more food is necessary when there is a baby in womb. But I am poor, how can I afford it?" (A pregnant woman of 21 years old)
Some food, like ducks, pigeons, beef and Hilsha fish were considered as 'hot' and were restricted during pregnancy. Some fish like Taki, Chanda and Puti, which were within their affordability, were also restricted during pregnancy. There were no restrictions reported in consuming fruits among the extreme poor households.
Restrictions and mobility during pregnancy
It is generally believed among the extreme poor households that evil spirits are more active in the evening, at noon and at night, so pregnant women avoided leaving their houses during those times. Walking through graveyards was also thought to be harmful for pregnant women. If they did so, they tied up their hair and covered their heads with veils.
"Evil spirits could cause miscarriage of the fetus,that is why I did not go out in prayer time" (A lactating mother of 31 years old)
A few women reported their beliefs about carrying a piece of iron which would ensure protection. Matches were also reported to be effective in keeping away the evil gaze of the spirits. Most of the respondents mentioned that lunar and solar eclipses could affect pregnant women. They reported (those who got eclipse during last pregnancy) that they had stayed inside the household, walked near the home or inside the home, but had never laid down on the bed during eclipses. They also reported certain restrictions during this period - like they did not eat or cook, cut, and twist anything, as they perceived that the child would be born with a cleft palate or with deformed features. Many of the women reported that elderly family members and husbands were the main informants as to when there would be a lunar or solar eclipse. In any case, restrictions in movement had never been imposed by any health providers but rather from the elderly women of the family.
Support from husband
Present study found that in the midst of poverty, the husband could play a positive role in taking care of his wife during the pregnancy period. An illustrative case:
All that Mamtaz's husband can claim as his own are the homestead land and the house. He inherited three decimals of land from his father on which he has built a house to live in. He is physically disabled. He does not have any source of income other than the 2/3 kg of rice that he gets from begging door to door. From that amount, Mamtaz keeps whatever is required for the household and sells the remaining to buy other necessities such as salt, vegetables to run her family. Sometimes when her husband is unable to go for begging, Mamtaz would go to other people's houses for work during pregnancy. Her husband did not wish for her to work at other people's houses during her pregnancy and expressed that whatever he earned through begging was enough for them to sustain. But still, when he was not at home and someone called her for assistance, she would go to their houses to boil paddy or for maintenance of floors in exchange of one or half a kg of rice. (A pregnant woman of 23 years old)
Women considered this attitude of their husbands as a positive attitude if the women were too weak to work or continue the usual household work. In three cases, women consulted with their husbands and jointly decided to stop their other child's schooling so that the child would rear the animals and the women could rest during their pregnancy. Overall, during pregnancy, women reported that husbands and other family members helped them in doing heavy work. Activities such as fetching water, boiling and husking rice, lifting heavy cooking utensils and preparing food for animals were generally regarded as heavy work.
Birth preparedness
Birth preparedness for this present study included selecting a skilled birth attendant, arranging delivery kit needed for a safe birth, identifying where to go in case of emergency, and arranging necessary money and transport for delivery. We found only one woman who had a birth plan (took into consideration all the outlined stages of the preparation) before delivery. Most women did not contact the birth attendant who is locally known as traditional birth attendants (TBAs or dais) in advance because they thought TBAs could make some jadutona (Black magic) in advance during pregnancy so that without their presence delivery would not occur and that there were greater chances to pay more for delivery.
"After I started having pain on the morning of the 3rd day, my husband went out to call the TBAs. TBAs was not informed beforehand as she took more money if asked to stay for a longer period of time. This TBA perhaps is trained. Most of the children in this locality were delivered by her (A lactating mother of 19 years old)
Few families, especially the husbands, could put aside some money for delivery purpose. One husband had financial constraints, so he saved 40 kg of rice. Twelve women said that they only collected some old clothes, which they had kept separately, but they had not stitched any new dresses or Kathas (local quilt covering) for the arrival of the new baby. The women believed that it was bad to buy new clothes or make too many plans in advance for the new arrival as it could bring bad luck. Moreover, they were not sure whether the coming child would survive or not. Money spent on her/him was considered to be unnecessary. Women assumed that transportation would be available either from a family member or from a neighbour when needed and, as such, did not plan for the transportation in advance.
Delivery care
We found that after the initiation of labour pain, elderly women usually took matters into their own hands by taking various steps and observing certain rituals to facilitate early delivery of the baby. Women reported that sometimes relatives fed them pora pani (enchanted water) to boost up their mental strength, which referred to the psychological aspect of the expectant mothers as being strong enough to face the labour pain. For providing energy to the delivering mother as well as to intensify the labour pain, five mothers said that they had received saline with an injection (oxytocin) from a neighbouring Pallichikitshok (Village doctor).
Place of birth and attendance at delivery
Most of the deliveries took place at home (19 out of 20). The TBA was usually called after the onset of strong labour pain. TBA or friends/relatives were the most common persons to be present as the birth attendant during delivery. Almost all the deliveries took place on the floor. Four women even gave births on just the bare floor, but for the rest, the deliveries took place on spread out cloths or jute sacks or straw. Delivery was not carried out on beds in order to avoid spoiling it. According to the women, few materials like straw, polythene, etc. if placed on the floor, made cleaning and disposing of impure blood and placenta much easier. Ten out of the 20 women reported that their preferred position was squatting while giving birth. However, this may have, and often did change, as labour progressed. For three of the women, squatting position was found to be more painful than lying. Usually, the position to be adopted was often decided upon discussion with the TBA and other female relatives. No cases were found where any male members of the household were involved during delivery.
Health system factors such as staff attitudes from healthcare, either public or private, also had an impact on maternal care practice. Poorly attitude of the healthcare staffs were perceived to exist in most health facilities; these included usage of abusive language, denial of providing services, lacking compassion in general and refusal to assist properly.
"I went to government facility for antenatal care. The concerned person told me I might need cesarean, and I would die if I did not go to the hospital. Are these words good to tell someone who is pregnant?" (A pregnant woman of 17 years old)
The mothers were asked whether or not the birth attendant had washed their hands with soap before delivery, and whether or not the instrument used for cutting the umbilical cord and the thread used for tying the cord were boiled before use. Washing hands before conducting the delivery was very low. Boiling the blade was high, but it was reported that they did not boil the thread. Women reported that at times, the TBAs kept the thread aflame only and did not boil it if the thread was new.
Practices to speed up the delivery of placenta
It was found that the focal point of attention after birth of the baby was mainly on the removal/expulsion of the placenta, as the placenta was believed to have spiritual value. It was believed that after the baby's birth, if the placenta was not delivered quickly, the mother would be in danger. Nine women believed that the placenta could move up to the throat and choke them to death if not removed promptly. To release the placenta after delivery or in cases where there was a delay in the process, TBAs or relatives were found to massage the abdomen of the women, gag her with her hair or give kerosene oil or onion juice to induce vomiting which was believed to help expel the placenta through abdominal contractions. A woman reported that the TBA wiped her chest with a dirty cloth (which was used in mud cleaning) and this was followed by expulsion of the placenta. Treatment of placenta was sometimes considered a priority than treatment of the newborn immediately after birth. It was believed that placenta should be buried in the dry soil so that the child would not suffer from any cold or cough at a later stage. To save some money, some women preferred to cut their umbilical cord themselves. Eight out of 20 women cut their umbilical cord in their last delivery. If any other woman had cut the umbilical cord for them, then they had to pay a minimum of Tk. 20 (US$ 0.30).
Post-partum care
During the post-partum period, especially during the first 5-9 days of isolation, the mothers reported various dietary restrictions imposed on them which deprived them of proper nutrition intake. Most food available in these extreme poor households was thought to be inappropriate during lactation. In the case of four women, no food at all was allowed for consumption during the first few days after delivery, and commonly no food was given at all during the first day after delivery to allow healing of the birth passage. Moreover, women were considered to be impure during this time. They were not allowed to touch any food for preparing meals for other family members. In-depth interviews revealed that the mothers-in-law and the elders played a dominant role in deciding what foodstuffs the mother could eat. Shujata's child, who was not even a month old, lived with her family consisting of her husband, mother and an elder sister. She said:
"We all live together, use the same kitchen but have separate rooms. Since the child's delivery, my mother and sister prepare the food as the newly delivered women (Poaati ma) are not supposed to cook till 40 days after the delivery because their body is considered to be impure. People wouldn't like it if I cook and it's not good for me even. My mother brings me food in my room and gives me lesser than my usual intake of food so that I don't fall ill. Poaati ma (lactating mother) should eat as less as possible till her umbilical cord dries up. It does not matter if I'm still hungry and feel weak and as long as I don't have to spend money for doctor's visit. It does not harm if you follow the elder women. I have the whole life to myself to eat more. So it's fine if I eat a little less the 1st 1-2 months. I prefer weakness to illness. (A lactating mother of 23 years old)
These women did not seem to have any problem with this imposed dietary restriction because their economic condition did not allow them to buy animal source food like beef, chicken anyway.
The most common items eaten during the post-partum period included rice, smashed potato with spices, raw tea, green banana, black cumin, poppy seed, fenugreek leaves etc. These are believed to keep the stomach cool and initiate the production of breast milk. Whatever special food was consumed during post-partum period, it was reported to be only for a few days while the imposed food restrictions continued for a longer time i.e., 21-40 days. Opinions given on the intake of spicy food were mixed. It was given for the first few days for healing of the birth passage but later on, the same was restricted to avoid heart-burning.
Women reported that during their last pregnancy they felt weak with severe body-aches (11 out of 20 interviews) after delivery. It lasted for one to three weeks. None of them had gone to any health providers for seeking any service for this weakness and body-ache. These women reasoned that they did not go for the check-up because they were not even aware about the availability of the post-partum check-up. Four women reported that their husbands or mothers had gone to pharmacies to fetch vitamin tablets or saline when they had expressed about their weaknesses. This weakness was however considered to be a common part of their post-partum life. To quote one woman:
"It is normal to have some bodyache and fever after delivery, these would be cured automatically" (A lactating mother of 24 years old)