Maternal autonomy and high-risk pregnancy in Bangladesh: the mediating influences of childbearing practices and antenatal care

Maternal and perinatal deaths as well as poor pregnancy outcomes is recognised as one of the major public health problems in Bangladesh. The common immediate causes of adverse pregnancy outcomes are mainly understood in terms of women’s physiological health during pregnancy and childbirth. Although pregnancy is a universal part of female physiology and biology, this event is shaped by the surrounding social environment [1]. A pregnancy becomes high-risk when either the mother or the newborn (or both) have a significant risk of morbidity or mortality [2, 3]. Studies on pregnancy health and childbirth are mainly concerned with physiological aspects, and only pay limited attention to maternal fertility behaviour, healthcare practices, and women’s socio-economic background. This study extends this knowledge by examining the relationship between maternal autonomy and the severity of pregnancy health complications followed by high-risk pregnancies among Bangladeshi women.

As highlighted in previous studies, women with low levels of education, low income and living in rural areas tend to enjoy low level of autonomy in reproductive health matters which increase the risk of poor pregnancy outcomes [4‐9]. The identified risk factors for developing pregnancy complications were also found to be associated with certain childbearing practices which contribute to poor outcomes. A large number of studies have identified the adverse effects of adolescent pregnancies which increased the chance of experiencing several health complications during pregnancy: anaemia, hypertension or pre-eclampsia, gestational diabetes, placental problems, preterm labour and postpartum haemorrhage [10‐14]. In Bangladesh, most studies arrived at similar conclusions: adolescent pregnancies hold an increased risk of pregnancy and delivery complications [15‐17].

Also, women who had given birth to a large number of children (more than three births) and had them in shorter birth intervals of less than 18 months were found to be more vulnerable to experience several pregnancy complications: pre-eclampsia, pregnancy infections, miscarriage, stillbirth and low birth weight [16, 18‐22]. Additionally, access to reproductive healthcare services remained a key determinant of a sound pregnancy and healthy outcome [17, 23]. In this context, a large number of studies from developing countries including Bangladesh identified women’s autonomy as a significant factor in the utilisation of antenatal care services [9, 24‐27]. Although the associations between pregnancy health status, and maternal childbearing practices as well utilization of maternal healthcare have been widely recognized, the association between maternal autonomy and pregnancy health complications followed by high-risk pregnancies has not yet received similar attention. This study therefore investigates the association between women’s autonomy and high-risk pregnancies, and also examines the mediating role of women’s childbearing practices and antenatal care utilization in this relationship. The assumed key relations between autonomy and high-risk pregnancies through the pathways of maternal childbearing practices and antenatal care are shown in the diagram in Fig. 1.

The present study is based on data from the Verbal Autopsy Questionnaire of Bangladesh Demographic and Health Survey 2011 (BDHS), which was the most recent survey that used the WHO Verbal Autopsy Questionnaire. Through this questionnaire, information on several health complications during pregnancy and delivery was collected from ever-married women aged 10–49 years for their most recent pregnancy in the five years preceding the survey. In the BDHS, the participants were recruited using a two-stage stratified cluster sample of households yielding a response rate of 98%. Details of data collection and management procedures are described elsewhere in 2011 BDHS [28]. The analysis reported here is based on a sample of 327 women for whom information was available for all the variables used in this paper.

Pregnancy is a complex and long-term biological transition in a woman’s life with many associated health complications. Most pregnancies that result in natural vaginal births involve minor complications, such as nausea and vomiting, headache, blurred vision, puffy face or shortness of breath. On the other hand, major health problems during pregnancy include high blood pressure, convulsion, gestational diabetes, or pregnancy infections. When women experience several of these complications, they are deemed to be carrying a high-risk pregnancy, which contribute to poor outcomes for mother and baby, requiring special medical attention. However, the concept of high-risk pregnancy has not received the same level of attention in the literature as childbearing in general. The present study therefore examined high-risk pregnancies in Bangladesh from a socio-demographic viewpoint.

This study specifies an entrenched pattern of high-risk pregnancies in Bangladesh. The results of the present study identified a significant proportion of women in Bangladesh have experienced a number of health complications during pregnancy. Also, a significant number of women had multiple complications that contributed to an increased chance of pregnancy risks, either low or high. The findings on the relationship between women’s autonomy, childbearing practices and pregnancy risks illustrate that all three dimensions of women’s autonomy, when no other variables were included in the analysis (Table 4, Model 1), had significant influences on high-risk pregnancies. Earlier studies identified some indirect influences of autonomy indicators on pregnancy health status. It was found that freedom to go outside the home for healthcare purposes resulted in better maternal outcomes [9, 26, 29]. Independence in mobility can enable women to gather relevant information about pregnancy health, complications and remedy measures, thus contributed to healthy outcomes. In addition, high level of decision-making power about contraception, having children at a favourable time, spacing and number of children, as well as decision about own and child’s healthcare also contributed to better pregnancy outcomes. In this context, decision-making autonomy, women’s freedom of movement and ability to spend money when necessary to access maternal healthcare facilities reduce the prevalence of several health complications during pregnancy by ensuring higher levels of antenatal care utilization, which in turn decreases the chances of high-risk pregnancy. In this way, all three dimensions of maternal autonomy were found to be associated with sound pregnancy health.

This study explores that the high-risk pregnancy is strongly affected by childbearing practices and the use of antenatal care services. Akin to other developing countries, adolescent pregnancy is prevalent in Bangladesh and is subject to experience more complications. Our study demonstrates that the teenage and late pregnancies are more likely to possess several life-threatening complications. Teenage mothers are more likely to be less educated and less autonomous, and are lacking in awareness and experience regarding the danger signs of pregnancy complications. Thus they are less likely to receive proper prenatal and antenatal care to safeguard themselves from life-threatening complications. At the same time, some health complications during teenage pregnancy are triggered because of the biological effects of early childbearing. This phenomenon has also been focused in some earlier studies [14‐16, 30‐32]. Our study mimics the exposition of previous research that caesarean deliveries, preterm birth and stillbirths are likely to be more prevalent for grand multiparous (more than three children) women [19, 33]. Our empirical study demonstrates that high-risk birth interval, high birth order, and adolescent or delayed childbearing increase the risk of multiple complications during pregnancy which in turn leads to high-risk pregnancy outcomes.

Earlier studies investigated the adverse effects of short birth intervals on pregnancy health [20, 28, 34]. Women with very short birth intervals experienced anaemia, gestational diabetics and high-blood pressure which contributed increased risks of premature or low birthweight babies. This study also explored that short birth intervals of less than 18 months contributed to multiple health complications during pregnancy, and thus had significant effect on high-risk pregnancies. In addition to this, maternal health complications could occur due to the adverse biological effects of high parity and short birth intervals. Generally, in high order births (more than three) women experience multiple and life-threatening complications. Grand multiparous women are older and less likely to have accessed antenatal care, which results in an increased risk of maternal complications and poor neonatal outcomes [16, 18, 35]. The results also showed a significant relationship between high-risk pregnancies and maternal healthcare utilisation. Only one-half of women in the study had received sufficient antenatal care during pregnancy. Women who received sufficient antenatal care and who received treatment for health complications were more likely to experience sound pregnancy health and reduced chances of high-risk pregnancies.

The main focus of this research was to investigate the associations between women’s autonomy and high-risk pregnancy, and as discussed above, all three indicators of autonomy appeared to have significant effects on high-risk pregnancy (Model 1). However, once the effects of childbearing practices and antenatal care were accounted for, the effects of autonomy in physical mobility became insignificant. This phenomenon indicates that women’s freedom of movement influences high-risk pregnancies through maternal age, parity, birth interval as well as uptake of antenatal care. Thus, both childbearing practices and antenatal care mediate the association between maternal autonomy in physical mobility and high-risk pregnancies. In other words, the effects of autonomy are mediate only in a limited way through the mediating factors. To reduce the prevalence of high-risk pregnancies in Bangladesh, attention needs to be given to increase the level of autonomy of women, in particular their autonomy in decision making and economic matters. It is equally important to pay attention to women’s age at birth, number of children, intervals between births and access to antenatal care services so as to improve mothers’ reproductive health and pregnancy outcomes for both mother and child.