What do women want? An analysis of preferences of women, involvement of men, and decision-making in maternal and newborn health care in rural Bangladesh

A cross-sectional survey was conducted in the households of three sub-districts of Brahmanbaria district in Bangladesh in 2018. Brahmanbaria district is located in the central-east region, which is 102 km away from Dhaka, the capital of Bangladesh. The three sub-districts which were selected in this study were Bijoynagar, Kasba and Sarail; each with an approximate population of 300,000 [29]. Population, administrative structure and health systems details of the three sub-districts are summarised in additional table 1.

Women who had given birth in the 12 months preceding the survey and who were permanent residents of the study sub-districts were considered to be eligible and were identified through stratified cluster sampling. The three sub-districts were considered as the strata, and the villages, with an approximate population of 1000, were regarded as the clusters [30, 31]. Probability proportional to size (PPS) sampling was adopted to select 20 villages/clusters from each sub-district (strata) [31‐33]. A sketch map was drawn for the selected villages indicating village boundaries, household locations, and important landmarks. Then all households were enumerated and listed, following which all women who had a birth in the past 12 months were identified within each household using a screening form. All eligible women from the selected villages/clusters were invited to participate in the survey. A total of 1367 women were successfully interviewed using an interviewer-administered structured questionnaire. The non-response rate was less than 1%. This was achieved by making up to three consecutive visits to households at different times and on different days of the week when women were not available at the first and second attempts. In addition, the data collectors were locally recruited, which facilitated their access to the communities and their ability to build rapport with the respondents.

Data were collected between March and May of 2018. All eligible women were approached for an interview by trained interviewers (20 females and 13 male) who administered the structured questionnaire. Women were interviewed in their households alone, without the presence of their husbands or other family members.

The questionnaire included a number of questions regarding knowledge, preference and practices of women, their husbands and families around MNH including husband involvement. The data collection tools were pre-tested in the non-selected clusters/villages of the sub-districts, and then the tools were revised based on the pre-test findings.

Data collectors were recruited locally so that they would be familiar with the local language, culture, and norms. They received 3 days of extensive training by master trainers of icddr,b (formerly known as the International Centre of Diarrhoeal Disease Research, Bangladesh), followed by 4 days of field practice. Furthermore, bi-weekly refresher training was conducted during the data collection.

Data analysis was performed using STATA 14.0 (StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP.).

Socio-demographic characteristics, e.g., age, educational attainment, and parity, were transformed into categorical variables. Due to small numbers, all other religions except ‘Muslim’ were grouped into one category and coded as ‘other’. We used the standard steps of principal component analysis to generate the socio-economic index of households that were interviewed, based on which the wealth quintile was generated [34, 35]. Household-level variables such as household possessions; materials used for the construction of floor, wall, and roof; drinking water source; toilet facilities; and ownership of land and domestic animals were used to generate this index.

Husbands’ involvement in care during pregnancy, childbirth, and following birth were considered as the main outcomes of interest in this paper. The following indicators, as reported by women, were used to denote husbands’ involvement:

The above mentioned six indicators were given a score of 1 (yes) or 0 (no), and a composite score of 0–6 was created. Then the composite scores were categorised as non-active involvement (0–3 aspects) and active involvement (4–6 aspects). The composite scores were also categorized as 1–2, 3–4, 5–6 to understand the minute changes. Similar indicators were used to assess the preferences of the women regarding their husbands’ involvement. Frequency with confidence intervals for the above mentioned six indicators for women’s preferences and husbands’ reported involvement are presented in additional table 2. Three components of MNH-related decision-making were categorised as joint decision making (women and husband jointly), women only and husband only and prevalence was explored. Then, the decision making indicator was re-categorized as joint decision making (women and husband jointly) and not joint decision making (women only and husband only) for further exploration.

Chi-square tests were initially used to explore whether there was an association between explanatory variables (women’s preferences, husbands’ participation in decision-making, background characteristics, etc.) and outcomes of interest (husband’s involvement during pregnancy, labour, and childbirth). Then measures of association between different explanatory variables were tested through binary logistic regression. The effect of covariates and known confounders were adjusted by multiple logistic regression models for the following factors: age, education, religion, parity, husband’s living status, women’s involvement in income generating activities, wealth quintile, joint decision-making and women’s preferences [36‐39]. All odds ratios (ORs) and adjusted odds ratios (AORs) were reported with 95% confidence intervals (CI). An association (OR or AOR) was considered significant if both the lower and the upper limit of the CI were more or less than one.

Table 1 represents the background characteristics of the women who had a history of childbirth in the past 12-month preceding the survey. Around half of the women were under 25 years of age, whereas only 8% of the respondents were over 34 years of age. Sixty-two percent women had 6 or more years of schooling. Around 40% of women had completed primary schooling. Nearly all of the respondents were Muslim (97%). Around 70% of the respondents were multiparous. Just over half of the respondents reported that their husbands lived with them whereas the other half reported that their husbands lived in another place within the country or lived abroad. A negligible proportion of the women (less than 5%) had been involved in any kind of income-generating activities in the previous 12 months of the survey period.

Figure 1 illustrates women’s preferences regarding the six aspects of their husbands’ involvement during pregnancy, childbirth and after birth and husbands’ reported involvement by the women. The first column shows the preference of women (i.e. whether or not she reports that she wanted her husband to be involved in that aspect of MNH care). The stacked bars in the second column presents husbands’ reported involvement, differentiating between involvement when the women reported desiring the particular category of involvement and when the women did not. Nearly all women reported that they wanted their husbands to support them during pregnancy and nearly all women reported that their husbands were very supportive or somewhat supportive in taking care of the women during pregnancy. However, difference between the proportion of women’s preference and involvement of husband is statistically significant (P-value 0.004). While more than 90% of women wanted their husbands’ involvement in BPCR, only 69% of husbands were reported to have participated in BPCR (P-value 0.000). Similarly, around 83% of women would have liked for their husbands to be present during an ANC visit, yet only one-third reported that their husband was present during any ANC contact. Most (85%) women reported that they would have liked their husband to be present during childbirth, but only half were present (P-value 0.000). Although 78% of women desired their husbands’ presence during PNC, only 6% of husbands accompanied their wives during this contact (P-value 0.000). The preference of women in favour of husbands’ involvement in newborn care was near-universal (96%), and around 88% husbands actively participated in newborn care practices (P-value 0.000). Altogether most women (88%) desired their husbands’ involvement in 4–6 aspects on MNH care, less than half of the husbands exhibited such engagement in the composite score. Moreover, there was significant difference between the proportion of women’s preference and the proportion husbands’ involvement in 4–6 aspects of MNH care (P-value 0.000). Across all aspects, a negligible proportion of husbands were involved in MNH care when it was not desired by their wives.

Figure 2 presents the types of physical or emotional support husbands provided to their wives for self-care during pregnancy as reported by women. Almost all of the women reported that their husbands supported them to eat well. Around 95% reported their husband’s support in reducing workload, taking proper rest, and accessing health services.

Figure 3 summarizes the reasons for husbands being physically absent during childbirth as reported by women. Out of the husbands who were not present during childbirth (n = 917), around 40% of them were busy with their work, and 30% did not consider their presence to be important. Around one-fourth were absent as they lived in other places (within the country or abroad). A further 9% could not be present as the health facility or the birth attendant did not permit them to be present during childbirth. Only 3% of women reported that they did not want their husbands’ to be present during the childbirth.

Figure 4 illustrates husbands’ roles and participation in decision-making related to MNH care-seeking as reported by the women. Two-thirds of women reported taking joint decisions with their husbands (about their care), but around 20% of women reported that their husbands took decisions on their own. Although joint decision-making regarding newborn health was slightly lower (48%), a similar proportion of men (17%) took decisions regarding newborn health on their own. Around 37% of women took joint decisions with their husbands regarding whether the women could go outside home alone for MNH care. Around 29% of the husbands took this decision on their own.

Table 2 presents the relationship between husbands’ active involvement (four or more out of six aspects) with women’s preferences regarding husbands’ involvement and the husband’s roles in decision-making for MNH case-seeking practices controlling for the effect of other background characteristics. Women’s preferences (4–6 aspects) were strongly associated with husbands’ active involvement (AOR 2.94, p = 0.00). Similarly, if the husbands were jointly participating with their wives in decision-making for any of the three categories of MNH care seeking practices, the likelihood of their involvement in MNH care during their wives’ pregnancy, childbirth and after birth increases twofold (AOR 1.75, p = 0.00), compared to sole decision-making by the woman or sole decision-making by the man. Husbands who lived with their wives were also more likely to be involved in MNH care (AOR 5.07, p = 0.00).

Figure 5 demonstrates the relationship between women’s preferences for their husbands’ involvement in MNH care and husbands’ reported involvement in MNH care. It also presents the relationship between joint decision-making for MNH care-seeking and husbands’ reported involvement in MNH care. The likelihood of women reporting their husbands were involved in 3–4 aspects of MNH care was 2.89 times higher when the women preferred their husbands to be involved in 3–4 aspects of MNH care. The likelihood increased to 3.65 times when the women preferred their husbands to be involved in 5–6 aspects. Similarly, the likelihood of husbands’ reported involvement in 3–6 aspects of MNH care was 1.43 times higher when they jointly participate in 1–2 categories of decision-making. The likelihood increased to 2.02 times when they jointly participate in all three categories.