Utilisation of postnatal care in Bangladesh: evidence from a longitudinal study

Utilisation of health services is a complex behavioural phenomenon. Empirical studies of preventive and curative services in Bangladesh have often showed that the use of health services is related to the availability, quality and cost of services, as well as to social structure, health beliefs and personal characteristics of the users. The present paper attempts to examine factors associated with the utilisation of healthcare services during the postnatal period in Bangladesh by using prospective data from a survey on maternal morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERT). Both bivariate and multivariate analyses of the data confirmed that the mother's age at marriage had a significant and positive impact on the utilisation of quality healthcare services. The husband's occupation also showed a strong impact on healthcare utilisation, indicating higher use of quality care for postpartum morbidity by wives of business and service workers. The bivariate analysis showed that the number of pregnancies prior to the index pregnancy and desired pregnancies are significantly associated with the utilisation of postpartum healthcare. However, the results of this study were inconclusive on the influence of other predisposing and enabling factors, such as maternal education, the number of previous pregnancies, the occupation of the husband, antenatal care visits during pregnancy and access to health facilities. Multivariate logistic regression estimates did not show any significant impact of these factors on the use of maternal healthcare.     

Encouraging maternal health service utilization: an evaluation of the Bangladesh voucher program

With the ultimate goal of reducing maternal and neonatal mortality, many countries have recently adopted innovative financing mechanisms to encourage the use of professional maternal health services. The current study evaluates one such initiative - a pilot voucher program in Bangladesh. The program provides poor women with cash incentives and free access to antenatal, delivery, and postnatal care, as well as cash incentives for providers to offer these services. We conducted a household survey of 2208 women who delivered in the 6 months before the survey (conducted in 2009) in 16 intervention and 16 matched comparison sub-districts. Probit and linear regressions are used to analyze the effects of residing in voucher sub-districts on the use of professional maternal health services and associated out-of-pocket expenditures. Using information on birth history, we conducted sensitivity analyses employing difference-in-differences methods, comparing women's reported births before and after the program's initiation in the intervention and comparison sub-districts. We found that the program significantly increased the use of antenatal, delivery, and postnatal care with qualified providers. Compared to women in matched comparison sub-districts, women in intervention areas had a 46.4 percentage point higher probability of using a qualified provider and 13.6 percentage point higher probability of institutional delivery. They also paid approximately Taka 640 (US$ 9.43) less for maternal health services, equivalent to 64% of the sample's average monthly household expenditure per capita. No significant effect of vouchers was found on the rate of Cesarean section. Our findings therefore support voucher program expansion targeting the economically disadvantaged to improve the use of priority health services. The Bangladesh voucher program is a useful example for other developing countries interested in improving maternal health service utilization.     

Maternal Education and Child Healthcare in Bangladesh

Child health is one of the important indicators for describing mortality conditions, health progress and the overall social and economic well being of a country. During the last 15 years, although Bangladesh has achieved a significant reduction in the child mortality rate, the levels still remain very high. The utilization of qualified providers does not lead to the desired level; only a third relies on qualified providers. This study is mainly aimed at investigating the influence of maternal education on health status and the utilization of child healthcare services in Bangladesh. This study is based on the data of the Household Income Expenditure Survey (HIES) conducted by the Bangladesh Bureau of Statistics (BBS) during 2000. The analysis of the findings reveals that 19.4% of the children under five reported sickness during 30 days prior to the survey date. Moreover, approximately one out of every thirteen children suffers from diarrhoea in the country. It is striking to note that a significant portion of the parents relied on unqualified or traditional providers for the children’s healthcare because of low cost, easy accessibility and familiarity of the services. The study suggests that maternal education is a powerful and significant determinant of child health status in Bangladesh. Maternal education also positively affects the number of children receiving vaccination. In order to improve the health condition of children in Bangladesh maternal education should be given top priority. The public policies should not just focus on education alone, but also consider other factors, such as access to health facilities and quality of services. Health awareness campaign should be strengthened as part of the public health promotion efforts. More emphasis should also be given to government-NGO (Non Government Organization) partnerships that make vaccination programs successful and, thereby, reduce the incidence of preventable diseases.     

Utilization of maternal health care services among indigenous women in Bangladesh: A study on the Mru tribe

Despite startling developments in maternal health care services, use of these services has been disproportionately distributed among different minority groups in Bangladesh. This study aimed to explore the factors associated with the use of these services among the Mru indigenous women in Bangladesh. A total of 374 currently married Mru women were interviewed using convenience sampling from three administrative sub-districts of the Bandarban district from June to August of 2009. Associations were assessed using Chi-square tests, and a binary logistic regression model was employed to explore factors associated with the use of maternal health care services. Among the women surveyed, 30% had ever visited maternal health care services in the Mru community, a very low proportion compared with mainstream society. Multivariable logistic regression analyses revealed that place of residence, religion, school attendance, place of service provided, distance to the service center, and exposure to mass media were factors significantly associated with the use of maternal health care services among Mru women. Considering indigenous socio-cultural beliefs and practices, comprehensive community-based outreach health programs are recommended in the community with a special emphasis on awareness through maternal health education and training packages for the Mru adolescents.     

Complications during pregnancy, delivery, and postnatal stages and place of delivery in rural Bangladesh

The utilization of safe motherhood services including maternity care in Bangladesh is very poor. Only a very small proportion of deliveries takes place in a hospital/clinic. This study is based on data from a follow-up study on maternal morbidity in rural Bangladesh. Analysis is performed on the nature of complications by place of delivery. Most of the deliveries have taken place in the women's own or her mother's home. In addition, home deliveries are mostly assisted either by an untrained birth attendant or by relatives or others. Education, economic status, whether pregnancy was wanted or not, regular visits for antenatal care, past history of breathing problems and liver diseases, and palpitation during pregnancy appear to have significant association with place of delivery in rural Bangladesh. The utilization of a hospital/clinic instead of birth at home is higher among women with secondary or higher level of education, who desired the pregnancy, and who made regular visits for antenatal care. Delivery at a mother's home appears to be positively associated with higher economic status, desired pregnancy, gainful employment, and visits for antenatal care. If the respondents suffer from diseases/symptoms, then it is more likely that the delivery would take place in the mother's home.     

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

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.     

National female literacy, individual socio-economic status, and maternal health care use in sub-Saharan Africa

The United Nations Millennium Development Goals have identified improving women's access to maternal health care as a key target in reducing maternal mortality in sub-Saharan Africa (sSA). Although individual factors such as income and urban residence can affect maternal health care use, little is known about national-level factors associated with use. Yet, such knowledge may highlight the importance of global and national policies in improving use. This study examines the importance of national female literacy on women's maternal health care use in continental sSA. Data that come from the 2002-2003 World Health Survey. Multilevel logistic regression was used to examine the association between national female literacy and individual's non-use of maternal health care, while adjusting for individual-level factors and national economic development. Analyses also assessed effect modification of the association between income and non-use by female literacy. Effect modification was evaluated with the likelihood ratio test (G(2)). We found that within countries, individual age, education, urban residence and household income were associated with lack of maternal health care. National female literacy modified the association of household income with lack of maternal health care use. The strength of the association between income and lack of maternal health care was weaker in countries with higher female literacy. We conclude therefore that higher national levels of female literacy may reduce income-related inequalities in use through a range of possible mechanisms, including women's increased labour participation and higher status in society. National policies that are able to address female literacy and women's status in sub-Saharan Africa may help reduce income-related inequalities in maternal health care use.     

Reducing child malnutrition in Nigeria: combined effects of income growth and provision of information about mothers' access to health care services

Using a sample of 1359 Nigerian households from the 2003 Demographic and Health Surveys, this article investigates the contribution of improved maternal information about access to community health services toward the reduction of child stunting and undernourishment. The analysis shows that family wealth and region-specific knowledge about community health care access positively affects child nutrition status measured by height-for-age and weight-for-age. However, these nutrition gains can be reinforced or tempered by differences in mother's education and/or her access to community health services. These findings suggest that interventions which enhance public knowledge about availability and access to health care could strengthen more general development-oriented child nutrition-enhancing interventions, such as poverty reduction or growth in health services infrastructure.     

The socio-economic determinants of maternal health care utilization in Turkey

The purpose of this study is to investigate the individual-, household- and community-level factors that affect women's use of maternal health care services in Turkey. The data used for the study come from the 1993 Turkey Demographic and Health Survey (TDHS), a nationally representative survey of ever married women 15 to 49 years of age. In order to assess the impact of socio-economic factors on maternal health care utilization, we use logistical regression techniques to estimate models of the prenatal care use and birth delivery assistance among women who have had at least one birth in the three years prior to the survey. Separate models are also estimated for urban and rural women. The results indicate that educational attainment, parity level, health insurance coverage, ethnicity, household wealth and geographic region are statistically significant factors that affect the use of health care services thought essential to reduce infant and child mortality rates. The results of the model are used to provide insights for both micro- and macro-level planning of maternal health service delivery.     

孕产妇孕期保健服务利用的多因素分析

目的了解我国孕产妇孕期保健服务需求和利用现状,探讨影响孕产妇孕期保健服务利用的关键因素。方法应用自行设计的调查问卷对2009年7—12月之间分娩的妇女进行调查,利用多元Logistic回归分析法对我国孕产妇孕期保健服务利用的影响因素进行分析,并探讨关键因素。结果多元Logistic回归分析结果显示,孕产妇的文化程度、居住地、民族、对孕期检查的重视程度以及对产前保健知识咨询的重视程度等是影响孕产妇孕期保健服务利用的重要因素。结论孕产妇孕期保健服务利用受到多方面因素的影响。     

A socio-anthropological study of birth in Morocco

BACKGROUND: To understand the role of beliefs, notions of risk and local practices in explaining the low utilization of maternal health services in Morocco. METHODS: Ethnographic research in three sites in Morocco, including interviews with 126 women and observation of medical encounters at health facilities. RESULTS: Local practices are not incompatible a priori with the use of health services, and women manifest a relatively pragmatic and flexible attitude towards the decisions they make regarding birth. The different factors that influence women's choices are analyzed, in particular those related to obstacles of accessibility and quality of services. CONCLUSION: The pluralism and eclecticism that characterize beliefs and behaviors related to birth in Morocco suggest that an improvement in the quality of care would encourage more women to seek care from health facilities.     

非户籍妇女孕产期保健服务利用影响因素的定性研究

目的:了解非户籍妇女孕产期保健服务利用状况,并分析其影响因素,为研究孕产期保健服务的可及性和公平性提供依据。方法:通过个别深入访谈的方法,选择在上海市南汇区分娩的非户籍人口孕产妇进行调查。结果:非户籍妇女孕产期保健服务利用不足。社会经济地位、本人及她人既往分娩经历、妇女的角色与孩子的性别均不同程度影响非户籍妇女的孕产期保健服务利用。结论:应针对非户籍妇女进行形式多样的孕产期保健宣传教育,包括其家庭成员的教育,在城市建立流动人口平产分娩点对非户籍妇女孕产期保健具有积极意义,政府应支持多部门协作,对非户籍人口实行综合管理,同时在财政上予以支持。     

Is demand-side financing equity enhancing? Lessons from a maternal health voucher scheme in Bangladesh

Demand-side financing (DSF) is used in the less-developed countries of the world to improve access to healthcare and to encourage market supply. Under DSF, households receive vouchers that can be used to pay for healthcare services. This study evaluated the effects of a universal DSF on maternal healthcare service utilization in Bangladesh. A household survey was conducted in and around the voucher scheme area one year after the initiation of the project. Women who gave birth within a year prior to the survey were interviewed. The utilization rates of maternal health services were found to be higher for all socioeconomic groups in the project area than in the comparison areas. Voucher recipients in the project area were 3.6 times more likely to be assisted by skilled health personnel during delivery, 2.5 times more likely to deliver the baby in a health facility, 2.8 times more likely to receive postnatal care (PNC), 2.0 times more likely to get antenatal care (ANC) services and 1.5 times more likely to seek treatment for obstetric complications than pregnant women not in the program. The degree of socioeconomic inequality in maternal health service utilization was also lower in the project area than in the comparison area. The use of vouchers evidenced much stronger demand-increasing effects on the poor. Poor voucher recipients were 4.3 times more likely to deliver in a health facility and two times more likely to use skilled health personnel at delivery than the non-poor recipients. Contrary to the inverse equity hypothesis, the voucher scheme reduced inequality even in the short run. Despite these improvements, socioeconomic disparity in the use of maternal health services has remained pro-rich, implying that demand-side financing alone will be insufficient to achieve the Millennium Development Goal for maternal health. A comprehensive system-wide approach, including supply-side strengthening, will be needed to adequately address maternal health concerns in poor developing countries.     

Safe Motherhood Practices Among Women of Urban Slums in Bangladesh

In this article we examine the prevalence and factors associated with the utilization of safe motherhood practices among slum-dwelling women of Bangladesh using the 2006 Bangladesh Urban Health Survey data. Overall, the utilization of maternal health care services was very low. The binary logistic regression analyses yielded significantly increased skilled services utilization for women with higher education levels, nonworking women, non-Muslims, women undergoing their first pregnancy, women who had lived in the slum longer, and amongst the rich. Awareness should be created through information, education, and communication programs, and services should be provided with minimum cost to promote safe motherhood practices among the urban poor in Bangladesh.     

Safe motherhood practices among women of urban slums in bangladesh

In this article we examine the prevalence and factors associated with the utilization of safe motherhood practices among slum-dwelling women of Bangladesh using the 2006 Bangladesh Urban Health Survey data. Overall, the utilization of maternal health care services was very low. The binary logistic regression analyses yielded significantly increased skilled services utilization for women with higher education levels, nonworking women, non-Muslims, women undergoing their first pregnancy, women who had lived in the slum longer, and amongst the rich. Awareness should be created through information, education, and communication programs, and services should be provided with minimum cost to promote safe motherhood practices among the urban poor in Bangladesh.     

Do health care reforms in Turkey have a significant effect in equal access to maternal and child health services in Turkey: An evidence from 20 years

This study aimed to investigate whether there was an improvement in the equitable access to maternal and child health care services by examining the effects of socioeconomic and individual factors in Turkey from 1993 to 2013 and determine the effectiveness of health care reforms implemented mainly under the Health Transformation Program since 2003 on equitable access t;o maternal and child health care services in terms of years. The study used nationally representative 5 Turkey Demographic and Health Surveys (1993, 1998, 2003, 2008, and 2013). Prenatal care utilization rate increased from 67.0% in 1993 to 96.2% in 2013 while the rate of women giving birth at health care facilities increased from 63.8% to 98.1% in 2013. Prenatal care utilization and giving birth at health care facilities were higher among women who were under health insurance coverage, first time mothers, those staying in the western region and urban areas, and those with the highest level of wealth. The findings suggest that the issue of equity in the utilization of maternal and child health care services exists in Turkey, and the latest health care reforms under HTP are not effective in diminishing the effect of wealth.     

Family structure, socioeconomic status, and access to health care for children

OBJECTIVE: To test the hypothesis that among children of lower socioeconomic status (SES), children of single mothers would have relatively worse access to care than children in two-parent families, but there would be no access difference by family structure among children in higher SES families. DATA SOURCES: The National Health Interview Surveys of 1993-95, including 63,054 children. STUDY DESIGN: Logistic regression was used to examine the relationship between the child's family structure (single-mother or two-parent family) and three measures of health care access and utilization: having no physician visits in the past year, having no usual source of health care, and having unmet health care needs. To examine how these relationships varied at different levels of SES, the models were stratified on maternal education level as the SES variable. The stratified models adjusted for maternal employment, child's health status, race and ethnicity, and child's age. Models were fit to examine the additional effects of health insurance coverage on the relationships between family structure, access to care, and SES. PRINCIPAL FINDINGS: Children of single mothers, compared with children living with two parents, were as likely to have had no physician visit in the past year; were slightly more likely to have no usual source of health care; and were more likely to have an unmet health care need. These relationships differed by mother's education. As expected, children of single mothers had similar access to care as children in two-parent families at high levels of maternal education, for the access measures of no physician visits in the past year and no usual source of care. However, at low levels of maternal education, children of single mothers appeared to have better access to care than children in two-parent families. Once health insurance was added to adjusted models, there was no significant socioeconomic variation in the relationships between family structure and physician visits or usual source of care, and there were no significant disparities by family structure at the highest levels of maternal education. There were no family structure differences in unmet needs at low maternal education, whereas children of single mothers had more unmet needs at high levels of maternal education, even after adjustment for insurance coverage. CONCLUSIONS: At high levels of maternal education, family structure did not influence physician visits or having a usual source of care, as expected. However, at low levels of maternal education, single mothers appeared to be better at accessing care for their children. Health insurance coverage explained some of the access differences by family structure. Medicaid is important for children of single mothers, but children in two-parent families whose mothers are less educated do not always have access to that resource. Public health insurance coverage is critical to ensure adequate health care access and utilization among children of less educated mothers, regardless of family structure.     

Delivery complications and healthcare-seeking behaviour: the Bangladesh Demographic Health Survey, 1999-2000

Maternal health services have a potentially critical role in the improvement of reproductive health. The use of health services is related to the availability, quality and cost of the services, as well as to social structure, health beliefs and the personal characteristics of the users. The present paper examined the factors that influence the use of maternal health services for some selected pregnancy-related complications (e.g. prolonged labour, excessive bleeding, high fever/discharge and convulsions) in Bangladesh by using data from the Bangladesh Demographic Health Survey, 1999-2000. It was found that younger mothers were significantly less likely to seek professional healthcare at the time of birth. The odds for rural women seeking healthcare services from a doctor, nurse and/or midwife were half those of urban women. The strong influence of the mothers' education and parity on the utilisation of healthcare services is consistent with findings from other studies. The possession of assets emerged as an important predictor of seeking care from health professionals at the time of birth. Another factor, i.e. a husband's concern about pregnancy complications, showed a significant and positive impact on the utilisation of healthcare services, which is very important for rural women when they are dependent on their spouses. It was observed that the respondents living in urban areas, who had higher levels of education and lower parity, and more assets (used as a proxy for income), visited trained healthcare providers more often and were more likely to use healthcare facilities provided by trained personnel at the time of delivery. This is a reflection of the fact that, irrespective of their needs, only people from higher economic or educational groups can afford to seek healthcare from trained personnel in Bangladesh. In other words, predisposing and enabling factors appear to have a strong association with women's healthcare utilisation during pregnancy.     

Health care utilization patterns of Russian-speaking immigrant women across age groups

The collapse of the Soviet Union in 1989 substantially increased the numbers of refugees and immigrants to the United States from the former Soviet Union. Little research has been conducted with this population although studies found that immigrant's access to health care services are based on patterns of utilization in their countries of origin. The purpose of this study was to learn about the experiences of immigrant women from three former Soviet Republics (Belarus, Russia, and Ukraine) with women's health care services. Three focus groups of women were formed; ages 20–30, 37–46, and 60 and above. A focus-group guide was used to learn about their health care experiences. These immigrant women did access health care services based on patterns of utilization in their countries of origin. Greater understanding of immigrant populations' cultural patterns of health care utilization is needed to improve access and delivery of health care services to these populations.     

基层医疗保健机构孕产妇保健服务利用现状与相关因素分析

目的 探究影响孕产妇利用保健服务的相关因素,并结合地区实际,提出了相关建议和措施.方法 对在我院进行保健服务的1558名孕产妇进行调查分析,结合实际情况用SPSS 18.0统计学软件进行系统分析.结果 文化程度、家庭年收入水平、居住地距离、职业和医保等因素对孕产妇保健服务利用影响较大;同时,在1 558名受访者中,接受孕前保健指导的比率相对较低,早孕检查、5次以上产检率和住院分娩率结果相对较高,说明近几年来孕产妇对保健服务利用的意识有所提高,但产后访视比例仅为21.76％,比例较低.结论 针对当前现状,研究认为,个人、基层医疗保健机构及卫生管理部门等各方应当分别在提高认识水平、提高服务水平及加强基层系统建设等方面进行改善,以提高孕产妇保健服务的利用,提高优生优育水平.