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Practices and determinants of delivery by skilled birth attendants in Bangladesh Islam, Nazrul; Islam, Mohammad T; Yoshimura, Yukie Dec 11, 2014

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RESEARCHPractices and determinantam) apngeyre02ommended for all the pregnant women so as to make [8]. Home delivery assisted mainly by Traditional BirthIslam et al. Reproductive Health 2014, 11:86http://www.reproductive-health-journal.com/content/11/1/86ners have also been supporting the CSBA training to theBritish Columbia, Room# 417, 2206 East Mall, Vancouver, BC V6T 1Z3, CanadaFull list of author information is available at the end of the articlesure a normal delivery is conducted well, related com-plications are recognized early and referred immedi-ately to the appropriate healthcare facilities [4]. Birthattendance by SBAs is considered as the “single mostAttendants (TBAs) is as high as 71% in Bangladesh [9,10].Government of Bangladesh initiated the Community-based Skilled Birth Attendant (CSBA) program to in-crease accessibility to skilled delivery at home in 2003with the target to train 13,500 government field staff asCSBAs. As of June 2014, nearly 9,000 government CSBAshave been trained. Besides, some of the development part-* Correspondence: nazrul.islam@ubc.ca†Equal contributors1School of Population and Public Health, Faculty of Medicine, University ofcess to Skilled Birth Attendants (SBAs) is strongly rec-identify the potential determinants of delivery by SBAs.Results: The respondents were aged between 16 and 45, with the mean age of 24.41 (± 5.03) years. Approximatelyone-third (30.06%) of the women had their last delivery by SBAs. Maternal occupation, parity, complications duringpregnancy and antenatal checkup (ANC) by SBAs were the significant determinants of delivery by SBAs. Womenwho took antenatal care by SBAs were 2.62 times as likely (95% CI: 1.66, 4.14; p < 0.001) to have their deliveryconducted by SBAs compared to those who did not, after adjusting for other covariates.Conclusion: Our findings suggest that ANC by SBAs and complications during pregnancies are significantdeterminants of delivery by SBAs. Measure should be in place to promote antenatal checkup by SBAs to increaseutilization of SBAs at birth in line with achieving the Millennium Development Goal-5. Future research should focusin exploring the unmet need for, and potential barriers in, the utilization of delivery by SBAs.Keywords: Skilled birth attendants (SBAs), Bangladesh, Determinant(s), Practice(s)BackgroundMaternal deaths across the globe have been estimated tobe approximately 289,000 in 2013, while the death toll ofnewborn within the first 4 weeks of birth has reached at3.6 million [1-3].Most of the complications related to pregnancy andchildbirth are unpredictable, and take place around thetime of delivery and postpartum period. This is why, ac-important factor in preventing maternal deaths” [5].Delivery attendance by SBAs is also very important inpreventing stillbirths and improving newborn survival[4,6]. The proportion of births attended by SBAs is oneof the two indicators of the progress toward achievingMillennium Development Goal (MDG)- 5 [7].The utilization of SBAs at birth is quite low in Bangladesh.About one in every five deliveries is attended by SBAs;the proportion is even lower in slum and tribal areasbirth attendants in BanglNazrul Islam1*, Mohammad Tajul Islam2† and Yukie YoshiAbstractIntroduction: Utilization of Skilled Birth Attendants (SBAsSBAs is considered as the “single most important factor inpractices and determinants of delivery by SBAs in rural BaMethods: The data come from the post-intervention survconducted to evaluate the impact of limited post-natal cawomen with a recent live birth in rural Bangladesh (n = 7© 2014 Islam et al.; licensee BioMed Central. TCommons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.Open Accesss of delivery by skilleddeshura2†t birth is low (20%) in Bangladesh. Birth attendance byreventing maternal deaths”. This paper examined theladesh.of a cluster-randomized community controlled trial(PNC) services on healthcare seeking behavior of). Multivariable logistic regression model was used tohis is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Descriptive statistics were presented to give an overviewof the study participants. Bivariate analysis was doneto find association between the explanatory variablesand the outcome variable. Delivery by SBAs was de-fined as delivery conducted by qualified doctors, nurses,Community-based Skilled Birth Attendants (CSBAs), andFamily Welfare Visitors (FWVs).Odds ratio (OR) and 95% Confidence Intervals (CI)were calculated as effect measure. The variables foundto be associated with the dependent variable at 10% levelTable 1 Socio-demographic characteristics of therespondentsCharacteristics No. %Age in years<20 98 13.9620-34 563 80.20≥35 41 5.84Mean (SD) 24.41 (5.03)ReligionIslam 625 89.03Hinduism 77 10.97Women’s educationNo education 105 14.961-5 years 164 23.36≥6 years 433 61.68Women’s occupationHousewife 667 95.01Others 35 4.99Husband’s educationNo education 180 25.901-5 years 177 25.47≥6 years 338 48.63Husband’s occupationLaborer 430 61.25Jobs including professionals 68 9.69Islam et al. Reproductive Health 2014, 11:86 Page 2 of 7http://www.reproductive-health-journal.com/content/11/1/86private candidates, especially to cover the hard-to-reachareas. Recent evaluation of the CSBA program indicatesthat even though CSBAs are available in the rural areas,their utilization is low in the community [11]. It is,therefore, imperative to examine the determinants ofdelivery by SBAs so as to understand well the areas thatrequire further policy reform and programmatic inter-ventions in line with progress toward MDG-5. Determi-nants of delivery by SBAs identified in previous studieshave been inconsistent, and there is paucity of infor-mation in Bangladeshi context. Current paper aims atidentifying the determinants of delivery by SBAs inrural Bangladesh.MethodsThe data analyzed in this study originated from the post-intervention survey of a cluster-randomized communitytrial (postnatal care intervention trial) conducted inMonohardi, a rural upazila (sub-district) of Narsingdidistrict, Bangladesh. The objective of the trial was to testthe effectiveness of engaging community volunteers, wor-king under the community support groups, in increas-ing the coverage of postnatal care by skilled healthcareproviders. The study was implemented by the Govern-ment under the Safe Motherhood Promotion Project(SMPP) [12], supported by Japan International CooperationAgency (JICA) in collaboration with a non-governmentorganization, CARE-Bangladesh. Out of 11 unions (subsub-district) of the upazila, 6 were randomly selected (3for intervention and 3 for comparison) for the study.The intervention was implemented in the villages wherecommunity support groups were present.Total population of the intervention and comparisonareas was 42,370. The expected annual births were esti-mated as 957 based on crude birth rate of 22.6 per 1,000population [9]. However, 702 women who had a livebirth between November 2010 and October 2011 (studypopulation) were identified through household visits andwere interviewed by the data collectors.Twelve female interviewers were recruited for the datacollection. The interviewers were graduates from differentdisciplines with prior experience in data collection. Super-vision and monitoring of data collection were done by the4 SMPP project staff. All the data collectors and supervi-sors were trained for three days on the contents of thequestionnaire, and data collection techniques. However,they were blinded about the objectives of the study. ThePrincipal Investigator of the PNC study coordinated andsupervised the whole efforts. Data were collected be-tween 20 December 2011 and 1 January 2012.A structured pre-coded questionnaire was used forface-to-face interview. This paper analyzed the data toexplore the delivery care practices and factors associatedwith the delivery by SBAs in rural Bangladesh.Business/Living abroad 204 29.06Monthly family income (BDT)≤ 6,000 196 27.926,001-10,000 313 44.59>10,000 193 27.49Parity (Number of children)0 or 1 276 39.322 or more 426 60.68Any ANC by SBAs 409 59.02Complications faced during pregnancy 169 24.07BDT = Bangladeshi Taka; ANC = Antenatal Care; SBAs = SkilledBirth Attendants.of significance in bivariate analysis was included in themultivariable Logistic Regression model to adjust forconfounding effects after checking for multicollinearity.All the tests were two-sided, and a p-value of less than0.05 was considered as significant. Data were analyzedin SPSS (version 20.0), and STATA (SE 12.1) [13].Ethical considerationThis study used secondary data generated in an inter-vention study. Both the intervention and analysis of datafor this study were approved by the Directorate Generalof Health Services (DGHS). DGHS is the implementingand coordinating body of all the health related activitiesin Bangladesh under the Ministry of Health and Familycare (ANC) by SBAs, and almost a quarter (n = 169) of therespondents experienced complications during pregnancy.About three-fourth (73.65%; n = 517) of the women hadtheir delivery at home while 84.76% (n = 595) had normalvaginal delivery.Figure 1 shows the antenatal care practice of the re-spondents. A substantial proportion (>40%) of womendid not seek antenatal care from SBAs, or did not seekfor any antenatal care at all. Figure 2 demonstratestypes of complications the respondents experiencedduring the last pregnancy. Prolonged labor (labor painfor more than 12 hours) was the single leading compli-cation. Figure 3 shows that a substantial proportion ofdelivery was conducted by traditional birth attendantsIslam et al. Reproductive Health 2014, 11:86 Page 3 of 7http://www.reproductive-health-journal.com/content/11/1/86Welfare. Verbal informed consent was obtained from therespondents before data collection.ResultsIn total, 702 women were interviewed who had a livebirth between November 2010 and October 2011. Ap-proximately one-third (30.06%) of the respondents hadtheir last delivery by SBAs. Table 1 summarizes the socio-demographic characteristics of the respondents. The meanage of the women was 24.41 (± 5.03) years, mostly be-tween the ages of 20 and 34 years. Approximately 14%experienced teenage pregnancy. Almost 90% of the re-spondents were Muslim while 95% were housewives.More than 60% of the participants were educated up tosecondary level and beyond, while about 15% neverattended school. About half the participants’ husbandscompleted primary schooling and continued to secondaryeducation; however, a quarter of them did not attendschool ever. Monthly family income ranged between 1,500and 80,000 BDT (Bangladeshi Taka; 1 USD ≈ 78.55 BDT)with median income of 8,000 BDT (≈US$ 100). About 40%of the respondents had one or no child before this preg-nancy. About 60% of all the respondents took antenatalFigure 1 Antenatal care provider to the respondents (multiple respon(TBAs).Associations between respondents’ socio-demographiccharacteristics and pregnancy-related behaviors (e.g., ante-natal care by skilled healthcare providers, pregnancy-related complications etc.) and delivery by skilled birthattendants are summarized in Table 2. It shows thatwomen’s occupation, husband’s occupation, parity, ante-natal care (ANC) by SBAs, and complication during preg-nancy were significantly associated with delivery by SBAsin bivariate analysis.The results of multivariable logistic regression aresummarized in Table 3. It shows that, after adjustmentfor covariates in the model, the variables found to besignificantly associated with delivery by SBAs were non-housewives (OR: 3.08; 95% CI: 1.27, 7.51; p = 0.013),having 2 or more children (OR: 0.61; 95% CI: 0.40, 0.93;p = 0.023); ANC by SBAs (OR: 2.62; 95% CI: 1.66, 4.14;p < 0.001), and complications during pregnancy (OR:15.00; 95% CI: 9.39, 23.95; p < 0.001).DiscussionIn this study, proportion of women who took any ante-natal care by SBAs was 59.02%, which is higher than theses were there).earlier estimates of 48.7% in 2007 and 46.4% in 2011[9,14]. Approximately one-third (30.06%) of the parti-religion is a significant determinant of delivery by SBAswhich is not compatible with our findings.Maternal age was found either to have no effect orto increase the utilization of SBAs at birth in severalstudies. Marital status was found to have no associa-tion with delivery by SBAs [17-19]. Studies also iden-tified racial [20], and ethnic and/or religious [21-26]disparities in the utilization of SBAs, unlike the find-ings of our study. Many studies found women’s andtheir husbands’ education as potential determinants ofdelivery by SBAs [4,27], which was not evident in ourstudy, nor in another study by Anwar et al. [16]. Othersignificant determinants of delivery by SBAs includeANC [4,27-29], parity/birth order [30,31], complicationsduring pregnancy [4,27], and maternal occupation [32]among others.Figure 2 Complications experienced during delivery by theparticipants (multiple responses were there).Islam et al. Reproductive Health 2014, 11:86 Page 4 of 7http://www.reproductive-health-journal.com/content/11/1/86cipants had their last delivery by SBAs which is higherthan the 2006 estimates of 14%, 2007 estimates of 13.2%[14], 2009 estimates of 19.2% [15], and 2011 estimatesof 25.2%, but little less than another estimates of 35%in 2006 [16]. Several factors have been identified as po-tential determinants of delivery by SBAs. In our study,maternal occupation, parity, complications during preg-nancy and antenatal checkup by SBAs were statisticallysignificant determinants of delivery by SBAs. Monthlyfamily income was significant only when it was morethan 10,000 BDT/month. Some of our findings are com-patible with the findings from other studies while othersare not. For example, complications during pregnancy,ANC visits (2 or more), and asset quintile were foundto be significant determinants for delivery by SBAs (lattershowing a dose–response relationship) in Bangladesh,while women’s education was not found to be a signifi-cant determinant [16]. All these findings are compatiblewith our study. However, this study [16] also found thatFigure 3 Delivery providers.ANC has also been found to be associated with in-creased institutional delivery, and improved perinatalsurvival [33]. Physical accessibility to skilled birth at-tendants has also been identified as potential determin-ant of delivery by SBAs [4]. However, data on these aremissing in our study which is one of the major limi-tations of our study. Other possible reasons for poorutilization of SBAs during delivery may include: insuffi-cient community awareness regarding the usefulness ofutilization of SBAs during the delivery, lack of appro-priate information with regard to availability and de-livery services provided by SBAs etc. [27,29]. However,health information awareness program targeting wo-men (and their husbands) may not be sufficient in im-proving the utilization of SBAs since women, and inmost cases even their husbands, are not included indecision-making process even when the issues primar-ily pertain to them [27]. Mothers and mother-in-lawsshould also be included in the awareness campaign sincestiSIslam et al. Reproductive Health 2014, 11:86 Page 5 of 7http://www.reproductive-health-journal.com/content/11/1/86Table 2 Association between socio-demographic characteribirth attendantsDelivery byCharacteristics Yes (n = 211)they are often the decision makers in the issues related todelivery [27].Of all the deliveries by SBA, majority (85.78%) wereconducted at the health facilities. Only 5.8% of thehome deliveries were conducted by SBAs. Governmentof Bangladesh introduced CSBA training program inAge in years<20 33 (15.64)20-34 165 (78.20)≥35 13 (6.16)ReligionIslam 188 (89.10)Hinduism 23 (10.90)Women’s educationNo education 23 (10.90)1-5 years 29 (13.74)≥6 years 159 (75.36)Women’s occupationHousewife 190 (90.05)Others 21 (9.95)Husband’s educationNo education 34 (16.11)1-5 years 43 (20.38)≥6 years 134 (63.51)Husband’s occupationLaborer 93 (44.08)Professionals 36 (17.06)Business/Living abroad 82 (38.86)Monthly family income (BDT)≤ 6,000 42 (19.91)6,001-10,000 83 (39.34)>10,000 86 (40.76)Parity (Number of children)0 or 1 102 (48.34)2 or more 109 (51.66)Any ANC by SBAsYes 164 (78.47)No 45 (21.53)Complication during pregnancyYes 121 (57.35)No 90 (42.65)cs and pregnancy-related behavior and delivery by skilledBAsNo (n = 491) OR (95% CI) p-value2003 in collaboration with World Health Organization(WHO) and United Nations Population Fund (UNFPA)[11]. The goal of the program is to provide at least 2CSBAs in each of the unions. About 7,000 CSBAs havebeen trained until 2012. The CSBA evaluation conduc-ted in 2011 shows that the utilization of CSBAs are poor65 (13.24) 1.22 (0.78, 1.93) 0.384398 (81.06) Ref.28 (5.70) 1.12 (0.57, 2.22) 0.745437 (89.00) Ref.54 (11.00) 0.99 (0.59, 1.66) 0.97082 (16.70) Ref.135 (27.49) 0.77 (0.42, 1.41) 0.393274 (55.80) 2.07 (1.25, 3.42) 0.005477 (97.15) Ref.14 (2.85) 3.77 (1.88, 7.56) <0.001146 (30.17) Ref.134 (27.69) 1.38 (0.83, 2.29) 0.215204 (42.15) 2.82 (1.83, 4.35) <0.001337 (68.64) Ref.32 (6.52) 4.07 (2.40, 6.92) <0.001122 (24.85) 2.44 (1.70, 3.50) <0.001154 (31.36) Ref.230 (46.84) 1.32 (0.87, 2.02) 0.195107 (21.79) 2.95 (1.89, 4.59) <0.001174 (35.44) Ref.317 (64.56) 0.59 (0.42, 0.81) 0.001245 (50.62) 3.56 (2.44, 5.17) <0.001239 (49.38) Ref.48 (9.78) 12.41 (8.29, 18.58) <0.001443 (90.22) Ref.Islam et al. Reproductive Health 2014, 11:86 Page 6 of 7http://www.reproductive-health-journal.com/content/11/1/86Table 3 Determinants of delivery by skilled birthattendants from multivariable logistic regressionDelivery by SBAsCharacteristics Adjusted OR (95% CI) p-valueWomen’s educationNo education Ref.1-5 years 0.54 (0.25, 1.20) 0.131≥6 years 0.98 (0.47, 2.03) 0.950Women’s occupationHousewife Ref.Others 3.08 (1.27, 7.51) 0.013for home deliveries. Several problems have been identi-fied for this, which include busy schedule of the serviceproviders trained as CSBA, inadequate monitoring andsupervision, and lack of community awareness. Otherstudies also indicate lack of awareness of communityabout CSBA in the locality. These findings indicate thatpromotional activities are required to improve utiliza-tion of CSBAs by the community for home delivery.Finally, according to Millennium Development Goal(MDG) 5 target set for Bangladesh by 2015, deliveryby skilled birth attendants has to be increased to 50%,and (at least one) antenatal care coverage has to be in-creased to 71.2%. However, if the government has toachieve the MDG target of at least 50% deliveries bySBAs, either institutional delivery has to be increasedCompeting interestsHusband’s educationNo education Ref.1-5 years 0.98 (0.51, 1.90) 0.958≥6 years 1.36 (0.73, 2.54) 0.335Husband’s occupationLaborer Ref.Professionals 1.87 (0.92, 3.82) 0.086Business/Living abroad 1.63 (1.02, 2.61) 0.043Monthly family income (BDT)≤ 6,000 Ref.6,001-10,000 1.36 (0.79, 2.35) 0.269>10,000 2.32 (1.26, 4.29) 0.007Parity (Number of children)0 or 1 Ref.2 or more 0.61 (0.40, 0.93) 0.023Any ANC by SBAsYes 2.62 (1.66, 4.14) <0.001No Ref.Complication during pregnancyYes 15.00 (9.39, 23.95) <0.001No Ref.The authors declare that they have no competing interests.Authors’ contributionsAll the authors contributed substantially in this manuscript. NI, TI, and YYconceptualized the paper; TI and YY were actively involved in projectimplementation and data collection; NI and TI did the data analysis; NI wrotethe first draft of this manuscript; all three authors revised and providedsignificant intellectual contribution to the final version of the manuscript.All authors read and approved the final manuscript.AcknowledgementsJapan International Cooperation Agency (JICA) provided financial andtechnical support to the whole project.Author details1School of Population and Public Health, Faculty of Medicine, University ofBritish Columbia, Room# 417, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada.2Japan International Cooperation Agency, Dhaka, Bangladesh.or home delivery by SBA has to be increased. About 3million births take place annually in Bangladesh. A 20%increase of institutional delivery means that at least anadditional 600,000 deliveries need to be conducted atthe health facilities. Though rural health facilities, ingeneral, are under-utilized, the health facilities are notprepared to accommodate such a huge number of de-liveries at this moment. On the other hand, to promotehome delivery by SBA, mass awareness of communityand physical accessibility to CSBAs need to be con-sidered. The findings from this study, supported bythose from other studies, suggest that Bangladesh hasto exert much concerted effort to meet the indicatorsof MDG-5 [34-36].ConclusionThe proportion of deliveries by SBAs was similar tothe estimates of nationally representative survey fin-dings though the proportion of women received anyANC was higher. Maternal occupation, parity, compli-cations during pregnancy and antenatal checkup bySBAs were the significant determinants of delivery bySBAs. Promotion of quality antenatal care in the com-munity may improve the delivery by skilled providersin rural areas of Bangladesh. Further research to ex-plore the unmet need for, and potential barriers in,the utilization of skilled birth attendants for deliveryis recommended.AbbreviationsANC: Antenatal Care; CI: Confidence Intervals; SACMO: Sub-assistantCommunity Medical Officer; CSBA: Community Skilled Birth Attendant;FWV: Family Welfare Visitor; JICA: Japan International Cooperation Agency;MBBS: Bachelor of Medicine and Surgery; MDG: Millennium DevelopmentGoal; PNC: Postnatal Care; SBA: Skilled Birth Attendant; TBA: Traditional BirthAttendant; UNFPA: United Nations Population Fund; WHO: World HealthOrganization.Received: 20 January 2014 Accepted: 29 November 2014Published: 11 December 2014Utilization of Maternal Health Care Services: Evidence from Matlab.Washington, DC: World Bank; 2004.30. Navaneetham K, Dharmalingam A: Utilization of maternal health careservices in Southern India. Soc Sci Med 2002, 55:1849–1869.31. 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Reproductive Health 2014 11:86.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistribution24. De Broe S: Diversity in the use of pregnancy-related care among ethnicgroups in Guatemala. J Fam Plann Reprod Health Care 2005, 31:199–205.25. Short SE, Zhang F: Use of maternal health services in rural China.Popul Stud 2004, 58:3–19.26. Celik Y, Hotchkiss DR: The socio-economic determinants of maternalhealth care utilization in Turkey. Soc Sci Med 2000, 50:1797–1806.27. Paul BK, Rumsey DJ: Utilization of health facilities and trained birthattendants for childbirth in rural Bangladesh: an empirical study. Soc SciMed 2002, 54:1755–1765.28. 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