Factors Influencing Womens Choices and Use of Safe Delivery Clinics

ABSTRACT

Background:

Although the debate on the safety and women’s right of choice to a home delivery vs. hospital delivery continues in the developed countries, an undesirable outcome of home delivery, such as high maternal and perinatal mortality, is documented in developing countries. In spite of having some quality health facilities in study areas a small portion of that community is using and large porting of community does not. However, little is known about the factors that influence women to choices of and use of Safe Delivery Clinic.

Objectives:

This study was undertaken to find out the current status of use of maternal health service, the existing care seeking practices and the various factors influence women’s choice of and use of place of delivery in rural areas of Bangladesh.

Methods:

This cross-sectional study was done during January 2010  to June 2010 in administratively and geographically well-defined unions of Khansama Upazilla under Bogura district. There were no intermediate levels of private or government hospital or maternity homes in the study areas. Interviews were carried out on 140 women who delivered within 6 months from the date of the interview with a pre-tested structured questionnaire.

Results:

Multi-parity (P=.003), five Antenatal care visits (ANC) (P=<.001)_s place of previous delivery (P^-<.0()1), expenses of delivery (P=<.001), and role of decision maker (P=<.001) showed statistically significant association with chooses and use of place of delivery. The results suggested that mothers who had low wealth status (56%), poor education level (<Primary school) (62%), were muslim (54%), and whose husbands was service holder (71%) delivered at home more frequently.

Conclusions:

The findings of this study suggest that there is a need for awareness-raising efforts in the community regarding the danger signs of pregnancy and also, healthcare providers need to be trained and made aware of the complications, so that they can identify the complicated cases and make timely referral of women to the appropriate facilities.

INTRODUCTION

The World Health Organization estimates that about 580,000 women of reproductive age die each year from pregnancy-related complications, and a high proportion of these deaths occur in sub-Continent ^(1)- The ratio of maternal mortality in the region is one of the highest in the world, reaching levels of 686 per 100,000 live births ⁽¹⁾‘ Women play a principal role in rearing children and in the management of family affairs, and their death due to maternity-related causes is a significant social and personal tragedy.

Studies demonstrating the high levels of maternal mortality and morbidity in developing countries and research identifying causes of maternal deaths have repeatedly emphasized the need for antenatal care and availability of trained personnel to attend women during labor and delivery ^}‘ Globally, at least 1,600 women die from complications of pregnancy and childbirth per day, 99% of maternal mortalities occur in the developing countries and over 50 million women experience pregnancy-related complications, (morbidity) during or after child birth and Fifteen percent of these women suffer serious or long-term often debilitating complications.

The majority of births (63%) in the developing world occur at home with a large proportion (47%) being assisted by untrained personnel ²‘. High rates of home deliveries with untrained providers are the most pronounced in Asia especially Bangladesh.

The importance of tetanus toxoid injections given prior to birth to reduce neonatal mortality has been documented as well. Since a large proportion of maternal and neonata deaths occur within the first few days following delivery, safe motherhood programs have recently increased their emphasis on the importance of postnatal care.

In Bangladesh, the levels of maternal and infant mortality and morbidity are still high. The maternal mortality rate in 2004 was 3.2 per 1000 live births, and the infant mortality rate was 65 per 1,000^J. One explanation for poor health outcomes among women and children is related to the non-use of modern healthcare services by a sizeable proportion of Bangladeshi rural women. Previous studies have clearly demonstrated that the use of available maternal health services is very low in the country. Several studies in the 2002 have shown that about 40% of Bangladeshi women received antenatal care where as in Khansama areas 70% women receive ANC, and more than 90% births take place at home and only 14% deliveries are attended by a skilled attendant . Despite the fact that the use of maternal healthcare is essential for further improvement of maternal and child health, little is known about the current magnitude and factors that influence the use of these services in rural of Bangladesh.

BACKGROUND OF THE STUDY

Plan Bangladesh has been working in Khansama, one of the poorest Upazilla in Bogura district since 1994. Khansama is located 40 km to the east of district head quarter and is about 382Km from Dhaka. There are six unions in Khansama Upazilla. At present Plan is working in 37 villages of the 6 unions of Khansama Upazilla, covering 22,524 HH and 113000 Population⁴.

The situation of child and maternal health in the upazilla has improved considerably since the time Plan started working here. Now children are regularly immunized, weighed and referred and provided treatment on time. Pregnant mothers receive TT immunization and arc checked up regularly. Plan Khansama has achieved all this through partnering with a local NGO and supporting continuous efforts at raising people’s awareness, changing behavior and organizing clinics at community and center levels.

However the situation of safe delivery and after delivery care could not be improved much in this time. Most (95%) of the deliveries take place at home and are attended by Traditional Birth Attendants . As a result, delivery related complications, delay in reaching an appropriate facility due to poor communication system and long distance and poor quality of care in the treatment centers leads to frequent disability and deaths and immense suffering to the mothers and children of the target areas. Some of this information has been shared by the mothers with Plan and Partner NGO staff during assessing the community situation with regards to child and maternal health and was reflected in baseline survey of Plan (September 2003).

The government health facility, the Upazilla Health Complex (UHC), is located in Angarpara Union. However it suffers from persistent unavailability of doctor, nurses and logistics and has no basic emergency obstetrics services. The nearest district hospitals as well as other referral hospital are very far (50-60 KM) from these communities.

Considering all these, Plan Bangladesh constructed ‘Safe Delivery Unit’ adjacent to a health center or static clinic in each union that is manned by a trained midwife and remains open for providing services 24 hrs. This has been tried out in a small way in two unions and has been highly appreciated by the community people.

Basic EOC services are delivering through these Safe delivery units with a minimum cost. There is also a provision safety net for the hardcore poor. But this is interesting that in spite of having these quality health facilities a small portion of that community is using and large porting of community does not. That’s why I am interested to find out the factors that influence to use of and choice of Safe Delivery Clinic.

RESEARCH QUESTION:

What are the factors that influence women’s choices of and use of safe delivery clinic in rural area of Bogura?

OBJECTIVES

GENERAL OBJECTIVES:

To find out the factors that influence women’s choices of and use of safe delivery clinic in rural area of Bogura District, Bangladesh

SPECIFIC OBJECTIVES:

1. To find out the current status of use of maternal health services (ANC, safe delivery) by social class of women in facilities
2. To identify the existing care seeking practices during delivery
3. To elucidate the various factors influencing use of safe delivery clinic
4. To find out the socio-economic factors related to clinic use and home delivery

• To relate the factors influencing use of safe delivery clinic and not using safe delivery clinic.

VARIABLES

This analysis is not set to test any formal theory of healthcare-seeking behavior. Nevertheless, each of the independent variables is selected for inclusion in the analysis based on previous literature.

1. Socio-demographic and economic characteristic of the respondent:

• Age of the respondents
• Religion
• Number of Children
• Wealth being status of the respondents
• Educational Status of the respondents
• Educational Status of the husband of the respondents
• Occupational Status of the respondents
• Occupational Status of the husband of the respondents
• Marital status of the husband of the respondents

2. History of Ante Natal clinic (ANC):

• ANC Checkup
• Number of the ANC Checkup
• Place of getting ANC Checkup

3. Status of Safe Delivery Clinic and its communication:

• Location of the clinic
• Distance of the clinic
• Source of information about the services of clinic
• Condition of the road
• Safe Delivery Clinic

4.Safe delivery Clinic      Client perspective

Staff Capacity                  Distance

Logistic Supply                Affordability

General cleanliness         Poor staff attitude

Privacy Status                Poor awareness of the community

5. Other variables relate with the choice and use of place of delivery

•     Decision maker for choosing place of delivery

•    Facing obstacle for choosing the place of delivery

•     Developing complication during or after delivery

•     Previous place of delivery

•     The cost of deliver

OPERATIONAL DEFINITION

Some terms has been used in this study which needs clarification for clear understanding and those are as follows:

Safe Delivery Clinic: In rural areas of Bogura, Plan Bangladesh, Khansama Program Unit has established some clinics that are staffed with trained midwives and paramedics and located at remote areas. These clinics are equipped with necessary logistics (medicine, equipment) and remain open for providing services 24 hrs. Following basic Essential Obstetric Cares (EOC) are provided through these clinics:

• Management of normal labor and delivery
• Performance of episiotomy
• Assessment of fetal well being
• Recognize onset of complications
  • Start treatment and supervise the referred mother and baby for
    interventions that are beyond the facilities of the center or
    provider competence
  • Primary management of haemorrhage
  • Initial management of eclampsia
  • Manual removal of retained Placenta
  • Essential new born care- Resuscitation

These clinics were initially established to ensure qualitative PHC among the adjacent 6000 populations. By the time, the demand is increased and they provide their support among the total population of whole union (Household* 5389, Population* 25084 in one union in an average). A Clinic Management Committee that has been elected by respective community and ensured participation of men, women, and adolescent manages these clinics. There are a strong referral linkage among these clinics with LAMBHospital (70 Beds Hospital having Emergency EOC Facilities) and DistrictHospital. Plan Bangladesh has been provided a safety net for the poor for referral and clinic management committee has developed a poor fund by collecting different fund to help the hardcore poor that is identified by them.

Wealth being Status: Resource and economical status of each and every household of these two unions has been identified through participatory wealth ranking process based on following selection criteria selected by community themselves.

After dividing the families into three categories of families, a hard-core poor group was extracted from poor group for ensuring support to them, as they don’t usually seek any health support during their illness. Following selection criteria had been considered to segregate them:

• No land / only a piece of land for home
• House made of straw, bamboo, or mud
• Do not have any savings
• Water leaks from the roof
• Spends nights on others mercy
• No mosquito net
  • Poor condition of utensils or no utensils; normally 1 piece of silver or mud made
    plate, 1 pot to cook with or without cover or uses plate as cover and 1 glass
  • Ragged cloths
  • Worn out bed sheet and pillow with out cover and a kantha
  • Begging due to blindness, dumb & deaf, paralysis, crippled
  • Searches food here and there
  • No one to look after and to provide food
  • Widow/widowed
  • Use open places for defecation
  • Baths once/twice in a month
  • Thrown away by or separated from husbands
  • Lucky to get enough food once in a day
  • Suffers from different diseases
  • Undomesticated due to mental illness
  • Not getting facilities offered by government VGD cards, old age allowance

The following table showed the mode of receiving subsidy for using Safe Delivery Centers according to wealth being Status:

Sources of information about services of Clinic: As the Safe Delivery Clinic managed and functioning by a CBO involving different type of stakeholders, so respondents may have awarded about the clinic from different source. The probable sources are mentioning below:

• Village Health Volunteer
• Community Health Worker

1. Clinic Management committee,
2. Others CBOs,
3. Union Parishad,
4. 6.       Others Stakeholders like different NGOs.

LIMITION OF THE STUDY

The study had limitations arising from problems encountered during fieldwork as follows:

1. Due to time constrain some respondents found not spontaneous for giving the interview.
2. Few respondents were absent as they visited their mothers and others relatives home. Therefore, interviewer had to visit several times to take the interview of the respondents.
3. As the sample sizes were selected purposively, which was relatively smaller size that may not represent the total population.

LITERATURE REVIEW

The high level of maternal mortality in developing countries has been attributed partly to the non-availability of services and partly to the poor utilization of these services when they are available. The immediate medical causes of maternal deaths are similar for women all over the world: postpartum hemorrhage, infection, toxemia, obstructed labor and septic abortions. However, these diagnostic categories conceal the underlying mechanisms and reasons for the deaths: the unavailability and inaccessibility of qualified health care; and the logistic problems of providing emergency obstetric care where and when it is needed ³.

Access to quality care during pregnancy and especially at delivery seems to be the crucial factor in explaining the disparity in maternal mortality and morbidity between the developing and the industrialized world. An estimated 90% of maternal deaths could be avoided, if adequate care was provided ⁶. Childbirth is a risk-producing event, and timely and adequate medical care for women who experience obstetric complications is an option for mitigating the risk. This has been well illustrated in a historical case of a religious sect in the U.S., whose female members refuse to utilize modern obstetric care. Although socioeconomic ally privileged compared to the women in developing countries, this group experiences a maternal mortality rate similar to that of developing countries 872/100,000 live births⁷.

Maternal mortality ratio in Bangladesh is 3.2 per thousand live births (National Maternal Mortality Survey: 2001) 80 percent of such deaths occur at home, where delivery is attempted under unhygienic conditions and assisted by trained or untrained traditional birth attendants (TBAs), close relatives or neighbors. The review of performance of trained TBAs conducted in 1995 by BIRPERHT showed that they continued several harmful birth practices such as performing unhygienic and un-necessary vaginal examination, applying pressure on the abdomen, tying over the abdomen tightly, asking mothers to press prematurely, slapping on the baby’s back and shaking the baby, etc3. In spite of such facts, due to existing cultural beliefs and social practices, more than 90 percent of deliveries are still occurring at home, mostly attended by the TBAs.

An important indicator for maternal health status of a country is the number of deliveries assisted by skilled attendants. Evidence shows that countries that have a maternal mortality ratio below 1 per 1000 live births have at least 85 percent of their deliveries conducted by skilled attendants e.g. Thailand (85%), Sri Lanka (95%) and DPR Korea (99%) in the South East Asia Region4. In Bangladesh, only 13 percent of deliveries is assisted by individuals with any medical training e.g. doctors,   nurses/ midwives/ Female Welfare Visitors (FWV)/ other medical assistants. Most of such ‘professionals’ lack proper midwifery training.

During the 1990s, the Government of Bangladesh (GOB) pursued the strategy of strengthening   institutional   support   for   safe   motherhood   by   providing for emergency obstetric care (EmOC) services at the Upazilla health complexes and district hospitals. However, these services are under-utilized by the community and safeties during majority of pregnancies (> 90%) need immediate attention.

In Bangladesh, maternal mortality is high and the need for treatment of women with obstetric complications is inadequately met. The mode of organization of obstetric services, where a woman is to give birth and who should attend a normal delivery is still debated, and the lessons to be learned by developing countries from the history of industrialized west is being scrutinized and explored.

Although the debate on the safety and women’s right of choice to a home deliver) vs. hospital delivery continues in the developed countries, an undesirable outcome of home delivery, such as high maternal and prenatal mortality, is documented in developing countries ^s‘⁹.study in Tanzania showed that in home births conducted without a trained attendant, the perinatal mortality was three times higher than that for hospital or dispensary births with trained attendants ^IO In Papua New Guinea, a high rate of obstetric complications was found amongst seemingly normal pregnancies delivering at home ^M .The Dutch system is an exception to the rule in the developed countries, as it is still based on the idea that women with low-risk pregnancies are free to choose where to give birth to their children. And in 1991, 35% of all Dutch babies were born at home ‘.Dutch perinatal mortality statistics are comparable with that in the Scandinavian countries, and are uninfluenced by was the relatively high proportion of home deliveries. In a Norwegian study, it was

Reported that the safety of low-risk women while delivering in small maternity clinics run by midwives with a general practitioner as the formal leader was unquestionable and that a decentralized birth organization should be offered to low-risk population is more a question of politics, than a medical problem ¹⁴. At the same time, in the U.S., where automobiles and highways are plentiful, it has been shown that geographical inaccessibility to obstetric care is associated with more frequent negative pregnancy outcomes. Women who live in communities with poor access to antenatal and obstetric services are likely to bear infants who are premature and have prolonged hospitalizations with higher costs or both ^l5.

A review on concepts, operational definitions and measurement of place of residence as an exposure measure for general health effects conclude that conflicting evidence about the extent and magnitude of place effects on general health may be due to differing conceptualizations and operationalizations ¹⁶. Relation to maternity care, place of delivery can be conceived as an exposure measure of maternal morbidity and mortality, or as an outcome measure itself also determined by different socio-economic variables. The place of delivery and its determinants have been on the research agenda for a long time”

Elo in 1992 found quantitatively important and statistically reliable estimates of the positive effect of maternal schooling on the use of prenatal care and delivery assistance.   In addition, large discrepancies were found in the utilization of maternal health-care services by place of residence ¹⁹. Bolam et al. (1998) have reported that multiparty and lower maternal education is associated with home delivery ^e. In rural Nigeria, maternal education and occupation, religion, and occupation of the husband are found to be most consistently associated with the use of health institutions for delivery – at the same time maternal age, parity, and marital status and place of the residence are not significantly associated .In a Ugandan study, it was shown that access to maternity services is one of the influencing factors in choice of delivery site. In most of these studies, low socio-economic status of the women measured by different variables individually or by combining information from several variables is implicated as being a predictor for home delivery.

A review of the literature reminds us that there is no consensus on the definition of socio-economic status and there are longstanding debates on its measurement ^22-23 Composite measure of education, income and occupation is classically used in Great Britain as a constructed variable of social class for studying general health issues. A household social class measure is proposed to serve as a better predictor of reproductive outcomes and economic level, than does individual social class

Standing”. The distance to the maternity hospital has been reported to be more important in maternity care than other general curative health services .

Many women in developing countries receive no antenatal care, almost half give birth without a skilled attendant, and the vast majority receives no postpartum care. Poor, rural women in sub- Saharan Africa and South Asia are the least likely to receive antenatal, delivery, or postpartum care. Distance from health services, lack of transport, and the cost of services keep millions of women from seeking care, even when complications arise. In addition, health workers often treat women in an insensitive manner, do not pay attention to their concerns, and are rude. These negative interactions with health care providers are also bamers to care.³⁵

Part of maternal mortality and morbidity in developing countries caused by different socio-economic factors is mediated through the place of delivery. It is important to identify the risk factors, which lead either to home or hospital delivery. Hence we are reporting the effect of socio-economic factors, ethnicity,. and distance from maternity hospital, family structure, obstetric history, and antenatal care received during the present pregnancy in a developing country like Bangladesh on the choice between home and hospital deliveries.

A study was conducted ³⁶in Nigeria showed no observed differences in the educational or occupational status of the spouses of booked patients compared with emergency admitted (EA) at maternity center. However, there were more uneducated women among the EA than the booked. IN both groups younger patients (15-34) had format education compared with the older patients (35+), strengthening the hypothesis that education is the most influential factor in patient’s acceptance of modern maternity care. Polygamy and Islam were more prevalent among the EA than the booked. It is believed that the economic affects of polygamy exercise more direct adverse effects on reproduction than religion. The purdah system, practiced by Muslims confines women to their homes, interfering with their ability to get pre-natal care. Fewer number of EA lived with their spouses compared with booked patients. Lower social class is associated with larger numbers of adverse factors in reproductive outcomes such as increased rates of low birth weight babies, multiple pregnancies and fetal abnormalities.

Poverty is almost universally associated with inequitable access to health services, particularly maternal health services. The burden of reproductive and sexual ill-health is greatest in the poorest countries where health services tend to be scattered or physically inaccessible, poorly staffed, resourced and equipped, and beyond the reach of many poor people. Too often, improvements in public health services disproportionately benefit the better off, and it is theoretically possible to achieve some of the international health goals without including the lowest income quintile and vulnerable population groups ³⁷ .

Since the 1980s, various health-sector reforms have been introduced in many countries, affecting availability of, and access to, health services, including those for reproductive and sexual health. Financing projects, such as prepaid insurance schemes and means-tested subsidies, have frequently failed to result in the desired equitable access for poor people. Thus, special attention is needed to ensure that disadvantaged groups can access prevention, treatment and life- saving services such as emergency obstetric care³⁷.

Up-to-date practices implemented in teaching hospitals and special projects are frequently not adopted throughout the system, with the result that overall performance remains poor and inequalities in both quality and access persist. Decentralized planning and responsibility associated with health-sector reforms need to give special attention to facilitating system-wide adoption of good practices. Logistical systems for sustained provision of essential commodities must be established^j7.

Where health services exist, there are many reasons – social, economic and cultural – why people nevertheless do not use them, particularly in relation to reproductive and sexual health. Identifying and overcoming obstacles requires working with women, young people, and other community groups to understand better their needs, analyze problems and find acceptable solutions’³ .

In many countries, inadequate human resources are a major barrier to the expansion of comprehensive reproductive and sexual health services, and to better quality of care. Weaknesses include the severe shortage of personnel, inadequate skills of available personnel, rapid turnover and loss of skilled workers, and the inefficient use and distribution of those who are already in the system. Low or unpaid salaries and poor training, supervision and working conditions are root causes of poor performance and high turnover of health-care professionals. Strategic planning for building and retaining an appropriately skilled health workforce, including for instance skilled birth attendants, is crucial to progress in reproductive and sexual health care ^l7.

In addition to the barriers that poor and other disadvantaged people face in accessing health services generally, such as distance from services, lack of transport, cost of services and discriminatory treatment of users, reproductive health presents special difficulties. These derive from social and cultural factors such as taboos surrounding reproduction and sexuality; women’s lack of decision-making power related to sex and reproduction, low values placed on women’s health, and negative or judgmental attitudes of family members and health-care providers. A holistic examination by communities and local health-care providers of beliefs, attitudes and values offers an important start to overcoming these fundamental obstacles^j7.

Another study   inferred that use of maternity waiting shelters and complications during the pregnancy were important factors for hospital delivery, whereas unemployment and being without a husband were associated with deliveries outside the hospital. Identification as high risk of a complicated pregnancy by application of the existing guidelines was not associated with place of delivery. Delivery at a location that did not conform to the existing guidelines was associated with non-use of maternity waiting shelters, unemployment or being without a husband and use of traditional care.

Most women with previous pregnancy complications can safely give birth in the rural health center. High-risk women had an elevated risk of complications in the index pregnancy and that better utilization of maternal health care, especially for delivery, reduced adverse perinatal outcomes ³⁹ .

A study ⁴⁰ on the utilization of maternal health services in Ejisu district of Ghana was carried out in January and February 1990. 1200 women aged between 15 and 49 were interviewed in 80 communities. The findings of the study indicated that over 50% of respondents married under 20 years, 70% of them attended antenatal clinic at least 4 times in their last pregnancy, over 80% had their last delivery in a health facility and over 80% knew about at least one modern method of family planning. Only 5.5% were currently using a modern family planning method. 90% of them were willing to stay in a maternity waiting home if advised to do so. Most would be prepared to stay for a month or 2. 20% of the respondents knew about local herbal preparations used for first aid in bleeding in pregnancy, although they would seek definitive treatment at a health facility. From the study, some women were not using the services. These would have to be reached through improving the quality of care in health facilities and increasing community awareness on maternal health in order to improve accessibility and utilization further.

Impact of health center (HC) availability on the knowledge, opinion and practices related to maternity care and pregnancy outcome was assessed ^4I after adjusting the effect of socio-economic status. Except 17 women (2.8%), everyone knew at least one correct purpose of antenatal care (ANC) and 98.2% women had contacted health staff for ANC. However, knowledge of the respondents about the components of ANC was found to be poor in study villages. Traditional birth attendants (TBAs) conducted delivery in 76.1% cases in sub-center (SC), 75.6% in villages without a HC compared to 49.8% in primary health center (PHC) village. However, preference for TBAs in PHC village was 14.9%, in SC village 33.5%, and in villages without HC 36.3% (p < 0.001). Among respondents having better awareness about ANC components, preference and utilization of modern delivery attendants was found to be higher. For maternity illnesses, consultation rate of government functionaries was 67.9% in PHC village, 52.2% in SC village and 55.8% in villages without a HC. Perinatal mortality rate of 76.0/1000 births in villages without HC was not significantly different from the rate of 87.4/1000 in SC village but rate of 38.9/1000 in the PHC village was significantly lower (p < 0.01). Awareness and availability of modern maternity services were found t< have significant influence on the health seeking behavior and pregnancy outcome.

Study design:

It is a cross sectional comparative type of study conducted among the women who delivered six months before the date of interview.

Study Areas:

The study was canned out in Bhabki  and Goaldihi union of Khansama Upazilla of Bogura district where Safe deliveries Clinics are proving maternity services.

Khansama Upazilla¹: Khansama is one of the poorest Upazilla in Bogura district

which is located 30 km to the East of district head quarter and is about 382Km North –West of Dhaka. There are six unions in Khansama Upazilla.

• Demographic: Like other parts of Bangladesh, Khansama is also one of the most densely populated Upazilla in the district, having a population of 150,000 in an area of 114 SKM (11634 hectare) with over 800 people live in per square kilometer which is expected to be 170,000 by the year 2010. 40 % of the population is children up to 18 years. Nearly 70 % people live bellow poverty line of which nearly 20% are extreme poor. Women life expectancy is shorter, even lower than national (60.7 years for male and 60.5 for the female) that is contributed by lack of community awareness about early marriage and child bearing, weak maternal health system, superstitions and discrimination against women.

•     Economy:   Economy   is   agriculture   based   and   depends   on   favorable   weather condition. Economic production is predominantly governed by traditional agriculture and practices, scarcity of HYV inputs and time supply, flash floods, draughts etc. which push the marginalized farmers towards landless / asset less. Rich and absentee landlords own majority cultivable land . Around 70 % households own less than 0.5-acre land while 17 % are landless. Majority labor forces (nearly 80%) are agricultural labor. Average daily wage rate for adult male is TK. 50/- and Tk. 30/- for female which is almost 50% lower than national wage rate (100 /- for male and 60 /- for the female). Similarly, Unemployment is 32% & underemployment is 70% (less than 35 hours) but National estimates are  17% & 35% respectively. Monthly per capita income of the poorest stands at TK. 500 / – 800 /. Other major non occupations include Pretty Trading, Rickshaw and Van Pulling, Fishing, Cattle Rearing, Carpeting etc, growth of these sectors are being supported by major micro finance institutions.

•     Monga, Seasonal Migration and Climate:    Monga, a local term is generally meant for describing seasonal crisis, lean periods which usually begins first in the month of April and May and later during September and October when major sector agriculture can not generate adequate employment to huge labor force. As a result, nearly 25 % seasonal migration takes place during the period.

Weather is generally extreme in nature, cold wave and very low temperature even down to 5 Degree Fahrenheit sometimes particularly in January and February, cripples normal daily life and causes extreme suffering to the poor who cannot protect themselves from sever weather condition and as a result many people die every year. Apart from flash flood that comes from occasional heavy rainfall, the area is not generally flood prone.

Social system and belief is influenced by religion and superstitions, although 76% population is Muslim which peacefully coexists and maintain communal harmony with Hindu, Christian and Ethnic minorities. Absence of poor friendly administrative structure, vertical social strata, inefficient and inadequate government services do not address the needs of the poor, as such NGO services have become absolute necessity. Absence of accountability and pro poor administrative and political system hinders development and empowerment of the poor. While accessibility of health and education services to the poor has increased, quality is not improved.

• Ethnic Minority: There are ethnic minorities called Showthal who constitute less than 2 % of the total population, live mainly in Khamarpara, Angarpara and Alokjhari unions and belong to the poorest and marginalized. They suffer from various social exclusions from language barrier, religions, illiteracy, awareness etc. that hinders in main streaming and overall development. There is no any scope for capitalizing their rich cultural heritage and values.
• Gender discrimination: from a few years’ experiences of child centered program implementation it reveals that in spite of constant efforts for addressing child rights and gender issue and favorable government policy, situation has not improved much Enrollment of sirts is although increased yet gender discrimination and different social problems such as early marriage, dowry, polygamy and other form of abuses are in alarming state. Restricted movement and high illiteracy isolate women from broader social life and beyond.

Poverty and Causes: About 70 % of Khansama populations are either land poor or landless. They depend on selling their manual labor to the rich and earn inadequate income for the family and children to basic needs. Lack of rural employment and land scarcity is a result of seasonal and permanent migration (urban migration is estimated (6 %). The microfinance institutions than micro enterprise development and capacity building to create more employment generation emphasize micro credit. As a result, growth of agro based as well as non-agro based sectors have not developed to generate more employment opportunity and over all economy of the area is not flourishing at desired level. And thus rural poverty remains aggravated. Main causes of poverty are weak governance, endemic corruptions, centralized system and bureaucratic control and democratic process to ensure public participation in decision making, nonfunctioning of local governance, non-equity based resource holdings and distribution.

Environment: Environmental degradation is in alarming situation that cause recurrent flash floods, draughts and destruction of natural resources endowment. The stress on agricultural production increases soil overuse, improper fertilizer doses and continued deforestation. Stress from population, poverty and natural hazards contribute to high environmental degradation, which leads rural people to more poverty and migration. Arsenic in drinking water is an emerging major public health emergency in country context but Arsenic condition of PU area is very good. As far 3400 tube-well water has been examined for arsenic test & 110 arsenic is reported yet. Health and Hygiene practices in the Program area are as follows:

• Only 31%’ family are using sanitary latrine and others are defecating in open places.
• About 69.99% ‘ family are using potable water only for drinking purpose all year round in the program area but many of these are not safe water.
• Waste (both solid and liquid) management system is very poor. GSA said that only28% families had adequate solid waste disposal facilities
• Bacteriological content of this tube-well water along with other pollutants challenges the safety profile for drinking water. Most of them are C&D groups. The same water source is using for washing utensils and clothes, bathing, toileting and cattle bathing .So the water sources are being contaminated and polluted.
• Sanitary situation in the schools are also poor. Latrines are constructed in the government primary schools but most of those are out of order due to lack of maintenance. In some primary schools there is inadequate number of latrines in comparison to number of students
• Some cultivation practices are using for years and years with no using crop rotation and organic manner which reduce the land fertility and destruct the natural environment.
• Due to deforestation people are suffering from fire wood supply but the tree plantation program is not satisfactory, particularly C and D category people have no land for plantation.
• Children are affected indirectly from smoking as the adult peoples smoke Cigarette frequently and in every place.
• Women are suffering from smoke due to traditional cooking practices.

Health and Nutrition Status: The situation of child and maternal health in the upazilla has improved considerably since the time Plan Bangladesh started working here. Child mortality and morbidity are a major public health concerned. Though rate of malnourished children is 41.60% which is less than national data (48%), the child mal-nutritional status is still high in Khansama Many of women do not have access to good quality health services during, pregnancy and childbirth – especially women who are poor, uneducated:

• About 35.46 %’ mothers of child bearing age do not use modem family planning method,
• Almost 31.11%   of women of Khansama Upazilla receive no antenatal car during pregnancy;
• Approximately one third of all  deliveries(30%’) take place without a skilled attendant
• 62.83%¹ of married women who reported to have their first child birth be fore 19 years and
• 66%¹ of women receive no postpartum care in the six weeks following delivery

There is one Upazilla Health Complex, 5 Family Welfare Centers and 19 community clinics are located all over the Upazilla. The government health facility, the Upazilla Health Complex (UHC) is located in Angarpara Union. However it suffers from persistent unavailability of doctor, nurses and logistics and has no basic emergency obstetrics services. The nearest district hospital as well as other referral hospital are very far (50-60 KM) from these communities.

 Bhabki Union: Is a rural area consisting 14 villages, 15-20 kilometer apart from Upazilla head quarter with a total household of 5375 and population of 26337. The majority are local farmer, wage laborers, van puller. There is one UnionFamilyWelfareCenter located at kachinia Bazar without Safe delivery facilities and equipments, three community clinic which are not been using for a long times. The Upazilla health complex located about 5-10 KM apart and 30-40 KM distances from DistrictHospital

Goaldihi Union: Is a rural area consisting 4 villages, 10-15 kilometer apart from Upazilla head quarter with a total household of 5290 and population of 25900. The majority are local farmer, wage laborers, van puller. There is one Union Family Welfare Center located at Goaldihi Village without Safe delivery facilities and equipments, three community clinic which are not been using for a long times. The Upazilla health complex located about 5-10 KM apart and 40-45 KM distances from DistrictHospital.

Study period:

The study was conducted from January 2010 to June 2010

 Study population:

Women who had history of delivery six moths before the study.

Sample size & sampling technique:

The total sample size was 140 women who delivered within 6 months from the date of the interview. 70 Women who gave childbirth at Safe Delivery Unit were selected purposively from the clinic’s records book. Another 70 women who gave childbirth at home were selected purposively from the union’s register book.

Data collection tool:

An interview schedule was made in Bangla, which included 39 questions for clinic delivery and 33 questions for home delivery related to the objectives of the study. A few additional questions in the questionnaire were added purposively to find out the mode of transports to clinic and assess some sort of quality of services offered by safe delivery clinic. The questionnaires were mostly structured. The questionnaire was pre tested and minor modifications were done after pretest of the questionnaire.

 Data collection procedure:

After explaining the purpose of the study data were collected through face-to-face interview using a Bangla structured questionnaire. Community Health Worker (CHW) of LAMB-PI an Project collected the data. The CHW have educational level minimum SSC pass and have got 4 months long basic training from LAMB and are responsible for 800-1000 Household coverage. Before the data collector all CHW were got one daylong orientation about the objectives of the study and process of data collection,

The data collector gave an explanation on the nature and purpose of the study to the respondents and verbal consent and cooperation for them was obtained prior to the interview. If the eligible woman was not at home, or if the time was not convenient for her to be interviewed, the interviewer came back later. All questionnaires were reviewed daily and any missing information and visible inconsistencies were completed as soon as possible by revisiting the mother for clarification.

 Data processing and analysis:

Data were entered into computer and analysis was done by SPSS (Statistical Package for Social science) statistical computer software. Frequency tables cross tables and figures were produced. Appropriate tests were done according to the objectives of the study.

4. Results

A comparative cross-sectional study was carried out among women who delivered with 6 months from the date of the interview. The study commenced from January 2010 and continued up to June 2010 in Bhabki and Goaldihi unions of Khansama Upazilla, Bogura. The results of the study have shown in the following tables and figures.

A. General characteristic of the respondents

Age range of the respondents was 14-35 years and mean age was 22.23 +_3.64. Most the respondents were Muslim (72.9%) and poor (60.7%) in economically. Housewife (93.6%) was the major occupation of the respondents where as day labor (53.6%) was major occupation among respondent’s husband. A little more than 47% of respondents had first childbirth. 36% of the respondents were illiterate where as 40% of the respondent’s husbands were illiterate.

Table : Distribution of the respondent by socio-demographic characteristics:

B. Distribution of respondents by place of delivery and different socio-

Demographic characteristics.

Table  : Distribution of the respondents by their age

Mean age: 21.6+3.2                                                             Mean age: 22.8+4

Range: 14-30 years                                                  Range: 16-35 years

The mean age of the respondents of clinic delivery was 21.64 years with standard deviation of 3.2 while the mean age of the respondents of home delivery was 22.8 years with standard deviation of 4. In both groups 51 % of women were in the age group of 20-24 years of age. Adolescent mothers were higher in the clinic delivery group (23%) than home delivery group (17%).

Table  : Distribution of the respondents by religion

Majority of the respondent in both group were Muslim (72.9%). But when it analyzed by place of delivery and region, it was found that clinic delivery was higher in hind religion (60.5%) than Muslim (46.1%).

Table  : Distribution of the respondents by childbirth order

Majority of the respondents (65.2%) used clinic in their first childbirth. As childbirth order increased, clinic utilization had been decreased and home delivery had been increased simultaneously.

Table :: Distribution of the respondents by wealth status

Clinic use in childbirth was higher among the economically rich respondent (63.2%) compare to poor and middle. Among the poor respondents, 38(45.2%) respondents gave childbirth at clinic while the percentage of home delivery was higher among the poor group (54.8%).

Table  : Distribution of the respondents by their occupation

Among the respondent most of them were housewives. Almost equal proportion of the respondents who were housewife used clinic and home in childbirth. Uses of clinic in childbirth among the Day laborers were almost double than the use of home.

Table  : Distribution of the respondents by their husband’s occupation

* It includes van and rickshaw puller, blacksmith, potter, fisherman, labor etc.

Most of respondent’s husband’s occupations in both groups were farming and Van/Rickshaw pulling. Van/Rickshaw puller’s wives used clinic and home in childbirth was almost equal, which is 49% and 51 % respectively. Among the farmers group, it shown that farmer’s wives often used clinic (58%). Surprisingly it had been observed that respondents whose husbands were services holder chose home delivery than the clinic delivery,

Table  : Distribution of the respondents by their educational status

Most of the respondents in both groups (73 % of clinic delivery and 76% of home delivery) were literate. Respondents who passed or read up to primary school chose home delivery almost twice than clinic delivery. Respondents passed or read up to SSC were most dominant figure in the both groups and they were more likely to use clinic (55%) in delivering their baby rather than home (44%). Surprisingly it had been observed that respondents those were illiterate chose and used clinic delivery than home delivery.

Table : Distribution of respondents by husband’s educational status

More than 70% of respondent’s husbands were literate. Respondent’s husbands those passed or read up to primary school chose clinic delivery (57%) more than home delivery. But the respondent’s husbands passed or read up to SSC were less likely to use clinic in delivery ( 45%). Wives of the illiterate husbands chose home most in delivery rather than clinic.

Table : Distribution of the respondents by their husband’s marital status

Among the total respondent’s husband’s, 11.4 % of respondent’s husband had more than one wife. Polly married husband’s wives were more likely to choice clinic (68.8%) as place of childbirth than home (31.2%). It was found that wives of single married husbands chose home (52.4%) more than clinic (47.6%) in delivering their baby.

Table : Distribution of the respondents by the marital order of Polly-married husband.

respondent’s husbandClinic DeliveryHome Delivery% of TotalX²

P

N%N’%First787.5112.5502.61

.106

Second or more45045050

Respondents who had co-wife/wives, marital orders of the 50% respondents were as first wife while rests of the 50% were second or more. But frequency of using clinic in childbirth was quite high up amid the first wife compare to other. Among the first wife, 87.5% of respondent delivered their baby at clinic while it was 12.5 % at home.

C.  Distribution of the respondents by caring and care seeking during

Pregnancy and place of delivery:

Table : Distribution of the respondents by ANC and place of delivery

It showed that 90% of total respondents received ANC (at least one visit during

Pregnancy). Use of clinic (51%) and home (49 %) in childbirth almost equal among the

respondents those received ANC.

Table : Distribution of the respondents by number of ANC visits and place of delivery

Mean: 4.44                    Mean: 3.87

Std. Deviations   1.19     Std. Deviation:-!-   1.24

The mean number of ANC visits among the respondents who delivered baby at clinic was 4.44 (SD^l.194) while it was 3.87(SD+_1.235) amongst the respondents delivered baby at home. This table demonstrates that among the respondents who received < 4 ANC visits. 30.67r of them used clinic in childbirth while it was 69.4 % (more than twice) in home delivery. Respondents who received > 5 ANC visits were more likely to use clinic (63.6%) in childbirth compare to home (36.4%).

Table-: Distribution of the respondents by place of receiving ANC service and of delivery

totalX²PN%N%Static Clinic*1551.7%1448.323.02.013.909Satellite4950.54849.576.98

*Staric Clinic: Safe Delivery Clinic, Upaiilla Health Complex, Family Welfare Center. **Saiellite Clinic: NGOs clinic, Government Clinics

This tabie (Table-13) shows that maximum portion of the respondents received ANC from different satellite clinics (77%). Respondents who got ANC either from static clinic or satellite clinics had not any remarkable difference in choosing the place of delivery (Static: 52% of clinic and 48% of home and satellite: 50.5 % of clinic and 49.5 % of home)

D. Distribution of respondents by    service related factors and place of delivery:

Table : Distribution of the respondents by location of the clinic and place of delivery

Most of the respondents came from different villages (79.3%) rather than the village where the Safe Delivery Clinic located. The native villagers as well as dwellers from different villages utilized the Safe Delivery Clinic almost equally (48.3% of Native Villagers and 50.5 % of Neighbor Villagers).

Table : Distribution of the respondents by distance of the clinic from respondent’s residence and place of delivery.

The table reflects that highest number (84.3%) of respondents dwelled with in 5 KM to Safe delivery Clinic. Respondents lived more than 5 Km away from the clinic, used the clinic proportionally more (68%) than respondents lived with in 5 KM (47%).

Distribution of the respondents by the source of information about the and the place delivery

Among the total respondents, 46% of respondents got information about clinic and it’s services from single source and 54 % of respondents from multiple sources. Respondents informed by single informant (54%) chose home more in childbirth while the respondents informed by multiple sources chose clinic (53%) more in childbirth.

Table  :    Distribution of road’s condition to travel clinic from respondent’s residence by place of delivery.

Above the table illustrates that road to get clinic from respondent’s residence was bad for 64.3% of respondents. It indicates that over all road communication was not smooth. However, about half (48%) of respondents those had to travel on bad road to get service from clinic gave childbirth at clinic. While the respondents had good road traveling clinic 54% of them save childbirth at clinic.

E: Distribution of respondents by social and other medical factors and place of delivery

Table : Distribution of the respondents by decision maker and place of delivery

* Family Member: Husband, Father in Ian; Mother in  law

** Health Providers: Health Worker, Village Health Member of Clinic Management Committee.

This table shows that decision for choosing the place of delivery dominated by the respondent herself (39 % of total) that is followed by family member (34 %)and health provider (26%). Among the respondents took decision by herself, 80 % of them gave childbirth at home. While the health care provider’s decision insisted 97.4% of the respondent of respective group on using clinic in childbirth. But when the decision makers were others family members only 47.9 % of the respondents used clinic in childbirth.

Table : Distribution of the respondents by facing obstacle to choose place of delivery and place of delivery

Most of the respondents (94%) did not confront of any obstacle to choose the place in childbirth. Among the respondents met obstacle, most of them for choosing clinic (67%) as a place for delivery. Whereas 50% of the respondents those did not have to confront obstacle, deliver their baby at clinic.

Table : Distribution of the respondents by developing complication after childbirth and place of delivery.

Only 22.1% of the total respondents developed complications just after delivering baby irrespective of place. But among the respondents developed complications 55% of them gave birth at home. And among the respondents did not develop complications 51% of them save birth at clinic.

Table : Distribution of the respondents gave childbirth at clinic by privacy of the clinic.

81% of respondents gave childbirth at clinic were satisfied with the existing privacy ensured in labor room while 13% of respondents were not satisfied.(Table-21)

Table : Distribution of the respondents by previous place of delivery and last place of delivery

This analysis was done among the 92 Multi-Para respondents. The table shows that 75% of the total respondents had delivered their previous baby at home and among them, only 29% of respondents used clinic in the subsequent childbirth. While 74% of respondents used clinic in their consecutive delivery those had used clinic in predecessor delivery.

Table : Distribution of the respondents by most important reasons (according to respondents) for choosing the place of delivery.

T

delivery133.3%266.7%2.14Transport facilities ⁴003100.0%2.14

y

Complication in delivery² : Privacy in clinic³: Transport facilities⁴ : Financial ability⁵:

Clinic delivery- Yes; Home Delivery- No Clinic delivery- Yes; Home Delivery- No Clinic delivery- Yes; Home Delivery- No Clinic delivery- available; Home Delivery- not available Clinic delivery- Yes; Home Delivery- No

According to the respondent’s statement, it is found that complication in childbirth played a significant role in choosing the place of delivery. More than 55 % of the respondents chose clinic as they had developed complication in childbirth. Family decision influences more than 31% of the respondents to chose place of delivery and mostly home delivery( more than two third). About 11 % of the respondents chose the place of delivery by considering privacy status of labor room of the Safe Delivery Clinic.

E : Distribution of the respondents by expenditure in delivery and place of delivery

Mean: 210.79,             Mean: 91.79

Table showed (table-24) that more then half of the respondents spent taka <200 for childbirth. One quarter of respondents spent nothing and more than two third of them gave childbirth at home. While another quarter of respondents spent taka >200 for childbirth and more than 80% of them gave childbirth at clinic. The mean cost of delivery was 91.79 for home and210.79 for clinic.

F. Relationship between choice and use of place of delivery and selected variables

Choice and use of delivery places was not found significantly correlated with the socio-economic and demographic variable except childbirth order of the respondent. Childbirth Status of respondents was found significantly associated with the place of delivery (P=.003). It was found that only 5 ANC visits (X² =13.7, P= <0.001) could change the decision of the respondents to choose the place in childbirth.

Wherever the Safe Deliver Clinic was situated (either native or neighbor village) and whatever the distances to the clinic from respondents residence, it did not have any significant relation for choosing the place of delivery. Roads condition to avail health service during childbirth did not have significant associates for influencing respondents for choosing place of delivery.

Choice and use of delivery places among the multi-para respondents was found significantly correlated with the place of predecessor of delivery (x² = 14.5  P=<0.001). A strong association between decision maker and the place of delivery had been found Choice and use of delivery places was found significantly correlated with delivery cost (P=<0.001).

DISCUSSION

This study compared the factors influencing women’s choices and use delivery places o two groups of rural Bangladeshi women. One group of women attended Safe Deliver Unit for childbirth and the other group did not attend the Safe Delivery Unit but gave childbirth at home. The discussion on the implication of the finding will follow the order in which result have been presented. Preceded by methodological consideration, a discussion will follow on socio-demographic factors, caring and care seeking during pregnancy, Service related factors and place of delivery, and Social and other related medical factors.

All cross sectional study have a problem in the random variation of the variable studied however; the outcome measures of home or clinic delivery could not be influenced by recall bias. Interviews were conducted at the mother’s place of residence and confidentiality was assured. External validity and representative of our study may mainly be applied to similar rural area and population having safe delivery clinic within the distance of median one hour and having health center and primary health care facilities for providing antenatal care.

Women aged 20-24 years represented the largest proportion (51%) between the both groups. The mean ages of respondents of clinic delivery were 21.6+ 3.2 with the range of 14-30 years. While mean age of respondents of home delivery were 22.8+ 4 with the range of 16-35 years. These points out that younger woman are more likely to for childbirth. This finding is comparable with the findings of Bhatia. 1991

Another interesting finding of the study is that religious status of the respondent significant role in choosing safe delivery clinic during childbirth. It found that Hindu communities used more the clinic that Muslim communities. This finding interpreted that there may have many religious believe or myth among the Muslim community that influence respondents choosing home delivery. This again points out that even with the threat of serious health consequences, “pordah” or seclusion practiced by Muslim women may pose a barrier to seeking services available at the rural hospitals. The findings of 1CDDR, B (Center for Health and Population Research), 1999 showed similar findings that the non- Muslims utilized the services of the HealthCenter more than the Muslims(P<0.01).

Socio-economic status has been found as a predictor for place of delivery. Higher socioeconomic status influenced the clinic use. More than 63% of respondents from rich group used clinic for childbirth and more than half (53%) belonged in the middle-income group. Other studies also have implicated different socio-economic factors as determinants of place of delivery. In a Nigerian study, 41% of the mothers who did not deliver in hospital explained that they could not afford the hospital bill, and 31% said they had inadequate transportation possibilities

Respondents those had passed or read up to primary school, more than 62% of them chose home delivery. It found that illiterate respondents were more like to choose clinic (about 53%) Although analysis showed a significant difference in the use of clinic by the women had passed or read up to SSC than those with fewer years of schooling; however. this was not significant in the Chi-square test. This suggests education of mother is not the sole predictor of the place of delivery, and hence other mechanisms or causal pathways for predicting the place of delivery have also to be entertained.

It was interesting that respondents were comparatively more educated than their husband. Approximately 29 % of total respondents husbands were illiterate while it was 26% among the respondents. Continuation of schooling after passing primary school gradually decreased among the husband while it observed among the respondents just after passing SSC. It was found that neither respondents nor husband’s educational status could influence to choice the delivery place.

Occupation of respondents was not found to be significantly associated with the place of delivery . This could be due to the correlation of the respondent’s occupation with decision-making power of the women. Very few women (about 6%) in the study area were working outside their homes, and this had no effect on the use of services. Women’s occupation was day labor used clinic more for childbirth compare to home. This suggests that occupation also plays an important role in men’s attitudes toward their wives’ well being.

The present study showed that 65 percent of the respondents attended clinic for their first delivery. It also found that as childbirth order increased, clinic delivery had been decreased and home deliver)’ had been increased simultaneously. This indicates that women had passed or read up to SSC than those with fewer years of schooling; however, this was not significant in the Chi-square test. This suggests education of mother is not the sole predictor of the place of delivery, and hence other mechanisms or causal pathways for predicting the place of delivery have also to be entertained.

It was interesting that respondents were comparatively more educated than their husband. Approximately 29 % of total respondents husbands were illiterate while it was 26% among the respondents. Continuation of schooling after passing primary school gradually decreased among the husband while it observed among the respondents just after passing SSC. It was found that neither respondents nor husband’s educational status could influence to choice the delivery place.

Occupation of respondents was not found to be significantly associated with the place of delivery (table-02). This could be due to the correlation of the respondent’s occupation with decision-making power of the women. Very few women (about 6%) in the study area were working outside their homes, and this had no effect on the use of services. Women’s occupation was day labor used clinic more for childbirth compare to home. This suggests that occupation also plays an important role in men’s attitudes toward their wives’ well being.

The present study showed that 65 percent of the respondents attended clinic for their first delivery. It also found that as childbirth order increased, clinic delivery had been decreased and home delivery had been increased simultaneously. This indicates that women are more concerned for their first delivery than the subsequent ones (P=0.003). This may also be related to the fact that primi parae tend to be younger and are, therefore, more susceptible to complications during pregnancy and childbirth

Occurrence of poly marriage by the respondent’s husbands was not uncommon (11%) in the study areas. Studies shown that more than two thirds of women with poly married husbands utilized clinic for childbirth. First wives of poly-married husbands were more likely to give childbirth at clinic (88%) rather than home delivery.

Antenatal care attendance in the study areas (90%) was higher than national average . Antenatal care (ANC) during pregnancy up to 4 visits did not have influence on women to choose delivery at clinic. But those mothers had completed 05 ANC were more likely to choose delivery at clinic (P <. 001). More than half (51.7%) of the clinic users had received antenatal care from the static clinics (Safe Delivery Unit, UHC, FWC). Thus, it may be inferred that wherever the place of getting ANC (either static or satellite clinic), it did not insist on women choosing the place for delivery.

Noorali, Luby, & Rahbar, chose the distance in kilometers rather than travel time as an indicator of physical accessibility ” “The reason given was the subjectivity involved in measuring travel time, particularly in a rural area where the mothers are not accustomed to using watches. In this study, travel time could not possible to measure in both group due to limitation of study method but road’s condition to travel clinic had been considered.

There was an assumption that location and distance of the clinic might have significant association for choosing the place of delivery. But the study showed that neighbor villagers (50.5%) used more the clinic in childbirth than the native villagers (48.3%). And distance also found as non-influential factors for choosing place of delivery. Respondents resided more than 05 kilometers away from clinic were more likely to choose the clinic (68%) compared to other group (47%). Besides, condition of roads to travel clinic were also an important factor to determine the place of delivery. It showed that bad road condition encouraged home delivery (52%).

However, if we had chosen a study population that included persons from farther area, we expect that distance would have even greater effect on place of delivery. In Kenya, the most significant predictors of choosing home delivery (an informal delivery setting) are the distance from the household to the nearest maternity bed . Le Bacq, & Rietsema reported that hospital delivery in Kasama, Zambia seemed generally to be possible only for mothers living within walking distance of that institution, and that a dose-response relationship between distance and maternal mortality existed .

Husbands and other family members like father and mother in law in the study were found to play a vital role in the decision making process. It is interesting that respondent’s decisions had accepted more for home delivery rather than clinic that indicates limited decision-making power of the women in choosing clinic (20%) Significant decision came from family members and more than half (52%) of family members chose home delivery. The inference of these data could be given that most of the family members were pre-set for home delivery and they changed their decision when complication arose. Analysis of the findings of the study indicates that rural mothers still depend on counseling given by health care provider (26%) for choosing the place of delivery. Since education has a link to decision-making efforts, widespread education of women is important, especially in the context of rural Bangladesh.

Previous place of delivery had significant role in choosing place for delivery (P <. 001). Multi para women those had given previous childbirth at clinic, were more likely to choose clinic for consecutive deliveries (74<£). The reasons for more using of clinic for successive delivery might depend on the satisfaction of women and others family members in services of clinic. It found that only 20<~c of women developed complication during postnatal period of that gave childbirth at clinic.

The delivery room was established in a manner so that privacy should be strictly maintained. But about 17% of women claimed of breaching privacy during delivery. Women and her family faced obstacle for attending clinic twice than home delivery. So the inferences could be given that obstacle comes more for clinic delivery rather than home delivery.

Expenditure of delivery was an important factor to determine the place of delivery (P <. 001). The expenditures includes transport cost, medicine cost, services charge. Mean expenditure of clinic delivery (211) was more than double of home delivery (92). As there was provision of safety net for hardcore poor that’s why clinic deliver)’ had high standard deviation. It seems that expenditure for home delivery would not be analyzed in depth (includes details expenditure like gift for dai, treatment of complication etc.) that might lead to miscalculate and misconception of women and family.

According to their statements it found that developing complication or not in delivery influenced women for choosing the place of delivery. More than half of women influenced by family decision for choosing home delivery. Those have confidence on clinic had utilized 15 times more for childbirth. Complication, family decision and confidence on clinic played an important role and these results stated same findings that discussed above.

Four major steps require attention when a woman has an obstetric complication. The first step is the recognition of the life-threatening complications by the woman and her family, the Birth Attendants or other providers who cannot manage the complication. The second is the decision to seek care, typically made by family members other than the woman if she is in poor condition. Once the problem is recognized, the third step is to overcome impediments to accessing services, such as distance, lack or cost of transport, geographical or weather constraints, and the perceived poor quality or attitude of the providers. The last step is the quality of care available and provided services are once accessed

The findings are similar in many developing countries although we can see the opposite in developed countries like The Netherlands .The Dutch researchers reported that compared to the higher socio-economic status group, there was an increased risk of hospital delivery in the lower socio-economic group in the Netherlands. This is jus opposite to our findings, though it can be easily appreciated that home deliveries in Bangladesh are in no way comparable to Dutch home deliveries with a trained midwife and immediate access to emergency transport. In developed countries, women may prefer to give birth at home for dimensions of experience unavailable in hospital. Indeed, it was reported from New Zealand, that mothers who choose a home delivery.

CONCLUSION

On the basis of the results obtained and the discussion with regard to the “Factors influencing women’s choices of use of safe delivery clinics”, the study could be concluded as birth order of mother’s plays a significant role in using and choosing the place of delivery. Other variables like five Antenatal Care visits (ANC), role of decision maker, expenses of delivery, and previous place of delivery are major causal components for choosing the place of delivery. While religious status, wealth being status, occupation of women, educational statuses, and physical distance from the maternity hospital have little influence or are not risk indicators for the place of delivery. The study shows that not only availability of service helps women to choose clinic delivery along with others factors played as determinants for choice and use of safe delivery clinic.

RECOMMENDATIONS

Changing behavior and established practice is a difficult and complex process. As the findings in this study reveal, encouraging changes to practice is particularly challenging if health care providers and different stakeholders do not internalize the need for change. if they are afraid of the implications of a change in practice, and if the change requires new skills and training.

In the light of analysis and conclusions of this study in the preceding sections the following recommendations are forwarded:

1. Results of this study clearly show that there is a strong need for awareness-raising efforts in the community regarding the danger signs of childbirth. As the literacy rate in rural Bangladesh is low, pictorials can be used to raise such awareness.
2. Quality of services in terms of availability of essential & emergency medicine and equipment and capacity of clinic staff need to extend to offer more support during complicated labor.
3. Quality and number of ANC during pregnancy could be promoted and increased. 05 visits enhanced delivery at clinic and it can be incorporated in the ANC target instead of 04 visits.
4. More involvement of Muslim community in the Clinic Management Committee and CBO’s committee may promote clinic-based delivery among the Muslim community.   Besides,   Counseling   and  BCC   session   should   be   given   more emphasis with in Muslim community.
5. Delivery cost should be analyzed in depth among the community during Bin Planning seminar and BCC/counseling session that will give a clear picture and hopefully boost the community to use clinic during delivery.
6. Always good communication encourages clients to use health services more. Roads to travel at clinic are very poor that needs to improve.
7. To carry out different anthropological and operations research to identify barriers to use of services and devise and test measures to overcome them.