Pregnancy and Delivery Risk Among Bangladeshi Women

Introduction

The maternal mortality ratio (MMR) is not merely an indicator of maternal health but is also considered to be an important indicator of the health status and well being of a nation. Bangladesh has made a significant improvement in several health indicators. Nevertheless, although the maternal mortality ratio has declined from more than 600 in 1980 to 322 in 2004, it ^{1, 2} is still one of the highest in the world. Regional variations in MMR are also observed in Bangladesh.

In Bangladesh, pregnancy and delivery-related deaths account for 20 percent of the deaths in women of reproductive age. Ten percent death occurs during delivery, and the one in five occurs before delivery and remaining death after delivery. The leading causes of maternal deaths are hemorrhage (29 percent) and eclampsia (24 percent). Other direct major causes of maternal deaths are prolonged/obstructed labor and puerperal sepsis. The lack of knowledge on maternal health and negative attitude towards seeking delivery care from qualified providers contribute largely to the high rate of maternal deaths in Bangladesh .

The key challenges in reducing maternal and neonatal mortality include lack of access, and inadequate and poor quality of maternal and neonatal health (MNCH) services. Although the government has developed a comprehensive maternal and child health service delivery infrastructure from grassroots to higher levels, there is a significant underutilization of the existing capacity due to both demand- and supply side barriers. These barriers can be well understood in the framework of the three delays: (i) delays in making the decision to seek care for lack of awareness, and social-cultural-gender inequality, (ii) delays in reaching a medical facility due to transportation related obstacles, and (iii) delays in receiving adequate treatment or management at the facility. The first two delays reflect the demand-side barriers while the third delay occurs at the supply-side, which, in turn, affects the demand side barriers.

With impressive progress made in recent years, Bangladesh is one of few developing countries on track to achieve Millennium Development Goal 4 to reduce child mortality. Between 2004 and 2007 child mortality has fallen from 88 per 1,000 live births to 65 per 1,000 live births.1 However, despite this encouraging trend, neonatal mortality in Bangladesh is still high, accounting for more than half of all under-five deaths and more than two-thirds of infant deaths. An estimated 120,000 newborns die every year in Bangladesh. The share of neonatal deaths to infant mortality has increased over the period 2002-2006, largely because there has been little progress in preventing neonatal deaths. Poor neonatal health and under-nutrition of both mothers and children could affect the current success in improving child survival.

Rational of the study

Different studies show that utilization of antenatal care (ANC) and delivery care can reduce maternal mortality and morbidity significantly. However, the utilization of maternity care provided by trained professionals during and after delivery is alarmingly low in Bangladesh. While there has been some improvement in the recent years, about half of the pregnant women still do not seek any ANC The World Health Organization (WHO) and the Government of Bangladesh recommend a minimum of three ANC visits, with one visit every three months. Only one in three pregnant women made three or more ANC visits Among those who receive ANC, 31 percent receive services during the first trimester and 24 percent delay seeking care until the third trimester. The frequency of ANC visits and early initiation of ANC is higher among women with first births, women in urban areas, those who have completed secondary school, and those from among the wealthiest households.

Pregnancy and delivery-related deaths account for 20 percent of the deaths in women of reproductive age (NIPORT et al. 2003). Two-thirds of maternal deaths occur after delivery; one in ten occurs during delivery, and the remaining one in five occurs before delivery. The leading causes of maternal deaths are hemorrhage (29 percent) and eclampsia (24 percent). Other direct major causes of maternal deaths are prolonged/obstructed labor and puerperal sepsis. The non-availability of trained providers, low uptake of services by women, and infrastructure difficulties all contribute to the high rate of maternal deaths in Bangladesh.

To reduce the health risks for mothers and children, it is important to increase deliveries by skilled providers with adequate medical supervision. Yet, delivery at home remains almost universal in Bangladesh. About 85 percent of babies are born at home. Seven percent of deliveries occur in public health facilities; and eight percent occur in private hospitals and clinics. Trained providers (doctors, trained nurses or midwives, or paramedics) attend only 15 percent of deliveries. Only 29 percent of women with complications during delivery receive treatment from trained providers; 33 percent visit unqualified providers. The remaining one-third does not seek any care for maternal complications at all. The proportions of institutional deliveries are higher among women of higher socio-economic status, women in urban areas, and women with secondary school or higher education. To examine the knowledge of antennal and delivery care among the pregnant women who were attended in Magura district hospital for receiving maternal health services.

Literature review

Bangladesh has the highest maternal mortality rates in the world. In most countries maternal deaths accounts for less than 2% of all deaths among women of reproductive age, whereas in Bangladesh maternal deaths account for 27% of all deaths ¹⁰. In addition to the high risk of death associated with pregnancy and childbirth, women in Bangladesh are at even greater risk because of high-fertility norm ¹¹. the current maternal mortality ratio is 320/100000 live births  and approximately 28000 women die due to pregnancy related complications in each year ¹².

The major causes of maternal mortality are hemorrhagic, unsafe abortion, eclampsia, puerperal sepsis, and prolonged labor. Maternal morbidity situation is even more alarming. More than 90% of women give birth at home, with only traditional birth attendants assisting in the delivery. Findings from 1999-2000 Bangladesh Demographic and Health Survey suggest that 70% of the pregnant women under the age 20 did not receive any antenatal care. Over 90% of women give birth at home, often with assistance from untrained birth attendants. Several government and non-government organizations are implementing innovative approaches to reduce maternal mortality in Bangladesh. ¹³

It is not just the unfortunate women who must bear the burnt of negligence and ignorance. The weak state of the mother is passed on the fetus. Thirty to fifty percent of all babies are born with a low birth weight ¹⁴ and for 1000 babies born alive, 12 die within hours of birth, 8 of them due to birth injuries. Three forth of the babies born to women who die during do not live to see their first birthday. Data from 54 countries show that in Bangladesh, Chad, Guinea and Nigeria more than 1 in every 10 women have their first child before age fifteen ¹⁵. Sixty seven percent of pregnant women receive no antenatal care in Bangladesh. The expected outcome of pregnancy is a healthy mother with a healthy child. Antenatal and emergency obstetrics cares (EOC) are the two acknowledged measures in Bangladesh for the reduction of maternal morbidity and mortality. Proper and timely antenatal care and delivery under strict hygienic conditions by trained service providers can significantly reduce the risks of maternal mortality ¹⁷. However, the utilization of maternity care provided by trained professionals during and after delivery is alarmingly low in Bangladesh. While there has been some improvement in the recent years, about half of the pregnant women still do not seek any ANC.

The World Health Organization (WHO) and the Government of Bangladesh recommend a minimum of three ANC visits, with one visit every three months. Only one in four pregnant women makes three or more ANC visits ¹⁸. Among those who receive ANC, 31 percent receive ANC services during the first trimester and 24 percent delay seeking care until the third trimester. The frequency of ANC visits and early initiation of ANC is higher among women with first births, women in urban areas, those who have completed secondary school, and those from among wealthiest households. Also these countries need reliable and cost effective ways to measure their progress toward reducing maternal mortality.

Most of the women in Bangladesh do not receive antenatal care. 2007 BDHS findings suggest that 40 percent of the women do not go for antenatal care. Only 20 percent of women go four times or more for antenatal care during pregnancy.  Those who receive care tend to receive it from doctors (35%), from nurses, midwives, paramedics or FWVs (16%). Nine percent of pregnant mothers receive antenatal care from non qualified service providers. Data indicate that tetanus Toxoid coverage is relatively widespread in Bangladesh. Overall, 60% of mothers received two or more tetanus Toxoid injections during pregnancy visits .

To reduce the health risks for mothers and children, it is important to increase deliveries by skilled providers with adequate medical supervision ²⁰. Proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infections that can cause death or serious illness for either the mother or the newborn. Yet, delivery at home remains almost universal in Bangladesh. Almost 85% of babies are born at home. Only 7% of deliveries occur in public health facilities and 7% occur in private hospitals and clinics. Qualified service providers (doctors, nurses, midwives or paramedics) attend only 18% of deliveries ²¹. Only 35% of women with complications during delivery receive treatment from a qualified doctor, 36% visit unqualified providers. Nineteen percent women did not seek any care for maternal complications ²². The proportion of institutional deliveries are higher among women of higher socio-economic status, women in urban areas, and women with secondary school of higher education ²³.

Ideally, postnatal care is one of the most essential elements in ensuring reproductive health because it deals with such broad issues as safe motherhood, child survival, growth and development of infants and children, post partum fertility regulation and sexual health. The PNC service components as suggested in the official document of the government, include provision of nutritional advice, iron/folic tablets, high potency vitamin A capsule within 14 days of delivery, contact by an FWV within 14 days, breast-feeding counseling, care of reproductive organs to protect against infections, cleanliness of new born’s cord, advice on post-partum family planning (birth spacing), physical exercise and immunization.

Service providers are supposed to advise women during pregnancy or delivery to have a health check-up after the baby’s birth and women are supposed to receive a check-up by health/FP worker within six weeks of delivery. In a comparative research it has found that, such advice and check-ups were not provided to all. Advice on PNC was received b 81 percent women under standard package by NGOs and 93 percent women under innovative package of  NGOs, and only 68 percent women under standard and 84 percent under innovative reported actually receiving a check-up within six weeks of delivery. The comparison shows that the situation is better in the NGOs funded areas than in the country as a whole. While other studies report that 6-10 percent of women receive PNC services from a trained provider, this was 55 percent in the NGOs funded areas ²⁵.

Health care seeking behavior patterns during pregnancy describe who is getting which type of health services. Culturally, hospitalization of women is not considered important and pregnancy is not looked upon as a risky event. These perceptions lead to increase maternal mortality and morbidity rates in Bangladesh as well as many developing countries. Post natal care is a crucial component of safe motherhood. Postnatal checkups provide an opportunity to assess and treat delivery complications and to counsel mothers on how to care for themselves and their children. A large proportion of maternal and neonatal deaths occur during the 24 hours following delivery. In addition, the first two days following delivery are critical for monitoring complications arising from the delivery. Post natal care among women in Bangladesh is very poor. Seventy percent of the women do not take any PNC. Only 21% percent of mothers get any postnatal checkups from trained providers within 42 days of delivery.

Most women are checked up within their first two days after delivery. The percentage of postnatal checkups is lower among women in rural areas, in those from lower socio-economic status, and in those who are illiterate ²⁷. The main reason for not receiving a postnatal checkup is the perceived absence of need (56%) followed by cost of treatment (22%). Comparatively older women, women with higher parity, low education and those in poorer households report cost as a barrier for not seeking postnatal care ²⁸.

Distance is known to negatively impact service utilization and is also cited as a reason why women choose to deliver at home rather that in a health facility. Given the cultural context, the remarkable effect of distance on use of facility based care is not surprising. However, the same effect of distance on home based care was unexpected. This highlights the fact that attending a home birth is complicated, often involving several steps. Someone has to travel out side the households to call the midwife, the midwife has to walk or arrange transport, and she may have to travel long distance to reach the home or at night when the security is of grave concern.

Prevailing cultural norms may also represent barriers for the midwives to travel far away from their home, particularly at night. Religion is significantly associated with the delivery practices. Muslim women are less likely to have their delivery assisted by medically trained persons probably because of their conservatism and religious taboo. ²⁹ Appropriate BCC activities need to be under taken to overcome conservatism and religious taboos against delivery. There is a need for further investigation to examine the effects of some programmatic and cultural factors, on the deliver practices of the women. Because, community is an important factor that effects safe delivery practice in all settings .

A study on safe motherhood programs in Bangladesh found that women’s low status in society, the poor quality of maternity care services, lack of trained providers, low uptake of services by women and infrastructure all contribute to the high rate of maternal deaths. This is compounded by strong cultural and traditional ties that deter women from delivering at health centers or with medically-trained attendants because their mothers have given birth “naturally” for generations. There is also little understanding about taking rest or additional nutritious food during pregnancy. Moreover, the low status of women within the family means one in every two women will have her health care decided by her husband. Often her mother-in-law will be a key decision maker. ^28-32

Another key factor in the high mortality rate is dealing with emergency obstetrics care. Despite the presence of a well-established service delivery infrastructure in Bangladesh and various measures taken so far, the utilization of emergency obstetric care (EmOC) services is still low.

The Bangladesh Maternal Mortality Survey (BMMS) 2001^33-38 found there were delays in recognition of emergencies, and further delays in deciding what treatment should be sought. The BMMS found that two in five women could not decide whether to seek treatment within six hours of recognizing complications. There are then delays in travelling to treatment facilities, with the survey finding that travel time was more than one hour in about one fifth of the cases. There are often delays in actually receiving the treatment and the costs involved are yet another deterrent for many people in a country where 36 per cent of the population live on less than US$1 a day

Violence against women is another problem in curbing maternal mortality, with 14 per cent of the deaths of pregnant women associated with injury and violence. Few women attend hospital after violence, or even for a check up, because of the patriarchal social structure.

Research question

What is the level of knowledge of women regarding pregnancy risk in selected hospital?

 General objective

To explore the self-assessment knowledge of pregnant women about hospital delivery and risk of pregnancy attending in Magura district hospital?

Specific objectives

1. To examine the relation between socio-demographic indicators and service seeking behavior of the pregnant mothers attending in the Magura district hospital.
2. To find out the status of knowledge of the pregnant women regarding danger signs during pregnancy attending in Magura district hospital.
3. To explore the current attitude of the pregnant women towards seeking maternal services from Magura district hospital.
4. To measure the ANC, natal and PNC rate among the women who ever got pregnant from the pregnant women attending in the study hospital.
5. To explore the barriers to seek maternal health services who live in the rural district of the country.

Operational definition

Maternal health and its services

Maternal health care is a concept that encompasses family planning, preconception, prenatal, and postnatal care. Goals of preconception care can include providing education, health promotion, screening and interventions for women of reproductive age to reduce risk factors that might affect future pregnancies. Prenatal care is the comprehensive care that women receive and provide for themselves throughout their pregnancy. Women who begin prenatal care early in their pregnancies have better birth outcomes than women who receive little or no care during their pregnancies. Postnatal care issues include recovery from childbirth, concerns about newborn care, nutrition, breastfeeding, and family planning. All the services that designed to ensure maternal health is called maternal health services

Status of Knowledge

This study will include the knowledge of the respondents about safe motherhood, ANC, PNC, immunization and risk factors that affecting pregnancy and the services of the hospital available for the maternal health services.

Qualified providers

 It does means doctors, staff nurses and trained TBAs.

Service seeking behavior

Attitudes of the respondents about seek service for enjoying a better and healthful life during pregnancy

Knowledge scale of the mothers about ANC knowledge and pregnancy risks:

1. Know what is ANC?
2. Know the time of visit to the hospital.
3. Know how to detect the pregnancy risks.
4. Know the danger sign of pregnancy.
5. Know about diet during pregnancy.
6. Knowledge about extra rest during pregnancy.
7. Knowledge about risky job during pregnancy.
8. Know on TT vaccine.
9. Know about taking extra calorie.
10. Know what to do during any emergency.

Very good knowledge: When answer was found corrected for 8 to 10 questions then it was scored as very good knowledge.

Good knowledge: When answer was found corrected for 5 to 8 questions then it was scored as good knowledge.  

Satisfactory knowledge: When answer was found corrected for 3 to 5 questions then it was scored as satisfactory knowledge.  

Poor knowledge: When answer was found corrected for below 3 questions then it was scored as poor knowledge.

Study type

It was a cross sectional study.

Sampling technique

For determining sample size, in this cross-sectional study, used following formula:

n = (z²pq)/d²

where,

                n = required sample size

z = 1.96 (The value of 95% CI of normal distribution)

d= 0.10 (desired precision)

p = 0. 5

q= 1-p = .5

Using those values the sample size, n = 96.04 @ 100

Study population

The study populations were the pregnant women attending in the Magura district hospital for the maternal health services.

Dependent variables

Self-assessment risk of the mother about pregnancy and hospital safe delivery.

Socio-demographic variables

• Age
• Sex
• Education
• Employment

Outcome variables

• Knowledge of maternal health and service seeking attitude
• Barriers to seek services from qualified providers
• Received quality services from the providers
• Reasons for not seeking maternal services from qualified providers
• Visited health center clinic to receive maternal information and service.
• Know the sources of services

Inclusion criteria

• Female of reproductive age 15-49 years who visit the study health center for health information or services during study period
• Willing to take part in the study
• Present during the time of data collection

Exclusion criteria

• Unwilling to participate in the study
• Age below 15 years and above 49 years
• Not present during the time of data collection

Data Collection, Management & Analysis

The data was collected through a structured questionnaire and checklist. Baseline information on socio-demographics, knowledge, attitude and practice with respect to maternal health was collected from the study participants through interviewer administered questionnaire through face to face interview. Questions were asked about the danger signs and symptoms during pregnancy.

Ethical consideration

Prior to the commencement of this study, the research protocol was approved by the research committee of ADUST. The aims and objectives of the study along with its procedure, risks and benefits of this study was explained to the respondents in easily understandable local language and then informed consent was taken from each participant. Then it was assured that all information and records will be kept confidential and the procedure will be used only for research purpose.

Informed Consent

A well and clearly understood inform consent form was filled in up by the respondents and interviewer. However, translations was carried out according to the need of the respondents. This ensures that each of participants got the information they need to make an informed decision.

Results

Table  Percent distribution of women of reproductive age by background

Information was collected from married women of reproductive age. The distribution of women of reproductive age according to age, education, marital status and occupation status is presented in Table 1. Findings indicate than 19 % of women are aged below 20, 39% of respondents are aged between 20-24 years and 32% are between 25 to 29 years old.

Table  Percent distribution of women of reproductive age by education

The distribution of women according to their husband’s information is presented in Table 3. About 60% of the respondent’s husbands have completed primary and 15% have completed secondary and 17% have completed higher secondary education. Forty seven percent of the husbands are gainfully employed in skilled or unskilled manual labor and 32% in service and only 21% of the husbands are involved with small or large business.

Table  Percent distribution of women of reproductive age by their economic status.

Economic status of the respondents households are described in Table 4. Sixty nine percent of the respondents do stay in their own homestead and only 31% of the respondents have any cultivable land in their position. Respondents were asked whether they thought their household was a surplus or deficit household in terms of food consumption. Only 8% of the respondents indicated that they have a surplus of food, while 37% of the respondents mentioned that they have neither a deficit nor a surplus of food and 27% of the respondents always have sometimes deficit.

Table  Percent distribution of women of reproductive age by visit health center

Education, exposure to media, and work participation are some of the means by which women gain status and autonomy, both important aspects of their empowerment. To measure women’s autonomy and freedom of movement respondents were asked whether they go alone to the health center which has presented in Table 5. Only 16% of women say that they go alone to the health center and rest of others either with their husband or with neighbors go to the health centers.

All the participants mentioned they need to take permission before go to the health center. 85% of the women need to take permission from their husbands’ and 15% from their parents in law. In case of final decision majority have mentioned that husband decide to go to health center.

Table  Percent distribution of women of reproductive age by the number of child they have at present

The distribution of all women by number of children is presented in Table 6. The table shows that more than half of the respondents have two child and only 8% have more than two children. Thirty four percent of the respondents have a history of child death.                                                            

Table  Percent distribution of women of reproductive age by knowledge of FP methods

Knowledge of family planning methods is presented in Table 7. Findings show that virtually all the respondents know about family planning methods. More than half (69%) of the respondents have ever used any family planning methods and among them majority (65.2%) has taken oral pill to avoid pregnancy.

The most commonly known family planning methods among women are the pill (82%) and injection (73%), followed by condom (56%) Norplant (16%), female sterilization (4%). Sixty two percent of the respondents mentioned they have heard about FP first from their relatives or friends.
Table Percent distribution of women of reproductive age by pregnancy risk

To assess the knowledge about the health risk of pregnant women respondents were asked whether they can identify the potential health risk of a pregnant woman.

One third of the women do not know any health risks of a pregnant mother. Forty six percent of the respondents mentioned prolonged labor as a major health risk followed by risk to life of mother (26%), eclampsia (19%), obstructed labor (13%), and risk to life of baby (8%).
Table  Percent distribution of women of reproductive age by knowledge of ANC

*Multiple responses

Table 9 and 10 shows the health seeking behavior of women during pregnancy. Respondents were asked from where one can get pregnancy care and table shows that 45% of the respondents identified public hospitals and 37% health and family welfare centers for pregnancy care, 46% qualified doctors and 9% of the respondents mentioned abut NGO clinic or hospital.

Respondents were asked whom they have heard about pregnancy care and half of the respondents mentioned about field workers. One fourth of the respondents said they heard from qualified service providers and 28% mentioned about relatives. Ninety eight percent of the women think women should go for ANC and 54% think it should be in case of complications. Only 17% said women should go at one to three months of pregnancy duration.

Table : Percent distribution of women of reproductive age by knowledge of ANC

 As the pregnant women responded to the question, whom you heard about ANC, PNC &  delivery care, the response were as followed Upazila health complex 2%, Health and family welfare center 6%, Doctors/Service providers 25%, Field workers 50%, Relatives 28%, Reading materials 4%.

Pregnant women should go for medical checkup, the answer were; Yes 98%, Don’t know–2%.

The respondents described that in case of any complications the pregnant women usually go to seek health care (54%), other 17% told that during 1-3 months of pregnancy the women go to seek health care and 29% women said that they have no idea about it.

Table  Percent distribution of women of reproductive age by ANC visit

Respondents were asked whether they went for ANC in their last pregnancy and it is found that 94% of the women had ANC. Among them 60% visit two or three times and 26% more than three times. Sixty six percent of the respondents said they visited when they were less than six months of pregnant. Those who did not take ANC they mentioned not perceived as necessary (16.7%), too far (33%), religious bindings (16.7%) and don’t know about the service (33.3%).

33% respondents do not know about the health services, 17% think that the health services are no a necessary things and the same percentage were not attend the health services due to religious bindings and 33% did not attend as the health centers are so far from their houses.

Table  Percent distribution of women of reproductive age by service provider for ANC

Table number 12 shows that, respondents were asked from whom they took the ANC. Sixty percent of the respondents sought treatment from Family Welfare Visitor (FWV) and 28% from a qualified doctor (Table 12)

Table  Percent distribution of women of reproductive age by ANC services

*Multiple responses

The services respondents received during ANC were presented in Table 13 and 14. Findings suggest that weight measured (81.9%), height measured (58%), blood pressure was checked (93.6%), urine was tested (44.7%) and ultrasonogram was conducted (27.7%) of the respondents. Almost 98% of the respondents received TT injection and out of them 72.3% received it two times. 88% respondents mentioned they have taken iron intake during pregnancy. Fifty four percent of the respondents spend up to taka 500 for ANC

Table  Percent distribution of women of reproductive age by ANC services

During pregnancy the pregnant women takes TT injection was given Yes 92% and Don’t know about TT vaccine was 2%. Number of TT injection given as per the respondents One 10%, Two 68%, Three–8%, More than three 6%, Don’t know 2%.

Table  Percent distribution of women of reproductive age by delivery care

Table  presents the distribution of births by place of delivery and whom last delivery was assisted. Children delivered with the assistance from qualified doctors are 20%, and majority is delivered by TBA (57%). Seventy seven percent of the births occur at home. Twenty percent of the delivery occurs in public hospital and another 3% in private health care centers. Thirty two percent of the respondents mentioned they did not spend any money for delivery, 38% spend up to taka 1000 and another 13% spend about 15000 taka for delivery care.

As respondents responded about the birth place of their last child; District hospital 17%, Maternal and child welfare center 2%, Upazila health complex     1%, Private clinic/hospital 3%, Home 77%.

Table Percent distribution of women of reproductive age by knowledge of health centers

Respondents were asked whether they know the nearest health center in her locality (Table 16). Findings suggest all the participants know the health center near by their home and all the participants know the field worker in her locality. Sixty two percent of the respondents mentioned health worker visited her home in the last six months.

Table   Percent distribution of women of reproductive age by quality of health services

* Multiple responses                       

Respondents health seeking behavior was assess in the survey. Table 17 shows that only one fourth of the respondents visited any health center in the last one year for seeking any services. Fifty two percent of the respondents visited for general diseases treatment, 36% for FP service and 24% for ANC. All of them said they were satisfied with the service provided to them and 72% said they did not need to pay any money for the service.

Discussion

In Bangladesh, pregnancy and delivery-related deaths account for 20 percent of the deaths in women of reproductive age (NIPORT et al. 2003). Ten percent death occurs during delivery, and the one in five occurs before delivery and remaining death after delivery. The leading causes of maternal deaths are hemorrhage (29 percent) and eclampsia (24 percent). Other direct major causes of maternal deaths are prolonged/obstructed labor and puerperal sepsis. The lack of knowledge on maternal health and negative attitude towards seeking delivery care from qualified providers contribute largely to the high rate of maternal deaths in Bangladesh. ¹⁹

Information was collected from married women of reproductive age. Findings indicate than 19 % of women are aged below 20, 39% of respondents are aged between 20-24 years and 32% are between 25 to 29 years old. The educational status of women reflected that10% women are illiterate, 68% have primary education, 12% have secondary and 10% have completed higher secondary and higher education. There are often delays in actually receiving the treatment and the costs involved are yet another deterrent for many people in a country where 36 per cent of the population live on less than US$1 a day.

With regard to mass media exposure, 83% of the women do not listen to the radio. The proportion of women who listening to the radio only 17% In terms of watching television, 24% of the respondents watch television every day. In case of reading newspapers or magazine only 2% reads newspaper every day. Only 20% of women have any affiliation with any club. About 60% of the respondent’s husbands have completed primary and 15% have completed secondary and 17% have completed higher secondary education. Forty seven percent of the husbands are gainfully employed in skilled or unskilled manual labor and 32% in service and only 21% of the husbands are involved with small or large business. Community is an important factor that effects safe delivery practice in all settings .

Sixty nine percent of the respondents do stay in their own homestead and only 31% of the respondents have any cultivable land in their position. Education, exposure to media, and work participation are some of the means by which women gain status and autonomy, both important aspects of their empowerment. Only 16% of women say that they go alone to the health center and rest of others either with their husband or with neighbors go to the health centers. All the participants mentioned they need to take permission before go to the health center. 85% of the women need to take permission from their husbands’ and 15% from their parents in law. In case of final decision majority have mentioned that husband decide to go to health center. The percentage of postnatal checkups is lower among women in rural areas, in those from lower socio-economic status, and in those who are illiterate ³⁴.

Findings show that more than half of the respondents have two child and only 8% have more than two children. Thirty four percent of the respondents have a history of child death.  Report shows that virtually all the respondents know about family planning methods. The most commonly known family planning methods among women are the pill (82%) and injection (73%), followed by condom (56%) Norplant (16%), female sterilization (4%). Sixty two percent of the respondents mentioned they have heard about FP first from their relatives or friends. More than half (69%) of the respondents have ever used any family planning methods and among them majority (65.2%) has taken oral pill to avoid pregnancy.

One third of the study women do not know any health risks of a pregnant mother. Forty six percent of the respondents mentioned prolonged labor as a major health risk followed by risk to life of mother (26%), eclampsia (19%), obstructed labor (13%), and risk to life of baby (8%). Respondents were asked from where one can get pregnancy care and table shows that 45% of the respondents identified public hospitals and 37% health and family welfare centers for pregnancy care, 46% qualified doctors and 9% of the respondents mentioned abut NGO clinic or hospital.  One fourth of the respondents said they heard from qualified service providers and 28% mentioned about relatives. Ninety eight percent of the women think women should go for ANC and 54% think it should be in case of complications. Only 17% said women should go at one to three months of pregnancy duration. Among them 60% visit two or three times and 26% more than three times. Sixty six percent of the respondents said they visited when they were less than six months of pregnant. Those who did not take ANC they mentioned not perceived as necessary (16.7%), too far (33%), religious bindings (16.7%) and don’t know about the service (33.3%). Respondents were asked from whom they took the ANC. Sixty percent of the respondents sought treatment from Family Welfare Visitor (FWV) and 28% from a qualified doctor. ^{13, 17}

Findings suggest that weight measured (81.9%), height measured (58%), blood pressure was checked (93.6%), urine was tested (44.7%) and ultrasonogram was conducted (27.7%) of the respondents. Almost 98% of the respondents received TT injection and out of them 72.3% received it two times. 88% respondents mentioned they have taken iron intake during pregnancy. Fifty four percent of the respondents spend up to taka 500 for ANC.

Children delivered with the assistance from qualified doctors are 20%, and majority is delivered by TBA (57%). Seventy seven percent of the births occur at home. Twenty percent of the delivery occurs in public hospital and another 3% in private health care centers. Findings suggest all the participants know the health center near by their home and all the participants know the field worker in her locality. Sixty two percent of the respondents mentioned health worker visited her home in the last six months. Findings show that only one fourth of the respondents visited any health center in the last one year for seeking any services. Fifty two percent of the respondents visited for general diseases treatment, 36% for FP service and 24% for ANC. All of them said they were satisfied with the service provided to them and 72% said they did not need to pay any money for the service.

Conclusion

The maternal mortality ratio (MMR) is not merely an indicator of maternal health but is also considered to be an important indicator of the health status and well being of a nation. Bangladesh has made a significant improvement in several health indicators. There has been a substantial decline in the infant mortality rate from 110 per 1000 live births in the mid-eighties to 65 per 1000 live births in 2004. The neonatal mortality rate too declined from 52 in 1993 to 41 in 2004, which is largely attributed to the success of the vaccination program.

One third of the study women do not know any health risks of a pregnant mother. Forty six percent of the respondents mentioned prolonged labor as a major health risk followed by risk to life of mother (26%), eclampsia (19%), obstructed labor (13%), and risk to life of baby (8%). 45% of the respondents identified public hospitals and 37% health and family welfare centers for pregnancy care, 46% qualified doctors and 9% of the respondents mentioned NGO clinic or hospital.  One fourth of the respondents said they heard from qualified service providers and 28% mentioned about relatives. Ninety eight percent of the women think women should go for ANC and 54% think it should be in case of complications. Only 17% said women should go at one to three months of pregnancy duration. .Among them 60% visit two or three times and 26% more than three times. Sixty six percent of the respondents said they visited when they were less than six months of pregnant. Those who did not take ANC they mentioned not perceived as necessary (16.7%), too far (33%), religious bindings (16.7%) and don’t know about the service (33.3%). Respondents were asked from whom they took the ANC. Sixty percent of the respondents sought treatment from Family Welfare Visitor (FWV) and 28% from a qualified doctor.

The study was an appropriate study which was conducted timely to know the service seeking behavior of the women in Barisal. It was found that still there is lack of knowledge of maternal health components and service seeking behavior. Study findings revealed that due to lack of correct knowledge of maternal health is one of the barriers for seeking services from qualified providers and health centers.