Utilization of Reproductive Health Care in Relation to Socio Demographic Status (Part-1)

ABSTRACT

The descriptive Cross Sectional Study was conducted on Utilization of Reproductive Health Care in relation to socio-demographic status. The objective of the study was to determine the relationship between socio-demographic status and utilization of Reproductive Health Care, the study population was 150 with mean age 24.99 years and SD of ± 4.4years.

Majority respondents had the low socio-demographic status like monthly family income <1,500/- (20°/o), illiterate 41°/b, Katachabari 64% for the dwelling 97% were housewife in terms of their main occupation. All the respondents were recent mother and they were in active reproductive life.

Reproductive Health Care coverage of the respondents were during their last pregnancy. 80% had knowledge about danger sigh of pregnancy, 62.7% taken additional food, 97.3°/o TT Vaccination and 65.3% received ANC. 80.7% delivered their last child at home conducted by TBA and relatives who had no institutional training regarding Intra-natal Care and its complication management. Among all the respondents only 19.3% had the institutional delivery.

Regarding referral of services it was found that a significant portion of respondents had taken their services by their own initiative (self, husband and relatives). In the present study this is very, hopeful information of decision making for services which may help to reduce maternal mortality and morbidity. In the study it was found that only 11.3% had taken PNC SS.3% had taken any one of the contraceptive method after their last delivery.

In the present study, it was found that reasons/barriers for not receiving Reproductive Health Care Services were due to poverty, nobody accompany, long distance of service centers only a few for social constraints. In the study reasons had the reation with socio-demographic status of the respondents which are statistically significant (p<0.05)

In the study, regarding contraceptive method 44.7% not received any method after their last child birth reasons for not receiving method due to Lactation Amenorrhea. They don’t have the knowledge that without menstruation pregnancy may occur. So there is more changes of unwanted pregnancy which increases MR, & unsaved abortion may leads to Maternal mortality and morbidity.

In this it was found that respondents with socio-demographic status had relatively less utilization of Reproductive Health Care like intake additional food during pregnancy receiving Antenatal Care, institutional delivery services, management of complications, postnatal care and its complications.

Introduction

Every minute of every day, somewhere in the world, a woman dies as a result of complications arising during pregnancy and childbirth. The majority of these deaths are avoidable.

Globally, an estimated 585,000 women die each year due to pregnancy and delivery-related complications. In developing countries,¹ in 48 women dies of pregnancy and childbirth-related complications compared to 1 in 1,800 in developed countries.

Although most pregnancies of healthy mothers end with the birth of a live baby in many occasions, childbirth is a time of pain, fear, suffering, and even death.

In Bangladesh, the current maternal mortality ratio is 4.3 per 1,000 live-births.² Hemorrhage, unsafe abortion, eclampsia, puerperal sepsis, and prolonged labor are the major causes of direct obstetric deaths. Majority of these deaths could be avoided if women could have access to and use of emergency obstetric care (EOC) services.⁴

Despite the existence of health service facilities, the use rate of services, particularly obstetric care services, is still very low in Bangladesh. Most mothers do not receive any antenatal care (ANC), and home delivery is almost universal. Ideally, all pregnant women should have regular antenatal checkups either by a paramedic or by a doctor.

The 1996-1997 Bangladesh Demographic and Health survey (BDHS) shows that only 29% of the pregnant women who gave birth during the five years prior to the survey received ANC, and only l9% had two or more ANC checkups.³ Only l6% of the deliveries were conducted by trained providers, such as doctors, nurses, paramedics, and trained traditional birth providers.

A review of service use for delivery at 25 Upazila Health Complexes (HCs) showed that deliveries at the UHCs ranged from 0.7 to 4.2% of the total estimated deliveries.

A study conducted in two rural field sites of the Operations Research Project (ORP) of ICDDR, B showed that only 16% of the women with obstetrics complications were treated by medically-qualified practitioners, such as doctors, paramedics (FWVs), and Medical Assistants (MAs).

The rest of the women consulted either a village practitioner or a homeopath or did not consult anyone these care givers are not qualified to provide obstetric services.

Results of a qualitative study conducted in one upazila in Bangladesh showed that the majority of women, who had complications, consulted untrained providers for the treatment of their obstetric complications before coming to the UHC.

It has been observed that identification of high-risk pregnancies during the antenatal period alone cannot reduce maternal morbidity or mortality, since every pregnant woman is at risk. It is estimated that about 15-20°/o of all the pregnant women may develop serious complications which are difficult to predict or prevent and need immediate hospital care.

Thus, for the management of obstetric complications, availability and use of EOC services is essential for preventing maternal deaths and disability.

The right to life is a fundamental human right, implying not only the right to protection against arbitrary execution by the state but also the obligations of governments of foster the conditions essential for life and survival, Human rights are universal and must be applied without discrimination on any grounds whatsoever, including ‘sex. For women human rights include access to services that will ensure safe pregnancy and childbirth. 

Since the 1940s, maternal deaths have become increasingly rare in developed countries. The same cannot be said however of developing areas where the persistence of high levels of maternal mortality is symptomatic of a pervasive neglect of women’s most fundamental human rights. Such neglect affects most acutely the poor the disadvantaged, and the powerless.

For more than half a million women death in the last episode in a long story of pain and suffering; millions more women are damaged and disabled, many of them for the rest of their lives.

The suffering often goes beyond the purely physical and affects women’s ability to undertake their social and economic responsibilities and to share in the development of their communities. Maternal death is a tragedy for individual women, for families, and for their communities. 

High levels of maternal mortality are not only a “woman’s problem”. Poor maternal health and its inevitable corollary poor infant and child health affect everyone. Women are the mainstays of families, the key educators of children, health care providers. Careers of young and old alike, farmers, traders, and often the main, if not the soic, breadwinners.

A society deprived of the contribution made by women is one that will see its social and economic life decline, its culture impoverished, and its potential for development severely limited. 

Background of the study

In 1987, the first International Safe Motherhood Conference took place in Nairobi and the goal of a 50% reduction in the 1990 levels of maternal mortality by the year 2000 was formulated.

This goal was later adopted by national governments and by other international conferences, including the World Summit for Children in New York in 1990, the international conference on population and Development in Cairo in 1994 and the Fourth World Conference on Women in Beijing in 1995.³

Much more is known now than it was 10 years ago about the interventions that are effective, the barriers to access to care, the constraints on implementation of programmers, and the specific elements of care that must be provided. The lessons that have been learned were highlighted at an international Technical Consultation held in Colombo, Sri Lanka.

In October 1997 to mark the tenth anniversary of the Safe Motherhood Initiative. In the course of the Consultation, the United Nations agencies most closely involved in the development and implementation of reproductive health programmers reached consensus on the measures that work what they cost and how they can be effectively implemented. This joint statement reflects that consensus and presents the way forward for everyone concerned with any aspect of safe motherhood. ⁵

1.        Safe motherhood is a human rights issue

The death of a woman during pregnancy or childbirth is not only a health issue but also a matter of social injustice.

Of the human rights currently acknowledged in national constitutions and in regional and international human rights treaties, many can be applied to safe motherhood. Many such treaties and conventions are based on the 1948, Declaration of Human Rights; they include the Convention on the Elimination of All Forms of Discrimination against Women, the Convention of the Rights of the Child, the European Convention for the Protection of Human Rights and Fundamental Freedoms, the American Convention on Human Rights, and the Africa Charter oh Human and Peoples Rights.

Human rights of relevance to safe motherhood can be grouped into the following four principal categories:

2. Rights relating to life, liberty and security of the person

Which require governments to ensure both accesses to appropriate health care during pregnancy and childbirth, and women’s rights to decide whether, when, and how often to bear children. Governments must therefore address factors within the economic, legal. Social and health systems that deny women these fundamental rights.

3. Rights relating to the foundation of families and of family life

Which require governments to provide access to health services and other facilities that women, need to establish families and to enjoy life within a family?

4. Rights relating to health care and the benefits of scientific progress, including

health information and education;

Which require governments to provide access to good sexual and reproductive health care with appropriate referral system. The measures needed to ensure safe mother-hood can be provided through primary health care irrespective of a country’s level of economic development. Central to these rights is information on a range of reproductive health issues, including family planning, abortion, and sex education.

5. Rights relating to equality and nondiscrimination

Which require governments to provide access to services such as education and health care without discrimination on grounds such as sex, marital status, age, and socioeconomic class. Discriminatory policies include requirements for a woman to obtain the consent of her husband for particular health care interventions.

Requirements for parental authorization which have a differential impact on girls and laws that criminalize medical procedures that only women need. Governments are in violation o their obligations when they fail to implement laws that effectively protect women’s interests or to allocate health resources to meet women’s particular need for safe pregnancy and childbirth.

Justification of the study

Although during the recent few years, Bangladesh achieved remarkable process in reducing child and infant mortality in the health and family planning sector, the progress is still inadequate in a relation to maternal mortality and morbidity. Still now 58% of under-five children are underweight and 51% are stunted; nearly 30°/o of the women suffer from chronic energy deficit; low birth weight incidence is estimated at 45% micro nutrient deficiencies are rampant (over 70%) mothers did not receive any qualified physician or any trained (TBA).

This result serious consequences in economic growth of the country resulting in lost, low productivity and also reduced intellectuals and learning capacity. In addition to causing individual tragedy like maternal and child mortality, this causes heavily impact in the disease burden, increased premature deliveries and other pregnancy related complications. The other issues that are of concern to health planners are overall lower utilization of government services by the poor, Quality of care (QOC), sustainability and cost effectiveness of the program.¹³

In addition, Bangladesh has also made a notable progress to reduce income poverty since the independence. The income poverty between nineties and 2000 shows a modest reduction 1% per year (from 58.8 to 49.8 percent). The pace of poverty reduction in nineties can’t step up the overall poverty reduction of the country. The human poverty considers three dimensions: deprivation of health, deprivation of nutrition and deprivation of education. The human poverty is accompanied by gender inequality, child mortality and’ the female – male gap in malnutrition.

With many roots and multidimensional characteristics of poverty, the efforts of the present government are to make all route measure to address underlying causes for practical interventions to mitigate poverty. The policy set up should foster human development of the poor by raising their capability through health, nutrition, education and social intervention.

In addition to this, more four interventions were suggested in PRSP that have maximum impact to minimize the severity of the poverty with special attention to the disadvantaged group. Special attention to the disadvantaged group. Specific measures are also considered in the document to ensure effective macroeconomic management to determine the well being of the poor.

To keep the pace of the Millennium Development Goals (MDG) considering the RH care the Infant mortality rate (IMR) and under five child mortality rate is declined considerably but still there are large disparities across the income group.

A significant improvement in maternal health care is noticed to reduce MMR in 392 per 100,000 live births but the delivery attended by the skilled health staffs is extremely low. It required a cross sectional approach (BBC and training of the mid-wives) to keep the MMR low. The CPR increases, fertility rate have labeled at 3.3 and 42% are using the modern method. The HIV/AIDS rate is low but the factors associated With HIV epidemic are present in Bangladesh.

The government of Bangladesh sets a medium term macroeconomic framework that is supported by financing and public resource provision to achieve the desired targets.

Considering the profile of the poor in Bangladesh tend to low levels of education have limited excess to land and highly concentrated in low paying, physically demanding and socially unattractive occupations as causal wage laborers.

In both urban and rural setting the poor lack much access to, modern amenities and services; they also tend to live in interior qualities. While poverty rates do not strongly correlated with gender of household, those female headed that are widow, divorced or separated have, a considerably higher incidence of poverty relative to others.¹

The Primary Health Care (PHC) services provided by the government are fairly good in reaching to the poor. The most pressing concern in health sector is to ensure access of the of the poorest group to an effective health care, as well as improving the state of reproductive health care. Study shows by Pulak et al. that the access in health facilities by the poor in rural level (THE, SC+EP, community clinics) is high than the rich but in case of special service (like Lab, test or X-ray) the rich are the privileged class than the poor. ¹¹

The priority area for the improvement of health outcomes of the poor; should address on access to the health care, creating a safety net for the poor, quality of the service provider and behavior change communication for better maternal health.

These can be achieved by contracting out the services, to reach poor to the poorest and strengthening the consumer’s voices. To improve maternal health, wider education efforts in favor of behavior change, (contraception, hygiene, and institutional delivery) and the need for postnatal care are likely to have high payoffs.

To achieve MDG 5, Bangladesh must reduce maternal mortality from 574 deaths per 100,000 live births in 1990 to 143 by 2015; increase the proportion of births attended by skilled health personnel to 50% and reduce the Total Fertility Rate to 2.2 per woman by 2010.

In addition to the above, a third target for Bangladesh in Reproductive Health (RH) Services for All as this is closely linked to maternal mortality and mobility. The indicators for RH are maternal malnutrition and median age at marriage. The target is to reduce maternal malnutrition from 45 percent in 2000 to less than 20 percent by 2015, and to increase the median age of girls at first marriage from 18 to 20 years.

In spite of the fact maternal mobility has declined from nearly 574 per 100,000 live births in the 1990 to between 320 and 400 in 2001, the maternal mobility ratio (MMR) in Bangladesh remains one of the highest in the world. It is estimated that l4% of maternal deaths are caused by violence against women, while 12,000 to 15,000 women die every year from maternal health complications. Some 45% of all mothers are malnourished.

The chief causes of maternal deaths are hemorrhage, unsafe abortion, and the ‘three delays dynamics’. The first delay, arising mainly from poverty, is in ‘seeking professional care; the second delay is logistical as most of the health centre’s and private clinics are located in district towns whereas 70 percent of the population is rural based; the third delay arises from the lack of adequate human recourse and trained at the service centre’s.

The number of births attended by skilled health personnel has increased from 5% in 1990 to 12% in 2000. In the context of Bangladesh, the increase is insignificant as the majority still do not receive such services. However, there are wide variations among income groups: 40 percent of births in the highest income quintiles are attended by skilled health personnel, compared to only four percent in the lowest quintiles. 

Total Fertility Rate:

There has been significant decline in the total fertility rate (TFR) from 6.6 per thousand live births in the mid 1970s to 3.3 in the mid 1990s with regional variations in the reduction pattern. However, in spite of a steady increase in contraceptive prevalence rate from 45 percent in 1994 to 54 percent in 2000, TFR has plateau, partly due to adolescent fertility which is, extremely high at 14.4 per 1000 live births.

Several measures have been taken to address these problems. The Essential Obstetrics Care (EOC) programme through the Maternal and Child welfare Centers (MCWC) was introduced in the early 1990s. Subsequently, a more holistic approach was adopted through the National Maternal Health Strategy 2001 which takes a rights-based approach to maternal healthy with Safe Motherhood as the central theme. The Strategy has been integrated into the Health and Population Sector Program (HPSP 1998-2003) and into its follow-up the health, Nutrition and Population Sector Program (HNPSP 2004-2006).

Interventions such as Safe Motherhood Services that provide iron, folic acid and vitamin A supplements to the target population have been included in the HNPSP, with the objective of reducing maternal malnutrition to below 20% by 2015. Other interventions under this project include training programmes for skilled health personnel.

Both the Government of Bangladesh and the donors are giving priority to the promotion of safe motherhood form the grassroots level upwards, through antenatal care, safe delivery, pre-natal care, essential obstetrical care and family planning.

Challenge 1:

If the population of Bangladesh stabilizes by 2035, there will b over 40 million women of reproductive age (15-45.) in 2015 who will be the target population for preventive and awareness raising  programmes on safe motherhood. In order to further reduce TFR, studies must be conducted to analyze the causes of its current stagnation. Advocacy programmes must be introduced on population stabilization.

Challenge 2:

In MMR is to be reduced to 143 per 100,000 live births by 2015, the decrease will have to be at substantial rates.

•    During 2005-2O08MMR must be reduced by 5.6 percent points a year

• During 2008-2011 MMR must be reduced by 7 percent points a year

•    During 2011-2014MMR must he reduced by 8 percent points a year

•    During 2014-2015 MMR must be reduced by 12 percent points a year

Meeting this challenge will require the following:

•    Bringing about a fundamental change in knowledge, attitude and behavior towards safe motherhood and gender equality through an advocacy campaign on safe motherhood involving 13 relevant ministries.

•    Increasing access to quality health facilities through public, private and NGO initiatives.

•    Increasing financial investments in the health sector including in skills development.

•    Specially targeting the poor for reproductive health interventions, as maternal mortality and morbidity is highest in the lower income groups.

•    According the reduction of malnutrition, especially for females of reproductive age.

Challenge 3:

In addition to the MDG 5 global targets, Bangladesh will also attempt to achieve the following RH target.

•    Halve maternal morbidity

•    Halve maternal malnutrition

•    Reduce TFR to 2.2

•    Improve adolescent reproductive health

•    Eliminate violence against women

In aiming for such ambitious targets some constraints need to be taken into consideration:

•    Reliable national estimates are not available for morbidity. Age specific female mortality rates will serve as proxies until better parameters are identified.

•    The picture of maternal malnutrition is bleak in Bangladesh – 45 percent,, of all mothers are malnourished and only one percentage point decline has been achieved per year. In a business-as-usual scenario, by 2015, about 25 to 30 percent of mothers will still remain malnourished; it is a expected that the new HNPSP will address some of the challenges relating to maternal malnutrition.

•    Adolescent reproductive health has to receive increased attention to ensure an improved health life cycle, and to put early preventive measures to the threat of the spread of HIV/AIDS. As data on ARH is scanty, teenage (15-19 years) pregnancy and motherhood can be used as a proxy. A survey carried out in 1992-2000 shows teenage pregnancy to be as high as 35 percent. A comprehensive strategy has to be developed if it is to be almost eliminated by 2015.

•    Violence against women is a major concern for health, productivity, dignity and maternal mortality in Bangladesh. It is estimated 14 percent of maternal deaths are caused by violence. Inclusion of this indictor when monitoring the MDGs will help raise awareness of this national problem. It will also promote quantitative methods for monitoring the progress towards the elimination of violence against women.

Social Constraints                                                                                                            

People in many cultures find it hard to discuss sex and reproduction. In these circumstances exercising choices-planning for contraceptive use, for example-can be experienced as shameful and humiliating. Discussing gender based violence, particularly sexual violence, is especially hard for poor women.

There is another crucial difference regarding reproductive health, only women bear children. They are exposed to risks that men can’t fully appreciate women are also more exposed to shared risks, such as sexually transmitted diseases, for reasons both of biology and of social disadvantage.

Social constraints affect women’s reproductive health care. Men are more likely to use formal health services, partly because they control the money needed to pay for them. Women are more likely to rely on traditional or other alternative services, because they are cheaper, closer at hand and more familiar. A woman may be unwilling to travel alone, or not allowed to go to health services without the approval of her husband or another man in the family or community.

Women’s experience of health care also affects the way they use it: they are not guaranteed sensitive treatment at the clinic or hospital. Health workers tend to look done on poor women. Illiterate women in particular may feel unable to describe their condition or understanding the advice they are given.

The reproductive health needs of the poor, and poor women in particular, do not command the attention of policy makers, or even of women themselves. The poor give priority to their many immediate and pressing needs. Pregnancy and childbirth are taken for granted ­and so are the attendant risks, though they come from easily preventable causes.¹²

Research Question

What are the relationships with utilization of reproductive health care and socio-demographic status of the respondents?

Objectives

General Objectives

To find out the relationship between socio-demographic status of the respondents and the utilization of reproductive health care.

Specific Objectives

1.         To estimate the proportion of respondents utilizing the reproductive health care.

2.         To find out the antenatal, intra-natal and postnatal care and utilization in terms of socio-demographic status of the respondents.

3.         To find out the barriers for non utilization of reproductive health care by the respondents.

Key Variables

Dependent variables

The various services component of reproductive health will my dependent variable. The main issues study wants to address in Reproductive health care are –

1.         Antenatal Care

2.         Delivery Care

3.         Postnatal Care

4.         Referral of the Respondent

5.         TT Coverage

6.         Family Planning

Independent Variables

It is a composite variable which was constructed by considering, the factors that have a secondary impact to the respondent causing barriers to utilize the reproductive health care. These are:

1.         Age

2.         Family Size

3.         Employment

4.         Poverty

5.         Women empowerment

6.         Monthly family income

7.         Occupation of the respondents

8.         Education of the respondents

9.         Housing condition

10.       Use of latrine

Operational Definition

Socio Demographic Status: It is the composite status of the respondents in terms of education, occupation, family income; sanitation condition of the housing. State as self scoring and rating <7 score for poor, 8-9 for middle, 10-12 for affluent and >12 very affluent.

Reproductive Health Care: Means family planning services, Antenatal Care. TT vaccination coverage, additional food taking during last pregnancy. Place of delivery post natal care

Respondents: Means married women of reproductive age 15-49 years age who delivered their last child within last 12 months.

Antenatal Carte: Means medical checkup by their medical personnel during the last pregnancy.

Postnatal Care: Means medical checkup by the medical personnel after their last delivery irrespective of developing complication.

Main Occupation: The job(s) performed by respondents more than twelve hours maintain their livelihood.

Family income: Total earning of the family members from different sources.

Limitation of the Study

1.         The sample size of the study was 150 which was selected purposively so the results of the study may not reflect the exact scenario of the whole country.
2.         Most of the Respondents were house wife. So they don’t had the enough time for the interview purpose during the period of data collection.
3.         Limited Resources in term of manpower and finance as it was the community based study.
4.         As there was no or less same study/research conducted in this field. So less availability of the literature review.

Review of Literature

A study was conducted by University Research Corporation (Bangladesh) 1995 on knowledge assessment among pregnant and lactating mother. They found that knowledge among pregnant and lactating mother was 11% for puerperal sepsis and 48% for prolonged labour. Unprompted knowledge was within the range of 35 to 48 percent for the essential obstetric complications except for p/v bleeding during pregnancy, perineal tear and puerperal sepsis. The unprompted’ knowledge about these three essential obstetric complications were low, ranging between 11% and 22°/o pregnant and lactating mother had higher leveled of unprompted knowledge on prolonged labour (45%) and induced abortion (45%). Puerperal sepsis and perineal tear were relatively less known.

Pregnant and lactating mother had the highest overall knowledge on prolonged labour and induced abortion (over 98% each). Overall knowledge on pre­eclampsia, eclampsia, retained placenta and food/hand/cord prolapse and pph was high over 75%. Prompted knowledge was almost similar for all essential obstetric problems, ranging between 41% and 48%. Urban women have a slightly higher unprompted knowledge and overall knowledge about all emergency obstetric problems were more than of their rural counter part of all essential problems Mother-in-law had higher level of unprompted knowledge on foot/hand/cord prolapse, retained placenta and eclampsia (41% to 43%).

The lowest percentage of knowledge on puerperal sepsis and penineal tears, 8% and 16% respectively. Overall knowledge was higher for + induced abortion (94%) and lowest for puerperal sepsis (46%). Both unprompted and overall knowledge was higher among the urban mother-in-law and among their rural counter parts.

A cross-sectional study was conducted by Akhter H H about the information from respondents for age of marriage, showed that over 40% of women got married before they were 15 years of age, mean, age at marriage being 15.1 years. Regarding antenatal care out of 6’193 respondents, 5529 (85%) took antenatal care. Among 5529 (27%) had pregnancy care at govt. Health care centre and clinic, 2.7% had at a satellite clinic, 3.9% from private clinic, 58% had their antenatal examination by healthcare provider at their home and 8.8% care had at home by untrained provider.

Relationship between age and maternal morbidity assessment shows rates of all life threatening and high risk morbidity were high except hypertension among age group 15-17 as compared to that of age group 18-39 years. Most morbidity was lowest among 18-24 age groups. Prevalence of having excessive bleeding rose from 1.8% in 18-19 years age group to 6% at age years or more. Fits and convulsion rate increased from 2.0% at age 18-19 years age group to 4.7% at 40 years and over age group. Among high age group similarly edema and hypertension, preeclampsia toxemia increased from 20.7 and 2.0 % respectively in 18-19 years age group to 33.8 and 7.7 percent respectively in 40 years and over age group.

Only hyperemesis decreased with increase age from 21.7% in 18-19 years age group to lS.8% in 40 years over age group. From the response of 6392 women it was observed that 98.5% of their deliveries were conducted at home and only l.5% of their” deliveries were conducted in hospital, clinic or in health center. Regarding birth attendant among 6392 respondents 49% reported that their deliveries were conducted by Dai or untrained TBAs and 39.2% by relatives and husbands and only 9. l% reported having deliveries which were conducted by trained attendants. Out of total 2.7°/o’ reported having their deliveries unattended.¹⁰

A study on KAP (knowledge attitude and practice) or pregnant and lactating women by associates for community and population research in Bangladesh regarding iron supplementation stated that only 8% of pregnant and lactating women considered additional food is necessary during pregnancy and lactation, 40% of the women did not take any additional foods. Those who had taken, on average, started taking the additional food at 4.5 months of pregnancy.

Elderly male and female considered the duration at 16 months. Most frequently mentioned addition load items were milk (70%), egg (60%), meat (1.45°/o), fish (47%), fruit (62%), light vegetables (48%) Nearly three-fifths (58%) perceived that additional food should be taken for the entire pregnancy period and another one-third said, so long breast-feeding 34% and till the weakness is overcome (30%). It was observed that food items like, fish, meat, egg, leafy vegetables are avoided by some women during pregnancy while some other considered the same items to be taken as additional diet during pregnancy and lactation.

In the FGDs it was ascertain that the same woman said those items were avoided but feel that these would be taken as additional diet reflecting a gap between their knowledge and practice.¹¹

Study on safe motherhood in South—Asia, socio-cultural and demographic aspects of maternal health, by Acsadi associates. New York (1990) stated that sequences of early marriage and child bearing. It was described that the adolescent years are a period of physiological, emotional and intellectual development.

Pregnancy and motherhood shorten the period of development of most South Asian girls drastically curtail their pre-adult socialization, which girls should experience in order to enable them to make decisions about matters relating to family building, their health and that of their children. Girls who are married and begin life as married women before or at the, onset of puberty (i.e. around 12 to 18 years old) are deprived of this natural evolvement in to adulthood and in health and other important aspects, are unprepared for motherhood.

It is thus likely that they will remain dependents, physiologically and socially as well as economically, and that they will have low self-esteem, low levels of formal education and in these countries is a corollary of early marriage’ of girls, is associated with high levels of morbidity and mortality among mothers as well as their young children.

This study is also staled regarding Bangladesh that the pregnancy and child bearing contribute greatly to the incidence of mortality among teenage girls.

Study was conducted by Akhter Hit stated that knowledge about for antenatal care among women of child bearing age were 72% and 15% could not provide correct or specific response to the query about antenatal care. Over 30% respondents were not aware of the place where antenatal care may available.¹⁰

Study by Fathalla M on women have a right to safe motherhood stated that every pregnancy involves risk, arid complications are not always predictable almost all obstetric emergencies can be managed.

However only 55% of the World’s women have a trained attendant to support them during delivery. Safe motherhood is a human rights issue for which governments should be held accountable and safe motherhood should be very high on the agenda of women’s movement.

Later issued regarding safe motherhood stated that every year 600000 maternal deaths occur in developing countries and an estimated 88-98 are preventable and result from causes which women on developed countries have rarely endured for over a century. The most inexcusable of these causes is puerperal sepsis, which claims the lives of almost 100000 women in developing countries every year and causes countless others long-term disability.

The ten leading causes of disease burden in women of reproductive age in developing counties, maternal mortality ratios throughout the world, maternal deaths by region and life time risk of+ dying in various African countries.

The document explains the effect of’ maternal mortality on the family and society, the cost of adolescent pregnancy, why women in developing countries experience such high rate of maternal mortality, reasons for delays in seeking health care, the proximate causes of maternal deaths and the effects of complications on mother and babies.¹⁶

A study, measured that men have a major rule to play in making pregnancy safe. The campaign for safe motherhood has not succeeded in reducing maternal mortality and morbidity in developing countries because it has not targeted the men who, in this settings, customarily make the decisions about family size and utilization of health care. In Sub-Saharan Africa, approximately 25% of mortality suffered by women aged 20 to 34 is related to pregnancy and reproduction.

It is vital to incorporate men in all safe motherhood campaigns in order to change male attitude and behaviour, Men should be encouraged to support women during pregnancy, childbirth, and the postpartum period and to be equal partners in childcare Specifically, men should accompany their wives to pre-natal clinics so the men can be taught about the importance of proper diet and rest during pregnancy and about the danger signs of pregnancy.

Men should be willing to reduce the burden of physically demanding work on pregnant wives and to provide funds for medical fees and transportation to medical- facilities. Men should also provide emotional support and not subject pregnant women to violent behaviour. In addition, men should learn about family planning methods and co-operate with their wives in their use.¹⁷

Reducing deaths from Pregnancy and childbirth Asia

It was reported in a study done by UNICEF that 99% of all maternal deaths occur in the developing world, and South Asian countries account for most deaths. The causes are obstructed labor, hemorrhage, pregnancy-related hypertension (eclampsia), or unsafe abortion. The United Nations Children’s fund estimates 340 maternal deaths for every

100,000 live births in India. In Indian rural areas, the maternal mortality rates is between 800 and 900 deaths per 100000 live births, in Bangladesh 600, in Nepal 830, in Bhutan 1710. In comparison, the rate in United States is 8 deaths per 100,000 live births. The technology for reducing maternal mortality has been utilized in most developed countries, as well as in parts of South Asia, in particular in Sri Lanka. The goal of the Safe Motherhood Initiative was to reduce maternal mortality by 50% by the year 2000. The immediate cause of maternal mortality includes pregnancy and delivery and the management of complications such as hemorrhage, toxic and bacterial infections (sepsis), eclampsia, obstructed labor.

The poor health, nutrition, and socio-Economic status of women are the underlying causes of maternal death. One study in India found that inadequate medical treatment contributes to 36% to 47% of maternal deaths in hospitals. In India, abortion services are legal and acceptable on social, religious, and political ground, but services are on social religious1 and political services are inaccessible. In Bangladesh, the availability of menstrual regulation is estimated to save100000 to 160,000 women from unsafe abortions each year. However, the inaccessibility of this service, accounts for 700,000 unsafe abortion and 7000 maternal deaths.

Gender bias in the allocation of meager food supplies results in the poor health and nutritional status, of women, rendering a women’s pelvis too small, which causes obstructed labor and even death. Socio-economic status is linked to access the family planning and health services which affect mortality and reproductive health. In Sri Lanka and Kerala, government investment in health and education has resulted in relatively high literacy and education levels and low infant and maternal mortality compared to the rest of the region.

Maternal Mortality in 3angladesh

Maternal deaths are commonly under-reported, even in technologically, sophisticated industrialized societies. Vital registration of death data exists in 69 of the 166 member states of WHO, covering about 30% of the world’s population. Even when vital registration exists, there may be incorrect classification of causes of death. Many social, religious, emotional or practical reasons are responsible for not classifying a maternal death.

The community studies, in rural Bangladesh in Jamalpur and Tangail district found maternal mortality ratio of approximately 623 and 566 per 100000 live births, respectively. Other studies by in rural Bangladesh reflected a ratio of 440 and 430 per 100,000 live births. According to Bangladesh Bureau of statistics 1998, the maternal mortality ration was 420 per 10,000 live births.

In a study from matlab demographic surveillance system by Fauveau et. al. the causes of maternal deaths were mainly from direct obstetric complications. Postpartum haemorrhage and abortion were the leading causes of maternal death in all the studies.