Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
Final Report
Study Title: Evaluation of the ACCESS/Bangladesh and MaMoni Programs: Population-Based Surveys in the Sylhet Division of Bangladesh
Baseline Evaluation on Maternal & Newborn Health, 2010 Habiganj
Report prepared by:
Child Health Unit of Public Health Sciences Division ICDDR,B
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
Acknowledgements
We would like to acknowledge the large number of people and organizations that provided support in the completion of baseline evaluation survey on the maternal and newborn health indicators of the ‘MaMoni’ project in Habiganj. To begin with, we express our profound appreciation to the women and household members who took time out of their busy daily routines to answer the survey questions. We thank them for their patience and willingness to respond to questions of a sensitive nature. We would also like to thank the many community leaders and health facility workers who provided information to the survey team.
Save the Children, USA provided financial support and substantive technical advice concerning the design, field work and preparation of this report. We extend our appreciation and gratitude to the members of MaMoni team, Save the Children USA in Bangladesh.
We would like to acknowledge the tremendous support provided by the district and upazila GoB officials like; Civil Surgeon, Deputy Director-Family Planning, Upazila Health and Family Planning Officers, Upazila Nirbahi Officers, Upazila Family Planning officers. We also express our deep gratitude to the members of the local NGOs (Shimantik and FIVDB).
Associates for Community and Population Research (ACPR), was the data collection and research partner in this survey. The technical requirements of this activity were many, and they handled them in an efficient and professional fashion. We would particularly like to thank Dr.M Sekander Hayat Khan, APM Shafiur Rahman and Tauhida Nasrin for their effort and dedication.
We also thank Prof.Nitai Chakraborty for his valuable technical assistance in the process of MaMoni baseline evaluation.
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
Contents
Page # List of tables ...... 5 List of figures ...... 10 Summary findings ...... 13
Chapter-1: Background ...... 16
1.1 Maternal & Newborn health situation ...... 16 1.2 Neonatal health interventions in Bangladesh ...... 18 1.3 ACCESS/MaMoni project in Habiganj ...... 20 1.4 Chapter References ...... 21
Chapter-2: Methodology of the survey ...... 23
2.1 Respondent ...... 23 2.2 Midline Survey Design ...... 24 2.3 Sample size calculation ...... 24 2.4 Household census & Mapping of villages ...... 26 2.5 Household survey (data collection) ...... 26 2.5.1 Recruitment and training of field staff ...... 27 2.6 Survey instrument (Questionnaire) ...... 28 2.7 Survey implementation ...... 29 2.8 Quality assurance (QA) ...... 30 2.9 Data management and analysis ...... 31
Chapter-3: Demographic & Socio-economic status ...... 32
3.1 Demographic Characteristics of Households ...... 32 3.2 Pregnancy outcome ...... 34 3.3 Parity ...... 35 3.4 Educational Attainment of RDW ...... 35 3.5 Household characteristics ...... 37 3.6 Household Possessions ...... 39 3.7 Land ownership ...... 40 3.8 Religion...... 41 3.9 Relatives/Family members living abroad ...... 41
Chapter-4: Knowledge of Mother on Maternal and Neonatal Health ...... 42
4.1 Key components of birth plan ...... 42 4.4 Knowledge of Complications during Pregnancy ...... 43 4.5 Knowledge of Complications during Delivery ...... 44 4.6 Knowledge of Complications during Postpartum Period ...... 45 4.7 Knowledge of Neonatal Health Problems ...... 46
Chapter-5 Maternal Health ...... 48
5.1 Antenatal Care ...... 48 5.2 Components of Antenatal Care Checkup ...... 54 5.3 Information Received during Antenatal Care ...... 57 5.4 Birth Plan & Delivery ...... 60
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
5.5 Post Partum ...... 65
Chapter-6: Maternal Health Problems & Treatment Seeking Behavior ...... 68
6 Women’s Reporting of Maternal Complications ...... 68 6.1 Complications during Pregnancy ...... 68 6.2 Complications during delivery ...... 72 6.3 Complication during Postpartum ...... 76
Chapter-7 Newborn Health ...... 80
7.1 Prevention of Hypothermia ...... 80 7.2 Umbilical Cord Care ...... 84 7.3 Breast Feeding ...... 86 7.4 Bathing ...... 89 7.5 Postnatal Care (PNC) ...... 90 7.6 Newborn complication and care seeking ...... 93
Chapter-8: Birth Interval and Contraception ...... 99
8.1 Birth Interval ...... 99 8.2 Family Planning ...... 100
Chapter-9: Community Action Group (CAG) ...... 105
9.1 Existence of CAG and Membership ...... 105
Chapter-10: Hand washing ...... 107
Chapter-11: Neonatal Mortality ...... 113
Chapter-12: Discussion ...... 120
Chapter-13: Appendix 123
Appendix-A RDW listing form ...... 123 Appendix-B Evaluation indicators for midline survey ...... 124 Appendix-C Baseline questionnaire on maternal and newborn health ...... 126
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
List of Tables
Page
# Chapter-2: Methodology of the survey ...... 23
Table 2.3.1 Calculation of sample size of RDW for KPC estimate ...... 24 Table 2.3.2 Calculation of sample size for NMR ...... 25 Table 2.3.3 Sample size & required number of clusters by upazila ...... 25 Table 2.5.1 Completion date of data collection by upazila ...... 27 Table 2.7.1 Sample implementation status ...... 29
Chapter-3: Demographic & Socio-economic status ...... 32
Percent distribution of the household members by age group & sex, among households Table 3.1.1 with women that had pregnancy outcome during 01 May 2009 to 31 July 2010 in eight 33 intervention upazilas of Habiganj ...... Percent distribution of household size (number of usual members), among households Table 3.1.3 with a women who had a pregnancy outcome during 01 May 2009 to 31 July 2010 by 34 upazila of Habiganj ...... Percentage of recent pregnancy outcomes and male/female ratio among live-births in Table 3.2.1 the MaMoni upazilas of Sylhet (Pregnancy outcome period: 01 May 2009 to 31 July 34 2010) ...... Percent distribution of women with different birth orders by MaMoni upazila of Table 3.3.1 35 Habiganj 2010 ...... Percent distribution of women by level of education and age who had a pregnancy Table 3.4.1 36 outcome during 01 May 2009 to 31 July 2010 by upazila of Habiganj ...... Percent distribution of households by housing characteristics by upazila of Habiganj Table 3.5.2 38 ...... Percentage of households possessing various durable consumer goods by upazilas for Table 3.6.2 households with a woman had a pregnancy outcome during 01 May 2009 to 31 July 39 2010 in Habiganj ...... Table 3.6.3 Distribution of wealth index quintile by upazila of Habiganj ...... 40 Percent distribution of households with own land, among households with a woman had Table 3.7.1 a pregnancy outcome during 01 May 2009 to 31 July 2010 by upazila of Habiganj 40 ...... Table 3.8.1 Distribution of religion of RDW households by upazila of Habiganj ...... 41 Percent distribution of households with a woman had pregnancy outcome during 01 Table 3.9.1 41 May 2009 to 31 July 2010 by upazila, Habiganj......
Chapter – 4: Knowledge of Mother on Maternal and Neonatal Health ...... 42
Percentage of women cited the key components of birth plan by upazila, Habiganj Table 4.1.2 42 ...... Percent of recent mothers reported knowing danger signs of pregnancy by upazila, Table 4.4.1 44 Habiganj ...... Percent of recent mothers reported knowing danger signs during child birth by upazila, Table 4.5.1 45 Habiganj ......
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
Percent of recent mothers reported knowing danger signs of post partum by upazila, Table 4.6.1 46 Habiganj ...... Percent of recent mothers reported knowing danger signs of newborn baby within 7 Table 4.7.1 47 days of birth by upazila, Habiganj ......
Chapter- 5: Maternal Health ...... 48
Percentage of women received 4 ANCs from a skilled provider during their last Table:5.1.1 49 pregnancy by upazila,Habiganj ...... Percentage of women who received ANC by number of ANC visits during their last Table 5.1.2 pregnancy, by MaMoni upazilla and selected demographic and socio-economic 50 characteristics...... Percent distribution of women who received at least 4 ANC visits during their last Table 5.1.3 51 pregnancy by type of providers and by upazilla, Habiganj ...... Percent distribution of women received ANC during their last pregnancy by type of Table 5.1.3a 52 provider in Habiganj ...... Percent distribution of ANC provider, who provided ANC-1 to the women during their Table 5.1.4 53 last pregnancy by upazila and according to background characteristics, Habiganj Percent distribution of TT doses received (from card and history) by upazila of Table 5.2.1 55 Habiganj ...... Percent distribution of women received valid doses of TT (from card and history) Table 5.2.1a 55 during their lifetime by upazila of Habiganj ...... Percentage of children born protected from neonatal tetanus among live-births during Table 5.2.1b 56 their last pregnancy by upazila of Habiganj ...... Percentage of women consumed Iron-folic acid tablets during their last pregnancy by Table 5.2.2 57 upazila and by background characteristics in Habiganj ...... Percentage of women received counseling/advice from ACCESS counselor / MaMoni Table 5.3.1 health worker and percentage of whom received counseling by component during their 58 pregnancy by upazila, Habiganj ...... Percentage of women received at least 2 home visits by an ACCESS counselor / Table 5.3.2 59 MaMoni health worker during their last pregnancy by upazila of Habiganj..... Percent of women reported receiving counseling from an ACCESS Counselor/MaMoni Table 5.3.4 59 health worker on the importance of 4 ANC visits by upazila of Habiganj ...... Percentage of women reported receiving counseling from HA/FWA/MaMoni health Table 5.3.5 60 worker/ CHW by component of newborn care and by upazila ...... Percent of women reported having a birth plan during their last pregnancy by upazila, Table 5.4.1 61 Habiganj ...... Percent of recent mothers reported had a birth plan with 5 components during their last Table 5.4.2 61 pregnancy by upazila, Habiganj ...... Percent distribution of place of delivery by upazila and by background characteristics, Table 5.4.3 62 Habiganj ...... Percent distribution of type of birth attendant who assisted delivery at home (Except Table 5.4.4 64 family member) by upazilla and by background characteristics in Habiganj ... Percent of women who had birth kits for delivery and distribution of source from where Table 5.4.5 65 birth kits were received by upazila of Habiganj ...... Percentage of women reported receiving any PNC visit for themselves and percentage Table 5.5.1 65 of whom received a PNC within 3 days after child birth by upazila, Habiganj Percentage of women reported received at least two PNC visits for themselves from a Table 5.5.2 66 skilled provider after child birth by upazila, Habiganj ...... Percentage of women received PNC visits for themselves from a skilled provider within Table 5.5.3 66 3 days after child birth by upazila, Habiganj ......
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
Percentage of women reported receiving home visit by a HA/FWA/MaMoni health Table 5.5.5 67 worker/ CHW by timing of home visit after child birth and by upazila, Habiganj
Chapter- 6: Maternal Health Problems & Treatment Seeking Behavior ...... 68
Among women with reported danger signs during last pregnancy, percent distribution Table 6.1.1 69 of danger signs by upazila, Habiganj ...... Percent distribution of number of danger signs reported during last pregnancy by Table 6.1.2 69 upazila, Habiganj ...... Percentage of women reported danger signs during last pregnancy and percentage of Table 6.1.3 whom sought care from a skilled provider by upazila and by background characteristics, 70 Habiganj ...... Among women with reported danger signs during pregnancy and sought care, the Table 6.1.5 71 percent distribution of provider (by category) by upazila, Habiganj ...... Among women with reported danger signs during pregnancy and sought care, the Table 6.1.6 71 percent distribution of place of care by upazila, Habiganj ...... Among women had a danger sign during pregnancy and were advised to have Table 6.1.7 treatment, the percent distribution of persons or health care provider by upazilla, 72 Habiganj ...... Percentage of women reported danger signs during delivery and percentage of whom Table 6.2.1 73 sought care from a skilled provider by upazila and by background characteristics Among women with reported danger signs during delivery, percent distribution of Table 6.2.2 74 danger signs by upazila, Habiganj ...... Percent distribution of number of danger signs reported during delivery by upazilla, Table 6.2.3 74 Habiganj ...... Women who had complication during delivery and sought care, the percent distribution Table 6.2.5 75 of provider by upazila, Habiganj...... Women reported had complications during delivery and sought care, the percent Table 6.2.6 75 distribution of place of care by intervention upazilla, Habiganj ...... Women with a home delivery (without a skilled provider) had danger sign during Table 6.2.7 delivery and received advice to seek care by type of birth attendant / health service 76 provider in Habiganj ...... Percent of women reported danger signs during post-partum and percentage of whom Table 6.3.1 77 sought care from a skilled provider by upazila and by background characteristics Percent distribution of danger signs reported during post partum period by upazila, Table 6.3.2 78 Habiganj ...... Percent distribution of number of danger signs reported during post partum period by Table 6.3.3 78 upazilla ...... Women reported had complications and sought care during post partum period, the Table 6.3.6 79 percent distribution of place of care by upazila ......
Chapter -7: Newborn Health ...... 80
Women gave birth at home and had newborn care person (NBC) at birth; percent Table 7.1.1 81 distribution of type of newborn care person by upazila, Habiganj...... Percent distribution of type of immediate care that newborn received first after birth by Table 7.1.2 82 upazila, Habiganj ...... Percentage of newborns were dried and wrapped before the delivery of placenta in Table 7.1.3 82 home deliveries by upazila, Habiganj ...... Timing of both drying and wrapping of the newborn immediately after birth among Table 7.1.4 83 home deliveries by upazila, Habiganj ......
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
Percent distribution of time of delivery of placenta in minutes by intervention upazilas Table 7.1.5 83 of Habiganj (home delivery only) ...... Percent distribution of individual timing of immediate drying and wrapping of Table 7.1.6 84 newborns after birth in Habiganj (Home delivery only) ...... Percent of recent mothers who gave birth at home and whose newborns’ cords were cut Table 7.2.1 84 by type of instruments and by upazila, Habiganj ...... Percent distribution of women had CDK during child birth and used materials from Table 7.2.3 85 birth kit among home deliveries by upazila, Habiganj ...... Percentage of women applied specific substances to the umbilical cord of the newborn Table 7.2.4 85 within seven days after birth among home deliveries by upazila, Habiganj ..... Percentage of women applied specific substances to the umbilical cord after birth Table 7.2.5 86 among home deliveries by upazila, Habiganj ...... Percentage of women reported initiating breast feeding immediately following birth Table 7.3.1 86 (home delivery) by time since birth and placental delivery in Habiganj ...... Percent of recent mothers delivered at home reported initiating breast feeding within 1 Table 7.3.2 87 hour of birth by upazila, Habiganj ...... Table 7.3.3 Percentage of newborns received colostrum by upazila, Habiganj ...... 87 Table 7.3.4 Percentage of newborns received prelacteal feed by upazila, Habiganj...... 88 Percentage of newborns received solid or liquid food other than breast milk within 3 Table 7.3.5 88 days after birth by upazila, Habiganj ...... Timing of first bathing of newborns after birth by upazila, Habiganj. (Home delivery Table 7.4.1 89 only) ...... Percentage of newborns bathed after 3 days of birth for the first time by upazila and Table 7.4.2 selected demographic and socio-economic characteristics (Home Delivery Only) , 90 Habiganj Percentage of women reported receiving at least 2 PNC visits for their newborns by Table 7.5.1 91 upazila, Habiganj ...... Percent distribution of women received PNC by timing of first PNC received by Table 7.5.2 91 upazila, Habiganj ...... Percentage of women reported receiving at least two PNCs from a skilled provider by Table 7.5.4 92 upazila and selected demographic and socio-economic characteristics ...... Percent of women reported their newborns developed a danger sign at birth or within 28 Table 7.6.1 days after birth and percentage of whom sought care from a skilled provider by upazila 93 and by background characteristics ...... Percent distribution of signs and symptoms of newborns reported sick during first Table 7.6.2 94 month of life by upzila, Habiganj ...... Percent distribution of number of danger signs reported during 1st month of life of Table 7.6.3 95 newborns by upazila, Habiganj ...... Newborns (within 28 days of birth) had complications and sought care, percent Table 7.6.4 96 distribution of heath care provider by upazila, Habiganj ...... Percent distribution of sites from where a woman sought medical care for the sick Table 7.6.5 96 newborn by upazila, Habiganj ...... Percent of newborns who had a danger sign and were referred by an ACCESS Table 7.6.6 97 Counselor by upazila, Habiganj ...... Table 7.6.7 Reason of not seeking care for newborn illness by upazila, Habiganj ...... 97
Chapter -8: Birth Interval and Contraception ...... 99
Percentage of women reported desire to delay next pregnancy for at least two years by Table 8.1.1 99 upazila, Habiganj ...... Percentage of women whose recent pregnancies were actually delayed for at least two Table 8.1.2 100 years by upazila and by background characteristics ......
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
Percent distribution of women used any family planning method during first six months Table 8.2.1 101 after delivery by upazila, Habiganj ...... Percent distribution of women currently using contraceptive methods by method and Table 8.2.2 102 source of collection of method, Habiganj ...... Percentage of women accepted a contraceptive method within 6 weeks of postpartum Table 8.2.3 by method and by selected demographic and socio-economic characteristics in Habiganj 103 ......
Chapter -9: Community Action Group (CAG) ...... 105
Percent of women reported aware of the existence of a Community Action Group Table 9.1.1 (CAG) in their villages and percentage of whom held membership of CAG (herself or 105 any family member) by upazila, Habiganj ...... Percentage of women reported aware of activities of the community action group by Table 9.1.2 105 upazila, Habiganj ...... Percentage of women had postpartum complication or the newborn complication, used Table 9.1.3 emergency transport or benefited financing from CAG by intervention upazila of 106 Habiganj ......
Chapter -10: Hand washing ...... 107
Percentage of recently delivered women reported washed their hands before most recent Table 10.1.1 preparation of food for family members by type of material used and by upazila, 107 Habiganj ...... Percentage of recently delivered women reported washed their hands before taking their Table 10.1.2 108 last meal by type of material used and by upazila, Habiganj ...... Percentage of recently delivered women whose child is still alive reported washed their Table 10.1.3 108 hands before feed their children by type of material used and by upazila, Habiganj Percentage of recently delivered women whose child is still alive reported washed their Table 10.1.4 109 hands after cleaning their child’s anus by type of material used and by upazila, Habiganj Percentage of recently delivered women reported washed their hands after defecations Table 10.1.5 109 by upazila, Habiganj ...... Percentage of recently delivered women reported washed their hands with soap at least Table 10.1.6 3 times during last 24 hours by upazila and by selected demographic and socio- 110 economic characteristics, Habiganj ...... Percentage of recently delivered women reported washed their hands with soap by Table 10.1.7 111 category of work/activity during last 24 hours by upazila, Habiganj ...... Percentage of households had soap/detergent/other cleansing material at home observed Table 10.1.8 111 during the time of interview by upazila, Habiganj ...... Percentage of household was able to show stock of additional soap during the interview Table 10.1.9 112 by upazila, Habiganj ......
Chapter-11: Neonatal Mortality 113
Table 11.1.1 Neonatal Mortality Rate and Perinatal Mortality rate in Habiganj district 114 Table 11.1.2 Mortality estimates in neonatal period by background characteristics in Habiganj 115 Table 11.1.3 Rate of still-birth and abortion by background characteristics in Habiganj 117 Table 11.1.4 Rate of Perinatal death by background characteristics in Habiganj 118 Table 11.1.5 Distribution of deaths by age of newborn in Habiganj 119
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
List of figures
Page # Chapter-1 Background ...... 16 Fig 1.1 Trend of reduction of child mortality over the years in Bangladesh ...... 17 Fig 1.2 Causes of neonatal deaths ...... 17
Chapter-2 Methodology of the survey ...... 23 Fig 2.1 Map of Habiganj district ...... 23
Chapter-3 Demographic & Socio-economic status ...... 32 Fig 3.1 Population pyramid in MaMoni area of Habiganj ...... 33 Fig 3.2 Level of maternal education by MaMoni upazila, Habiganj ...... 36 Fig 3.3 Percentage of RDW had no education by upazila ...... 37 Fig 3.4 Percentage of RDW had no education by age group ...... 37
Chapter-5 Maternal Health ...... 48 Fig 5.1 Percentage of women received ANC during their last pregnancy by upazila ... 47 Percent distribution of women received first ANC during their last pregnancy by Fig 5.2 54 type of provider and by wealth quintile...... Percent of women delivered their baby in a health facility by level of maternal Fig 5.3 63 education ...... Percent distribution of women who had delivered in a health facility by wealth Fig 5.4 63 quintile ......
Chapter-6 Maternal Health Problems & Treatment Seeking Behavior ...... 68 Percentage of women reported had complication during pregnancy, delivery and Fig 6 68 postpartum, Habiganj ......
Chapter-8 Birth interval and contraception ...... 99 Fig 8.1 Sources of receiving contraceptive methods ...... 102
Chapter-11 Neonatal Mortality ...... 113 Fig 11.1 Early, late and neonatal death rates by maternal education ...... 117 Fig 11.2 Early, late and neonatal death rates by maternal socio-economic characteristic 117
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
Abbreviation and acronyms
ACCESS Access to clinical and community maternal, neonatal and women’s health services MaMoni Integrated safe motherhood, newborn care and family planning project ACPR Associates for Community and Population Research AC ACCESS Counselor BDHS Bangladesh Demographic and Health Survey BFS Bangladesh Fertility Survey BNCP Birth and Neonatal Care Preparedness BMMS Bangladesh Maternal Health Services and Maternal Mortality Survey CAG Community Action Group CHW Community Health Worker FWV Family Welfare Visitor FWA Family Welfare Assistant ICDDR,B International Center for Diarrheal Disease Research, Bangladesh KMC Kangaroo Mother Care LBW Low Birth Weight LAM Lactational Amenorrhea Method MIS Management Information System PROJAHNMO Project for Advancing the Health of Newborns and Mothers RDW Recently Delivered Women SACMO Sub-Assistant Community Medical Officer SC-USA Save the Children-USA TT Tetanus Toxoid TBA Traditional Birth Attendant TTBA Trained Traditional Birth Attendant UHC Upazila Health Complex WHO World Health Organization NCP Newborn care person
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
Preface
The baseline household survey was carried out in the eight upazilas of Habiganj district (MaMoni intervention area) during the year 2010. This survey conducted on a representative sample of rural Bangladesh was a collaborative effort of ICDDR,B and Associates for Community and Population Research (ACPR), a Bangladeshi private research firm. ACPR performed the data collection and ICDDR,B provided technical guidance for data collection. The financial support for the survey was provided by Save the Children, USA and United States Agency for International Development (USAID) /Dhaka. The baseline survey 2010 provides updated estimates of levels of neonatal mortality, maternal and newborn complications, and information on care seeking and delivery practices.
The information concerning maternal and newborn health and neonatal mortality at Habiganj will be instrumental in identifying new directions for the newborn health program in Bangladesh. The survey report will hopefully contribute to an increased commitment to improving the lives of mothers and children.
Deepest gratitude is extended to the members of the SC-USA, USAID Dhaka mission and ACPR for their valuable contribution during different phases of the survey. It is hoped that the survey results will be useful for re-designing the intervention package and for monitoring & implementation of the MaMoni program.
The contributors of the various chapters of this report deserve special thanks. Also expressed the heartfelt thanks to the professionals of the research unit of ICDDR,B, ACPR and SC-USA for their sincere efforts in the successful completion of the survey.
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
Summary of the findings:
Back ground: Currently more than 70% of all infant deaths are occurring in the first 28 days of life in Bangladesh (Bangladesh Demographic and Health Survey, 2007). Thus, to bring down overall infant mortality, it will be necessary to reduce deaths in this age group. Deaths at early days of life are often associated with unsafe delivery practices and improper newborn care, warranting introduction and adoption of essential maternal and newborn care practices. Under the USAID’s global flagship programme MCHIP (Maternal, Child Health Integrated Program), MaMoni is a USAID associate award to partnership of several organizations including JHPIEGO Corporations and Save the Children, USA. MaMoni is a continuation of ACCESS project in Sylhet and is being implemented by Save the Children-USA in Bangladesh through two local NGOs, aimed at improving the health of mothers and newborns. ICDDR,B was contracted by Save the Children-USA to evaluate the MaMoni programme in terms of programme coverage, improvements in key practices and impact on neonatal mortality. As part of this evaluation, a baseline survey was conducted to measure baseline levels of indicators on knowledge and practices, and establish baseline neonatal mortality rate in Habiganj.
Methods: The baseline survey was conducted in the eight upazillas of Habiganj district (Ajmiriganj, Baniachung, Lakhai, Nabiganj, Madhabpur, Chunarughat, Bahubal and Habiganj Sadar) included in the MaMoni intervention program. This study estimated neonatal mortality rate by district and coverage, knowledge and practice indicators by upazila. There was no comparison area to measure for secular trends and effects of other existing programs and factors. A population file 2009 projected from 2001 BBS census was prepared and continuous cluster formation was done by taking 800-1200 population so that at least 22 recently delivered women (last one year) were available. We estimated a sample size of 11,000 live-births over a 12 month period (July 2009 to June 2010) for the study area to estimate neonatal mortality rate and a sample size of 243 pregnancy outcomes over the same period in each of the 8 upazilas of the MaMoni area. Accordingly 600 clusters were randomly selected by using Population Proportion to Size (PPS) from the eight upazilas of Habiganj and interviewed recently delivered women (pregnancy outcome period was 1st May 2009 to 31st July 2010) from 23rd September to 21st December, 2010.
Findings: Socio-demographic characteristics of the women in the survey: About 64% of women interviewed were between 20-29 years old. (36% was 20-24 years and 28% was 25-29 years old). Around 10% of the women were <20 years and the remaining (25%) were 30 years or older in the eight intervention upazilas of Habiganj. About 84% of them were Muslim and 15% Hindu. Around 35% of the women in the survey had no education, and 44% had five or more years of schooling, including secondary or higher education in both the areas. The rest had less than 5 years of education. In women 15-24 years old, 52% women had five or more years of schooling in Habiganj. Household possessions were used to determine economic status through the development of a wealth index constructed from household asset variables using principal component analysis. Overall results indicate that in the sampled households, there were no such variations in wealth by upazila of Habiganj. There were 20% in eachof the five categories (lowest, second, middle, fourth and highest) was revealed.
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010
Regarding demographic characteristics, proportion of female population (51.5%) was slightly higher than the male population (48.5%) at baseline. In particular, for age groups 30-49, the proportion of females in the population was almost thrice that of males. This is attributed to the large proportion of males in this age group working and residing outside/abroad. In addition, the age structure of the population demonstrated a preponderance of younger age groups because of relatively high fertility. In comparing the study population’s demographic characteristics against those reported in the BDHS, little discrepancy is observed except that nationally the numbers of women and men were more or less similar in all age groups including 30-49 years of age. This indicated that the large numbers of males working abroad is a more prominent feature of Habiganj (Sylhet division) than in other parts of Bangladesh. Maternal health and care-seeking: Around 40% of the women in the MaMoni area reported receiving any ANC during their last pregnancy and only about 10% received 4 ANCs from a skilled provider. Around 28% of the women in the highest wealth quintile reported receiving four ANCs during their last pregnancy, while it was only 4% in the lowest wealth quintile group. Around 92% of the women reported (card + history) received at least 2 doses of TT and 58% received 5 or more doses. Of them received 5 doses, 46% had valid 5 doses of TT vaccination and 85% of the newborns were born protected against neonatal tetanus. 36% women reported consumed iron-folic acid tablet during their last pregnancy. Eighty-five percent of deliveries in Habiganj were at home. Rate of home delivery was around 90 percent or more in the Baniachong, Lakhai and Azmeriganj upazilas. The percentage of women delivering in a health facility was the highest in Sadar and Nabiganj (around 20 percent) and lowest in Baniachong and Lakhai (8 percent). There were significant variations in the percentage of health facility delivery by maternal education (47 percent among women had secondary or higher level of education), birth order (38 percent among women with 0 parity) and wealth quintile (33 percent of women in highest wealth quintile). 3% of women who delivered at home in the intervention areas were attended by a skilled provider, and the rate was high (around 5 percent) in sadar, Bahubol and Chunarughat upazilas. Around one in eight women in Habiganj district reported received any post-natal care (PNC) for themselves after termination of their last pregnancy. The rate was high in Sadar (25%) and Nabiganj (16%) while the rate was low in Baniachong (5%) and Azmeriganj (6%). Around 31% of the women reported a complication during their last pregnancy, 33% during delivery and 40% during the post partum period. The most common complications reported during pregnancy included severe abdominal pain (10%) and severe weakness (9%). Prolonged labour (11%), excessive vaginal bleeding (7%) and swelling of feet or face (8%) were the three most common complications during delivery. Post-partum complications included breathlessness/weakness (15%), severe lower abdominal pain (24%) and fever (16%). In the MaMoni area, almost 63% of women with reported complication during pregnancy sought care from a skilled provider, care- seeking from a skilled provider for a pregnancy complication was high in Sadar (74%), Nabiganj (75%) while the rate was low in Azmeriganj and Chunarughat (52%). Care-seeking from a skilled provider for delivery complications as a whole in Habiganj was low (39%), the coverage was more among women who had secondary or more level of education (80%) and women at highest quintile level (81%). Care-seeking from a skilled provider for complications during delivery was the high in Sadar (59%) and Nabiganj (48%) while it was low in Baniachong (25%) and Azmeriganj (30%). Only 22% of women with reported post partum complications sought care from a skilled provider and the rate was almost similar across the upazilas.
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Immediate newborn care: Five percent of newborns in Habiganj were reported to be dried and wrapped within five minutes of birth, and another 43% within 6-10 minutes. Almost three-fourths of babies were dried and wrapped within 15 minutes of birth. Around 12% newborns in Nabiganj and 8% in Sadar were dried and wrapped within five minutes, while it was only around 2% in Chunarughat and Bahubol. Initiation of breast feeding within an hour after birth occurred with 77% of newborns in home deliveries, this was high (>80%) in Baniachong and Sadar while low (68%) in Azmeriganj and Madhabpur. Around only 5% of women from intervention upazilas reported cutting the umbilical cord with a blade from a birth-kit. However, a new blade was used to cut the cord in 93% of the babies. Using blade from birth-kit was highest (7.4%) in Chunarughat and lowest (2%) in Azmeriganj. Application of various materials to the umbilical stump was reported for 33% of the newborns in the intervention area (mostly mustard oil, anti-septic, antibiotics and boric powder). Around 70% newborns were reported bathed within 3 days of birth. 35% were immediately bathed and 55 percent were bathed within 24 hours of birth. Only 8% of neonates in the received two or more PNC visits and most of them received care from skilled providers. The rate was high in Sadar (19%) and Chunarughat (11%) while it was low in Bahubol and Baniachong (4%).
Newborn complications and care seeking: Neonatal complications were reported in 62% of neonates in the intervention area and most commonly reported complications included cough & cold (42%), fever (35%), pneumonia (8%) and difficult/fast breathing (4%). Almost all (97%) mothers reported seeking care for their sick newborns and of them 42% sought care from skilled providers. (95% from MBBS doctors of those sought care from skilled provider) in Habiganj. By site of care, 46% of the care seeking was from pharmacies, 23% from the private chambers of MBBS doctors, 12% at home and 20% from a hospital or clinic. Care-seeking from skilled providers for neonatal complications was high in Nabiganj (58%) and Sadar (57%) while it was low in Azmeriganj (19%).
Neonatal mortality : The early neonatal mortality rate (0-6 days) was 22.7/1000 live-births, the late neonatal mortality rate (7- 28 days) was 5.7 per 1000 live-births and the neonatal mortality rate (0-28 days) was 28.4 per 1000 live- births in Habiganj district.
Conclusion: We note that certain recommended practices, e.g., care-seeking from skilled providers for maternal or neonatal complications were almost similar of baseline-2007 findings in the ACCESS areas of Sylhet. Among the eight MaMoni intervention upazilas, most indicators were much better for Sadar and Nabiganj upazilas compared with the other six. The situation in Baniachong and Azmeriganj upazila was relatively worst and need special attention and strategy. Neonatal mortality was much lower in Habiganj than was hypothesized at the time of the development of the project. Neonatal mortality rate was found 5 percent point higher than Sylhet ACCESS baseline report 2007. Overall, the mortality rate and the knowledge and practice of women has found better than expected, requiring indepth review to maximize impact.
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Chapter-1 Background:
1.1 Maternal and Newborn Health Situation
The four million neonatal deaths that occur annually account for two-thirds of all infant deaths and two- fifths of all under-5 deaths.26 Most neonatal deaths take place in developing countries, at home, and in the absence of skilled care. In many developing countries, neonatal mortality now accounts for over a third of all child deaths, with about half dying on the first day and three quarters of deaths occurring in the first week of life.25 Neonatal deaths are systematically under-reported because of cultural reluctance to report.2 Nevertheless, an estimated 98 percent of the neonatal deaths occur in developing countries, mainly in Asia and Africa where many countries have a neonatal mortality rate of more than 40 per 1000 live births and several countries have a rate of more than 60 per 1000 live births.1 Despite significant declines in infant and child mortality rates in recent decades, neonatal mortality rates remain high in Bangladesh. An estimated 120,000 neonates die each year in Bangladesh which accounts for 70 percent of infant and 55 percent of under-five deaths.27
Maternal mortality in Bangladesh is one of the highest in Asia at 320 per 100,000 live births.5 Over 90 percent of deliveries occur at home and only one in eight deliveries is attended by a skilled birth attendant. The large majority of births are assisted by untrained traditional birth attendants or by family birth attendants. The 2007 Bangladesh Demographic and Health Survey (BDHS) showed that 52 percent of the pregnant women received at least one antenatal care (ANC) from a medically trained provider while only 18 percent of births were attended by medically trained providers and less than 15 percent took place at health facilities. However only 21 percent of mothers and 22 percent of neonates received Postnatal care (PNC) from a medically trained provider within 42 days after birth.27 The main causes of maternal deaths are similar to those of most developing countries: haemorrhage, eclampsia, infection, obstructed labour and the consequences of unsafe abortion. High malnutrition rate among women, vitamin A deficiency and anaemia contribute significantly to morbidity and mortality.
ACCESS baseline survey report-200729 conducted in the seven intervention upazilas of Sylhet showed that 88 percent deliveries occurred at home and only one in ten deliveries was attended by a skilled birth attendant. The large majority of births were assisted by untrained traditional birth attendants or by family birth attendants. Around 49 percent of the pregnant women received at least one antenatal care (ANC), 14 percent received 4 or more ANCs and only 10 percent from a skilled provider. 12 percent deliveries in the intervention upazilas took place in the health facilities. Only 10 percent women reported received postnatal care (PNC) within 42 days after delivery. Care-seeking from a skilled provider for delivery complications in the ACCESS area was 36 percent and for post-partum complication was 12 percent. 2 percent women reported used clean delivery kit (CDK) during their deliveries and 4 percent newborns were dried and wrapped within 5 minutes after birth and 73 percent were breast fed within an hour of birth. Only 6 percent newborns received at least two PNCs from a skilled health care provider. For newborn sickness almost all mothers sought care but of them 44 percent sought care from skilled health care provider. The early neonatal mortality rate (0-6 days) was 16.8/1000 live-births, the late neonatal mortality rate (7- 28 days) was 6.4 per 1000 live-births and the neonatal mortality rate (0-28 days) was 23.1 per 1000 live- births in the ACCESS intervention areas.
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Under-five mortality has significantly declined in the last fifteen years, this decline is mostly due to reduction in the child mortality (1-4 years) rate: from 1991 to 2004, under-5 mortality decreased from 133 to 65, and infant mortality decreased from 87 to 52 deaths per 1000 live-births. During the same period neonatal deaths declined from 52 to 37 deaths per 1000 live births.27 The average annual rate of reduction of under five mortality was 9.4 percent per year for death rates in the age group 1-4 years, 5.8 percent among 1-11 months old infants and only 2.6 percent in neonates (Figure-1.1). The overall rate of reduction of under 5 mortality in this period was 4.9 percent. It is clear that while reductions in death rates in older children have been rapid the decrease in neonatal mortality has been minimal in recent years. Thus more than (57 percent) of under-5 deaths in Bangladesh occur in the neonatal period.
Fig: 1.1 Trend of reduction of child mortality over the years in Bangladesh (Data source: BDHS 2007 report)
140 133
120 116
100 94 87 88 80 82 66 60 65 65 52 48 52 40 42 41 37 20
0 1991 1994 1997 2001 2004
Under-five morta lity Infant mortality Neona ta l morta lity
About 50% of the neonatal deaths occur in the first three days of life due mostly to birth asphyxia, infection, complications of preterm birth and birth injuries. Poor health of mothers and lack of knowledge about safe maternal and newborn care practices also influence pregnancy outcomes such as low birth weight (LBW), stillbirths, premature births and neonatal infections. Although half of all neonatal deaths and about two-thirds of maternal deaths occur immediately after delivery, only 18 % of the mothers receive any postpartum care.5 According to the BDHS 2004 report, the main causes of neonatal death in Bangladesh were birth asphyxia (21%), low birth weight (11%) and possible severe infection (34%) and acute respiratory infection (10%) as shown below:- Fig:1.2 Causes of Neonatal Deaths
Causes of Neonatal Deaths (BDHS 2004)
N.Tetanus, 4% ARI+Diarr, 1%
Diarrhea, 1% ARI, 10% Birth asphyxia, 21%
Possible serious LBW/PMB, 11% infection, 34%
Birth injury, 4% Cong.abnormality, 5% Others, 2% Unspecified, 4% Undetrmined, 3%
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Low utilization of trained providers and health facilities for maternal, obstetric and neonatal care services is a critical problem in Bangladesh. This can mainly be attributed to poor quality of services, inadequate skilled staff, lack of supplies and lack of demand from the community. While recognition of danger signs by the families are poor, the problem is further compounded by the fact that in some areas, restrictions on the movement of both the mother and the newborn in the first forty days after delivery is a common social norm. As a result, the majority of mothers and newborns do not have access to appropriate health care when their need is critical. Lack of access to essential health information is also an important factor for low demand of services. Families in general do not know about improved home-based practices, early recognition of illnesses and emergency conditions that require hospital care. Improving the quantity and quality of this information would help generate demand for services. At the same time, the information would enable families to avert the deaths of mothers and newborns.
1.2 Neonatal health interventions in Bangladesh
Community-based Effectiveness Trial of Newborn Interventions: Sylhet, Bangladesh (Projahnmo-1)
Projahnmo ('Generation' in Bangla) was a community-based cluster randomized trial to evaluate the impact of a package of maternal and neonatal care interventions on neonatal mortality rates. The package was delivered through two different health service delivery approaches at the rural level. At home by trained community health workers (CHW), and at the community level by trained community mobilizers. The Projahnmo intervention package was designed to improve newborn health in the three (Beanibazar, Zakigonj and Kanaighat) upazillas of Sylhet District. The upazillas were divided into 24 clusters each having about 20,000 people and randomly allocated to a Home Care (HC) arm, a Community Care (CC) arm and a Comparison arm. The study outcomes were knowledge and practices, cost and cost- effectiveness, equity, and neonatal mortality. Projahnmo was a broad-based partnership involving governmental and non-governmental organizations (Government of Bangladesh, ICDDR,B, Shimantik, BRAC, Institute of Child and Mother Health, Dhaka Shishu Hospital, Save the Children Federation, Johns Hopkins University) and supported by the agencies of Saving Newborn Lives Initiative/SCF, USA; USAID/Washington and Bangladesh; and others.
In the Home Care arm of study the following services and activities were carried out:
1. CHWs: Surveillance to identify pregnant women 2. CHWs: 2 Antenatal home based birth and newborn care preparedness visits (BNCP) 3. CHWs: 3 Postpartum home visits (days 1, 3, 7) 4. CHWs: Home based screening/management of sick newborn including referral 5. Community mobilizers: Group meetings for women and men 6. Orientation for traditional birth attendants (TBAs) on newborn care 7. Strengthened health facilities for routine maternal/ neonatal care and management of maternal/newborn complications 8. Usual care through government health facilities and outreach services, private providers
In the Community Care arm of the study, there were no community health worker activities, i.e. activities 1-4 as stated above were absent. In the Comparison arm, no project interventions were carried out and usual health care by the MoH and NGOs were continued.
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Projahnmo, Sylhet: Phase-1 Evaluation In order to evaluate the activities of the project, the following surveys were carried out: Baseline and end-of-project surveys in 2002 and 2006 Three periodic sample household surveys were conducted Interventions introduced in July 2003 Data from the management information system (MIS) were routinely collected and process evaluation on selected key processes were conducted.
Results:
High coverage was achieved of birth and newborn care preparedness (BNCP) home visits during pregnancy by CHWs. For the first home visit, the coverage remained about 90% throughout the life of the project, while for the second visit it remained around 80%. Achieving coverage of newborn care home visits proved to be more difficult and required more time for CHWs to gain acceptance in the community. Initially it was only 42% and during the end-of-project survey it was 81%. The coverage of ANC was increased by 30% in Home Care, 17% in Community Care, and 20% in Comparison areas. IFA consumption increased by 40% in Home Care with no change observed in Community Care and Comparison areas. Compared to baseline rates, the use of clean cord cutting instruments increased by 51% in Home Care, 28% in Community Care and 20% in Comparison areas. Practice of applying nothing to the umbilical stump increased by 62% in Home Care, 29% in Community Care and 17% in Comparison areas. There was a substantial and sustained increase in families in Home Care area who were delaying the first bath of the baby by >3 days. There was a smaller increase in the Community Care area, with some increase also in the Comparison area. Study was able to demonstrate a 33% reduction of NMR in last 6 months of the project in the Home Care area, with no such reduction in the Clinic Care area. When only the singletons were considered in the analysis, were able to demonstrate a 43% reduction in the last 6 months in the Home Care area, while observed a 9% reduction in the Clinic Care area.
Conclusions Project demonstrated that: A cadre of community-based health workers can gain high acceptance in the community with the information and services they provide A package of maternal and newborn interventions, when delivered through community-based workers and existing health facilities, is – effective in improving pregnancy, delivery, and newborn-care practices, and – significantly reduces neonatal mortality
Significant mortality reduction in the home care arm was achieved within a year of implementation. Lack of impact in the clinic-care arm may be due to the fact that a longer period of implementation was required or the inputs were inadequate for an under-served population to achieve a mortality impact.
Recommendation: The intervention package and delivery system can be scaled up within the existing government and NGO health services after appropriate adaptation.
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1.3 ACCESS/MaMoni project in Sylhet
The ACCESS Program (Access to clinical and community maternal, neonatal and women’s health services) is a global program sponsored by the United States Agency for International Development (USAID) aimed at reducing maternal and newborn deaths and improving the health of mothers and newborns. In Bangladesh, ACCESS had been implemented a community-based maternal neonatal health intervention program through two local NGOs (Shimantik and FIVDB) in 7 upazillas of Sylhet district under the supervision and technical assistance of Save the Children USA, Bangladesh. The long-term goal of this activity was to improve maternal and neonatal outcomes. The ACCESS/Bangladesh program Strategic Objective was: to increase the practice of healthy maternal and neonatal behaviours in a sustainable and potentially scalable manner. This Strategic Objective included following intermediate results: to increase knowledge, skills and practices of healthy maternal and neonatal behaviours in the home, to increase appropriate and timely utilization of home and facility-based essential maternal and neonatal health services, to improve key systems for effective service delivery, community mobilization and advocacy, to mobilize community action, support and demand for the practice of healthy maternal and neonatal behaviours, and to increase key stakeholder leadership, commitment and action for these maternal and neonatal health approaches. The ACCESS intervention was started in March 2007 in the communities through local NGOs. The primary components included services and counselling by community based workers (Access Counsellors- AC) and community mobilizers (Community Supervisor/Mobilizer- CSM). The ACs were females recruited from the communities where they were serving with the responsibilities of identifying and registering pregnant women, conducting domiciliary visits for service provisions including counselling and negotiation and neonatal and postpartum care visits to mothers and newborns, establishing linkages with community resources like TBAs and other formal and informal service providers. The CSMs were the supervisors of ACs and provided support to them, and perform community mobilization efforts to supplement enhancement of ACCESS interventions in the communities. The household based baseline survey was designed to assess the impact of the project interventions on knowledge, practices, and service utilization, and on neonatal mortality. Comparison upazillas were non- randomly selected from Sunamganj, Moulvibazar and Hobiganj districts. Population-based surveys were conducted at the beginning to assess change in selected indicators: intervention coverage, knowledge and practices, outcome and impact on neonatal mortality. Results were described at the beginning of this chapter.
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1.4 References:
1. CHR, Child Health Research Project: Reducing Perinatal and Neonatal Mortality, in Report of a Meeting. 1999, Johns Hopkins University: Baltimore, MD.
2. SCA, State of the World's Newborns. Saving Newborn Lives. 2001, Washington, DC: Save the Children Federation-US. 1-49.
3. IOM, Improving Birth Outcomes: Meeting the Challenge in the Developing World, ed. J. Bale, B. Stoll, and A. Lucas. 2004, Washington, D.C.: The National Academies Press.
4. Child Health Research Project. Reducing Perinatal and Neonatal Mortality. in Report of a Meeting. Baltimore, MD May 10-12, 1999: Johns Hopkins University.
5. Moss, W., et al., Research priorities for the reduction of perinatal and neonatal morbidity and mortality in developing country communities. J Perinatol, 2002. 22(6): p. 484-95.
6. WHO, Perinatal mortality: A listing of available information, in World Health Organization. 1996: Geneva, Switzerland.
7. Moss, W., et al., Research priorities for the reduction of perinatal and neonatal morbidity and mortality in developing country communities. J Perinatol, 2002. 22(6): p. 484-95.
8. NIPORT, MA, and MACRO, Bangladesh Demographic and Health Survey 1999-2000. 2001, National Institute of Population Research and Training, Mitra and Associates, and ORC Macro: Dhaka, Bangladesh and Calverton, Maryland (USA).
9. Baqui, A., et al., Causes of Childhood Deaths in Bangladesh: Results of a Nationwide Verbal Autopsy Study. Bull World Health Organ, 1998. 76(2): p. 161-171.
10. Baqui, A., et al., Causes of Childhood Deaths in Bangladesh: An Update. Acta Paediatr, (submitted for publication).
11. Stoll, B., The global impact of neonatal infection. Clin Perinatol, 1997. 1(24): p. 1-21.
12. Ahmad, O., A. Lopez, and M. Inoue, The decline in child mortality: a reappraisal. Bull World Health Organ, 2000. 10(78): p. 1175-91.
13. Reingold, A.L. and C. Phares, Infectious Diseases. in Interational Public Health: Diseases, Programs, Systems and Policies, 2001. Editors: Merson MH, Black RE, Mills AJ.
14. Winch, P., et al., An implementation framework for household and community integrated management of childhood illnesses. Health Policy and Planning, 2002. 17: p. 345-353.
15. Winch, P., et al., Impact of training in Integrated Management of Childhood Illness (IMCI) on prescribing and dispensing of antimicrobials and their administration to sick children in the home in Bougouni District, Mali. Tropical Medicine and International Health, 2003. submitted for publication in January.
16. Pariyo, G., et al., Improving health facility based care for sick children in the real world: effect of IMCI on health worker performance in Uganda. Unpublished draft, 2003.
17. WHO, Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact. Retrieved from http://www.who.int/imci-mce/, 2003.
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18. WHO, Mother-Baby Package: Implementing Safe Motherhood in Countries. 1998, World Health Organization: Geneva.
19. Mitra, S., et al., Bangladesh Demographic and Health Survey, 1996-1997. 1997, National Institute of Population Research and Training, Mitra and Associates, and ORC Macro: Dhaka, Bangladesh and Calverton, Maryland (USA).
20. Dewey, K., Guiding Priniciples for Complementary Feeding of the Breastfed Child. 2003, Pan American Health Organization: Division of Health Promotion and Protection: Washington, D.C. p. 1-26.
21. Santosham, M., et al., Newborn Thermal Care Practices in Rural India: A community-based program to prevent and improve recognition and management of hypothermia. USAID Project Proposal, 2003.
22. Bergstrom, S., Perinatal health, in Health and disease in developing countries, S.B.P.H.M.M.P. Kari S. Lankinen, Editor. 1994, London, England, Macmillan Press. p. 287-296.
23. Winch, P., et al., Community-Based Interventions to Reduce Neonatal Mortality in Bangladesh. Research Protocol, 2001.
24. Bari, S., et al. Trends in use of referral hospital services for care of sick newborns in a community-based intervention in Tangail district, Bangladesh. JHPN 2006 Dec; 24(4):519-529
25. Edmond KM, Bard EC, Kirkwood BA. Meeting the child survival millennium development goal. How many lives can we save by increasing coverage of early initiation of breastfeeding? Poster presentation at the child survival countdown Conference, London UK. December 2005.
26. Neonatal survival series, The Lancet, March 2005.
27. BDHS-2007. Survey provides national level estimates of under-5 mortality for the five years preceding the survey. The mortality estimates are thus reported for the middle of 5 years period. Thus for the last survey conducted in 2007, the mortality estimates are reported for 2004, the middle of the period 2002-2006.
28. Baqui A et al. Effect of community-based newborn-care intervention package implemented through two service delivery strategies in Sylhet district, Bangladesh: a cluster randomized controlled trial. The Lancet 2008; 371:1936-44
29. ACCESS baseline survey report 2007
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Chapter-2 Methodology of the Survey:
MaMoni intervention area comprises all the eight upazilas (sub-district) of Habiganj district of the north eastern region of Bangladesh. The upazilas are Ajmiriganj, Bahubol, Baniachung, Lakhai, Nabiganj, Madhabpur, Chunarughat and Habiganj Sadar.
Fig; 2.1 Map of Habiganj district
2.1 The Respondent: In order to obtain information on pregnancy and its outcome, and recent experience and practices during pregnancy, childbirth and the neonatal period, the survey was designed to interview women with a pregnancy outcome during a one year period prior to the survey. These respondents were termed as ‘Recently Delivered Women’ (RDW), or to be more specific, they were the women with a recent pregnancy outcome. The RDWs were defined as ‘any women from the intervention areas having a pregnancy outcome in the previous 12 months from a specified date before the start of the survey’. Based on previous experience and due to the inherent problem of determining the date of the outcome from a woman in a community set up, we anticipated an error of reporting these dates around the fringes of the definition window period. To avoid this, we extended the period of the window by adding two months preceding and one month following the RDW definition period of 12 months. So, in practical terms, in the field the definition was ‘any woman from the intervention areas having a pregnancy outcome in the previous 15 months from a specified date before the start of the survey’. It is worthwhile to mention that for analysis purposes the original 12 month period was considered.
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2.2 Design and Methods: A population file was prepared from BBS 2001 census report by village, union and upazila for the eight intervention upazilas of Habiganj district. Population was projected for 2009 by taking growth rate of 2001 (BBS census) by upazila. Population was clustered by union by taking population range of 800- 1200 with the prediction that at least 31 women are available who delivered during the last 15 months in each cluster. We followed single procedure to select recently delivered women (RDW) and currently married women of reproductive age (CMWRA) from a cluster, because we needed only 1 (one) CMWRA from each cluster to interview. Number of clusters required by upazila was determined from the sample size to estimate NMR divided by expected number of RDW listed from each cluster. (Required number of clusters by upazila has shown in Table-2.2) Clusters were selected using Population Proportion to Size (PPS). Each cluster contains a village or a group of villages or a part of a village. Following was the procedure of cluster selection using PPS:- 1. First calculate the sampling interval by dividing the total number of cluster by 15 (say the interval is k). 2. Choose a random starting point (x) between 1 and the sampling interval (k) by using the SRS method. 3. The first selected cluster will be the x th cluster. Continue to select clusters by adding k cumulatively. e.g. the next selected cluster will be (x+k)th cluster then (x+2k)th and so on. Data base of clusters was sent to Data Management System (DMS) for random cluster selection as per number mentioned in table-2.2 by upazila using population proportion to size (PPS).
2.3 Sample size calculation: There were two considerations in estimating the required sample for the baseline household survey. The first was to achieve a sample size large enough to give statistically valid estimates for coverage, knowledge and practice indicators by upazila, and the other was to have a valid estimate of the impact of the intervention on neonatal mortality by district.
Sample size estimating for knowledge, practice and coverage (KPC) by upazila: Since we had no information on expected population levels of the indicators, we assumed a population proportion of 50% as this would result in the largest minimum required sample size. Assuming 95% confidence level and 80% power, applying an alternative proportion of 40% resulted in a minimum required sample size of 194 RDW per measurement unit (Upazila). This basic sample size for a unit of measurement was used to calculate the total sample size for the Habiganj baseline survey in the MaMoni Intervention area. Since we used a multi-stage sampling scheme with a cluster as a sampling unit, a design effect of 1.25 was used based on the assumptions regarding the complexity of the survey for estimating sample size. Consequently, after applying the design effect, the RDW sample required for estimating measures for indicators related to knowledge, practice and coverage for each union became 243 (194 x 1.25). Assuming that the total absent and refusal was 20%, sample size for KPC estimate by upazila was 304. Table-2.3.1 Showing sample size of RDW to estimate KPC by upazila
Respondent: RDW (Sample Size for KPC estimate by upazila) Minimum required sample size: 194 Multiplied by 1.25 as design effect (194 x 1.25) 243 Assumed 20% absent and refusal (243/.80 ) 304
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Sample size for estimating neonatal mortality rate by district: We anticipated neonatal mortality rate of 40/1000 live births in the MaMoni intervention area (Habiganj) at baseline. To detect a 20 percent reduction in mortality from an anticipated rate of 40/1000 live births after intervention provided, and assuming a significance level of 5%, power of 80% and design effect of 1.25, it was calculated that a sample size of 10,950 (rounded to 11,000) live births is required for district level estimation. Assuming 25% absence, refusal and non-live birth, this sample size became 14,667. We anticipated errors in the reporting of pregnancy outcome dates during listing and listed women with reported pregnancy outcomes in the 2 months preceding and 1 month following the RDW definition period – leading to a functional listing window of 15 months, adding 25% to get live births of one year (1 May 2009 to 31 July 2010), the sample size became 18,333. It was anticipated that 25 births/1000 population per year. So, required number of RDW sample by cluster was 31 (25 x 1.25).
Table-2.3.2 Showing sample size to estimate NMR by district
Respondent: RDW Sample size for district level NMR estimate Total district Average RDW/ upazila Minimum required sample size: 11,000 1,375 Assumed 25% absence, refusal and non-livebirths (11000/.75) 14,667 1,833 Adding 25% to get live-births of one year (14667 x 1.25) 18,333 2,292
Calculation of sample size by upazila and required number of cluster: Calculation of sample sizes for NMR and KPC by upazila were done from projected population for 2009, number of clusters needed to get the required sample size and the interval for KPC interview for RDW. Following table-1.3 shows detail calculation of SS and number of cluster required by upazila.
Table-2.3.3 Calculation of SS and required number of clusters by upazila
Upazila Population Sample Interval for Sample # of clusters by Require to 2009 projected size of KPC size of upazila select # of from 2001 RDW to interview for RDW to RDW (Growth Rate estimate RDW estimate sample by by upazila) NMR KPC by cluster Upazila Code upazila 08 Ajmiriganj 110,538 1,036 3.40983255 304 33.89683542 (34) 31 09 Bahubal 195,824 1,745 5.74400912 304 57.10067252 (57) 31 10 Baniachung 298,081 2,802 9.22413724 304 91.69630970 (92) 31 11 Chunarughat 297,064 2,786 9.17090904 304 91.16717304 (91) 31 12 Sadar 322,546 2,869 9.44625334 304 93.90434575 (94) 31 13 Lakhai 129,644 1,259 4.14414127 304 41.19653159 (41) 31 14 Madhabpur 292,137 2,843 9.36053878 304 93.05226505 (93) 31 15 Nabiganj 323,874 2,994 9.85683161 304 97.98586693 (98) 31 1,969,682 18,333 2430 600
RDW Selection process in Habiganj (for both Part-A and Part-B): It was decided that when 24-36 RDWs were identified in a cluster during the household listing, then all the RDWs were interviewed. If less than 24 RDWs were found, then additional villages were added to get the required number of RDW. If more than 36 RDWs were found, then Systematic Random Sampling
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Procedure was followed to select 31 RDWs. Before drawing a sample, a frame was made for the selection of RDW. RDW for Part-A (KPC) were selected by SRS procedure in the following manner:
Upazila Code Upazila Name Interval for KPC interview for RDW 08 Ajmiriganj Every 3rd 09 Bahubal Every 5th 10 Baniachung Every 9th 11 Chunarughat Every 9th 12 Habiganj Sadar Every 9th 13 Lakhai Every 4th 14 Madhabpur Every 9th 15 Nabiganj Every 9th
After the selection of Part-A, rest f the RDWs were interviewed for Part-B questionnaire.
2.4 Household census and Mapping of villages: A complete census and mapping of villages were done in the selected 600 clusters. In order to identify the RDW sample, a complete household listing of selected villages was conducted by a group of enumerators. Hand-drawn maps of selected villages were made; all the households were visited to identify and list all “recently delivered woman” (RDW). There were 17 teams, each consisting of a male mapper and two female listers, and completed the task between 18 August-14 November, 2010. In the process of reviewing of listing data, it was identified that 14 clusters did not have the required number of RDWs (less than 24). In those 14 clusters, additional villages were added from adjacent areas (not in the previous list) and conducted census and RDW listing activities to fulfill the sample requirements. It should be noted that these additional villages were not selected by Probability Proportion to Size (PPS) technique; instead these were selected from adjacent areas of previously randomly selected clusters. Household listings were done by the female enumerator using a listing form (appendix-A form-2). Teams completed village mapping and listing of RDW in 3 months time according to plan of weeks those were randomly selected. A separate cadre of data collectors interviewed women as per serial of randomly selected weeks.
2.5 Household survey (Data Collection):
The survey field work was contracted out to a renowned survey firm – ACPR (Associates for Community and Population Research). Selection of sample, data collection, data editing and re-interviews were conducted by ACPR as per conditions and standards set out in the contracted scope of work with detailed field and data processing procedures. ICDDR,B with over all responsibilities assisted ACPR during the training of the data collectors, field implementation, supervision and monitoring of field activities. In addition to the embedded quality assurance procedures of ACPR, there was an independent data quality assurance system conducted by ICDDR,B. Data entry and cleaning, data analysis and report generation, sharing of findings were the specific responsibilities of ICDDR,B. A separate cadre of field workers was recruited as Data Collectors. There were a total of 15 teams in the field to collect baseline data in the intervention areas and interviewed both RDW and CMWRA simultaneously using different questionnaires for different category. Data collection started on 23 September, 2010 and completed as per date mentioned in the following table-1.4:
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Table 2.5.1: Completion date of data collection by upazila (Habiganj)
Sl. # Name of Upazila Date of completed data collection 1 Ajmiriganj 10 December, 2010 2 Bahubal 29 November, 2010 3 Nabiganj 05 December, 2010 4 Chunarughat 19 December, 2010 5 Sadar 21 December, 2010 6 Lakhai 21 December, 2010 7 Baniyachung 18 December, 2010 8 Madhabpur 19 December, 2010
Each data collection team consisted of one Male Team Leader, one Female Supervisor/Editor, and four Female Data Collectors/Interviewers. Team leader acted as the team coordinator in the field and ensured the logistics and identification of villages for the survey. He performed the spot checks on the correctness of interviews. Female supervisor accompanied the data collector inside the household and facilitated data collection, observed interviews and edited questionnaires to assure data quality in the field. Teams were organized and assigned according to the number of clusters in each upazila. Cluster or group of clusters was organized as per convenience and plan of interview RDW and CMWRA was prepared by week. Like; cluster 1 and 2 will be completed in week-1, cluster 3-4 in week-2 and so forth. Then keeping the cluster-wise plan fixed, weeks were randomly selected to implement data collection. (example: if the week-3 comes first and then week-8, then interview will be conducted in those cluster/clusters which were planned in week-3 then in week-8 and so forth). As per plan there were 60 data collectors in total constituted 15 teams (Each team=4 DC+1 Sup+1 guide). Total 600 clusters, and assignment of teams has shown below:-
Azmiriganj 34 clusters 1 team Bahubol 57 clusters 2 teams Baniachang 92 clusters 2 teams Chunarughat 91 clusters 2 teams Sadar 94 clusters 2 teams Lakhai 41 Clusters 1 team Madhabpur 93 clusters 2 teams Nabiganj 98 clusters 2 teams 8 upazilas 600 clusters 15 teams
2.5.1 Recruitment and training of field staff:
ACPR recruited 90 field staff (60 Female interviewers, 15 Female supervisors and 15 Team Leaders) for the survey. All the interviewers and supervisors had at least a graduation degree and majority had prior experience in the relevant area. Detailed training and practice sessions were conducted for the enumerators and data collectors involved in the mapping, listing and survey data collection. Enumerators for mapping and listing underwent a training of three days and field practice with active feed-back sessions. The workers were trained until they achieved the expected level of knowledge and skill. Similarly, 7 full days training was designed for the data collectors involved in the survey. The training was conducted during August, 2010 for Habiganj MaMoni Survey.
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2.6 Survey instrument (Questionnaire) For MaMoni Baseline Survey in Habiganj, four different tools and questionnaires were developed, pre- tested and administered for data collection. The following section is a description of the tools and questionnaires used for the survey. These included a household listing form and three questionnaires for collecting (i) household and socio-economic data, (ii) pregnancy history and mortality data, and (iii) knowledge, practice and coverage data. The questionnaire was a modified version of the questionnaires used in the ACCESS baseline, Bangladesh Demographic and Health Survey (BDHS) and Projahnmo project implemented in Sylhet district. The questionnaire addressed the MaMoni indicators and were finalised with active input from MaMoni project. The questionnaires were then translated into Bangla with inputs to accommodate local Sylheti context.
Household listing form This instrument was used to list all households, record the location of each household and assign the household a unique identification number. The data collected using this form includes the cluster number, household number, name of the head of the household, and number and names of married women who had a pregnancy outcome as per criteria explained before.
Questionnaires i. Questionnaire for household and socio-economic data This instrument was used to collect information regarding the usual members of all surveyed households and to collect age and sex by category, level of education and occupation of RDW and their husband. This questionnaire also collected information on the availability of basic amenities and facilities in the households, and socio-economic information including ownership of land and livestock, possession of durable goods, type of construction material used in the house’s roof, wall and floor. ii. Questionnaire for pregnancy history and mortality data This form was used to collect information about the pregnancy history and particulars of last pregnancy outcome (live birth, still birth and spontaneous or induced abortion), including the date of outcome. This also recorded information of age at death of the newborn, if a baby was reported dead. iii. Questionnaire for knowledge, practice and coverage data This questionnaire was for information on key knowledge and practices regarding the antenatal period, delivery, and the postpartum period pertaining to maternal and newborn care. It also recorded sickness and care-seeking data for antenatal, delivery, postpartum and neonatal period. This tool included section on community action group and hand washing which are components of MaMoni intervention package. The following box gives an over view of the three questionnaires consisting of 11 sections:
Questionnaires and sections Contents Questionnaire for Section - A Household members, household status, possession of household and socio- land, etc. economic data Section - B Respondent and her husband’s age, education and occupation
Questionnaire for Section - C Woman’s reproduction and birth history including date pregnancy history and of birth and or death of the ‘index’ child. mortality data Questionnaire for Section - D Woman’s knowledge on ANC, birth plan, PNC, knowledge, practice complications during and after pregnancy, complications and coverage data during delivery as well as newborn complications and knowledge about Kangaroo Mother Care. Section - E Woman’s actual ANC practice and complication history Section - F Woman’s actual delivery care practice and complication 28 | Page
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history Section - G Newborn care practice including drying, wrapping, applying substances to the umbilicus, bathing and feeding Section - H Postnatal visits by health workers as well as attitude and practices for addressing the complications of the mother and newborn Section - I Woman’s perception about community action group (CAG) and the availability of facilities from CAG as or when required. Section – J Family Planning Section – K Hand Washing practice
2.7 Survey Implementation The survey field work was contracted out to a renowned survey firm ACPR (Associates for Community and Population Research). The census including mapping and listing, data collection, data entry and data cleaning were conducted by ACPR as per conditions and standards set out in the contracted scope of work with detailed field and data processing procedures. ICDDR,B with over all responsibilities assisted ACPR during the training of the data collectors, field implementation, supervision and monitoring of field activities. In addition to the embedded quality assurance procedures of ACPR, there was an independent data quality assurance system conducted by ICDDR,B. Data entry, analysis and report generation, sharing of findings were the specific responsibilities of ICDDR,B. Data were collected by interviewing RDW through a set of questionnaire from September 23 to December 21, 2010. Each team of six persons (one supervisor, one enumerator and four data collectors) was engaged for two days to complete one cluster. There were total fifteen teams and they completed interview of 18,000 RDWs and 580 currently married women of reproductive age (15-49 years) in the selected 600 clusters in the eight intervention upazilas during the mentioned time period (three months). Following table shows the status of implementation. Table 2.7.1: Sample Implementation (Percent distribution of RDW by results of individual interviews and by upazila, Habiganj (MaMoni 2010)
Azmeriganj 1,046 N= Bahubol 1,722 N= Baniachang 2,850 N= Chunarughat 2,637 N= Sadar 2,735 N= Lakhai 1,284 N= Madhabpur 2,811 N= Nabiganj 2,994 N= TOTAL N= 18,079 989 1,604 2,496 2,522 2,675 1,159 ,682 2,793 16,920 Interview Complete (94.6) (93.2) (87.6) (95.6) (97.8) (90.3) (95.4) (93.3) (93.6) No HH member OR competent respondent 2 4 3 3 13 20 8 10 63 were present at home at time of HH visit (0.2) (0.2) (0.1) (0.1) (0.5) (1.6) (0.3) (0.3) (0.4) 0 0 0 1 0 0 0 0 1 Interview cancelled (0.0) (0.0) (0.0) (0.04) (0.0) (0.0) (0.0) (0.0) (0.006) 1 0 0 0 0 0 0 1 2 Refused to give interview (0.1) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.04) (0.01) 0 0 1 2 1 0 0 8 12 Could not find the residence (0.0) (0.0) (0.04) (0.1) (0.04) (0.0) (0.0) (0.3) (0.1) Woman who has recently delivered is 38 55 224 60 16 37 39 100 569 absent (3.6) (3.2) (7.9) (2.3) (0.6) (2.9) (1.4) (3.3) (3.1) No recently delivered woman Pregnancy 6 42 96 22 11 40 52 61 330 outcome in the last 15 monthMay’09 to (0.6) (2.4) (3.4) (0.8) (0.4) (3.1) (1.8) (2.0) (1.8) Junly’10 found 10 17 30 27 19 28 30 21 182 Others (1.0) (1.0) (1.1) (1.0) (0.7) (2.2) (1.1) (0.7) (1.0)
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There were rigorous embedded quality assurance inputs in the implementation of the survey. There were two distinct systems in place for the duration of the survey. One was from the ACPR as part of its field procedures. The other was the independent additional umbrella approach from ICDDR,B. The quality assurance procedures included:
1. Verification of village and house: Quality team checked and verified 74 houses randomly to assess the correctness of identification of house (Bari), village and number of households in the house. Result showed that: Houses were within the correct villages:- 100% Houses were within the sampled list:- 100% Number of households in each house was correct:- 92.2% Mean: 97.4%
2. Verification & Identification of sample: Eight female Field Research Assistants (FRA) were engaged full time stationed at the upazila level to verify correctness of selection of Bari, household and RDW in all the eight upazilas of Habiganj districts. The FRA randomly identified samples for quality check and collected the face sheet information from survey team. The FRAs were engaged in verifying the correctness of HH and RDW within 3 days of completion by the data collections so that if there were any need for repeating the incorrect survey they could do it easily as they were nearby. During 3 months of survey period in Habiganj, the team completed 1,352 verifications of houses, HHs and RDWs. All the verification checks revealed consistent and correct administration of the surveys, in terms of the house (Bari), household and individual respondents. Selection mistake of RDW was only 0.5% (7 out of 1,352)
3. On-site observation of interview: The female FRAs (Field Research Assistants) were able to observe the interview on site. They conducted 187 observations on site for Part-A questionnaire and 1,164 observations on site for Part-B questionnaire. The performance was measured using a scale 1-4 (one being poor and 4 being very good) with mean score of 3.23 for part-A and 3.48 for part-B. Part-A Part-B 1. Explained objective 3.35 1 Explained objective 3.36 2. Identified correct RDW 4.00 2 Identified correct RDW 3.99 3. Consent taken 4.00 3 Consent taken 3.99 4. Face sheet found correct 3.50 4 Face sheet found correct 3.51 5. Section-A 3.30 5 Section-A 3.34 6. Section-B 3.40 6 Section-B 3.42 7. Section-C 3.30 7 Section-C 3.40 8. Section-D 2.80 8 Respondent understood Ques 2.99 9. Section-E 2.90 9 Questionnaire checked 3.29 10. Section-F 3.00 Mean 3.48 11. Section-G 2.90 12. Section-H 3.00 13. Section-I 3.20 14. Section-K 3.10 15. Respondent understood Ques 2.71 16. Questionnaire checked 3.05 Mean 3.23 4. Repeat interviews:
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The Quality Assurance team collected the list of RDWs (interview completed within preceding 3 days) from the survey teams by cluster. Female FRAs randomly selected RDWs by village and by DC from that list and interviewed the same as a repeat. The same FRA observed interviews on site and also interviewed RDWs selected for repeat from nearby village. The FRA collected a photocopy of the completed questionnaire of quality sample from the main team for one to one matching. A matching report was usually made available within one week and a summary of the report (gathered from all FRAs) was shared with ACPR for immediate remedies. For speedy feedback, mobile phones were used. Total 179 repeat interviews were done for part-A questionnaire in Habiganj and 9.2% questions were found mis-matched with the original data. Similarly total 1,136 repeat interviews were done for part-B and 5% questions were found mis-matched with the original data. Section wise report has shown below:- Part-A % mismatched Part-B % mismatched 1. Section-A 7.60 1 Section-A 7.60 2. Section-B 9.90 2 Section-B 9.90 3. Section-C 6.10 3 Section-C 6.10 4. Section-D 14.0 Mean 5.00 5. Section-E 13.0 6. Section-F 10.0 7. Section-G 9.90 8. Section-H 8.20 9. Section-I 1.70 10. Section-K 13.0 Mean 9.20
2.9 Data Management and Analysis:
All questionnaires and data forms were reviewed for accuracy, consistency and completeness. This was done immediately after data collection, before the respective survey teams left the area. The data collectors made additional field visits to clarify inconsistencies or to collect missing information. After editing, the data was entered in databases using custom-designed data entry programs. In reality, to ensure prompt feedback, data collection and data processing progressed almost simultaneously. Necessary range and consistency checks were in-built with the program to trap error during data entry. Data were periodically checked by running and reviewing frequency distributions and cross-tabulations. For data analysis Visual Basic 6 was used at front end as user interface and SQL Server 2005 was used to store the data. Analysis was done with STATA (version 10). The data was analyzed to provide the estimates of the indicators at the level of the measurement units described earlier in this chapter. Given the sampling scheme, these were self-weighted estimates. However, weighted estimates for all indicators were calculated for the overall MaMoni intervention area.
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Chapter-3 Demographic and Socio-economic status:
Characteristics of Households and Respondents:
Maternal health care utilization, health knowledge, and neonatal health outcomes can be significantly influenced by demographic and socioeconomic characteristics. This chapter presents the socio- demographic characteristics of the study population, including age and sex by age group, educational level and occupation of RDWs and their husbands. In addition, selected socioeconomic characteristics of the respondents’ households are examined, including housing type, drinking water sources, sanitation facilities, assets, landholding resources, and availability of electricity.
This chapter presents findings of demographic and socioeconomic characteristics of the study population in Habiganj. Among different demographic characteristics, age and sex are important variables and are the primary basis of demographic classification in vital statistics, censuses, and surveys. These variables are important for understanding and interpreting the findings of the survey and also provide an opportunity to compare the sample distribution with the overall population of the country. Therefore, whenever possible, survey results have been compared to 2007 Bangladesh Demographic and Health Surveys (BDHS) data, and when appropriate, to the Bangladesh Maternal Health Services and Maternal Mortality Survey (BMMS) preliminary results 2010.
A household questionnaire was used to collect data on demographic and social characteristics of all usual residents (living for the last six months from the date of census) of the households listed through a census. The study collected information from all usual residents of the selected households. The results are based on this population. However, given that a significant proportion of the populations in Sylhet division reside abroad, we have also collected information on respondents’ relatives and family members residing abroad. Often these family members are the major source of household income through remittance.
3.1 Demographic Characteristics of Households
Total of 16,920 recently delivered women were interviewed from 16,920 households in the eight upazilas of Habiganj. A total of 107,670 household members were recorded from those households. 51.3 percent of which were females and 48.7 percent males (Table 3.1.1). The age structure shows a preponderance of younger age groups due to relatively high rates of fertility (Figure 3.1). Among individuals between 15- 29 years of age, the proportion of females in the population was almost 1.6 times higher than males. This can be attributed to the large proportion of males that work and reside abroad, usually in Middle Eastern countries, the United Kingdom, and the United States.
Table 3.1.1 shows the distribution of the population by age category among the households surveyed; around 24 percent was 0-4 year age, 21percent was 5-14 years, 27.2 percent was 15-29 years, 17.4 percent was 30-49 years and 10.3 percent was more than 49 years in Habiganj district. The male female ratio in each age group was almost same except 21:33 in 15-29 year age group and 24:12 in the 30-49 year age group.
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Table 3.1.1: Percent distribution of the household members by age group & sex, among households with women that had pregnancy outcome during 01 May 2009 to 31 July 2010 in Habiganj
Age Group (in Upazilas of Habiganj years) Male % of total male Female % of total Female Total % by age group 0 – 4 13,027 24.8 12,819 23.2 25,846 24.0 5 – 14 11,151 21.3 11,513 20.9 22,664 21.0 15 – 29 11,219 21.4 18,090 32.8 29,309 27.2 30 – 49 12,333 23.5 6,391 11.6 18,724 17.4 > 50 4,730 9.0 6,396 11.6 11,126 10.3 Total 52,462 100.0 55,208 100.0 107,670 100.0
Fig:3.1 Population pyramid of Habiganj, 2010 (MaMoni area)
Table 3.1.3 shows the average household size (6.4) in Habiganj intervention area. There was no significant variability of mean household size by intervention upazila except in Chunarughat (5.7).
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Table 3.1.3: Percent distribution of household size (number of usual members), among households with a women who had a pregnancy outcome during 01 May 2009 to 31 July 2010 in Habiganj
Number of usual members < 3 4 5 6 7 8 9+ Total Mean ± Std; (Median) Total area # 1943 2769 2971 2687 2092 1415 3043 16920 6.4 ± 2.9 % 11.5 16.4 17.6 15.9 12.4 8.4 18.0 100.0 (6) Upazila Azmeriganj # 77 167 184 157 114 93 197 989 6.6±3.0 % 7.8 16.9 18.6 15.9 11.5 9.4 19.9 100.0 (6) Bahubol # 190 240 279 256 216 153 270 1604 6.3±2.9 % 11.9 15.0 17.4 16.0 13.5 9.5 16.8 100.0 (6) Baniachang # 252 340 380 382 341 203 598 2496 6.9±3.3 % 10.1 13.6 15.2 15.3 13.7 8.1 24.03 100.0 (6) Chunarughat # 369 490 498 384 311 195 275 2522 5.7±2.3 % 14.6 19.4 19.8 15.2 12.3 7.7 10.9 100.0 (5) Habiganj Sadar # 320 442 446 448 316 222 481 2675 6.4±3.0 % 12.0 16.5 16.7 16.8 11.8 8.3 18.0 100.0 (6) Lakhai # 115 199 230 188 133 102 192 1159 6.3±2.8 % 9.9 17.2 19.8 16.2 11.5 8.8 16.6 100.0 (6) Madhabpur # 334 478 503 450 317 206 394 2682 6.0±2.6 % 12.5 17.8 18.8 16.8 11.8 7.7 14.7 100.0 (6) Nabiganj # 286 413 451 422 344 241 636 2793 6.7±3.1 % 10.2 14.8 16.2 15.1 12.3 8.6 22.8 100.0 (6)
3.2 Pregnancy outcome: Table 3.2.1 shows the pregnancy outcome type. During the period of May 2009 to July 2010, a total of 17,101 pregnancy outcomes were recorded in Habiganj MaMoni area. Around 90.2 percent of all pregnancy outcomes were live-births. The percentage of still-births among all pregnancies was 2.1 percent, abortions within 3 months were 5.5 percent and abortion between 4-7 months of pregnancy was around 2.3 percent.
Table 3.2.1: Percentage of recent pregnancy outcomes and male/female ratio among live-births during 01 May 2009 to 31 July 2010 by upazila, Habiganj Upazila Total Live birth Still-birth Abortion 4 to Abortion within 3 Outcome 7 months of months of Male Female Total pregnancy pregnancy Azmeriganj 991 52.1 47.9 90.7 0.7 1.6 7.0 Bahubol 1624 52.7 47.4 89.5 2.0 2.7 5.9 Baniachang 2525 51.8 48.2 92.3 2.3 1.8 3.6 Chunarughat 2550 50.7 49.3 87.6 2.3 3.4 6.7 Habiganj Sadar 2699 53.0 47.0 91.5 2.1 1.2 5.2 Lakhai 1177 51.0 49.0 95.8 1.4 0.7 2.2 Madhabpur 2716 51.8 48.3 91.7 2.0 1.7 4.6 Nabiganj 2819 53.1 46.9 85.6 2.8 3.8 7.8 Total: 17101 52.1 47.9 90.2 2.1 2.3 5.5
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The Male/Female ratio among all live-births was 52:48 in the intervention upazilas. The Male/Female ratio was almost similar across the upazilas of Habiganj district. The percentage of live-births among all pregnancy outcomes varied slightly by upazila, and it was lowest in Nabiganj (86 percent) and highest in Lakhai (96 percent). Around <1-3 percent of all outcomes was still-births and was highest in Nabiganj (3 percent) and lowest in Azmeriganj (less than 1 percent). The percentage of abortions within 3 months of pregnancy ranged from 2 -8% approximately. This was highest in Nabiganj (8 percent) and lowest in Lakhai (2 percent).
3.3 Parity
Table 3.3.1 shows the distribution of women by parity and around 2 percent of women (parity-0) had been pregnant but there was no living child (as a result of abortion or still-birth or neonatal death) in the intervention areas. Around 27 percent of women had one, 24 percent of women had two, 17 percent had three and 12 percent had four living child in Habiganj. The percentage of women having five or more living children was 18 percent. There was no significant difference in the distribution by parity and by upazila.
Table 3.3.1: Percent distribution of women with different birth orders by upazila, Habiganj
Upazila Birth order N= 0 1 2 3 4 5 or more
Total: 16,920 2.3 27.4 23.5 17.1 11.5 18.2
Azmeriganj 989 1.2 24.7 24.2 18.9 10.9 20.1 Bahubol 1,604 2.1 25.1 23.6 16.8 11.8 20.7 Baniachang 2,496 1.5 25.0 21.7 17.0 12.5 22.3 Chunarughat 2,522 3.7 28.9 24.8 16.5 11.0 15.2 Habiganj Sadar 2,675 1.7 31.0 24.2 16.4 10.8 15.9 Lakhai 1,159 0.9 23.0 21.4 18.4 14.7 21.7 Madhabpur 2,682 2.2 30.0 25.3 17.0 10.4 15.2 Nabiganj 2,793 3.5 26.4 22.3 17.8 11.5 18.5
3.4 Educational Attainment of RDW
Table 3.4.1 shows the distribution of women according to their education level by intervention upazila and maternal age. Results indicate that almost 34 percent women had no education, 21 percent had below primary level of education, 40 percent completed primary level, while only 5 percent women had secondary or above level of education in Habiganj.
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Table 3.4.1: Percent distribution of women by level of education & age who had a pregnancy outcome during 01 May 2009 to 31 July 2010 by upazila, Habiganj.
No Education Primary Class 5 - 9 Class 10 + Total number
Azmeriganj 41.4 27.9 26.9 3.8 989 Bahubol 31.9 25.2 39.2 3.8 1,604 Baniachang 39.8 22.9 33.9 3.4 2,496 Chunarughat 33.6 17.7 43.5 5.2 2,522 Habiganj Sadar 27.4 15.4 46.7 10.5 2,675 Lakhai 39.8 24.9 33.9 1.4 1,159 Madhabpur 33.7 20.4 40.3 5.7 2,682 Nabiganj 32.3 18.8 44.8 4.1 2,793
Maternal age and level of education
<20 20.7 23.1 54.5 1.8 2,107 20 – 24 23.2 21.3 50.6 4.9 6,061 25 – 29 35.6 20.7 36.9 6.9 4,532 30 – 34 49.1 18.8 25.5 6.6 2,631 35 – 39 61.8 17.3 16.7 4.2 1,165 40 + 69.8 13.7 14.9 1.7 424 Total: 34.0 20.5 40.3 5.2 16,920
Fig:3.2 Level of education (in percentage) of Recently Delivered Women in Habiganj-2010 (N=16,920)
45 40.3 40 34 35 30 25 20.5 20 15 10 5.2 5 0 No education Primary completed Class 5-9 Class 10+
Among the different upazilas 27 percent of women in Habiganj Sadar and 41 percent in Azmeriganj had no education (Table 3.4.1 & Fig: 3.3). Around 11 percent of women in Sadar upazila had secondary or above level of education, while it was less than 5 percent in other upazilas except Madhabpur (6 percent). Level of education varied by age of women, around 70 percent of women aged 40 years or more had no education while it was only 21 percent in the younger age group (15-24 year). Similarly more than half of all women had primary completed level of education (class 5-9) while it was around 15 percent among women 35 years or more.
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Fig:3.3 Percentage of RDW had no education by upazila
45 41.4 39.8 39.8 40 33.6 33.7 35 31.9 32.3 30 27.4 25 20 15 10 5 0 Azmeriganj Bahubol Baniachong Chunarughat Sadar Lakhai Madhabpur Nabiganj
Fig:3.4 Percentage of RDW had no education by age group
80 69.8 61.8 60 49.1
40 35.6 20.7 23.2 20
0 <20 20-24 25-29 30-34 35-39 40+
3.5 Household characteristics
Household characteristics reflect the general socioeconomic condition of the population and provide crucial information regarding the hygienic environment of the households. For each household, information was gathered on access to electricity, sources of water to clean household utensils, type of toilet facility, and the construction materials of the roof, wall, and floor. Table 3.5.2 shows the distribution of housing characteristics. Results indicate that around 50 percent of households in the eight upazilas of Habiganj had electricity. There was marked variability in the distribution of electricity among intervention upazilas. 71percent of household in Habiganj Sadar had electricity while it was lowest in bahubol (38 percent). 45-55 percent households in other six upazilas had electricity. Table 3.5.2 shows around 60 percent of households in the upazilas of Habiganj had access to a tap/tube- well water as source to clean household utensils. About 40 percent of women reported using surface water (pond, river, well etc) for the same purpose. Variability was observed in source of water for cleaning utensils across the upazilas. Surface water was the predominant source for cleaning household utensils in Bahubol (54%), Baniachang (55%) and Nabiganj (56%) upazilas, while tube well was the main source of water for cleaning utensils in Azmeriganj (75%), Chunarughat (63%), Sadar (64%), Lakhai (77%) and Madhabpur (64%). It was observed that around 30 percent of households used hygienic latrines, 46 percent used pit latrine, 21 percent used hanging or open latrines and 4 percent used bush or field. Bahubol and Lakhai upazilas were doing better (around 43%) using hygienic latrines while only 18-22 percent householdes were using hygienic latrines in Azmeriganj, baniachong and Chunarughat upazilas. More than 16 percent of
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010 households in Chunarughat were using bush or field for defaecation while the rate was less than 4 percent in other upazilas. Less than 1 percent of households were using bush or field in Azmeriganj, Sadar and Nabiganj upazilas. In rural Bangladesh, tin is the main roofing material, and walls are usually constructed with natural materials, such as bamboo and mud. In the eight upazilas of Habiganj it was observed that around 92 percent of houses had tin roofs and the rate was similar across the upazilas. 44 percent of houses had bamboo and mud walls, 21 percent of houses had brick/cement walls and 38% had tin walls. Around 86.5 percent of houses had earth floor and rest 13.5 percent had cement/concrete floor. Roofs made by bamboo/thatch were found most frequently in Chunarughat (16%). Cement/concrete roofs were more prevalent in Habiganj Sadar (9%) Around 31-35% of houses in Nabiganj and Chunarughat and 15-21% households in Banichang, Bahubol, Chunarughat, Madhabpur had brick/cement walls. Pucca floor with cement was found more frequently in Nabiganj (18%) and Habiganj Sadar (26%) while only 6-7% households in Azmeriganj, Baniachang and Lakhai upazilas had pucca floors.
Table 3.5.2: Percent distribution of households by housing characteristics by upazila, Habiganj. Characteristic
Sadar Azmeriganj 989 N= Bahubol N=1604 Baniachang N=2496 Chunarughat 2522 N= N=2675 Lakhai N=1159 Madhabpur N=2682 Nabiganj N=2793 TOTAL N=16920 Electricity: Yes 51.7 38.4 46.3 39.7 70.5 45.5 55.4 48.3 50.4 Source of water to clean household utensils: Tap 0.2 1.6 0.7 4.5 11.6 0.2 1.1 2.8 3.4 Tube well 74.5 44.5 44.6 62.7 63.9 77.4 63.8 41.1 56.8 Surface water 25.3 53.9 54.8 32.8 24.5 22.4 35.1 56.1 39.8 Other 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Sanitation facility: Septic tank, modern 0.9 6.9 1.7 7.8 5.5 0.5 4.0 8.7 5.1 Water sealed / Slab lat. 20.9 35.9 16.8 9.4 31.4 42.6 19.4 30.5 24.5 Pit Latrine / not sealed 38.2 40.8 49.1 51.0 55.3 18.7 44.2 46.0 45.6 Open / hanging latrine 39.5 14.4 28.8 15.5 7.1 36.9 29.2 14.2 20.9 No facility / bush, field 0.4 2.1 3.7 16.3 0.8 1.2 3.3 0.5 4.0 Other 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Roof material: Katcha bamboo/thatch 0.8 7.7 1.6 15.5 1.8 1.1 8.4 1.9 5.3 Tin 97.7 90.7 97.1 83.0 90.1 97.9 89.3 93.6 91.6 Cement / concrete / tile 1.4 1.6 1.3 1.6 8.1 1.0 2.2 4.5 3.1 Other 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Wall material: Jute / bamboo / mud 31.7 68.0 23.0 71.1 30.1 16.6 51.9 44.5 43.7 Wood 0.3 0.4 0.3 0.2 0.3 0.0 0.2 0.5 0.3 Brick / cement 7.5 20.8 14.7 21.5 34.8 6.4 15.9 30.6 21.3 Tin 60.6 10.9 62.1 7.3 34.8 77.1 32.1 24.4 34.7 Floor material: Earth / bamboo 94.9 86.9 93.4 89.5 72.9 96.0 87.8 82.2 86.5 Wood / others 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Cement / concrete 5.1 13.0 6.6 10.5 27.1 4.0 12.2 17.8 13.5
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3.6 Household Possessions
Direct measurements of household income from developing counties are difficult to obtain. In order to measure household socioeconomic status, data were collected on the possession of various durable goods at the household level. In recent years, these durable goods were used to develop a proxy measure for economic status from Demographic and Health Survey data. Table 3.6.2 shows the distribution of the possession of household durable goods in the intervention upazilas of Habiganj. Results in table 3.6.2 indicate that 93 percent of households had at least one cot or bed, the most common durable good in the intervention upazilas. Around one-fourth households had at least one almirah/wardrobe and about three-fourth had a table and/or a chair. Around 27 percent had at least one functioning television, and about 60 percent of the households had a telephone or a cell phone. The rate of possessing cell phone was found almost similar across the upazilas except sadar (around 70%)
Table 3.6.2: Percentage of households possessing various durable consumer goods by upazilas for households with a woman had a pregnancy outcome during 01 May 2009 to 31 July 2010 in Habiganj
Goods
Sadar Azmeriganj 989 N= Bahubol N=1604 Baniachang N=2496 Chunarughat 2522 N= N=2675 Lakhai N=1159 Madhabpur N=2682 Nabiganj N=2793 TOTAL N=16920 Almirah / wardrobe 23.3 17.3 22.7 45.4 24.6 10.8 14.0 28.3 24.6 Table / Bench / chair 59.2 78.2 71.5 78.6 81.2 59.9 67.2 73.1 72.8 Watch / clock 26.8 30.1 33.0 37.7 46.3 23.6 31.2 33.7 34.4 Cot / bed 88.4 94.6 92.7 90.7 97.3 90.7 94.9 93.0 93.3 Functioning Radio 3.0 4.4 3.4 4.2 3.9 3.1 4.1 4.5 3.9 Functioning Television 23.8 20.1 19.6 24.0 41.6 18.4 29.4 29.5 27.1 Quilt (kombol) 73.5 83.7 82.9 84.7 93.9 85.2 85.1 83.5 85.0 Refrigerator 3.1 4.7 3.7 4.8 17.4 2.3 5.3 9.1 7.1 Bicycle 3.7 10.0 11.0 17.2 12.3 7.5 9.5 5.7 10.3 Motorcycle 1.0 3.2 2.6 3.3 5.4 1.1 2.1 3.7 3.1 Sewing machine 3.1 3.7 4.9 3.5 8.7 4.1 5.0 3.5 4.8 Telephone/ Mobile 49.5 58.0 59.0 54.9 69.3 50.0 61.3 60.2 59.3 Car / Micro-bus / tempo 0.1 1.8 0.4 1.0 3.2 0.2 1.5 1.5 1.4 Rickshaw / Van 0.4 2.8 1.4 3.9 5.8 2.6 5.6 2.3 3.4 Boat 7.5 2.6 15.9 0.2 2.1 12.3 3.7 10.4 6.5
A wealth index was constructed from the household asset variables using principal component analysis, which generated a weight for each durable asset. The weights were the standardized first principal component of the variance-covariance matrix of the observed household assets. Using the weights, an asset index was created using the following formula:
Ai=γ1x1i+…+γkxki
where Ai is the asset index for household i, the xik's are the k-th asset, and the γ's are the weights. In addition to durable goods, other household conditions, such as drinking water sources, sanitation facility,
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010 and construction materials for wall, roof and floor were taken into consideration for generating an asset index as a measure of socioeconomic status. For each household, an asset score was generated based on the principal component score. Households were ranked according to the total score of the household in which they resided and divided into wealth quintiles ranked from lowest to highest. Households were equally distributed according to five categories of wealth quintiles and falls 20 percent of households in each category (lowest, second, middle, fourth and highest). Around 32 percent of households in Azmeriganj was in the lowest wealth quintile, on the other hand 34 percent of households in Sadar upazila were in the category of highest wealth quintile.
Table 3.6.3: Distribution of wealth index quintile by MaMoni upazilas of Habiganj, 2010
Upazila Lowest quintile Second quintile Middle quintile Fourth quintile Highest quintile N # % # % # % # % # % Azmeriganj 319 32.3 203 20.5 154 15.6 200 20.2 113 11.4 989 Bahubol 309 19.3 359 22.4 368 22.9 266 16.6 302 18.8 1,604 Baniachang 542 21.7 526 21.1 545 21.8 519 20.8 364 14.6 2,496 Chunarughat 539 21.4 465 18.4 543 21.5 518 20.5 457 18.1 2,522 Sadar 250 9.4 423 15.8 520 19.4 567 21.2 915 34.2 2,675 Lakhai 238 20.5 301 26.0 266 23.0 245 21.1 109 9.4 1,159 Madhabpur 560 20.9 619 23.1 527 19.7 536 20.0 440 16.4 2,682 Nabiganj 627 22.5 488 17.5 461 16.5 533 19.1 684 24.5 2,793 Total: 3384 20.0 3384 20.0 3384 20.0 3384 20.0 3384 20.0 16,920
3.7 Land ownership
Table 3.7.1 shows the percent distribution of homestead and other land ownership in habiganj. 93 percent of RDW households had their own homestead and 35 percent possessed lands other than homestead, while 7 percent had neither homestead for living nor other land (for cultivation). 16 percents households in Chunarughat and 12 percent in Azmeriganj neither had their own homestead nor any other lands.
Table 3.7.1: Percent distribution of households with own land, among households with a woman had a pregnancy outcome during 01 May 2009 to 31 July 2010 by upazilas of Habiganj
Upazila Owns homestead Owns other land Neither Total households # % # % # % N Azmeriganj 868 87.8 302 30.5 120 12.0 989 Bahubol 1494 93.1 610 38.0 103 6.4 1,604 Baniachang 2373 95.1 947 37.9 119 4.8 2,496 Chunarughat 2103 83.4 892 35.4 407 16.1 2,522 Sadar 2615 97.8 1148 42.9 58 2.2 2,675 Lakhai 1090 94.1 460 39.7 66 5.7 1,159 Madhabpur 2601 97.0 1150 42.9 78 2.9 2,682 Nabiganj 2566 91.9 837 30.0 221 7.9 2,793 Total: 15710 92.9 6346 37.5 1172 6.9 16,920
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3.8 Religion
The population of Habiganj was predominantly Muslim (85 percent), and the rests were Hindu (15 percent). Only 0.1 percent population belongs to other religion (Table 3.8.1). Relatively slightly larger proportion of the population was Hindu in Azmeriganj (25 percent) and Chunarughat (22 percent) upazilas.
Table 3.8.1: Distribution of religion of RDW households by upazila, Habiganj
Upazila Religion Total Number of households Islam Hinduism Others # % # % # % N Azmeriganj 741 74.9 248 25.1 0 0.0 989 Bahubol 1,421 88.6 174 10.9 9 0.6 1,604 Baniachang 2,124 85.1 372 14.9 0 0.0 2,496 Chunarughat 1,970 78.1 543 21.5 9 0.4 2,522 Habiganj Sadar 2,459 91.9 215 8.0 1 0.0 2,675 Lakhai 979 84.5 180 15.5 0 0.0 1,159 Madhabpur 2,326 86.7 356 13.3 0 0.0 2,682 Nabiganj 2,372 84.9 421 15.1 0 0.0 2,793 Total: 14,392 85.1 2,509 14.8 19 0.1 16,920
3.9 Relatives/Family Member Living Abroad
A large proportion of individuals from Habiganj reside abroad, either as permanent citizens of a foreign country or workers in a temporary labor force. These individuals residing abroad are often the major source of the income for families in the intervention areas. Table 3.9.1 shows the percent distribution of relatives and family members living abroad. Results suggest that around 30 percent of RDWs in the MaMoni area reported that at least one of their family members or relatives was residing abroad at the time of interview. Of them, 13 percent were living in the UK, 89 percent in the middle-east countries and 4 percent in other areas (outside Habiganj). Almost 46 percent of RDWs reported receiving money from expatriate relatives. The percentage was high in Bahubol (38 percent), Nabiganj (38 percent) and Sadar (36 percent) while it was low in Azmeriganj and Lakhai (around 14 percent). Table 3.9.1: Percent distribution of households with a woman having a pregnancy outcome during the period of May’09 to Jul’10, and had relatives abroad by upazila, Habiganj. Relatives Number & Percentage of households with a relative Send money abroad living abroad that household can use Yes % UK/London % Middle-East % Others % % Azmeriganj 130 13.1 9 6.9 121 93.1 1 0.8 56 43.1 Bahubol 612 38.2 52 8.5 580 94.8 6 1.0 244 39.9 Baniachang 681 27.3 59 8.7 607 89.1 54 7.9 319 46.8 Chunarughat 729 28.9 34 4.7 704 96.6 11 1.5 314 43.1 Habiganj Sadar 958 35.8 144 15.0 847 88.4 38 4.0 435 45.4 Lakhai 167 14.4 7 4.2 144 86.2 19 11.4 41 24.6 Madhabpur 774 28.9 40 5.2 721 93.2 29 3.8 271 35.0 Nabiganj 1,055 37.8 300 28.4 814 77.2 49 4.6 644 61.0 Total: 5,106 30.2 645 12.6 4,538 88.9 207 4.1 2,324 45.5 41 | Page
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Chapter-4 Knowledge of Mother on Maternal and Neonatal Health:
The baseline survey in Habiganj extensively examined the knowledge of women on birth planning, danger signs and complications during pregnancy, delivery and post-partum period. In addition, the survey collected information on knowledge of complications of the newborns during the first month of life. One of the major focuses of this maternal and neonatal intervention program is to improve women’s knowledge and awareness of essential newborn care and potentially life-threatening conditions. The findings of the baseline knowledge will serve as the benchmark for the evaluation of the intervention program.
4.1 Key components of birth plan
Table 4.1.2: Percentage of women cited the key components of birth plan by upazila, Habiganj.
Multiple answers were accepted
Knowledge of RDW about the
components of Birth plan 02 abiganj Sadar Azmeriganj N= 317 Bahubol N=323 Baniachang N=304 Chunarughat N= 3 N=327 Lakhai N=303 Madhabpur N=334 N N=331 TOTAL N=2541 Deciding where to deliver 2.5 21.7 12.8 22.5 33.6 8.3 27.5 42.0 21.7 Deciding who will assist birth 5.4 28.2 16.5 31.1 25.4 48.5 10.5 19.9 22.9 Ensure a person for newborn care 1.9 3.1 5.9 10.9 14.4 12.2 3.0 16.3 8.5 Purchase /procure a safe delivery kit 0.0 0.6 0.0 0.3 1.8 1.0 0.3 0.6 0.6 Ensure emergency transport 1.9 5.0 6.6 5.3 8.9 6.6 1.8 7.0 5.4 Savings for emergency 18.0 15.8 16.5 14.9 18.7 40.6 16.8 24.5 20.6 Approval to seek care 0.3 0.0 1.0 2.7 6.7 0.3 0.9 0.9 1.6 Check up during pregnancy 5.7 8.7 1.6 15.9 14.1 5.9 4.2 18.1 9.3 TT vaccination 1.0 6.2 3.6 6.0 4.0 1.7 6.0 6.3 4.4 To take Iron tablet 0.6 4.0 2.3 6.6 3.7 5.0 1.2 7.3 3.8 Know danger signs for mother 0.0 0.0 1.0 0.3 0.3 0.3 0.0 0.3 0.3 Know danger signs for newborn 0.0 0.0 0.0 0.0 0.6 0.3 0.3 0.0 0.2 Extra food 17.7 15.5 15.1 37.8 31.5 27.4 18.9 25.6 23.7 Take adequate rest 11.0 6.8 8.2 16.6 9.8 7.3 8.4 19.0 10.9 Not to do heavy work 17.4 17.0 13.8 26.2 22.3 40.6 8.4 27.2 21.5 Ensure a trained TBA 1.0 1.2 1.6 3.0 1.5 1.0 1.5 0.3 1.4 A well lighted and airy delivery place 0.3 0.3 0.3 0.0 0.3 0.0 0.9 0.0 0.3 Prepare two pieces of cloth 69.7 47.7 37.2 25.8 34.3 43.2 27.5 17.8 37.8 Identify Blood Donor 1.6 3.7 0.7 2.3 1.2 4.3 1.2 2.1 2.1 Prepare boiled blade 79.5 75.2 74.0 43.1 62.7 71.6 77.8 24.5 63.5 Prepare boiled thread 71.0 66.3 69.4 40.1 59.0 78.6 68.0 23.0 59.2 Others 2.8 2.8 18.1 4.6 7.0 1.7 8.4 1.8 5.9 Can’t remember/Don’t know 1.6 2.5 3.0 6.0 1.5 0.3 0.9 2.7 2.3
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Table 4.1.2 shows the same trend among study upazilas. Knowledge of boiling the blade and thread for cord cutting was more or less similar in all Upazillas (60-65 percent) except Nabiganj (24 percent). Around 38 percent of women had knowledge about the preparation of two pieces of cloths, the knowledge was high (around 70 Percent) in Azmeriganj and low in Nabiganj (18 percent). Around 23 percent women had knowledge to decide birth attendant, which was high (49 percent) in Lakhai and low (5 percent) in Azmeriganj. Around 21 percent women knew about savings of money for emergency situation, selecting place for delivery and not to do any heavy work during pregnancy. Around 10 percent knew about the need of taking rest during pregnancy and medical check-up. About 16 percent women of Chunarughat had knowledge about check-up during pregnancy while it was only 2 percent in Baniachong. Around 1 percent of women had knowledge of the importance of trained TBAs for delivery and 4 percent told for TT (tetanus toxoid) vaccination during pregnancy which was low across all upazilas.
4.4 Knowledge of Complications during Pregnancy:
Pregnancy is a physiological condition that is associated with multiple risks for mothers and their babies. The five leading causes of maternal morbidity and mortality in Bangladesh are haemorrhage, eclampsia, unsafe abortion, sepsis, and obstructed labor.1 These are also the major causes of fetal and neonatal deaths, which require immediate professional medical and emergency obstetrical care services. Knowledge about these complications and availability of health care services in proximity is likely to help women in seeking appropriate medical care when needed. Women were asked to name conditions for which a woman should seek medical care. Table 4.4.1 shows that around 61% of recently delivered women (RDW) in the intervention upazilas named at least three conditions, including severe weakness (50 percent), excessive vomiting (46 percent), severe headache (43 percent) and severe abdominal pain (34 percent). There were no such differences in knowledge of danger signs of pregnancy by upazila. High blood pressure is the major criteria of pre-eclampsia, but it was mentioned only by 4 percent of women in the intervention areas. About 5 percent of women reported edema of face, hands and/or feet as major conditions that require medical attention. Accounting for an estimated 12 percent of the global maternal mortality each year, eclampsia is characterized by convulsions or coma and is considered to be the fourth most common cause of maternal mortality. Survey results indicate that 15 percent of women could mention convulsions as being a major complication during the pregnancy period. Hemorrhage, primarily during post-partum period, is the leading cause of maternal mortality and is attributed to an estimated 24 percent of all maternal deaths. Ante-partum hemorrhage is one of the most important risk factors for fetal deaths, only 8 percent of women mentioned excessive bleeding as a major complication of pregnancy. A low percentage of women (7 percent) mentioned the “reduced/absent fetal movement,” a fetal distress condition, as a life-threatening condition that requires immediate medical attention.
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Table 4.4.1: Percent of recent mothers reported knowing danger signs of pregnancy by upazila, Habiganj
Multiple answers were accepted
Danger signs
Sadar Azmeriganj N=317 Bahubol N=323 Baniachang N=304 Chunarughat N= 302 N=327 Lakhai N=303 Madhabpur N=334 Nabiganj N=331 TOTAL N=2541 Severe Headache 53.0 42.1 29.6 37.8 44.0 48.8 40.7 48.9 43.2 Blurred Vision 19.9 28.5 15.8 14.6 20.8 32.7 13.8 19.0 20.6 Fetal movement reduced/absent 4.7 3.4 9.2 8.6 9.5 5.9 3.0 9.4 6.7 High Blood Pressure 1.9 3.4 4.0 7.3 7.0 2.3 3.6 4.8 4.3 Edema of the face/swelling 3.5 6.5 5.6 10.9 5.2 1.7 1.8 8.2 5.4 Edema of the hands/ swelling 11.0 15.8 7.6 24.2 14.4 9.6 6.0 16.3 13.1 Convulsions/fits 9.5 14.2 13.5 14.9 18.0 5.3 24.0 16.9 14.7 Excessive Vaginal Bleeding 3.5 4.0 7.6 6.3 15.0 8.6 6.9 7.9 7.5 Severe abdominal pain 27.1 27.2 36.5 39.1 35.2 45.2 28.1 36.0 34.2 Edema of the legs 21.8 10.8 16.5 19.2 9.8 27.4 11.1 13.3 16.1 Fever 41.6 22.3 13.8 11.9 24.5 11.9 30.2 24.8 22.9 Premature rupture of membrane 0.6 2.2 0.3 3.3 1.2 0.7 0.9 0.9 1.3 Loss of consciousness 0.6 1.2 1.0 0.7 1.8 0.3 1.5 0.6 1.0 Difficulty breathing 1.6 2.8 1.0 1.7 0.9 0.0 1.2 1.2 1.3 Severe weakness 51.4 57.3 36.5 48.0 41.9 63.0 55.1 46.8 50.0 Excessive vomiting 51.7 52.6 33.9 45.4 33.6 68.3 40.4 44.4 46.2 Excessive whitish vaginal discharge 0.3 0.9 1.0 1.0 1.5 1.7 0.6 0.6 0.9 Others 0.3 0.6 1.0 0.7 0.9 0.0 0.0 0.0 0.4 Don’t know 0.3 1.9 2.0 6.0 0.6 0.0 0.3 0.3 1.4 Number of complication cited Did not mention any complication 0.3 1.9 2.0 6.0 0.6 0.0 0.3 0.3 1.4 Mentioned <3 Complication 27.8 39.3 60.9 34.8 42.8 20.1 42.2 33.8 37.7 Mentioned ≥3 Complications 71.9 58.8 37.2 59.3 56.6 79.9 57.5 65.9 60.9
4.5 Knowledge of Complications during Delivery:
Table 4.5.1 shows the percent distribution of the reporting of complications during the delivery (intrapartum) period. Around 2% of respondents were not able to mention the name of any adverse condition during the delivery that required immediate medical attention. Almost 98% of women that were able to name at least one adverse condition, 63% mentioned 1-2 complications while around 36% mentioned more than two. The most frequently cited conditions were prolonged labor (56%), breech presentation (30%), excessive bleeding (23%) and convulsions (24%); High fever, headache and retained placenta were additionally mentioned by 15-19% of women.
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Table 4.5.1: Percent of recent mothers reported knowing danger signs during child birth by upazila, Habiganj
Multiple answers were accepted
Danger signs
Azmeriganj N= 317 Bahubol N=323 Baniachang N=304 Chunarughat N= 302 Sadar N=327 Lakhai N=303 Madhabpur N=334 Nabiganj N=331 TOTAL N=2541 Excessive Vaginal Bleeding 23.0 10.8 19.1 26.2 33.6 26.1 19.5 21.8 22.5 Foul-Smelling Discharge 1.9 1.6 3.0 1.3 9.2 0.3 2.1 2.7 2.8 High Fever 29.7 10.5 14.1 7.0 8.6 7.3 19.2 19.6 14.6 Baby’s Hand or Feet Coming out first 26.2 42.1 26.3 14.6 26.9 58.8 18.6 24.2 29.6 Baby is in abnormal position 12.6 34.7 23.0 25.2 29.1 49.8 14.4 25.7 26.6 Prolong Labor (>12 hours) 52.1 50.5 50.7 68.5 59.0 49.5 54.8 60.4 55.7 Retained Placenta 6.9 15.8 10.9 20.2 12.5 38.0 10.5 11.5 15.6 Rupture uterus/Cervical/Vaginal tear 0.6 2.5 2.3 2.7 1.8 0.0 0.6 2.4 1.6 Cord Prolapse 0.0 0.6 0.7 1.7 0.6 0.0 0.0 1.5 0.6 Cord around neck 0.0 0.6 1.6 1.3 0.6 0.3 0.6 0.6 0.7 Convulsion 19.6 25.1 21.4 22.5 26.3 17.2 36.8 20.9 23.9 Severe headache 36.9 18.0 12.8 11.3 15.3 17.2 21.3 15.7 18.6 Greenish vaginal discharge 0.6 0.3 0.0 0.7 0.3 0.3 0.3 0.3 0.4 Loss of consciousness 5.1 1.9 1.3 2.7 3.1 1.0 2.7 1.8 2.4 Neonatal injuries 0.0 0.0 0.0 0.3 0.3 0.3 0.0 1.2 0.3 Blurring of vision 23.3 16.1 3.3 4.3 2.5 4.0 8.4 4.2 8.3 Others 0.3 4.0 1.0 2.0 1.8 2.0 0.6 2.4 1.8 Don’t know 1.3 1.6 1.6 4.0 1.2 0.3 1.2 0.6 1.5 Number of complication cited Did not mention any complication 1.3 1.6 1.6 4.0 1.2 0.3 1.2 0.6 1.5 Mentioned <3 Complication 55.8 64.1 79.3 64.9 63.3 40.6 66.5 69.5 63.1 Mentioned ≥3 Complications 42.9 34.4 19.1 31.1 35.5 59.1 32.3 29.9 35.5
4.6 Knowledge of Complications during Postpartum Period:
Table 4.6.1 shows, around 98% of women were able to name at least one complication during the postpartum period. Results indicate that while hemorrhage is the leading cause of maternal mortality, only 38% of respondents cited excessive bleeding as a postpartum complication. In contrast, 56% of women reported severe weakness and 36% abdominal pain as one of the major life threatening conditions in the intervention upazilas. Fever was cited by 28% of women and 18% mentioned convulsion as additional complication while 9% of women mentioned tetanus and 13% mentioned retained placenta. The table also shows little variation in the knowledge of complications during the postpartum period by upazilas. Around 97% of women in all the upazilas mentioned at least one complication and around 44% of women could mention more than two complications (danger sign) in the eight upazilas of Habiganj.
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Table 4.6.1: Percent of recent mothers reported knowing danger signs of post partum by upazila, Habiganj
Multiple answers were accepted
Danger signs
Azmeriganj N= 317 Bahubol N=323 Baniachang N=304 Chunarughat N= 302 Sadar N=327 Lakhai N=303 Madhabpur N=334 Nabiganj N=331 TOTAL N=2541 Excessive Vaginal Bleeding 27.4 23.8 31.3 40.1 49.9 63.7 31.4 37.5 38.0 Foul-Smelling Discharge 1.9 3.1 2.6 1.0 8.0 2.0 2.4 6.7 3.5 Fever 49.5 20.7 24.3 15.2 25.7 16.2 36.8 36.3 28.3 Inverted nipples 0.3 0.9 1.3 1.0 1.2 0.7 0.0 0.0 0.7 Tetanus 2.5 15.8 11.8 5.6 14.7 10.9 3.0 9.4 9.2 Retained Placenta 2.5 12.1 12.5 17.2 10.4 37.3 5.4 9.7 13.1 Severe lower abdominal pain 31.2 38.1 33.6 45.0 37.6 35.0 35.9 35.7 36.5 Convulsions/fits 15.5 14.6 21.7 20.2 20.5 12.5 24.6 15.7 18.2 Engorged breast/ swelling of breast 3.8 1.2 2.0 1.7 1.2 1.0 1.2 1.2 1.7 Fainting 2.5 1.9 2.3 2.0 3.1 2.3 6.3 3.6 3.0 Difficulty breathing 3.5 1.6 2.0 2.0 2.1 0.0 0.9 2.1 1.8 Severe weakness 69.1 68.4 34.2 55.0 43.4 72.6 62.3 45.0 56.2 Severe headache 32.8 22.9 11.5 12.9 14.4 20.1 22.2 19.0 19.6 Blurred Vision 22.4 17.3 3.6 6.6 5.8 6.6 10.8 5.7 9.9 Swollen hands/face 3.8 3.1 4.6 6.6 4.0 3.0 2.4 5.1 4.1 Others 0.3 0.9 0.0 0.7 0.9 0.3 0.3 0.3 0.5 Don’t know 1.0 1.6 2.0 4.3 0.6 0.3 1.2 2.4 1.7 Number of complication cited : Did not mention any complication 1.0 1.6 2.0 4.3 0.6 0.3 1.2 2.4 1.7 Mentioned <3 Complication 37.9 58.8 74.7 54.3 59.9 35.6 51.8 60.7 54.3 Mentioned ≥3 Complications 61.2 39.6 23.4 41.4 39.5 64.0 47.0 36.9 44.1
4.7 Knowledge of Neonatal Health Problems
While two thirds of neonatal deaths occur during the first seven days of life, the first few hours of life are often viewed as the critical period for newborn survival.2 Awareness and the recognition of life threatening conditions, and seeking immediate medical care for the newborns are the key factors necessary to prevent neonatal deaths. Table 4.7.1 shows the percent distribution of women’s reporting of medical conditions requiring immediate medical care of the newborns during the first month of life. Overall, almost 100% of women mentioned at least one adverse neonatal condition and almost three-fourths could mention 3 or more complications. The most frequently mentioned complications included fever (67%), cough & cold (89%), pneumonia (63%), difficulty in breathing (24%) and yellow skin in palm/feet/eye (15%). A small percentage of women (5%) reported convulsions and poor sucking/feeding (9%).
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Table 4.7.1: Percent of recent mothers reported knowing danger signs of newborn baby within 7 days of birth by upazila,Habiganj.
Multiple answers were accepted
Danger signs of new born
Azmeriganj N=317 Bahubol N=323 Baniachang N=304 Chunarughat N= 302 Sadar N=327 Lakhai N=303 Madhabpur N=334 Nabiganj N=331 TOTAL N=2541 Difficult and fast breathing 26.8 22.9 24.0 14.9 29.7 15.5 27.8 27.2 23.8 Pneumonia 78.2 32.5 69.1 45.0 52.0 93.4 56.3 78.0 62.9 Cough/Cold 94.6 90.1 72.4 94.4 83.8 97.4 90.4 84.9 88.5 Yellow skin/palm/feet/eye 9.2 10.2 12.2 10.6 19.9 37.0 7.2 16.9 15.3 Poor sucking or feeding 2.8 13.9 12.5 14.6 7.3 7.6 4.8 5.4 8.5 Pus, bleeding/ discharge from around cord 3.8 3.1 4.0 4.6 2.8 7.9 1.8 2.4 3.7 Skin lesions or blisters 5.1 4.3 1.6 5.6 2.1 6.3 4.8 0.9 3.8 Convulsion/ spasms/rigidity 4.1 9.6 5.9 5.0 6.1 1.7 4.8 5.1 5.3 Lethargy/ unconsciousness 0.0 0.6 0.7 1.3 0.3 0.0 0.3 0.3 0.4 Red or swollen eyes with pus 0.3 0.9 0.7 1.0 0.9 0.0 1.5 0.0 0.7 Baby feels cold 0.6 15.8 0.3 0.7 5.2 0.3 0.6 2.7 3.4 Baby doesn’t cry 1.9 3.1 1.0 2.0 2.5 1.0 2.7 1.5 2.0 Fever 77.0 78.0 59.5 77.5 65.4 54.5 66.8 58.6 67.2 Doesn’t pass urine 2.2 2.8 3.3 6.0 4.0 3.6 3.3 4.5 3.7 Doesn’t pass stool 5.4 3.1 4.0 8.0 5.5 7.9 5.7 6.7 5.8 Continuous vomiting 2.8 6.8 3.6 6.0 3.7 3.0 2.7 2.7 3.9 Distention abdomen 5.1 6.5 5.3 16.9 9.2 5.6 4.2 6.3 7.3 Difficult to make woke from sleep 0.0 0.6 0.3 0.0 0.0 0.3 0.0 0.0 0.2 Skin rash/Mashipishi 1.9 8.4 4.6 6.6 8.3 5.6 14.1 3.6 6.7 Measles 1.3 13.9 3.0 13.6 9.5 12.5 5.7 3.6 7.8 Others 0.6 0.6 0.3 2.7 0.3 2.0 0.0 0.6 0.9 Don’t know 0.0 0.0 0.0 0.3 0.0 0.0 0.0 0.3 0.1 Number of complication cited Did not mention any complication 0.0 0.0 0.0 0.3 0.0 0.0 0.0 0.3 0.1 Mentioned <3 Complication 20.5 36.2 39.1 24.8 28.4 9.9 25.5 26.9 26.5 Mentioned ≥3 Complications 79.5 63.8 60.9 74.8 71.6 90.1 74.6 72.8 73.4
CHAPTER 4 REFERENCES
1. Ahmed, S., Maternal Morbidity in Rural Bangladesh: Where do women go for care? ICDDR,B Working Paper No 113, 1997: p. 1-38. 2. SCA, State of the World's Newborns. Saving Newborn Lives. 2001, Washington, DC: Save the Children Federation-US. 1-49.
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Chapter 5 Maternal Health:
Globally, the leading cause of maternal mortality is hemorrhage1, which results in 24% of the estimated 515,000 annual maternal deaths.1 Risk factors for postpartum hemorrhage include anemia, uterine atony, inadequate contractions of the uterus, and retained placenta.1 Sepsis is the second leading cause of maternal mortality and accounts for an estimated 15% of maternal mortality worldwide each year.1 While information on the incidence and outcome of sepsis is limited due to the high proportion of deliveries occurring outside of the formal health sector, the principal causes of sepsis include the transfer of an infectious agent from the cervix or vagina to the uterus during labour or through exposure to contaminated instruments or fingers.1 Additional direct causes of maternal mortality include unsafe abortion (13%), eclampsia (12%), and obstructed labor (8%).1 Collectively these causes of maternal mortality can severely impact neonatal health outcomes and yet are largely preventable. Poor pregnancy care and inadequate maternal health care during delivery and postpartum period are the major proximate determinants of late fetal (stillbirth) and neonatal deaths. Therefore, it is expected that antenatal care (ANC), safe delivery practices and postpartum care of mothers – the three pillars of safe motherhood program strategies – can significantly improve neonatal and maternal health and survival. Essential components of ANC, including prevention and treatment of maternal complications, administration of tetanus toxoid, and counseling on adequate nutrition, can improve newborn health outcomes in two ways: (1) by allowing timely recognition of maternal health conditions that require treatment; and (2) by influencing the mother to adopt health behaviors during pregnancy and childbirth that will improve birth outcomes. In addition, safe delivery practices and postpartum care are essential for preventing major causes of neonatal and maternal mortality, particularly due to infections including tetanus and sepsis. This chapter presents data that were collected from recently delivered women (RDW) who had abortion, stillbirth or live birth within the 12 months preceding the survey. Women were asked if they had utilized ANC during the last pregnancy and if they did, what advice they received and what procedures were performed. Data on all aspects of birth preparedness, delivery care and postpartum care are also presented. Finally, differentials in maternal health care by certain demographic and socioeconomic variables were examined to facilitate the identification of marginalized women who are at the greatest risk of health care underutilization.
5.1 Antenatal Care
WHO Technical Working Group recommends a minimum of four antenatal check-ups for a normal pregnancy without complications. Table 5.1.1 and Fig: 5.1 show percent distribution of ANC during pregnancy by RDW. Results indicate that only 10% of women received at least four ANC check-ups during their last pregnancy, while 60% women did not receive any ANC in the intervention upazilas of Habiganj. This latter estimate of the percent of pregnancies that did not receive antenatal care is more than that estimated from the 2007 Demographic and Health Survey (BDHS) in Sylhet division (45.6%) and less than ACCESS baseline-2007 in Sylhet (67%).
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Table 5.1.1 also shows the higher percentage of women receiving any ANC during their last pregnancy was 50-60 percent in Sadar and Nabiganj upazilas while the rate was lower (around 30 percent) in the Baniachong and Azmeriganj upazilas. Similarly higher percentage of women (15-20 percent) reported received at least 4 ANCs during their last pregnancy in Sdar and Nabiganj upazilas while it was lower (5- 7 percent) in Lakhai and Baniachong upazilas. Around 10 percent of women reported received 4 ANCs with at least one from a skilled provider. Coverage was high in Sadar (19 percent), Nabiganj (15 percent) and 14 percent in Chunarughat while it was low (around 5 percent) in Lakhai and Baniachong and around 6 percent in Azmeriganj, Bahubol and Madhabpur (Table 5.1.1 and Figure-5.1).
Table 5.1.1: Percentage of women received 4 ANCs from a skilled provider during their last pregnancy by upazila, Habiganj.
Upazila N= Received any Received 4 Received 4 ANCs with at least 1 ANC ANC ANCs received from a skilled provider % % % Azmeriganj 290 30.7 6.9 5.9 Bahubol 311 38.3 7.1 6.8 Baniachang 291 29.2 6.2 4.8 Chunarughat 283 42.4 13.8 13.8 Sadar 311 58.2 19.9 19.3 Lakhai 295 32.5 5.4 5.1 Madhabpur 319 35.1 6.9 6.9 Nabiganj 304 51.0 15.1 14.5 Total: 2,404 39.8 10.2 9.7
Notes: Skilled provider: MBBS, Nurse/Midwife, Paramedic, FWV, SACMO/MA
Fig: 5.1 Status of ANC received during last pregnancy
70 58.2 60 51 50 42.4 38.3 40 35.1 32.5 30.7 29.2 30 19.9 13.8 19.3 15.1 20 13.8 14.5 6.9 7.1 6.2 5.4 6.9 10 5.9 6.8 4.8 5.1 6.9
0 Azmeriganj Bahubol Baniachong Chunarughat Sadar Lakhai Madhabpur Nabiganj
Received any ANC Received 4 ANCs Received 4 ANCs including 1 atleast from a skill
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Table 5.1.2: Percentage of women who received ANC by number of ANC visits during their last pregnancy, by upazilla and by background characteristics, Habiganj
Characteristics N Did not Received Received Received Received 4 or receive 1 ANC 2 ANC 3 ANC more ANC visits ANC visit visits visits Upazila Azmeriganj 290 69.3 8.3 9.3 6.2 6.9 Bahubol 311 61.7 13.8 11.3 6.1 7.1 Baniachang 291 70.8 8.6 9.3 5.2 6.2 Chunarughat 283 57.6 11.3 9.9 7.4 13.8 Sadar 311 41.8 13.5 12.5 12.2 19.9 Lakhai 295 67.5 15.3 9.5 2.4 5.4 Madhabpur 319 64.9 11.3 11.9 5.0 6.9 Nabiganj 304 69.0 14.1 14.1 7.6 15.1 Total: 2,404 60.2 12.1 11.0 6.5 10.2 Maternal education No education 834 73.1 10.7 7.3 3.7 5.2 Primary 509 71.7 8.8 9.0 6.1 4.3 Class 5-9 946 48.0 15.6 15.3 8.5 12.6 Class 10+ 115 15.7 7.0 11.3 13.0 53.0 Maternal age <20 254 57.5 12.2 13.8 9.5 7.1 20-24 882 58.3 13.8 10.1 7.1 10.7 25-29 678 59.0 12.7 13.0 5.2 10.2 30-34 374 62.6 9.6 9.4 5.6 12.8 35-39 170 71.8 6.5 7.1 6.5 8.2 40 + 46 67.4 8.7 13.0 6.5 4.4 Birth order 0 25 52.0 16.0 16.0 12.0 4.0 1 668 47.0 12.7 14.5 10.3 15.4 2 541 57.9 13.9 10.9 5.7 11.7 3 436 60.1 13.8 10.8 4.4 11.0 4 294 70.1 9.5 9.9 4.1 6.5 5+ 440 77.1 8.6 6.6 5.2 2.5 Wealth Quintile Lowest 481 78.4 7.5 6.4 3.3 4.4 Second 481 71.3 11.2 8.5 5.2 3.7 Middle 481 68.4 12.5 7.9 5.4 5.8 Fourth 481 51.6 17.3 15.8 6.4 8.9 Highest 480 31.3 11.9 16.5 12.3 28.1
Table 5.1.2 shows the distribution of ANC received by socio-demographic charecteristics. Women aged 20-29 years, had secondary or more level of education, low parity and with better socio-economic status were more likely to receive higher numbers of antenatal care check-ups. Around 53 percent women had secondary or more level of education reported received four or more ANCs during their last pregnancy while it was only 5 percent among women had no education or women did not complete primary level of education. Around 5 percent women reported received 4 or more ANCs 50 | Page
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whos ages were 40 years or above or with higher parity (4 or more). Women in the highest quintiles tend to receive higher number of ANCs (28 percent) compare to 4 percent in the lower wealth quintiles.
Table 5.1.3 shows the type of providers who rendered ANC services. Multiple answers were accepted from those women who received 4 ANCs during their last pregnancy. In Habiganj study area, 76% women received ANC from an MBBS doctor, 17% from nurse/midwives, 3% from a paramedic, 13% from FWV and 1% from FWA. Traditional birth attendants (TBAs), trained or untrained, were not found to provide ANC check-ups. Village doctors were found to provide ANCs in 3% of cases. Among women who received 4 or more ANCs, more than 80% of women in Bahubol, Sadar, Madhabpur and Nabiganj received it from MBBS doctor. In Bahubol around 23% of women received ANC from FWV, which was lowest in Chunarughat (8%). Village doctors were more likely to provide ANC in Azmeriganj (10%) but were completely absent in Chunarughat, Sadar, Lakhai, and Madhabpur.
Table 5.1.3: Percent distribution of women who received at least 4 ANC visits during their last pregnancy by type of providers and by upazilla, Habiganj
Multiple answers were accepted. Percentage calculated for each type of provider from whom at least one ANC was received by a pregnant woman
Women received at least 4
ANCs by type of provider Azmeriganj N= 20 Bahubol N=22 Baniachang N=18 Chunarughat N= 39 Sadar N=62 Lakhai N=16 Madhabpur N=22 Nabiganj N=46 TOTAL N=245 MBBS doctor 75.0 81.8 72.2 51.3 85.5 68.8 86.4 82.6 76.3 Nurse/midwife 5.0 9.1 16.7 51.3 8.1 31.3 9.1 8.7 17.1 Paramedic 5.0 0.0 0.0 0.0 3.2 0.0 0.0 6.5 2.5 FWV 10.0 22.7 16.7 7.7 11.3 12.5 9.1 15.2 12.7 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.2 0.4 MaMoni health worker 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 HA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 FWA 10.0 0.0 0.0 0.0 1.6 0.0 0.0 0.0 1.2 TTBA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 TBA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Homeopath 0.0 0.0 5.6 0.0 1.6 6.3 0.0 0.0 1.2 Herbalist (Ayurved) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.2 0.4 Traditional healer/Quack 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.2 0.4 Village doctor 10.0 4.6 5.6 0.0 0.0 0.0 0.0 4.4 2.5 Community Clinic 0.0 0.0 5.6 0.0 0.0 0.0 0.0 0.0 0.4 Spiritual Person/ Kabiraj 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other health worker 5.0 9.1 5.6 5.1 3.2 0.0 0.0 4.4 4.1 Other 0.0 0.0 5.6 0.0 1.6 6.3 0.0 2.2 1.6 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Table 5.1.3a shows the distribution of women received any ANC visit during their last pregnancy by type of provider. The percentages show that majority of the providers were MBBS doctors, followed by nurse/midwives and FWV irrespective of the number of ANC visit.
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Table 5.1.3a: Percent distribution of women received any ANC visit during their last pregnancy by type of provider in Habiganj.
Women received ANC by visit and by type of provider ANC-1 ANC-2 ANC-3 ANC-4 N=957 N=667 N=402 N=245 MBBS doctor 65.8 65.1 65.9 67.4 Nurse/midwife 11.6 12.7 12.4 13.1 Paramedic 2.1 2.6 2.7 1.6 FWV 10.3 9.3 9.5 9.4 Medical assistant/SACMO 0.1 0.2 0.0 0.0 MaMoni health worker/ CHW 0.1 0.2 0.3 0.0 HA 0.3 0.3 0.5 0.0 FWA 2.1 1.8 1.7 1.2 TTBA 0.0 0.0 0.0 0.0 TBA 0.1 0.2 0.3 0.0 Homeopath 0.1 0.5 0.3 0.4 Herbalist (Ayurved) 0.0 0.0 0.3 0.0 Traditional healer/Quack 0.6 0.5 0.5 0.4 Village doctor 2.6 2.6 1.7 1.6 Community Clinic 0.2 0.5 0.5 0.4 Spiritual Person/ Kabiraj 0.0 0.0 0.0 0.0 Other health worker 2.5 2.4 2.2 2.9 Other 1.3 1.5 1.2 1.6 Don’t know 0.1 0.0 0.0 0.0
Table 5.1.4 shows that among the women who received ANC, 66 percent of them received first ANC from a MBBS doctor during their last pregnancy and the rate was almost similar across the upazilas. Around 12 percent of women received first ANC from a nurse or midwife and the rate was high in Chunarughat and Lakhai (28-30 percent). About 10 percent of women received their first ANC from FWV and the rate was similar in all upazilas except it was 5 percent in Madhabpur. Almost 90 percent of women had secondary or more level of education received their first ANC from MBBS doctor while it was just half (48 percent) among women had no education. Chance of having first ANC was almost double among women in the highest wealth quintile group (84 percent) than the lowest (44 percent). Utilization of non-skilled ANC providers were more among women who had no education (16 percent) compare to women had secondary or more level of education (2 percent). Younger women tend to receive their first ANC from non-skilled provider (13 percent) compare to older mother (0-5 percent). There was no significant change in selecting non-skilled ANC provider by parity of women but women in the lowest quintile group tends to receive their first ANC from non-skilled provider four times higher (20 percent) than women in the highest quintile group (5 percent).
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Table 5.1.4: Percent distribution of women reported received their first ANC during their last pregnancy by provider and by background characteristics, Habiganj
N= MBBS Nurse / Paramedic FWV SACMO Others (non- doctor Midwife / MA skilled)
Upazila Azmeriganj 89 62.9 2.3 2.3 16.9 0.0 15.7 Bahubol 119 71.4 8.4 2.5 11.8 0.0 5.9 Baniachang 85 60.0 11.8 0.0 12.9 0.0 15.3 Chunarughat 120 58.3 30.0 0.8 7.5 0.0 3.3 Habiganj Sadar 181 70.7 8.3 4.4 9.4 0.0 7.2 Lakhai 96 57.3 28.1 0.0 7.3 0.0 7.3 Madhabpur 112 78.6 3.6 0.9 4.5 0.0 12.5 Nabiganj 155 62.6 4.5 3.2 13.6 0.7 15.5 Total 957 65.8 11.6 2.1 10.3 0.1 10.0 Maternal education: No education 224 48.2 15.2 3.6 17.4 0.0 15.6 Primary 144 59.7 14.6 0.7 14.6 0.0 10.4 Class 5-9 492 70.9 10.6 2.2 7.1 0.2 8.9 Class 10+ 97 89.7 4.1 0.0 4.1 0.0 2.1 Maternal age: <20 108 57.4 17.6 2.8 9.3 0.0 13.0 20-24 368 65.8 11.7 2.2 9.2 0.3 10.9 25-29 278 68.0 10.4 1.4 10.8 0.0 9.4 30-34 140 68.6 8.6 0.7 12.9 0.0 9.3 35-39 48 62.5 12.5 8.3 10.4 0.0 6.3 40 + 15 73.3 13.3 0.0 13.3 0.0 0.0 Birth order: 0 12 33.3 41.7 0.0 8.3 0.0 16.7 1 354 67.8 11.6 2.5 7.9 0.3 9.9 2 228 74.1 7.0 1.8 9.7 0.0 7.5 3 174 62.6 12.1 0.6 11.5 0.0 13.2 4 88 62.5 18.2 3.4 6.8 0.0 9.1 5+ 101 52.5 11.9 3.0 21.8 0.0 10.9 Wealth Quintile: Lowest 104 44.2 18.3 3.9 14.4 0.0 19.2 Second 138 54.4 15.2 3.6 12.3 0.0 14.5 Middle 152 54.6 16.5 0.7 17.1 0.0 11.2 Fourth 233 63.5 14.6 0.9 11.2 0.0 9.9 Highest 330 84.2 3.6 2.4 4.6 0.1 4.9
In summation, the results show that women in higher socio-economic status were more likely to receive their first ANC from a skilled provider and less likely to receive ANC from a non-skilled provider. Women having education of primary completed or more tend to receive their first ANC from a skilled provider and less likely to receive from a non-skilled provider.
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Fig 5.2: Percent distribution of women received first ANC during their last pregnancy by type of provider and by wealth quintile.
90 80 70 60 50 40 30 20 10 0 Lowest Second Middle Fourth H MBBS doctor 44.2 54.4 54.6 63.5 8 Non-skilled 19.2 14.5 11.2 9.9 FWV 14.4 12.3 17.1 11.2
5.2 Components of Antenatal Care Checkup
Tetanus Toxoid (TT) immunization coverage:
Globally, 355,000 neonates suffer from tetanus each year, of which about 250,000 die. Immunizing mothers with tetanus toxoid (TT) is a low cost antenatal intervention and is very cost effective. TT immunization coverage in Bangladesh has been high (around 80% with at least two doses of TT), as revealed from the national immunization coverage evaluation surveys for the last 12 years; it is thus difficult to determine the level of protection among women who received two doses or more in a life time or did not receive any during their last pregnancy. If women completed five valid doses of TT immunization and did not receive further doses during the last pregnancy, the women would be considered protected (for themselves and for the newborns). This baseline survey explored lifetime TT vaccination status with validity of the doses, Table 5.2.1 shows the distribution of women by TT immunization status. Results show that TT coverage, as was recorded only from the vaccination card, was low; whereas the coverage was higher when the women’s verbal report (from history) was considered. According to card and women’s verbal report an estimated 94 percent of women received at least one dose of TT during their lifetime and 58 percent of women received at least 5 doses of TT. Coverage of TT immunization by dose and by upazila was almost similar. Table 5.2.1a shows the coverage of TT immunization by valid doses (maintained minimum time interval between doses). Around 92 percent of women received two valid doses of TT, 83 percent three valid doses, 64 percent four valid doses and 46 percent received five valid doses during their lifetime. So, there was a decrease of 12 percent points in the coverage of 5 doses of TT vaccination when analysed as valid doses. Women in Nabiganj upazila received highest 58 percent of five valid doses of TT, 55 percent in Sadar, 52 percent in Chunarughat while it was lowest in Madhabpur (35 percent) and Baniachong (40 percent)
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Table 5.2.1: Percent distribution of TT doses received (from card and history) by upazila, Habiganj
Upazila N Not Received at least Received at least Received at least Received at least Received at least received 1 TT 2 TT 3 TT 4 TT 5 TT any TT card Card + card Card + card Card + card Card + card Card + history history history history history Azmeriganj 290 8.0 12.8 92.0 11.7 91.7 11.0 83.1 9.0 66.6 6.6 52.4
Bahubol 311 7.4 19.0 92.6 15.8 90.0 13.2 77.5 9.3 67.5 5.5 53.4
Baniachang 291 7.6 16.2 92.4 12.4 87.3 8.9 74.6 6.5 62.9 5.2 50.2
Chunarughat 283 3.5 18.7 96.5 14.8 96.5 10.6 89.4 7.4 78.8 4.6 66.4
Sadar 311 2.9 22.5 97.1 17.4 94.2 13.2 86.2 9.0 74.6 7.1 65.0
Lakhai 295 7.1 17.3 92.9 15.3 88.5 11.2 81.0 7.1 67.1 5.4 54.2
Madhabpur 319 3.8 24.1 96.2 21.9 94.5 19.4 87.8 14.7 75.6 9.1 58.0
Nabiganj 304 4.9 19.4 95.1 16.8 93.4 13.5 88.2 10.2 76.0 7.2 64.1
Total 2,404 5.6 18.8 94.4 15.9 92.0 12.7 83.5 9.2 71.2 6.4 58.0
Table 5.2.1a: Percent distribution of women received valid doses of TT (from card and history) during their lifetime by upazila, Habiganj
Schedule of validity: Dose Minimum dose interval TT-1 - TT-2 4 weeks from TT-1 TT-3 6 months from TT-2 TT-4 1 year from TT-3 TT-5 1 year from TT-4
Upazila TT-2 TT-3 TT-4 TT-5 N= Card + history Card + history Card + history Card + history
Azmeriganj 290 91.0 82.1 56.6 41.4 Bahubol 311 90.0 77.5 62.4 46.0 Baniachang 291 87.3 74.6 54.3 39.9 Chunarughat 283 96.5 89.4 71.7 51.9 Sadar 311 93.9 85.9 67.5 55.3 Lakhai 295 88.5 80.7 61.4 41.4 Madhabpur 319 94.7 87.2 66.8 34.8 Nabiganj 304 93.1 87.8 71.4 57.6 Total 2404 91.9 83.2 64.1 46.0
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Table 5.2.1b shows the percentage of neonates who were protected from neonatal tetanus. Eighty five percent of neonates were found to be protected in Habiganj, with the highest percentage being in Chunarughat (95 percent) and the lowest in Azmeriganj (76 percent). Table 5.2.1b Percentage of children born protected from neonatal tetanus among live-births during last pregnancies by upazila, Habiganj.
Protection schedule: Valid Dose Protection level TT-1 No protection TT-2 3 years TT-3 5 years TT-4 10 years TT-5 life long
If Mother received only 2 doses of TT and received TT-2 within 3 years before last delivery then the newborn is considered as protected. If the Mother received 3 doses of TT and received TT-3 within 5 years before the last delivery then the child is considered protected and so on.
Upazila Live-births Newborn was protected from tetanus N= (calculated from date of birth of newborn) % Azmeriganj 286 75.9 Bahubol 300 82.7 Baniachang 283 79.1 Chunarughat 272 94.8 Sadar 302 91.7 Lakhai 296 79.4 Madhabpur 310 85.2 Nabiganj 287 88.5 Total: 2,336 84.6
Iron Folic Acid coverage
Severe anemia is common in developing countries and contributes to high mortality from postpartum hemorrhage. In developing countries, an estimated 55 percent of all pregnant women have anemia2 and one-tenth of maternal mortality is attributed to iron deficiency.3 It is also suggested that the treatment of anemia may significantly improve neonatal mortality.1 Table- 5.2.2 shows the percent distribution of women who received iron tablets during their last pregnancy. 36 percent of recently delivered women reported consumed iron tablets during their last pregnancy in the intervention upazilas of Habiganj. Percentage of iron consumption was found high in Chunarughat and Sadar upazilas (around 47 percent) and low in Azmeriganj (27 percent). The use of iron tablets during pregnancy varied markedly by education and socio-economic status. Around 71 percent of women had secondary and higher level of education consumed iron tablets during their last pregnancy while it was 27 percent among women had no education. 58 percent of women in the
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highest quintile group reported consumed iron tablets while it was 23 percent among women in the lowest quintile group. There were no significant changes in the rate of iron consumption by age and parity of the women. Table 5.2.2: Percentage of women consumed Iron-folic acid tablets during their last pregnancy by upazila and by background characteristics, Habiganj
N=2,404 Consumed Iron- folic acid tablet % Total : 35.9 Azmeriganj 290 26.9 Bahubol 311 32.5 Baniachang 291 31.6 Chunarughat 283 47.0 Sadar 311 46.3 Lakhai 295 35.3 Madhabpur 319 33.9 Nabiganj 304 34.2 Maternal education No education 834 27.3 Primary 509 27.7 Class 5-9 946 43.7 Class 10+ 115 71.3 Maternal age <20 254 33.1 20-24 882 36.2 25-29 678 36.6 30-34 374 39.0 35-39 170 31.8 40 + 46 28.3 Birth order 0 25 48.0 1 668 39.5 2 541 37.9 3 436 39.0 4 294 31.3 5+ 440 27.5 Wealth Quintile Lowest 481 22.7 Second 481 26.6 Middle 481 29.9 Fourth 481 42.8 Highest 480 57.7
5.3 Information Received during Antenatal Care
Counseling is one of the main components of ANC checkup. During ANC checkups, the majority of women received advice on the importance of rest and nutrition, TT immunization and iron-folic acid (IFA) tablet intake for anemia in the study area. Delay in care-seeking, access and receipt are the major causes of maternal, late fetal and neonatal mortality. Therefore, a well thought-out plan to meet an adverse situation during pregnancy is essential 57 | Page
Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010 for avoiding these delays. In recent years, safe motherhood programs have increasingly emphasized birth preparedness as an integral component of ANC counseling.
Table 5.3.1: Percentage of women received counseling/advice from HA/FWA/MaMoni health worker and percentage of whom received counseling by component during pregnancy and by upazila, Habiganj.
Component of Antenatal counseling by HA/FWA/MaMoni health worker Azmeriganj N= 290 Bahubol N=311 Baniachang N=291 Chunarughat N= 283 Sadar N=311 Lakhai N=295 Madhabpur N=319 Nabiganj N=304 TOTAL N=2404
Women received counseling from HA 12 6 3 5 3 10 14 5 58 /FWA/MaMoni HW/CHW (4.1) (1.9) (1.0) (1.8) (1.0) (3.4) (4.4) (1.7) (2.4)
Check up during pregnancy 25.0 16.7 33.3 80.0 66.7 40.0 35.7 40.0 37.9 TT vaccination 16.7 16.7 33.3 0.0 33.3 0.0 42.9 0.0 19.0 To take Iron tablet 33.3 16.7 0.0 40.0 0.0 40.0 28.6 40.0 29.3 Regarding danger signs during pregnancy 0.0 0.0 33.3 20.0 0.0 0.0 14.3 0.0 6.9 Extra food 75.0 50.0 6.7 80.0 100.0 70.0 78.6 20.0 69.0 Take rest 66.7 66.7 33.3 60.0 66.7 100.0 57.1 20.0 63.8 Not to do heavy work 75.0 66.7 0.0 80.0 33.3 90.0 50.0 20.0 60.3 Savings for emergency 25.0 0.0 0.0 20.0 33.3 20.0 7.1 0.0 13.8 Ensure emergency transport 8.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.7 To deliver at a health facility 0.0 0.0 0.0 0.0 0.0 0.0 7.1 (20.0 3.5 Ensure a trained TBA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Ensure a person for newborn care 0.0 0.0 0.0 0.0 0.0 0.0 0.0 20.0 1.7 To use safe delivery kit 0.0 0.0 0.0 20.0 0.0 0.0 0.0 0.0 1.7 A well lighted and airy delivery place 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Prepare two pieces of cloth 0.0 0.0 0.0 0.0 0.0 0.0 7.1 0.0 1.7 Family planning 0.0 0.0 0.0 0.0 0.0 0.0 21.4 40.0 8.6 Breastfeeding 0.0 0.0 0.0 0.0 0.0 10.0 0.0 0.0 1.7 LBW baby care 0.0 0.0 3.3 20.0 0.0 0.0 0.0 0.0 3.45 Others 0.0 0.0 0.0 20.0 0.0 0.0 0.0 0.0 1.7 Can't remember 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Table 5.3.1 shows only 2.4 percent of women living in the intervention upazilas of Habiganj reported received counseling either from a HA/FWA/MaMoni health worker. Out of 58 women who reported receiving counseling/advice, around 69 percent of them received advice on extra food followed by 64 percent on adequate rest, 60 percent on not doing heavy work, 38 percent on having a check-up during pregnancy, 29 percent on iron-folate, 19 percent on TT vaccination and 14 percent on emergency savings. As the number of women received counseling was too low, comment on upazila wise coverage is not significant. Infections are the major cause of mortality and morbidity in neonates. Sepsis and tetanus affects more than one million neonates each year, of which half die. Early onset of neonatal sepsis during 48-72 hours usually results from unhygienic childbirths. Aseptic management of umbilical cord and hygienic delivery 58 | Page
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practices can significantly reduce neonatal infections and mortality. Acute respiratory infections (ARIs) during the early neonatal period are another major cause of mortality and morbidity, and are usually acquired from the maternal genital tract. Providing information on aseptic birth practices and reducing infections are one of the components of ANC. Results indicate that very few women (about 5%) reported receiving information on infection prevention methods through safe delivery practices. Survey data suggest that ANC counseling was not adequately targeted towards birth preparedness and activities surrounding the delivery period when mothers and neonates are at the highest risks of deaths and morbidities.
Table 5.3.2: Percentage of women received at least 2 home visits by HA/FWA/ MaMoni health worker during their last pregnancy by upazila, Habiganj.
Upazila N= Did not visit Visited once Visited twice
Azmeriganj 290 94.1 5.9 4.5 Bahubol 311 98.1 1.9 1.6 Baniachang 291 99.0 1.0 0.7 Chunarughat 283 97.2 2.8 2.1 Sadar 311 99.0 1.0 0.6 Lakhai 295 96.3 3.7 2.4 Madhabpur 319 94.7 5.3 3.8 Nabiganj 304 95.7 4.3 1.6 Total 2,404 96.8 3.2 2.2
Table 5.3.2 shows the percent distribution of women who received home visits from HA/FWA/MaMoni health worker during their last pregnancy. Results indicate that on an average only 3 percent were visited once and 2 percent were visited twice by GoB or MaMoni health workers during their last pregnancy.
Counseling on the importance of receiving 4 ANC checkups and newborn care was found to be very negligible in the intervention upazilas of Habiganj (Table 5.3.4 and 5.3.5).
Table 5.3.4: Percent of women reported receiving counseling from HA/FWA/MaMoni health worker on the importance of 4 ANC visits by upazila, Habiganj.
HA/FWA / MaMoni health worker counsel Upazilla N= about importance of 4 ANC visits Azmeriganj 290 0.7 Bahubol 311 0.3 Baniachang 291 0.0 Chunarughat 283 0.4 Sadar 311 0.0 Lakhai 295 1.4 Madhabpur 319 0.6 Nabiganj 304 0.3 Total 2404 0.5
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Table 5.3.5: Percentage of women reported receiving counseling from HA/FWA/ MaMoni health worker / CHW on newborn care by upazilas of Habiganj. Multiple answers were accepted
Components of newborn care 5 Azmeriganj N= 290 Bahubol N=311 Baniachang N=291 Chunarughat N= 283 Sadar N=311 Lakhai N=29 Madhabpur N=319 Nabiganj N=304 TOTAL N=2404 Women received counseling from 0 0 0 0 1 0 0 0 1 HA/FWA/ MaMoni health worker/ (0.0) (0.0) (0.0) (0.0) (0.3) (0.0) (0.0) (0.0) (0.05) CHW about Newborn care Clean/dry the baby immediately after 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 100.0 birth Wrap the baby immediately after birth 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 100.0 Put the baby to breast before delivery 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 of the placenta Nothing to be applied to the umbilicus 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Not to remove the vernix or the white 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 skin First bath should be given 72 hrs/3 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 100.0 days after delivery Not to give anything before breast 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 milk Exclusive Breastfeeding 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 KMC, Skin-to-skin contact 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 About family planning 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 About LAM 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Others 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Don’t know/ Can't remember 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
5.4 Birth Plan and Delivery
Table 5.4.1 shows the upazila wise distribution of different components of a birth plan that the RDW had adopted. The components that were frequently identified included selection of place of delivery, attendant, newborn care person, saving money and preparing two pieces of cloths for wrapping newborn. Around 59 percent of women mentioned that had selected a delivery place. The percentage was highest in Sadar (83 percent) and lowest in Azmeriganj (21 percent). Similarly, a little more than half of the RDW had selected their birth attendant with highest percentage being in Lakhai (69 percent) and lowest in Azmeriganj (18 percent). Around 29 percent of women reported having a plan to select a newborn care person. There were differences among the upazilas, and almost 50 percent of the women in Lakhai and Sadar selected a newborn care person while it was only 12 percent in Azmeriganj. Around 26 percent of women reported having a plan to prepare two pieces of cloths for drying and wrapping of newborn immediately after birth. The percentage was high (around 47 percent) in Bahubol and Azmeriganj while low in Nabiganj (11 percent). Around 30 percent of women had plan to save money for any emergency situation and the percentage was high (47 percent) in Lakhai and 12 percent in Baniachong.
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Table 5.4.1 Percent of women reported having a birth plan during their last pregnancy by upazila, Habiganj Multiple answers were accepted
Birth Plan
364 , Azmeriganj N=288 Bahubol N=302 Baniachang N=289 Chunarughat N=275 Sadar N=307 Lakhai N=294 Madhabpur N=313 Nabiganj N=296 TOTAL N=2 Selected place for delivery 20.5 59.6 41.5 74.2 82.7 58.2 57.5 73.3 58.6 Selected person to attend the delivery 18.1 64.9 43.9 61.8 65.8 69.1 50.8 51.7 53.4 Selected person to take the newborn 11.8 19.9 18.0 25.1 49.2 50.0 24.6 30.1 28.7 Purchase/procure a safe delivery kit 0.4 1.3 0.7 0.7 1.6 0.7 0.3 1.7 0.9 Arranged emergency transport 5.9 7.3 2.1 8.7 11.1 5.4 1.9 3.7 5.8 Saved money for emergency 31.9 22.5 12.1 39.3 31.6 46.9 23.6 30.1 29.7 Took approval to seek care 0.4 0.3 0.4 0.0 2.6 0.0 0.6 0.0 0.6 Check up during pregnancy 0.7 1.7 0.4 3.6 5.9 0.7 0.3 2.7 2.0 Took TT vaccine 0.0 2.1 3.8 2.2 2.0 1.0 1.0 2.7 1.9 Took Iron tablet/syrup 0.0 1.0 1.7 3.3 3.3 1.7 0.3 1.0 1.5 Knew danger signs for women 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Knew danger signs about new born 0.0 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Took extra food 9.7 6.6 10.4 9.5 8.1 10.2 1.0 4.4 7.4 Took adequate rest 9.0 3.6 7.3 4.7 1.0 2.7 1.0 6.4 4.4 Did not perform heavy work 13.5 7.3 6.9 9.1 3.6 25.5 2.9 4.4 9.1 Ensure a trained TBA 0.0 0.7 0.4 0.4 1.6 6.5 0.3 1.4 1.4 Selected a well lighted and Airy delivery place 0.0 0.0 0.4 0.4 0.3 0.0 0.0 0.0 0.1 Prepare two pieces of cloth 46.9 47.7 21.1 14.6 29.3 26.9 13.1 10.8 26.3 Identify Blood Donor 0.0 1.3 0.0 0.0 0.0 0.7 0.7 0.0 0.3 Others 1.0 19.9 5.5 8.0 9.8 5.4 7.7 6.4 8.0 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Table 5.4.2 shows only 1 percent of women reported all five selected components of a birth plan in the upazilas of Habiganj. Table 5.4.2: Percent of recent mothers reported had a birth plan with 5 components (Selection of place of delivery, selection of person to attend delivery, selection of person to take care of newborn, arranged transport during emergency time and saved money for emergency) during their last pregnancy by upazila, Habiganj.
N= Rreported all 5 selected components of birth plan Azmeriganj 288 0.0 Bahubol 302 1.0 Baniachang 289 0.0 Chunarughat 275 2.6 Sadar 307 2.9 Lakhai 294 2.4 Madhabpur 313 0.0 Nabiganj 296 0.7 Total: 2364 1.2
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Place of delivery
Overall, results indicate that 85 percent women delivered their last child at home (Table 5.4.3); this was proportionally lower than results from Projahnmo-1 in Sylhet (around 93 percent), 88 percent in ACCESS baseline 2007 in Sylhet and what was observed in the BDHS 2007 for Sylhet Division (93 percent).
Table 5.4.3: Percent distribution of place of delivery by upazilla and by background characteristics, Habiganj. (Heath facility includes FWC, UHC, medical college hospital, private/NGO hospital or clinic and specified hospital in other code)
Area N= Delivery at Home Delivery at Health facility Other places
Total: 2,364 85.2 12.9 1.9 Azmeriganj 288 89.6 10.1 0.4 Bahubol 302 87.1 12.3 0.7 Baniachang 289 91.4 8.3 0.4 Chunarughat 275 89.1 10.2 0.7 Habiganj Sadar 307 69.1 20.2 10.8 Lakhai 294 91.2 8.5 0.3 Madhabpur 313 85.6 14.1 0.3 Nabiganj 296 79.4 19.3 1.4 Maternal education: No education 815 93.0 6.1 0.9 Primary 499 91.2 8.2 0.6 Class 5-9 936 80.0 17.2 2.8 Class 10+ 114 44.7 47.4 7.9 Maternal age: <20 248 82.3 14.9 2.8 20-24 875 84..3 13.6 2.1 25-29 670 85.7 13.0 1.3 30-34 365 86.3 11.0 2.7 35-39 160 88.8 10.6 0.6 40 + 46 87.0 13.0 0.0 Birth order: 0 16 56.3 37.5 6.3 1 661 72.8 23.8 3.5 2 538 87.6 11.5 0.9 3 433 89.2 9.0 1.9 4 285 92.3 6.3 1.4 5+ 431 93.5 5.6 0.9 Wealth Quintile: Lowest 474 94.5 4.6 0.8 Second 473 93.0 6.8 0.2 Middle 473 90.5 8.0 1.5 Fourth 472 84.5 12.7 2.8 Highest 472 63.1 32.6 4.2
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Delivery at home was most common in Baniachang and Lakhai (91 percent) and least common in Sadar upazila (69 percent). Hence, Delivery taking place in a health facility was highest in Sadar and lowest in Baniachang and Lakhai. A high maternal education was correlated with a lower rate of home delivery and increasing rate of facility delivery. Among women having no education, 93 percent of deliveries occurred at home while the rate was 45 percent among women with 10 or more years of education.
Fig: 5.3: Percent of women delivered their baby in a health facility by level of maternal education
17.2
There was no much variability by maternal age but there was amarked difference by parity of women. Lower parity correlated with a higher percentage of health facility deliveries; like, 38 percent of deliveries took place at a health facility among women of ‘0’ parity, 24 percent with partity ‘1’, 12 percent with parity ‘2’, 9 percent with parity ‘3’, 6 percent with parity ‘4 and above’. Similarly, marked differences were found by wealth quintile. A lower quintile correlated with a lower percentage of health facility deliveries. Only 5 percent of deliveries took place at a health centre among lowest quintile group while it was 33% among women in the highest quintile group (Fig: 5.4.1).
Fig: 5.4: Percent distribution of women who had delivered in a health facility by wealth quintile
12
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Table 5.4.4 shows around 90% of deliveries at home were conducted by TBA/TTBA in Habiganj and the rate of home deliveries attended by a skilled birth attendant was only 3 percent. There were variations by upazilas: no home deliveries in Lakhai and Azmeriganj were attended by a skilled attendant and the highest rate of home deliveries by a skilled birth attendant was in Bahubol and Sadar (6%). Women’s educational and economic status was related to the type of provider who assisted during delivery. Around 1 percent of home deliveries were attended by a skilled birth attendant among women who delivered and had no education while the rate was 14 percent among women had secondary or more level of education. There were no significant variations by maternal age and parity but women in the highest quintile were also 5 times more likely to have their home deliveries conducted by skilled attendants compared to women belonging to the lowest quintile.
Table 5.4.4: Percent distribution of type of birth attendant assisted delivery at home (Except family member) by upazilla and by background characteristics, Habiganj 2010.
Area Skill Other health N= TTBA TBA Other*** No-one provider* professional** Total 2,013 2.9 0.3 15.1 75.3 3.2 3.2 Azmeriganj 258 0.0 0.0 12.0 77.9 5.8 4.3 Bahubol 263 5.7 0.0 12.6 78.7 0.8 2.3 Baniachang 264 2.3 1.1 18.9 71.6 3.0 3.0 Chunarughat 245 4.9 0.4 21.2 66.5 2.9 4.1 Sadar 212 6.1 0.0 10.4 75.5 5.2 2.8 Lakhai 268 0.0 0.4 20.2 74.3 1.5 3.7 Madhabpur 268 2.2 0.4 17.2 75.0 3.7 1.5 Nabiganj 235 2.6 0.0 6.8 83.0 3.4 4.3 Maternal education: No education 758 1.3 0.1 14.0 77.7 2.9 4.0 Primary 455 1.8 0.2 13.2 78.5 3.1 3.3 Class 5-9 749 4.4 0.4 16.4 72.6 3.5 2.7 Class 10+ 51 13.7 2.0 29.4 49.0 5.9 0.0 Maternal age: <20 204 2.5 0.0 16.7 73.0 5.4 2.5 20-24 738 3.0 0.4 15.6 73.6 3.5 3.9 25-29 574 2.8 0.2 13.1 78.4 2.4 3.1 30-34 315 3.5 0.6 14.6 76.2 3.5 1.6 35-39 142 1.4 0.0 14.8 76.8 2.1 4.9 40 + 40 5.0 0.0 32.5 60.0 0.0 2.5 Birth order: 0 9 0.0 0.0 22.2 77.8 0.0 0.0 1 481 4.0 0.2 17.7 71.1 4.2 2.9 2 471 4.0 0.6 14.2 73.5 2.8 4.9 3 386 2.1 0.3 13.5 76.7 5.2 2.3 4 263 1.9 0.0 15.6 78.3 1.9 2.3 5+ 403 1.7 0.3 14.1 78.9 1.7 3.2 Wealth Quintile: Lowest 448 2.0 0.2 13.4 78.4 2.9 3.1 Second 440 0.7 0.0 15.0 78.0 2.7 3.6 Middle 428 2.3 0.2 12.4 78.3 3.0 3.7 Fourth 399 1.3 0.3 16.3 75.7 3.3 3.3 Highest 298 10.4 1.0 20.1 61.7 4.7 2.0
Note: *Skiledl provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO **Other health professional includes HA, FWA and MaMoni health worker *** Others includes Village doctor, Quack, Ayurved, Homeopathy, Spiritual, Neighbor
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Table 5.4.5 shows that only 6% of women in the intervention area reported having a birth-kit during their last child birth. The use was highest in Chunarughat (9%) and lowest in Azmeriganj (4%). The main sources of collection of birth-kits were shop (26 percent) followed by NGO volunteer (19 percent) and FWC (17 percent). There were variations among upazilas in the source of birth-kits probably depending on the presence of NGO activities. 50-60 percent of women reported procure birth-kit from shop in Madhabpur and Nabiganj upazilas, 30-40 percent procured from FWC in Baniachong and Lakhai upazilas and 25-30 percent of women reported procured birth-kit from NGO volunteers in Bahubol and Chunarughat upazilas. Table 5.4.5: Percent of women who had birth kits for delivery and distribution of source from where birth kits were received by upazila, Habiganj.
Birth-kit Azmeriganj N=258 Bahubol N=263 Baniachang N=264 Chunarughat 245 N= Sadar N=212 Lakhai N=268 Madhabpur N=268 Nabiganj N=235 TOTAL N=2013 Had Birth-kit 3.5 4.9 4.6 9.0 6.1 4.9 6.7 6.4 5.7 Source of birth-kit received: FWC 11.1 15.4 41.7 18.2 7.7 30.8 11.1 6.7 17.4 Satellite clinic 0.0 0.0 0.0 0.0 7.7 0.0 0.0 0.0 0.9 Community clinic 0.0 0.0 0.0 0.0 0.0 0.0 5.6 6.7 1.7 NGO clinic 22.2 7.7 8.3 4.6 30.8 0.0 5.6 0.0 8.7 Shop 22.2 15.4 0.0 13.6 7.7 30.8 61.1 46.7 26.1 HA/FWA / MaMoni HW/CHW 11.1 0.0 8.3 0.0 0.0 0.0 0.0 0.0 1.7 Untrained TBA 0.0 15.4 0.0 18.2 0.0 7.7 5.6 6.7 7.8 NGO Volunteer 11.1 30.8 16.7 27.3 15.4 23.1 5.6 20.0 19.1 Others 11.1 7.7 25.0 4.6 23.1 0.0 0.0 6.7 8.7 Don’t know/ can’t remember 11.1 7.7 0.0 13.6 7.7 7.7 5.6 6.7 7.8
5.5 Post Partum Table 5.5.1 shows only 13 percent of women reported receiving at least one PNC in the intervention areas of Habiganj and three-fourths of them reported received PNC within 3 days after child birth and almost 90 percent within two weeks. More than one-fourths women in Sadar upazila reported received PNC after child birth while it was only 5 percent in Baniachong and 6 percent in Azmeriganj upazilas. Women who reported received PNC, around 96 percent of them received within 3 days of child birth in Sadar upazila while it was less than 60 percent in Chunarughat and Azmeriganj. Table 5.5.1: Percentage of women reported receiving any PNC visit for themselves and percentage of whom received a PNC within 3 days after child birth by upazila, Habiganj.
Upazila Time of first PNC received Received N= Within 3 4-6 7-13 14-27 28-41 any PNC >41 days days days days days days Total 2,404 12.7 73.5 7.19 8.5 4.6 4.3 2.0 Azmeriganj 290 6.2 55.6 5.6 11.1 5.6 11.1 11.1 Bahubol 311 10.9 70.6 2.9 5.9 8.8 8.8 2.9 Baniachang 291 4.8 78.6 7.1 0.0 7.1 7.1 0.0 Chunarughat 283 14.8 52.4 9.5 19.1 11.9 4.8 2.4 Habiganj Sadar 311 25.1 96.2 1.3 2.6 0.0 0.0 0.0 Lakhai 295 11.5 67.7 8.8 8.8 5.9 5.9 2.9 Madhabpur 319 11.9 71.1 15.8 7.9 2.6 2.6 0.0 Nabiganj 304 15.8 68.8 10.4 12.5 2.1 4.2 2.1
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Table 5.5.2 shows that 9 percent of women received at least two PNC visits for themselves after the birth of their most recent child. Of them, around 94 percent reported received PNC from a skilled provider and 6 percent from other providers except TBA and other health professionals. There were variations among the upazilas and 21 percent of women reported recived two or more PNCs in Sadar, 10 percent of women in Chunarughat while the rate was low in Azmeriganj (4 percent) and Baniachong (5 percent). The rate of receiving PNC from a skilled provider was high across the upazilas except Azmeriganj (75 percent).
Table 5.5.2: Percentage of women reported received at least two PNC visits for themselves from a skilled provider after child birth by upazila, Habiganj. Multiple answers were accepted Area N= Received 2 Type of PNC provider or more *Skilled TTBA **Other Health ***Others Don’t know/cant PNC provider and TBA professional remember Total: 2,404 8.6 93.7 0.0 0.5 5.8 0.5 Azmeriganj 290 4.1 75.0 0.0 0.0 16.7 8.3 Bahubol 311 7.4 100.0 0.0 0.0 0.0 0.0 Baniachang 291 4.5 92.3 0.0 0.0 15.4 0.0 Chunarughat 283 10.3 89.7 0.0 0.0 10.3 0.0 Sadar 311 20.9 98.5 0.0 0.0 1.5 0.0 Lakhai 295 8.8 88.5 0.0 3.9 7.7 0.0 Madhabpur 319 6.0 100.0 0.0 0.0 0.0 0.0 Nabiganj 304 6.6 90.0 0.0 0.0 10.0 0.0
Note: *Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO **Other health professional includes HA, FWA, MaMoni health worker, Village doctor, Quack, Ayurved, Homeopath. other health worker *** Others includes: Kabiraj, other
Table 5.5.3 shows that around 9 percent of women reported received PNC from a skilled provider within 3 days after delivery. The rate was high in Sadar upazila (24 percent) and low in Azmeriganj (2 percent and Baniachong (4 percent).
Table 5.5.3: Percentage of women received PNC visits for themselves from a skilled provider within 3 days after child birth by upazilas of Habiganj.
Area N= Received PNC within 3 days after child birth from a skilled provider Total 2,404 8.9 Azmeriganj 290 2.4 Bahubol 311 7.7 Baniachang 291 3.8 Chunarughat 283 6.4 Sadar 311 23.8 Lakhai 295 7.5 Madhabpur 319 8.5 Nabiganj 304 9.9
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Table 5.5.5 shows that almost all RDWs (99.8 percent) reported not received any home visit by HA/FWA/MaMoni health worker within 7 days of child birth.
Table 5.5.5: Percentage of women reported receiving home visit by HA/FWA/MaMoni HW/CHW by timing of home visit after child birth by upazila, Habiganj.
Timing of home visit by HA/FWA/MaMoni HW/CHW Counselor Area N= after child birth Within 24 hours Within 3 days Within 7 days Not visited Azmeriganj 290 0.0 0.3 0.3 99.7 Bahubol 311 0.0 0.0 0.0 100.0 Baniachang 291 0.0 0.0 0.0 100.0 Chunarughat 283 0.0 0.0 0.4 99.7 Sadar 311 0.0 0.0 0.0 100.0 Lakhai 295 0.3 0.3 0.3 99.7 Madhabpur 319 0.3 0.6 0.6 99.4 Nabiganj 304 0.3 0.3 0.3 99.7 Total: 2,404 0.1 0.2 0.3 99.8
CHAPTER 5 REFERENCES
1. IOM, Improving Birth Outcomes: Meeting the Challenge in the Developing World, ed. J. Bale, B. Stoll, and A. Lucas. 2004, Washington, D.C.: The National Academies Press.
2. WHO, The Prevalence of Anemia in Women. 1992, World Health Organization: Geneva.
3. WHO, The World Health Report 2002: Reducing Risks, Promoting Healthy Life. 2002, World Health Organization: Geneva.
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Chapter-6 Maternal Health Problems and Treatment Seeking Behavior
Early recognition of the symptoms of pregnancy complications, followed by immediate care seeking from trained health professionals, is essential for reducing risk of maternal morbidity and mortality, miscarriage, stillbirth and early neonatal deaths. Globally, 24% of maternal deaths are due to hemorrhage, 15% due to sepsis, 12% due to eclampsia, and 8% are due to obstructed labor.1 Maternal fever during labor and vaginal infection are risk factors for developing neonatal sepsis. Convulsions during pregnancy, the primary sign of eclampsia, are a major cause of placental abruption (an early separation of placenta) that adversely affects both the survival of mothers and their fetuses. The baseline survey interviewed recently delivered women to know about the occurrence of potentially life- threatening complications during and after their pregnancy, and their subsequent treatment seeking behavior.
6.Women Reporting of maternal Complications:
Recently delivered women in the intervention upazilas of Habiganj were asked to report whether they developed specific complications during their last pregnancy, delivery, or post-partum period. Figure-6 shows the proportion of women reporting at least one maternal complication during each time period. An estimated 31 percent of women reported that they experienced complication during pregnancy, around 33 percent during delivery and 40 percent during post-partum period.
Fig: 6 Percentage of women reported having complication during pregnancy, delivery and postpartum
6.1 Complications during Pregnancy
The proportion of women that reported each specific complication during pregnancy has shown in Table 6.1.1. The most commonly cited complications were severe abdominal pain (10 percent) and severe weakness (9 percent). Around 5 percent of women reported developing severe headache, 4 percent reported edema of legs, 4 percent had edema of hands/swelling of hands and 3 percent reported had fever during antenatal period. Almost same proportion of women reported each specific problem during their last pregnancy across the upazilas.
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Table 6.1.1 Among women with reported danger signs during last pregnancy, percent distribution of danger signs by upazilas of Habiganj.
Multiple answers were accepted
Danger signs during pregnancy Azmeriganj N= 290 Bahubol N=311 Baniachang N=291 Chunarugha t N=283 Sadar N=311 Lakhai N=295 Madhabpur N=319 Nabiganj N=304 TOTAL N=2404 Severe Headache 3.5 5.5 2.8 12.0 4.5 8.1 3.1 3.6 5.3 Blurred Vision 1.4 2.6 1.0 3.2 1.9 3.1 1.3 0.7 1.9 Fetal movement reduced/absent 1.4 1.0 0.3 0.4 1.9 1.0 1.9 2.0 1.3 High Blood Pressure 0.3 1.3 0.3 1.1 3.9 1.4 0.6 2.3 1.4 Edema of the face/swelling 0.3 2.3 1.7 3.5 0.6 1.7 0.0 2.6 1.6 Edema of the hands/ swelling 1.0 5.8 2.1 7.1 3.9 2.4 1.9 3.6 3.5 Convulsions/fits 0.0 0.3 0.0 1.4 0.6 0.0 0.0 0.3 0.3 Excessive Vaginal Bleeding 0.3 1.0 0.0 3.2 1.9 1.0 1.9 1.0 1.3 Severe abdominal pain 10.0 6.8 7.2 14.8 14.8 10.2 8.8 10.9 10.4 Edema of the legs 1.7 4.5 3.4 7.4 3.9 7.1 2.5 3.0 4.2 Fever 1.0 2.9 2.1 5.3 3.2 3.1 2.5 3.3 2.9 Premature rupture of membrane 0.3 1.3 0.0 1.4 1.0 0.7 1.3 1.3 0.9 Loss of consciousness 0.3 0.3 0.0 0.4 0.3 0.3 0.3 1.3 0.4 Difficulty breathing 0.7 0.0 1.0 1.1 1.0 0.0 0.6 2.0 0.8 Severe weakness 4.5 10.0 5.2 17.7 7.4 10.5 9.4 10.2 9.3 Others 3.1 2.9 1.7 5.0 4.2 2.0 3.5 4.6 3.4 Can’t remember/None mentioned 0.0 0.0 0.0 0.0 0.3 0.0 0.0 0.0 0.0
Table 6.1.2: Percent distribution of number of danger signs reported during last pregnancy by upazillas of Habiganj.
Upazila N No Complication 1 Complication 2 Complications ≥3 Complications Total: 2,404 69.1 18.3 8.6 4.0 Azmeriganj 290 77.9 16.2 4.1 1.7 Bahubol 311 72.4 12.5 11.9 3.2 Baniachang 291 79.4 14.4 4.8 1.4 Chunarughat 283 56.2 17.3 15.2 11.3 Sadar 311 63.7 23.5 9.0 3.9 Lakhai 295 68.8 19.7 4.4 7.1 Madhabpur 319 71.2 19.8 7.8 1.3 Nabiganj 304 63.5 22.7 11.5 2.3
Table 6.1.2 shows that around 18 percent women reported had single complication during their last pregnancies and 9 percent reported two complications and 4 percent of women had three or more complications. The rate did not very largely across the upazilas. Reporting 3 or more complications was highest in Chunarughat (11 percent) while it was around 1 percent in Madhabpur, Baniachong and Azmeriganj upazilas.
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Table 6.1.3: Percentage of women reported danger signs during last pregnancy and percentage of whom sought care from a skilled provider by upazila and by background characteristics, Habiganj.
N Reported Sought care for Sought care from a danger sign complication skilled provider* Total 2404 30.9 83.8 62.8 Upazila Azmeriganj 290 22.1 85.9 51.6 Bahubol 311 27.7 84.9 61.6 Baniachang 291 20.6 83.3 61.7 Chunarughat 283 43.8 66.9 52.4 Sadar 311 36.3 88.5 74.3 Lakhai 295 31.2 82.6 58.7 Madhabpur 319 28.8 91.3 62.0 Nabiganj 304 36.5 91.0 74.8 Maternal education No education 834 25.2 79.1 50.0 Primary 509 27.9 78.9 50.7 Class 5-9 946 36.3 86.9 70.8 Class 10+ 115 40.9 97.9 97.9 Maternal age <20 254 35.0 79.8 53.9 20-24 882 30.1 85.7 63.8 25-29 678 30.4 86.9 66.0 30-34 374 32.9 81.3 65.0 35-39 170 26.5 77.8 57.8 40 + 46 30.9 71.4 50.0 Birth order 0 25 52.0 76.9 61.5 1 668 34.6 87.9 68.0 2 541 29.9 90.1 70.4 3 436 29.6 81.4 60.5 4 294 30.3 74.2 49.4 5+ 440 26.8 78.0 55.1 Wealth Quintile Lowest 481 21.8 73.3 54.6 Second 481 27.4 79.6 68.6 Middle 481 29.5 80.3 63.2 Fourth 481 35.7 84.3 82.8 Highest 480 39.8 94.8 88.4 Note: *Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO
Table 6.1.3 shows around 31 percent of women reported complication during their last pregnancy. Among them, around 84 percent sought care from any health care provider and 63 percent from a skilled provider in the intervention upazilas of Habiganj. There was no notable variation in reporting complications across the upazilas. More than 80 percent women in all upazilas sought care for pregnancy complications. The pattern of seeking care from a skilled health providers were more than 70 percent in Sadar and Nabiganj, more than 60 percent in Baniachang, Bahubal and Madhabpur and less than 60 percent in Azmeriganj, Chunarughat and Lakhai. The rate of care seeking increased with increasing levels of education and was much higher among women who had at least 10 years of schooling (around 98 percent) while it was 79 percent among women 70 | Page
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had no education. This trend was similar for care-seeking from skilled providers with the exception that the rate was 50 percent among women had no education. No remarkable variability was found in care seeking from a skilled provider by maternal age, and parity across the upazilas. However, women from higher socio-economic status not only reported more danger signs, but more likely to seek care (around 88 percent) particularly from skilled providers.
Table 6.1.5: Among women with reported danger signs during pregnancy and sought care, the percent distribution of provider (by category) by upazilas of Habiganj.
Multiple responses were accepted AREA Other health N Skill provider* TTBA TBA Other*** Don’t know professional** Total: 622 74.9 0.3 0.3 0.5 27.0 0.0 Azmeriganj 55 60.0 0.0 0.0 1.8 41.8 0.0 Bahubol 73 72.6 0.0 0.0 0.0 28.8 0.0 Baniachang 50 74.0 0.0 0.0 0.0 28.0 0.0 Chunarughat 83 78.3 0.0 0.0 1.2 24.1 0.0 Habiganj Sadar 100 84.0 1.0 0.0 0.0 17.0 0.0 Lakhai 76 71.1 1.3 2.6 1.3 31.6 0.0 Madhabpur 84 67.9 0.0 0.0 0.0 33.3 0.0 Nabiganj 101 82.2 0.0 0.0 0.0 20.8 0.0
Note: *Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO **Other health professional includes HA, FWA and MaMoni health worker *** Others includes Village doctor, Quack, Ayurved, Homeopathy, Spiritual, Neighbor/ relative, pharmacy
Table 6.1.5 shows that among the women who sought care for their danger signs around 75 percent sought care from skilled providers with the highest being in Habiganj Sadar (84 percent) and lowest in Azmeriganj (60 percent) Less than 1 percent of women reported sought care from TBA/TTBA. Around 42 percent of women sought care from unqualified health professionals including village doctors in Azmeriganj. In other upazilas this proportion was around 30%.
Table 6.1.6: Among women with reported danger signs during pregnancy and sought care, the percent distribution of place of care by upazila, Habiganj. Multiple answers were accepted
Place of care
=101 Azmeriganj Bahubol N=73 Baniachang N=622 N=55 N=55 N=50 N=83 N=100 Lakhai N=76 N TOTAL Chunarughat Sadar Madhabpur N=84 Nabiganj At home 7.3 12.3 6.0 7.2 7.0 15.8 15.5 8.9 10.1 Satellite clinic 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 FWC 0.0 0.0 6.0 0.0 3.0 0.0 4.8 5.0 2.4 UHC 21.8 11.0 8.0 20.5 1.0 23.7 3.6 13.9 12.4 Chamber of MBBS doctor 16.4 48.0 34.0 36.1 48.0 30.3 26.2 41.6 36.3 Clinic 3.6 5.5 8.0 14.5 9.0 1.3 22.6 11.9 10.1 Community clinic 0.0 2.7 0.0 0.0 0.0 0.0 0.0 0.0 0.3 Hospital 18.2 8.2 16.0 7.2 21.0 18.4 8.3 9.9 13.2 Pharmacy 36.4 16.4 20.0 18.1 11.0 22.4 20.2 11.9 18.3 Other 0.0 0.0 6.0 0.0 4.0 0.0 1.2 2.0 1.6 Don't know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Table 6.1.6 shows that around 10 percent of women received care at home. Around 36 percent of women sought care from a chamber of MBBS doctor, 18 percent from pharmacies, 13 percent form hospitals, 12
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010 percent from UHC and 10 percent from clinics. Only 2 percent of women reported received care from FWC.
Table 6.1.7: Among women had a danger sign during pregnancy and were advised to have treatment, the percent distribution of persons or health care provider by upazillas of Habiganj. Multiple answers were accepted
Received advice from category of person Received Upazila MaMoni Family Relatives Neighbor TBA TTBA Others N= advice HW/ CHW members /friend
Total: 742 85.0 0.3 68.3 17.1 6.1 1.9 0.8 1.5
Azmeriganj 64 73.4 3.1 57.8 6.3 3.1 4.7 3.1 1.6 Bahubol 86 88.4 0.0 73.3 16.3 2.3 3.5 0.0 1.2 Baniachang 60 81.7 0.0 55.0 23.3 0.0 3.3 0.0 3.3 Chunarughat 124 78.2 0.0 62.1 18.6 8.9 0.8 0.0 1.6 Habiganj Sadar 113 91.2 0.0 78.8 20.4 7.1 0.0 0.0 2.7 Lakhai 92 84.8 0.0 67.4 17.4 6.5 3.3 3.3 0.0 Madhabpur 92 91.3 0.0 79.4 8.7 6.5 1.1 0.0 1.1 Nabiganj 111 87.4 0.0 65.8 22.5 9.0 0.9 0.9 1.9
Table 6.1.7 shows the percentage of women who had danger signs during pregnancy and were referred for treatment. The proportion of women reported received advice for referral has shown by upazila and category of person who gave advice to the women for referral. It was found that among the women who experienced pregnancy complications, 85 percent of them received any kind of advice from any person. The highest category was family members (68 percent), 17 percent of them were relatives, 6 percent were neighbors or friends and 3 percent by TBA/TTBA. The pattern of receiving advice for treatment or referral by different individuals was almost similar across the eight upazilas. 3 percent of women of Azmeriganj upazila reported received advice for treating complication from MaMoni health worker, 8 percent from TBA/TTBA and 58 percent from family members, while none from other upazilas reported about MaMoni health worker. Possibly this was due to mis-understanding of the question asked by the interviewers.
6.2 Complication during delivery:
Table 6.2.1 shows around 33% of women reported complication during their last delivery. Among them, around 70% sought care from any health care provider and 39% from a skilled provider. Rate of seeking care by the women who experienced complication during delivery is almost same across the upazilas. The likelihood of care-seeking from any health providers or from skilled providers increased with increasing levels of education and wealth. Women had no education were less likely to seek care from a skilled provider (28 percent) while it was very high (around 80 percent) among women had secondary or more level of education. Again women in the highest wealth quintile group were most likely to seek care from a skilled provider (around 81 percent) and only 39 percent of women from lowest wealth quintile category received care from skilled providers.
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Table 6.2.1: Percentage of women reported danger signs during delivery and percentage of whom sought care from a skilled provider by upazila and by background characteristics, Habiganj.
Upazila N= Reported delivery Sought care for Sought care from complication complication a skilled provider*
Total: 2,404 32.7 69.9 38.8 Azmeriganj 290 27.9 59.3 29.6 Bahubol 311 31.8 74.8 37.4 Baniachang 291 30.2 69.3 25.0 Chunarughat 283 37.5 63.2 37.7 Sadar 311 42.4 82.6 59.1 Lakhai 295 24.1 62.0 33.8 Madhabpur 319 33.9 65.7 29.6 Nabiganj 304 33.2 74.3 47.5 Maternal education No education 834 31.3 64.0 28.0 Primary 509 30.5 65.2 30.3 Class 5-9 946 33.9 73.8 45.5 Class 10+ 115 42.6 89.8 79.6 Maternal age <20 254 36.2 66.3 40.2 20-24 882 32.5 73.5 41.8 25-29 678 29.1 68.0 35.5 30-34 374 32.4 63.6 35.5 35-39 170 39.4 74.6 35.8 40 + 46 47.8 72.7 50.0 Birth order 0 25 72.0 72.2 44.4 1 668 38.8 76.1 52.1 2 541 26.8 62.8 31.7 3 436 28.4 71.0 36.3 4 294 28.6 67.9 33.3 5+ 440 35.5 66.0 27.6 Wealth Quintile Lowest 481 31.4 62.9 39.0 Second 481 30.8 62.8 37.6 Middle 481 30.8 68.9 42.2 Fourth 481 34.7 67.7 63.7 Highest 480 35.8 84.9 80.8
Note: *Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO
The proportion of women that reported each specific complication during delivery has shown in Table 6.2.2. The most commonly cited complications were prolonged labor (11 percent), and swelling of feet or face (8 percent) which did not vary largely by upazila. Around 7 percent of women reported excessive vaginal bleeding, 6 percent reported high fever, 4 percent of women reported severe headache, and 3 percent reported that the baby was in an abnormal position.
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Table 6.2.2 Among women with reported danger signs during delivery, percent distribution of danger signs by upazila, Habiganj. Multiple answers were accepted
Danger signs during delivery dhabpur Azmeriganj N=290 Bahubol N=311 Baniachang N=291 Chunarugha t N= 283 Sadar N=311 Lakhai N=295 Ma N=319 Nabiganj N=304 TOTAL N=3404 Excessive Vaginal Bleeding 6.6 5.5 5.8 11.7 10.9 2.7 8.5 4.9 7.1 Foul-Smelling Discharge 1.4 1.9 1.7 6.7 1.6 0.0 0.6 1.6 1.9 High Fever 8.3 4.5 5.5 9.2 5.5 1.4 8.2 5.9 6.0 Baby’s Hand or Feet Coming out 2.1 2.9 1.7 1.4 1.6 2.0 0.9 1.6 1.8 first Baby is in abnormal position 2.1 5.1 2.8 2.5 4.2 3.1 1.9 4.3 3.0 Prolong Labor (>12 hours) 11.0 11.3 9.6 11.0 10.9 9.2 12.9 14.5 11.3 Retained Placenta 5.5 3.2 1.7 1.8 1.0 1.7 3.5 0.7 2.4 Rupture uterus/Cervical/Vaginal 0.3 0.6 0.7 0.7 0.0 0.0 0.0 0.0 0.3 tear Cord Prolapsed 1.4 0.6 1.0 1.4 0.3 0.7 0.3 1.0 0.8 Cord around neck 2.8 3.2 1.0 0.4 1.9 2.4 1.9 0.3 1.8 Convulsion 0.7 0.3 0.0 2.8 0.6 0.0 1.3 1.0 0.8 Severe headache 4.1 3.2 3.1 7.1 4.8 0.7 3.8 3.6 3.8 Greenish vaginal discharge 0.0 0.0 0.0 0.7 0.0 0.0 0.9 0.3 0.3 Swelling of feet or face 2.8 10.9 8.9 12.0 10.0 5.4 10.7 4.3 8.2 Others 0.7 3.2 0.3 1.1 7.7 1.7 0.9 4.0 2.5
Table 6.2.3: Percent distribution of number of danger signs reported during delivery by upazillas of Habiganj.
AREA N No Complication 1 Complication 2 Complications ≥3 Complications Total: 2,404 67.3 20.5 7.5 4.7 Azmeriganj 290 72.1 15.9 6.6 5.5 Bahubol 311 68.2 18.7 6.8 6.4 Baniachang 291 69.8 21.0 6.5 2.8 Chunarughat 283 62.5 19.4 8.8 9.2 Habiganj Sadar 311 57.6 27.3 11.9 3.2 Lakhai 295 75.9 19.7 3.1 1.4 Madhabpur 319 66.1 18.8 9.4 5.6 Nabiganj 304 66.8 23.0 6.9 3.3
Table 6.2.3 shows that around 21 percent of women reported single complication during their last delivery which was almost similar across the upazilas. Around 8 percent women reported had two complications and around 5 percent of women experienced three or more complications. About 67 percent of women reported not experience any complications during last delivery. Percentages of women had no complication during their last delivery were almost similar across the upazilas.
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Table 6.2.5: Among women had complication during delivery and sought care, the percent distribution of provider by upazila, Habiganj. Multiple answers were accepted AREA N Skilled Other health TTBA TBA Other*** Don’t provider* professional** know
Total: 549 55.6 0.7 1.8 8.4 37.9 0.0 Azmeriganj 48 50.0 2.1 0.0 6.3 45.8 0.0 Bahubol 74 50.0 1.4 4.1 12.2 37.8 0.0 Baniachang 61 36.1 0.0 4.9 14.8 50.8 0.0 Chunarughat 67 59.7 0.0 1.5 1.5 40.3 0.0 Habiganj Sadar 109 71.6 0.0 0.9 5.5 25.7 0.0 Lakhai 44 54.6 0.0 0.0 6.8 38.6 0.0 Madhabpur 71 45.1 1.4 2.8 12.7 42.3 0.0 Nabiganj 75 64.0 1.3 0.0 8.0 33.3 0.0
*Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO **Other health professional includes HA, FWA and MaMoni health worker *** Others includes Village doctor, Quack, Ayurved, Homeopathy, Spiritual, Neighbor
Table 6.2.5 shows that among women had complication during delivery and sought care, more than half of them sought care from a skilled provider, 10 percent from TBA/TTBA and about 38 percent sought care from ‘other’ category which include village doctor/ quack/ ayurved/ homeopath/ Kabiraj and neighbor. Less than 1 percent of women sought care from HA, FWA or MaMoni health worker. Care seeking pattern was almost similar in all eight upazilas of Habiganj but care seeking from a skilled provider was little high (more than 60 percent0 in Sadar and Nabiganj upazilas.
Table 6.2.6 Women reported had complications during delivery and sought care, the percent distribution of place of care by upazilla, Habiganj.
Multiple answers were accepted
Place of care for delivery
complication
Azmeriganj N= 48 Bahubol N=74 Baniachang N=61 Chunarugha t N= 67 Sadar N=109 Lakhai N=44 Madhabpur N=71 Nabiganj N=75 TOTAL N=549 At home 27.1 47.3 37.7 34.3 32.1 45.5 47.9 34.7 38.1 Satellite clinic 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.3 0.2 FWC 0.0 1.4 0.0 3.0 0.9 2.3 0.0 0.0 0.9 Community clinic 0.0 1.4 0.0 0.0 0.0 0.0 0.0 1.3 0.4 UHC 18.8 6.8 4.9 10.5 3.7 22.7 7.0 22.7 10.9 Chamber of MBBS doctor 4.2 5.4 3.3 9.0 14.7 6.8 2.8 8.0 7.5 Clinic 6.3 13.5 16.4 11.9 16.5 6.8 19.7 16.0 14.2 Hospital 16.7 8.1 8.2 17.9 25.7 20.5 11.3 10.7 15.3 Pharmacy 29.2 17.6 31.2 14.9 4.6 0.0 15.5 12.0 14.8 Other 0.0 1.4 1.6 0.0 4.6 0.0 0.0 0.0 1.3 Don’t know /Can’t 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 remember
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Table 6.2.6 shows that around 38 percent of women received care at home. It was very similar in all the eight upazilas. About 15 percent of women received care from hospital, 15 percent from pharmacy, 14 percent from clinic and 11 percent from UHC. A very small proportion of women sought care from satellite clinic, FWC and community clinic. Around 23 percent women sought care from UHC in each of Lakhai and Nabiganj upazilas, more than 20 percent of women were seeking care from hospital in each of Sadar and Lakhai upazilas.
Table 6.2.7: Women with a home delivery (without a skilled provider) had a danger sign during delivery and received advice to seek care by type of birth attendant / health service provider/ other person in Habiganj.
Birth attendant/ Health service provider/ Received advice other person N= 513 Number % HA/FWA / MaMoni HW / CHW 2 0.4 TTBA 20 3.9 TBA 90 17.5 Family member/relative 299 58.3 Neighbor or friend 31 6.0 Village doctor 17 3.3 Community Health Worker 4 0.8 Spiritual person/ Kabiraj 2 0.4 Others 2 0.4 Don’t discuss 112 21.8
Table 6.2.7 shows the distribution of birth attendants/health care providers/other persons who were present at the time of childbirth and advised the mother to get treatment for the complication. Around 58 percent of women reported receiving advice from family members or relatives to seek care for the complication during childbirth. About 21 percent of women reported received advice from TBA/TTBA, 6 percent from neighbor or friends and 3 percent from a village doctor.
6.3 Complication durinf post-psrtum:
Table 6.3.1 shows around 40 percent of women reported any complication during post-partum. Among them, around 78 percent sought care from any health care provider and 22 percent from a skilled provider. No noticeable variation was seen in seeking care, as well as, seeking care from skilled provider by the women experienced complication during post-partum across the upazilas. There was no such variation in reporting a danger sign by level of maternal education, age, parity and wealth quintile which remained around 30 percent in all upazilas; but there were marked variations in seeking care from a skilled health care provider by level of education of mother and socio-economic status of the households. Women had complication during post-partum and had secondary or above level of education, around 59 percent of them sought care from a skilled provider, while it was only 13 percent among women had no education. Similarly women had post-partum complication and in highest qwealth quintile, 48 percent of them sought care from a skilled provider, while it was 15 percent among women in the lowest wealth quintile.
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Table 6.3.1: Percent of women reported danger signs during post-partum and percentage of whom sought care from a skilled provider by upazila and by background characteristics, Habiganj 2010.
Upazila N= Reported danger Sought care for Sought care from a sign complication skilled provider
Total: 2404 40.4 78.4 21.6 Azmeriganj 290 39.3 70.2 10.5 Bahubol 311 36.7 87.7 21.9 Baniachang 291 28.5 86.8 18.1 Chunarughat 283 56.5 69.4 21.2 Habiganj Sadar 311 43.4 80.0 26.6 Lakhai 295 30.5 92.2 25.5 Madhabpur 319 50.2 75.0 20.6 Nabiganj 304 38.2 75.9 27.6 Maternal education No education 834 41.1 72.9 13.4 Primary 509 42.4 77.3 19.0 Class 5-9 946 39.5 82.4 26.8 Class 10+ 115 33.9 94.9 59.0 Maternal age <20 254 42.1 68.2 17.7 20-24 882 37.8 77.8 21.9 25-29 678 42.0 80.4 20.0 30-34 374 40.4 78.8 23.9 35-39 170 43.5 85.1 27.1 40 + 46 47.8 86.4 22.7 Birth order 0 25 52.0 61.5 38.4 1 668 34.6 76.2 27.3 2 541 42.3 80.8 23.2 3 436 42.0 76.0 15.3 4 294 42.9 78.6 19.0 5+ 440 43.2 81.6 19.5 Wealth Quintile Lowest 481 38.7 70.4 15.3 Second 481 46.2 78.8 20.6 Middle 481 40.1 78.2 23.2 Fourth 481 41.8 78.6 30.4 Highest 480 35.4 86.5 48.3
The proportion of women that reported each specific complication during post-partum period has shown in Table 6.3.2. The most commonly cited complications were severe lower abdominal pain (24 percent), fever (16 percent), breathlessness, tiredness, palpitation and weakness (15 percent), excessive vaginal bleeding (8 percent), fainting (5 percent), fits and convulsion (5 percent) and 2 percent had foul smelling
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Final Report_MaMoni Evaluation_Habiganj_Maternal & Newborn health 2010 vaginal discharge. Percent distribution of complications by upazila was almost similar in all the eight upazilas of Habiganj. Table 6.3.2 Percent distribution of danger signs reported during post partum period by upazilas of Habiganj.
Multiple answers were accepted
Reported danger signs during
post partum
Azmeriganj N=290 Bahubol N=311 Baniachang N=291 Chunarughat N= 283 Sadar N=311 Lakhai N=295 Madhabpur N=319 Nabiganj N=304 TOTAL N=2404 Fever 21.0 12.5 8.9 23.7 16.7 12.9 20.7 14.5 16.4 Excessive vaginal bleeding 7.2 8.7 4.5 13.1 10.0 3.4 10.0 7.9 8.1 Foul smelling vaginal discharge 2.4 2.3 1.7 3.9 0.6 0.3 0.3 2.3 1.7
Severe lower abdominal pain 26.2 22.2 16.5 37.1 21.2 14.6 33.2 19.7 23.8 Breathlessness, tiredness, palpitation and weakness 16.6 15.4 8.9 29.0 18.3 8.5 15.1 12.2 15.4
Fainting 3.5 6.8 2.8 6.0 5.1 5.4 7.8 4.6 5.3 Fits and convulsion 1.0 1.0 0.3 2.8 1.6 0.3 0.6 0.3 1.0
Others 0.0 2.6 2.1 1.4 0.6 0.7 0.6 1.6 1.2
Table 6.3.3 shows that around 20 percent of women reported single complication during post-partum period which was almost similar across all upazilas. Around 12 percent of women reported two complications which also did not largely vary across the upazilas. Around 8 percent of women experienced three or more complications. The table also shows that about 60 percent of women did not report any complication during their post-psrtum period.
Table 6.3.3: Percent distribution of number of danger signs reported during post partum period by upazillas of Habiganj.
AREA N No Complication 1 Complication 2 Complications ≥3 Complications Total: 2,404 59.6 20.1 11.9 8.4 Azmeriganj 290 60.7 14.8 15.2 9.3 Bahubol 311 63.3 15.8 11.3 9.7
Baniachang 291 71.5 18.2 5.5 4.8 Chunarughat 283 43.5 23.7 16.3 16.6 Habiganj Sadar 311 56.6 23.2 11.6 8.7
Lakhai 295 69.5 18.3 10.2 2.0
Madhabpur 319 49.8 23.8 16.3 10.0 Nabiganj 304 61.8 22.7 8.9 6.6
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Table 6.3.6: Women reported had complications and sought care during post partum period, the percent distribution of place of care by upazilas of Habiganj.
Place of care
Chunarughat N= 111 Sadar N=108 Lakhai N=83 Madhabpur N=120 Nabiganj N=88 TOTAL N=762 Azmeriganj N= 80 Bahubol N=100 Baniachang N=72 At Home 22.5 25.0 18.1 23.4 25.0 37.4 18.3 22.7 23.9 Satellite clinic 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.1 0.1 FWC 0.0 1.0 1.4 1.8 0.9 0.0 0.8 2.3 1.1 UHC 6.3 6.0 2.8 6.3 0.9 9.6 1.7 4.6 4.6 Doctor's chamber 5.0 10.0 6.9 9.0 13.0 12.1 12.5 13.6 10.5 Clinic 0.0 3.0 2.8 4.5 3.7 3.6 6.7 11.4 4.6 Community clinic 0.0 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Hospital 3.8 5.0 6.9 9.0 14.8 3.6 5.8 4.6 7.0 Pharmacy 66.3 52.0 62.5 48.7 44.4 37.4 56.7 39.8 50.7 Others 0.0 0.0 0.0 0.0 2.8 0.0 0.0 0.0 0.4
Table 6.3.6 shows that women reported had post-partum complication, of them around 24 percent received care at home, motre than half received care from a pharmacy and 11 percent received care from a chamber of MBBS doctor. Only 7 percent of women received care from hospital and 5 percent from UHC. More than 60 percent women in Azmeriganj and Baniachong those had post-partum complication, received care from pharmacy while less than 2 percent of women sought care from UHC in Madhabpur and less than 4 percent sought care from clinic in each from Bahubol, Baniachong, Sadar and Lakhai upazila.
CHAPTER 6 REFERENCES
1. IOM, Improving Birth Outcomes: Meeting the Challenge in the Developing World, ed. J. Bale, B. Stoll, and A. Lucas. 2004, Washington, D.C.: The National Academies Press.
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Chapter-7 Newborn Health:
One of the primary goals of the MaMoni intervention is to improve newborn care practices at the household level in order to increase the best practices of newborn care in the community and thus reduce the risk of morbidity and mortality. The major direct causes of early neonatal deaths, which occur during the first week of life, are asphyxia, infection, and hypothermia.1. Deaths occurring during the late neonatal period of 8-28 days of life are primarily attributed to infection.1 In developing countries, more than 20% of children acquire an infection during the neonatal period, and infection contributes to 30-40% of all neonatal deaths.1 Appropriate neonatal care, including timely intervention to treat complications, can significantly reduce neonatal deaths. This chapter describes the neonatal care practices in the intervention area of Habiganj at baseline.
Immediate Newborn Care:
7.1 Prevention of Hypothermia
Neonatal hypothermia is defined as an abnormal thermal state during which the newborn’s core body temperature drops below 36.5°C (97.7°F) subsequent to the failure of homeostatic mechanisms to keep the body temperature within the thermoregulatory zone.2 Progressive reduction in body temperature can result in a range of adverse clinical conditions from mild metabolic stress to death.2 Neonatal hypothermia is a significant risk/ causal factor of neonatal morbidity and mortality in newborns in general, and among low birth weight (LBW) infants in particular.2 In an effort to prevent neonatal hypothermia and promote thermal care practice, two methods of preventing hypothermia are being promoted in the MaMoni intervention program. The first is drying the baby immediately after delivery, to prevent the latent heat loss caused by evaporation of the amniotic fluid. The second is wrapping the newborn immediately after drying, to prevent core body heat loss.
Table 7.1.1 shows that around 77 percent of women reported had a newborn care person at birth in the intervention upazilas of Habiganj. Percentage was high (86 percent) in Lakhai and low in Sadar (62 percent). Around 81 percent of women reported TBA/TTBA was the newborn care person at birth, 10 percent reported mother/mother in law as newborn care person and 5 percent reported family members/relatives were present as newborn care person at birth. The rate did not vary much by upazila and the scenario was almost similar across the intervention upazulas.
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Table 7.1.1: Among women gave birth at home and had newborn care person (NBC) at birth; percent distribution of type of newborn care person by upazilas of Habiganj.
Newborn Care Person
56 Azmeriganj N= 230 Bahubol N=253 Baniachang N=244 Chunarughat N= 215 Sadar N=193 Lakhai N=255 Madhabpur N=2 Nabiganj N=206 TOTAL N=1852
Had newborn care person 79.3 81.4 83.9 76.0 62.1 86.4 80.3 67.8 77.0 MBBS doctor 0.0 0.4 0.0 0.0 1.0 0.0 0.0 0.5 0.2 Nurse/midwife 0.0 4.4 1.6 4.2 4.2 0.0 1.6 1.9 2.2 Paramedic 0.0 0.0 0.0 0.5 0.0 0.0 0.0 0.0 0.1 FWV 0.0 0.4 0.8 0.0 0.0 0.0 0.0 0.0 0.2 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 MaMoni health worker 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 HA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 FWA 0.0 0.0 1.2 0.5 0.0 0.0 0.4 0.0 0.3 TTBA 11.7 12.3 17.2 19.5 9.8 18.0 17.2 5.8 14.2 TBA 64.8 74.3 58.2 58.6 71.5 71.4 71.9 63.1 66.9 Homeopath 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Ayurved 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Quack 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Village doctors 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Spiritual person/Kabiraj 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Mother/mother in law 14.8 5.5 13.5 14.4 6.7 6.3 5.1 14.1 9.9 Family members/relatives 5.2 2.4 5.7 1.9 4.2 3.5 3.1 12.6 4.7 Neighbors/friends 3.5 0.0 1.6 0.5 1.6 0.4 0.4 1.5 1.1 Mother herself 0.0 0.4 0.0 0.0 0.5 0.0 0.4 0.5 0.2 Others 0.0 0.0 0.0 0.0 0.5 0.0 0.0 0.0 0.1 Don’t know 0.0 0.0 0.0 0.0 0.0 0.4 0.0 0.0 0.1
Table 7.1.2 shows the percent distribution of type of immediate care that newborns were received after birth in the intervention upazilas. A very high percentage of women reported (around 97 percent) that umbilical cord was cut as an immediate care. Only about 2 percent women reported drying their babies as an immediate care of the newborn and less than 1 percent reported wrapping the baby. The rates were similar in all the upazilas.
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Table 7.1.2: Percent distribution of type of immediate care that newborn received after birth by upazila, Habiganj.
= 243 Azmeriganj N= 256 Bahubol N=259 Baniachang N=257 Chunarughat N Sadar N=208 Lakhai N=266 Madhabpur N=265 Nabiganj N=227 TOTAL N=1981 Cut the umbilical cord 93.4 96.1 98.4 97.1 95.7 99.6 98.9 98.2 97.2 Kept the baby over chest/abdomen of 0.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 mother with bare skin Left the baby alone 0.0 0.0 0.4 0.0 0.0 0.0 0.0 0.0 0.1 Dried the baby 4.3 2.7 0.4 1.7 2.4 0.0 0.8 0.9 1.6 Wrapped the baby with cloths 1.2 1.2 0.4 0.8 1.9 0.0 0.0 0.9 0.8 Bathed the baby 0.0 0.0 0.0 0.0 0.0 0.4 0.0 0.0 0.1 Let the baby sleep 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Breast fed 0.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Fed sugar water or other thing 0.0 0.0 0.4 0.0 0.0 0.0 0.0 0.0 0.1 Others 0.0 0.0 0.0 0.4 0.0 0.0 0.0 0.0 0.1 Don’t know/Can’t remember 0.4 0.0 0.0 0.0 0.0 0.0 0.4 0.0 0.1
Table 7.1.3 shows that only 5 percent of women in the intervention upazilas reported both dried and wrapped their newborns before the delivery (home) of the placenta. Among the upazilas, the percentage was highest in Habiganj Sadar (10 percent) and lowest in Azmeriganj (2 percent).
Table 7.1.3: Percentage of newborns were dried and wrapped before the delivery of placenta in home deliveries by upazila, Habiganj.
AREA Both dried & wrapped before the delivery of N= placenta Total: 1,981 5.2 Azmeriganj 256 2.0 Bahubol 259 6.2 Baniachang 257 2.0 Chunarughat 243 8.2 Habiganj Sadar 208 9.6 Lakhai 266 2.3 Madhabpur 265 5.7 Nabiganj 227 7.1
Table 7.1.4 shows that only 5 percent of women reported that their newborns were dried and wrapped within 5 minutes after birth, the highest percentage was in Nabiganj (12 percent) and lowest in Chunarughat (2 percent). Around 43 percent of women reported both dried and wrapped their newborns within 6-10 minutes, 27 percent within 11-15 minutes. So, about three-fourths of women reported both dried and wrapped their newborns within 15 minutes of birth. Rest 25 percent of women did the same after 15 minutes of birth. Majority of women reported that the newborn were both dried and wrapped within 6-10 minutes although it was reported that the placenta was delivered within 5 minutes after birth
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among 62 percent of women (Table 7.1.5). In about one-fourth of the women the placenta was delivered within 6-10 minutes after birth. The rest (12 percent) were delivered after 10 minutes.
Table 7.1.4: Timing of both drying and wrapping of the newborn immediately after birth among home deliveries by upazila, Habiganj.
Area <5 6-10 11-15 16-30 >30 Don’t Don’t DK N= minutes minutes minutes minutes minutes know dry timing Total: 1,981 5.3 42.5 26.7 15.2 3.4 0.2 6.6 0.1 Azmeriganj 256 6.3 44.9 17.2 18.4 2.7 0.0 10.6 0.0 Bahubol 259 2.7 56.8 24.3 11.2 2.7 0.0 2.3 0.0 Baniachang 257 5.5 41.3 26.5 16.7 5.1 0.0 5.1 0.0 Chunarughat 243 1.7 37.0 26.8 16.5 6.2 0.4 11.5 0.0 Habiganj Sadar 208 6.7 38.9 33.2 13.0 0.5 0.0 7.2 0.5 Lakhai 266 6.0 54.9 24.8 8.3 1.5 0.8 3.8 0.0 Madhabpur 265 3.0 33.6 34.3 18.1 6.8 0.0 3.8 0.4 Nabiganj 227 11.5 30.0 27.8 20.3 1.3 0.0 9.3 0.0
Table 7.1.5 Percent distribution of timing of delivery of placenta in minutes in Habiganj area (home delivery only)
Timing of placental delivery MaMoni area, Habiganj N= 1,981 Number % Within 5 minutes 1,232 62.2 6-10 minutes 495 25.0 11-15 minutes 80 4.0 16-30 minutes 131 6.6 >30 minutes 32 1.6 Was not delivered 0 0.0 Did not know 11 0.6
Table 7.1.6 shows the timing of drying and wrapping separately in the intervention area. Almost one- fourths women reported that their newborns were dried within 5 minutes only 6 percent wrapped within 5 minutes of birth. Around 50 percent newborns were dried and 44 percent were wrapped within 6-10 minutes of birth. It was reported that 90 percent of newborns were dried and 78 percent were wrapped within 15 minutes of birth.
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Table 7.1.6 Percent distribution of individual timing of immediate drying and wrapping of newborns after birth in Habiganj (Home delivery only)
Drying & wrapping of newborn immediately MaMoni area, Habiganj after birth Number % Drying the baby 1,852 Within 5 minutes 423 22.8 6-10 minutes 924 49.9 11-15 minutes 311 16.8 16-30 minutes 138 7.5 >30 minutes 51 2.8 Don’t know/can’t remember 3 0.2 Was not drying 2 0.1 Wrapping the baby 1,954 Within 5 minutes 111 5.7 6-10 minutes 854 43.7 11-15 minutes 563 28.8 16-30 minutes 352 18.0 >30 minutes 69 3.5 Don’t know/can’t remember 3 0.2 Was not wrapping 2 0.1
7.2 Umbilical Cord Care
The materials used to cut and tie the umbilical cord are often a source of infection, particularly for tetanus, among newborns.Table 7.2.1 shows that umbilical cords were cut with a new blade in almost 93 percent of cases, and in a small fraction (5 percent) a birth-kit (CDK) was used. Bamboo slices, scissors and old blades were used in about 2 percent of the cases. About 0.2 percent of mothers failed to report the type of instrument used for cutting the cord in the area. Across the upazilas, little variability in the use of new blades and blade from delivery kit for cutting the umbilical cord was observed. Table 7.2.3 shows that 6 percent of women reported had clean delivery kit during child birth in the intervention upazilas of Habiganj. There was no such variability among the upazilas.
Table 7.2.1: Percent of recent mothers who gave birth at home and whose newborns’ cords were cut by a type of instruments by upazila, Habiganj.
AREA N= Blade from New Old Bamboo Scissors Others Umbilicus Don’t birth kit blade blade strip was not cut know Total: 1,981 4.9 92.6 0.2 0.8 1.3 0.0 0.1 0.2 Azmeriganj 256 2.0 96.1 0.0 0.0 1.6 0.0 0.4 0.0 Bahubol 259 3.5 91.9 0.4 1.9 2.3 0.0 0.0 0.0 Baniachang 257 3.9 95.7 0.0 0.0 0.4 0.0 0.0 0.0 Chunarughat 243 7.4 86.8 0.0 1.7 3.7 0.0 0.4 0.0 Habiganj Sadar 208 4.8 94.2 0.0 0.0 0.5 0.0 0.0 0.5 Lakhai 266 4.5 94.0 0.0 0.4 0.8 0.0 0.0 0.4 Madhabpur 265 6.8 91.3 0.0 0.8 0.8 0.0 0.0 0.4 Nabiganj 227 6.6 90.8 0.9 1.3 0.4 0.0 0.0 0.0
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Table 7.2.3: Percent distribution of women had CDK during child birth at home by upazila, Habiganj.
Upazilla N= Had CDK (%) Total: 1,981 5.6 Azmeriganj 256 3.5 Bahubol 259 5.0 Baniachang 257 4.3 Chunarughat 243 8.6 Sadar 208 5.8 Lakhai 266 4.5 Madhabpur 265 6.8 Nabiganj 227 6.6
Immediately following the cutting of the umbilical cord, different substances are commonly applied to the cord in the belief that they will help prevent infection or other poor outcomes of the baby. Antibiotic powder or other medicines, such as gentian violet lotion, may reduce the risk of infection; however, other materials may be potentially harmful sources of infection. Table 7.2.4 and 7.2.5 show that medications or other materials were applied to the umbilical cords among 33 percent of the newborns in the intervention area. More than 50 percent of women in Baniachong reported applied chemicals/substances to umbilical cords of the newborns, 48 percent in Nabiganj while it was 22 percent in bahubol. The most commonly used substances were Mustard oil (53%), followed by antiseptic (25%), antibiotic powder or ointment (16%) and Boric powder (13%). The use of ash, vermilion, coconut oil and other harmful substances were low but were practiced, increasing the risk of infection in their newborns. Upazila wise distribution is also shown in table 7.2.5. Table 7.2.4 Percentage of women applied specific substances to the umbilical cord of the newborn within seven days after birth among home deliveries by upazila, Habiganj. Multiple answers were accepted
Specific substances applied to
the umbilical cord ganj N= 184 Sadar N=159 Lakhai N=147 Madhabpur N=233 Nabi N=194 TOTAL N=1455 Azmeriganj N= 154 Bahubol N=207 Baniachang N=177 Chunarughat Antibiotics (Powder / Ointment) 31.8 25.1 18.1 10.3 14.5 11.6 5.6 13.9 16.0 Antiseptic (Detol/savlon/hexisol) 49.4 5.8 58.8 16.9 18.2 37.4 5.2 21.7 24.8 Spirit/Alcohol 0.0 0.0 2.3 0.0 0.6 0.0 0.4 0.5 0.5 Mustard oil (with/ without 21.4 69.6 26.0 72.3 44.0 27.2 77.7 66.5 53.3 garlic) Chewed rice 0.0 0.0 1.1 0.0 0.0 0.0 0.0 0.0 0.1 Turmeric juice/powder 0.0 0.0 0.0 1.1 0.0 0.0 0.0 0.0 0.1 Ginger juice 0.0 0.0 1.1 0.0 0.0 0.0 0.0 0.0 0.1 Shidur 0.7 0.5 0.6 1.1 1.3 1.4 1.3 0.5 0.9 Boric powder 7.8 7.3 14.7 6.5 30.8 29.3 12.0 3.6 13.2 Gentian violet (Blue ink) 2.0 1.5 0.6 2.7 1.3 0.0 0.9 0.0 1.1 Talcom Powder 0.0 0.0 0.0 0.5 0.0 0.0 0.4 0.0 0.1 Ash 0.7 1.5 3.4 4.9 2.5 2.7 7.3 9.8 4.3 Coconut oil 2.0 0.5 1.7 0.0 2.5 1.4 3.4 1.0 1.6 Dust of earth-burner 0.0 0.5 0.6 0.0 1.3 0.0 1.3 3.1 0.9 Other thing 0.0 0.0 0.0 0.5 0.0 0.0 1.3 0.5 0.3 Don’t know 0.7 0.0 0.6 0.0 0.0 0.0 0.9 1.0 0.4 85 | Page
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Table 7.2.5: Percentage of women applied specific substances to the umbilical cord after birth among home deliveries by upazila, Habiganj.
AREA N= Applied something Applied nothing Don’t know
Total: 1,979 32.7 66.1 1.2 Azmeriganj 255 45.5 54.5 0.0 Bahubol 259 21.6 78.0 0.4 Baniachang 257 50.6 48.3 1.2 Chunarughat 242 26.5 72.7 0.8 Habiganj Sadar 208 32.7 65.9 1.4 Lakhai 266 26.3 72.6 1.1 Madhabpur 265 13.2 84.5 2.3 Nabiganj 227 47.6 50.2 2.2
7.3 Breast Feeding:
In addition to thermal care practices, immediate breastfeeding patterns were evaluated. Findings reveal that although more than three-fourths of the newborns were breastfed within one hour of birth, breastfeeding was initiated before the delivery of placenta in only 5 percent of newborns. Breast feeding was initiated in 95 percent of newborns after delivery of the placenta. Around 16 percent of newborns were breastfed after two hours of birth (Table 7.3.1). The rates of breast feeding initiated within an hour of birth were almost similar in all the upazilas (70-80 percent).
Table 7.3.1: Percentage of women reported initiating breast feeding immediately following birth (home delivery) by time since birth and placental delivery in Habiganj.
Initiation of breast feeding N=1,981 Number % Commencement of breast feeding Within 1 hour 1521 76.8 1 hour 112 5.7 2 hours 174 8.8 3+ hours 157 7.9 Never Breastfed 17 0.9 Placental delivery and breast feeding Before delivery of placenta 90 4.5 After delivery of placenta 1874 94.6 Don’t know /can’t remember 0 0.0 Never gave breast milk 17 0.9
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Table 7.3.2: Percent of recent mothers reported initiating breast feeding within 1 hour of birth by upazila,Habiganj. (home delivery only)
Upazilla N Within 1 hour 1 hour 2 hours 3+ hours Never breastfed
Total: 1,981 76.8 5.7 8.8 7.9 0.9 Azmeriganj 256 68.4 8.2 7.8 14.5 1.2 Bahubol 259 76.8 3.9 12.4 6.6 0.4 Baniachang 257 88.7 0.8 5.5 3.9 1.2 Chunarughat 243 76.1 4.5 12.4 4.9 2.1 Sadar 208 81.7 1.9 8.7 7.7 0.0 Lakhai 266 79.0 0.8 9.8 10.5 0.0 Madhabpur 265 68.7 12.5 7.9 9.8 1.1 Nabiganj 227 75.8 12.8 5.7 4.9 0.9
Table 7.3.3 shows the upazila wise distribution of newborns who received colostrum. Around 90% of the newborns were fed colostrums in the intervention area. The higher percentage of newborns that were fed colostrums was in Lakhai (97 percent), Madhabpur (92 percent) and Baniachang (91 percent). The rates were almost similar in other upazilas.
Table 7.3.3 Percentage of newborns received colostrum by upazila, Habiganj.
Area N= Newborn received colostrum
Total: 2,315 90.2 Azmeriganj 284 85.9 Bahubol 296 89.5 Baniachang 280 91.4 Chunarughat 271 89.7 Sadar 300 87.4 Lakhai 291 96.6 Madhabpur 308 91.9 Nabiganj 285 89.5
Prelacteal feeding (i.e., the practice of giving other liquids to a child during the first three days of life), is widely practiced in Bangladesh. Results in Table 7.3.4 reveal that around 54 percent of the children born in the year preceding the survey did not receive any prelacteal feed. The most common prelacteal food was misri water (51 percent) followed by honey (41 percent). Further detail on prelacteal feeding by upazila has also shown in table 7.3.4. Thirty one percent of newborns in Nabiganj were given water and baby formula was also common in certain areas such as Habiganj Sadar (28 percent). Table 7.3.5 shows the distribution of additional solid or liquid foods (other than breast milk) given to the newborns in the first 3 days after birth by upazila. Again sweetened water (misri water, honey, sugar water) was most commonly given followed by plain water, formula milk, and other liquids.
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Table 7.3.4 Percentage of newborns received prelacteal feed by upazila, Habiganj.
Prelacteal food
5 Azmeriganj N= 284 Bahubol N=296 Baniachang N=280 Chunarughat N= 271 Sadar N=300 Lakhai N=291 Madhabpur N=308 Nabiganj N=28 TOTAL N=2315 Gave pre-lacteal after birth 51.4 47.0 40.0 39.5 28.3 63.9 67.9 31.6 46.4 Honey 24.7 47.5 35.7 53.3 28.2 33.9 61.7 24.4 40.7 Misri water 56.9 44.6 53.6 41.1 38.8 73.1 41.2 44.4 50.7 Sugar water 5.5 5.0 4.5 11.2 5.9 2.2 3.8 8.9 5.3 Plain water 4.1 2.2 9.8 3.7 5.9 3.8 1.9 31.1 6.3 Fruit juice 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Baby formula Tin food 10.3 10.8 2.7 7.5 28.2 8.6 7.7 10.0 9.9 Cow milk 4.1 0.7 0.0 0.0 0.0 0.5 2.9 1.1 1.4 Other liquid 8.9 0.7 8.0 0.9 2.4 2.2 3.4 1.1 3.5 Smashed rice/flour 0.0 0.0 0.0 0.0 0.0 0.5 0.5 0.0 0.2 Banana 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Papaya / Mango 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Green vegetable 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Boiled rice / Bread 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Gram / cereal/ Dal 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other thing 0.7 2.9 1.8 2.8 1.2 0.0 0.5 0.0 1.1
Table 7.3.5 Percentage of newborns received solid or liquid food other than breast milk within 3 days after birth by upazila, Habiganj.
Additional food/drink
other than breast milk
Azmeriganj N= 146 Bahubol N=139 Baniachang N=112 Chunarughat N= 107 Sadar N=85 Lakhai N=186 Madhabpur N=209 Nabiganj N=90 TOTAL N=1074 Honey 24.0 46.8 33.9 54.2 28.2 33.9 61.2 4.4 40.3 Misri water 58.9 46.0 54.5 43.0 41.2 73.1 41.2 43.3 51.5 Sugar water 5.5 4.3 3.6 11.2 5.9 2.2 3.8 11.1 5.3 Plain water 4.1 2.2 9.8 3.7 7.1 3.8 2.4 32.2 6.6 Fruit juice 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Baby formula (Tin food) 11.0 10.8 2.7 7.5 28.2 8.1 7.7 10.0 9.9 Cow milk 4.8 1.4 0.0 0.9 0.0 0.5 3.4 0.0 1.7 Other liquid 8.9 0.7 8.9 1.9 1.2 2.2 3.4 1.1 3.6 Smashed rice/flour 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Banana 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Papaya / Mango 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Green vegetable 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Boiled rice / Bread 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Gram / cereal/ Dal 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other thing 0.0 3.6 1.8 1.9 0.0 0.0 0.5 0.0 0.9
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7.4 Bathing:
Table 7.4.1 shows that 35 percent of women in the MaMoni intervention upazilas of Habiganj reported bathed their newborns immediately after birth, an additional of 20 percent newborns were bathed within 24 hours. Around 50 percent newborns were bathed immediately after birth in each of Azmeriganj, Lakhai and Madhabpur upazilas while the rate was low in Sadar (14 percent) and Bahubol (17 percent). On an average, around 30 percent of women reported bathed their newborns after three days of birth; the rate was high (around 40 percent or more) in Baniachong, Sadar and Nabiganj while it was low (less than 20 percent) in Madhabpur and Chunarughat. The percentage of newborns being bathed after three days of birth was higher (46 percent) among women who had secondary or higher level of education, while it was 30 percent among women who had no education. There was no significant difference of practices observed by maternal age, but the results showed that the percentage was higher among women with lower parity than higher parity.
In terms of economic status, 24 percent of women in the lowest wealth quintile group reported bathing their newborns after three days of child birth, while it was 41 percent among women in highest wealth quintile group.
Table 7.4.1: Timing of first bathing of newborns after birth by upazila, Habiganj (Home delivery only).
N= Bathed Bathed within Bathed on Bathed on Bathed Not AREA immediately 24 hours 2nd day 3rd day after 3 days Bathed
Total: 1,981 34.5 20.1 4.9 9.3 30.4 0.7
Azmeriganj 256 52.0 15.6 5.5 5.5 21.5 0.0 Bahubol 259 16.6 20.1 5.4 20.9 36.7 0.4 Baniachang 257 35.4 9.7 3.5 5.1 44.8 1.6 Chunarughat 243 35.8 28.4 4.9 9.5 19.8 1.7 Sadar 208 13.9 27.4 5.3 10.1 42.8 0.5 Lakhai 266 47.7 18.1 3.8 4.1 25.9 0.4 Madhabpur 265 47.6 24.2 4.9 6.8 15.9 0.8
Nabiganj 227 21.2 18.9 6.2 13.7 39.7 0.5
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Table 7.4.2 Percentage of newborns bathed after 3 days of birth for the first time by upazila and selected demographic and socio-economic characteristics, Habiganj
Area N= Bathed first time after 3 days of birth Total: 1,981 30.4 Azmeriganj 256 21.5 Bahubol 259 36.7 Baniachang 257 44.8 Chunarughat 243 19.8 Sadar 208 42.8 Lakhai 266 25.9 Madhabpur 265 15.9 Nabiganj 227 39.7 Education: No education: 743 29.6 Primary 449 27.4 Class 5 - 9 739 32.1 Class 10+ 50 46.0 Maternal Age: 14 – 19 202 26.7 20 – 24 726 32.4 25 – 29 566 29.5 30 – 34 308 29.2 35 – 39 139 32.4 40+ 40 30.0 Birth Order: 1 477 34.8 2 466 30.0 3 379 30.6 4 262 28.2 5+ 397 27.0 Wealth Quintile: Lowest 442 24.4 Second 429 31.7 Middle 424 29.0 Fourth 392 33.2 Highest 293 41.0
7.5 Postnatal Care (PNC)
Table 7.5.1 shows that 87 percent of the newborns in the intervention upazilas did not receive any post- natal care (PNC). Around 4 percent received one PNC and 8 percent received two or more PNCs. Highest 95 percent newborns did not receive any PNC in Azmeriganj while lowest 83 percent newborns did not receive PNC in Nabiganj. Highest 19 percent newborns received two or more PNCs in Sadar while lowest 4 percent was in Azmeriganj. 5 percent newborns received two or more PNCs in Baniachong and 7 percent in each of Lakhai, Madhabpur and Nabiganj. Table 7.5.2 shows that 71 percent 90 | Page
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of newborns received their first PNC within 3 days of birth. The percentage greatly varied across upazilas (44-97 percent) and was highest in Habiganj sadar and lowest in Azmeriganj and Chunarughat.
Table 7.5.1: Percentage of women reported receiving at least 2 PNC visits for their newborns by upazila, Habiganj.
AREA N Did not receive Received 1 Received 2 or any PNC PNC more PNC Total: 2,314 87.3 4.4 8.3 Azmeriganj 284 94.4 2.1 3.5 Bahubol 296 90.5 1.4 8.1 Baniachang 279 93.6 1.8 4.7 Chunarughat 271 83.4 5.5 11.1 Habiganj Sadar 300 76.0 5.0 19.0 Lakhai 291 91.1 2.4 6.5 Madhabpur 308 86.7 6.5 6.8 Nabiganj 285 83.2 10.2 6.7
Table 7.5.2: Percent distribution of women received PNC by timing of first PNC received by upazila, Habiganj.
Area Received Within 3 4-6 7-13 14-27 28-41 After 41 PNC days days days days days days Total: 295 70.5 4.8 10.2 4.8 5.1 4.8 Azmeriganj 16 43.8 0.0 18.8 0.0 37.5 0.0 Bahubol 28 78.6 7.1 10.7 3.6 0.0 0.0 Baniachang 18 72.2 0.0 11.1 5.6 5.6 5.6 Chunarughat 45 44.4 8.9 15.6 13.3 6.7 11.1 Habiganj Sadar 73 97.3 1.4 1.4 0.0 0.0 0.0 Lakhai 26 69.2 7.7 7.7 11.5 3.9 0.0 Madhabpur 41 73.2 4.9 14.6 2.4 2.4 2.4 Nabiganj 48 56.3 6.3 12.5 4.2 6.3 14.6
Table 7.5.4 shows the distribution of PNC providers among women who received two or more PNC visits for their newborns during postpartum period. Around 91 percent of women in the intervention area reported receiving PNC from a skilled provider. A large difference was seen in Azmeriganj where half of the newborns received PNC from skilled provider and the rest half from unskilled providers including village doctors. Newborn of women aged 20-24, women who had completed secondary or higher level of education and women from the highest wealth quintile were more likely to receive two postnatal cares from a skilled provider than newborns born to other women (Table 7.5.4). 75 percent of women reported received PNC for their newborns from a skilled provider while it qas 100 percent among women had secondary or higher level of education. 58 percent women from the lowest wealth quintile received PNC from a skilled provider compared to 98 percent in the highest wealth quintile.
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Table 7.5.4: Percentage of women reported receiving at least two PNCs from a skilled provider by upazila and selected demographic and socio-economic characteristics in Habiganj. Multiple answers were accepted
AREA N Skilled Other health TTBA TBA Other*** Don’t provider* professional** know
Total: 193 90.7 1.6 0.0 0.0 8.3 0.0 Azmeriganj 10 50.0 0.0 0.0 0.0 50.0 0.0 Bahubol 24 95.8 0.0 0.0 0.0 4.2 0.0 Baniachang 13 84.6 7.7 0.0 0.0 7.7 0.0 Chunarughat 30 86.7 6.7 0.0 0.0 10.0 0.0 Sadar 57 98.3 0.0 0.0 0.0 1.8 0.0 Lakhai 19 94.7 0.0 0.0 0.0 5.3 0.0 Madhabpur 21 85.7 0.0 0.0 0.0 14.3 0.0 Nabiganj 19 94.7 0.0 0.0 0.0 5.3 0.0 Education: No education: 28 75.0 7.1 0.0 0.0 17.9 0.0 Primary 18 83.3 0.0 0.0 0.0 16.7 0.0 Class 5 - 9 102 92.2 1.0 0.0 0.0 7.9 0.0 Class 10+ 45 100.0 0.0 0.0 0.0 0.0 0.0 Maternal Age: 14 – 19 25 80.0 0.0 0.0 0.0 20.0 0.0 20 – 24 67 97.0 0.0 0.0 0.0 3.0 0.0 25 – 29 53 92.5 1.9 0.0 0.0 7.6 0.0 30 – 34 31 83.9 6.5 0.0 0.0 9.7 0.0 35 – 39 11 90.9 0.0 0.0 0.0 9.1 0.0 40+ 6 83.3 0.0 0.0 0.0 16.7 0.0 Birth Order: 1 95 91.6 1.1 0.0 0.0 7.4 0.0 2 44 97.7 0.0 0.0 0.0 2.3 0.0 3 25 84.0 4.0 0.0 0.0 12.0 0.0 4 13 76.9 7.7 0.0 0.0 23.1 0.0 5+ 16 87.5 0.0 0.0 0.0 12.5 0.0 Wealth Quintile: Lowest 19 57.9 5.3 0.0 0.0 36.8 0.0 Second 14 85.7 0.0 0.0 0.0 14.3 0.0 Middle 22 86.4 0.0 0.0 0.0 18.2 0.0 Fourth 34 91.2 2.9 0.0 0.0 5.9 0.0 Highest 104 98.1 1.0 0.0 0.0 1.0 0.0
*Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO **Other health professional includes HA, FWA and MaMoni health worker *** Others includes Village doctor, Quack, Ayurved, Homeopathy, Spiritual, Neighbor
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7.6 Newborn complication and care seeking
Table 7.6.1 shows the distribution of newborns who had developed danger signs and their treatment seeking practices by upazila and background characteristics. Around 62 percent of newborns developed danger signs within the first 28 days of their lives. Although, around 97 percent of mothers reported that their children were taken to a provider and 42 percent received treatment from a skilled provider. Receiving treatment from a skilled provider was relatively higher in Sadar, Nabiganj and Chunarughat upazilas (around 55 percent).
Table 7.6.1: Percent of women reported their newborns developed a danger sign at birth or within 28 days after birth and percentage of whom sought care from a skilled provider by upazila and by background characteristics, Habiganj.
N=2315 Reported danger Sought care for Sought care from a sign complication skilled provider Total: 2315 1424 (61.5) 1374 (96.5) 598 (42.0) Azmeriganj 284 71.8 95.6 18.6 Bahubol 296 57.4 95.3 41.7 Baniachang 280 49.3 97.1 34.1 Chunarughat 271 71.6 95.4 55.1 Sadar 300 64.0 97.9 56.8 Lakhai 291 56.0 97.6 38.1 Madhabpur 308 68.8 96.2 36.4 Nabiganj 285 53.0 97.4 57.7 Education: No education: 793 59.7 95.6 36.8 Primary 491 62.1 96.72 37.0 Class 5 - 9 920 62.9 97.4 45.8 Class 10+ 111 60.4 94.0 68.6 Maternal Age: 14 – 19 245 63.7 93.0 42.3 20 – 24 854 62.1 97.0 42.3 25 – 29 660 60.2 96.7 41.6 30 – 34 354 62.7 96.9 38.8 35 – 39 157 54.8 96.5 45.4 40+ 45 73.3 100.0 54.6 Birth Order: 1 652 63.2 95.6 46.6 2 533 61.7 97.3 44.7 3 424 59.9 95.7 39.4 4 282 61.4 97.7 37.6 5+ 424 60.4 96.9 36.7 Wealth Quintile: Lowest 466 62.9 94.2 33.3 Second 460 58.7 95.2 37.7 Middle 465 65.8 97.7 39.2 Fourth 461 61.8 97.2 42.6 Highest 463 58.3 98.2 65.3
Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO
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There were no significant differences in reporting newborn danger signs by level of education of mother, parity, maternal age and status of wealth quintile, but large differences were seen in care seeking practices. The likelihood of seeking care from a skilled provider increased with increasing level of education of mother, and household wealth and decreased with increasing parity (Table 7.6.1). Mothers with secondary or higher level of education were 1.9 times more likely to go to a skilled provider. Similarly, women in the highest quintile were 2 times more likely to seek care from a skilled provider. Although the differences were small, a decreasing trend of seeking care from a skilled provider was seen with increasing parity. Table 7.6.2 shows the distribution of the most commonly cited danger signs of the newborns in the intervention area which were cough/cold (42%) followed by fever (35%), pneumonia (8%) and difficult and fast breathing (4%), abdominal distension (4%). The other symptoms were reported in 3 or less than 3% of the cases. The same trend was seen across the upazilas (Table 7.6.2).
Table 7.6.2 Percent distribution of signs and symptoms of newborns reported sick during first month of life by upazila, Habiganj
Danger sign of newborn
2315 Sadar N=300 Lakhai N=291 Madhabpur N=308 Nabiganj N=285 TOTAL N= N=271 Baniachang N=280 Chunarughat Azmeriganj N=284 Bahubol N=296 Difficult and fast breathing 4.9 5.7 3.9 3.0 5.0 0.7 4.6 3.5 4.0 Pneumonia 21.1 2.0 8.6 4.1 4.7 13.1 9.1 3.9 8.3 Cough/Cold 59.2 33.1 27.1 55.4 39.0 39.9 50.1 32.3 42.0 Yellow skin/palm/feet/eye 3.5 3.7 1.8 1.9 6.0 4.8 2.0 2.8 3.3 Poor sucking or feeding 2.5 2.0 1.4 3.7 1.3 1.0 1.3 0.7 1.7 Pus, bleeding/ discharge from around cord 0.4 1.4 1.4 1.1 2.0 1.7 0.7 1.1 1.2 Skin lesions or blisters 2.8 3.4 0.4 4.4 0.7 3.8 2.0 2.5 2.5 Convulsion/ spasms/rigidity 0.4 1.0 0.7 1.1 0.3 0.3 0.7 0.7 0.7 Lethargy/ unconsciousness 0.0 0.3 0.0 0.7 0.3 0.0 0.3 0.4 0.3 Red or swollen eyes with pus 0.7 1.7 0.7 1.1 1.0 0.7 0.7 0.4 0.7 Baby feels cold 0.0 1.7 0.4 0.7 1.3 0.3 0.3 0.0 0.6 Baby doesn’t cry 0.0 0.7 0.4 1.1 1.7 0.0 0.3 0.0 0.5 Fever 55.3 34.5 28.9 53.1 27.3 24.7 34.7 21.1 34.8 Doesn’t pass urine 0.0 1.4 0.4 0.4 1.7 0.3 0.3 0.0 0.6 Doesn’t pass stool 1.8 0.3 1.1 2.2 2.7 1.7 2.9 2.1 1.9 Continuous vomiting 3.5 2.0 1.4 2.2 1.7 0.7 0.7 1.1 1.6 Distention abdomen 2.8 4.1 2.9 7.0 4.0 3.1 2.9 2.5 3.6 Difficult to wake from sleep 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.4 0.0 Skin rash/Mashipishi 0.7 4.4 3.2 1.1 1.7 1.0 5.5 1.4 2.4 Measles 0.0 1.0 1.1 1.5 1.3 0.7 0.7 0.4 0.8 Diarrhoea 3.2 4.1 1.4 6.6 4.0 1.0 2.0 1.4 2.9 Chest in drawing 0.0 0.0 0.7 0.0 0.0 0.0 0.0 0.0 0.1 Problem in ear 0.4 2.0 2.5 1.5 3.0 1.4 1.3 1.8 1.7 Others 28.2 42.6 50.7 28.4 36.0 44.0 31.2 47.0 38.5
Multiple answers were accepted
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Table 7.6.3 shows that 39 percent of newborns were reported not having any complication during the neonatal period. Rest 61 percent of newborns had developed complication. 23 percent of newborns reported developed one complication, 26 percent had two complications and about 13 percent had three or more complications during neonatal period. About 57 percent of newborns in each of Chunarughat and Azmeriganj were reported to suffer from 2 or more complication compared to only 22 percent in Nabiganj.
Table 7.6.3: Percent distribution of number of danger signs reported during 1st month of life of newborns by upazilla, Habiganj.
AREA N No Complication 1 Complication 2 Complication ≥3 Complication
Total: 2,315 38.5 23.2 25.5 12.7 Azmeriganj 284 28.2 14.8 28.5 28.5
Bahubol 296 42.6 23.0 22.6 11.8 Baniachang 280 50.7 19.3 21.8 8.2 Chunarughat 271 28.4 14.4 38.4 18.8
Sadar 300 36.0 27.7 27.3 9.0 Lakhai 291 44.0 23.0 24.7 8.3
Madhabpur 308 31.2 31.5 24.0 13.3 Nabiganj 285 47.0 30.9 17.5 4.6
Table 7.6.4 shows the distribution of health care providers among mothers whose babies had a complication and who sought care. Majority sought care from MBBS doctors (41 percent) followed by village doctors (39 percent) and homeopath (15 percent). The upazila wise distribution shows that in Azmeriganj almost three-fourths sought care from village doctors compared to only 20 percent from MBBS doctors. Again, Homeopaths provided service to 37 percent children in Madhabpur indictaing some contextual differences in care seeking.
According to Table 7.6.5 around 12 percent of women sought care for their sick newborns at home. Aroudn half of sick newborns sought care from local pharmacy and one-fourths from a chamber of MBBS doctor. Only 7 percent of sick newborns were taken to a public first level referral center, the upazila health complex (UHC). Around 16 percent of newborns sought care from a hospital or clinic. Seeking care from a chamber of MBBS doctor was high in Nabiganj (38 percent) and Sadar (35 percent) while around 12 percent sick newborns sought care from UHC in each of Chunarughat and Lakhai upazila. Around 29 percent of mothers whos babies were sick and sought care at home in Lakhai and 3 percent from FWC in Chunarughat.
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7.6.4: Newborns (within 28 days of birth) had complications and sought care, percent distribution of heath care provider by upazila, Habiganj.
Provider
Azmeriganj 195 N= Bahubol N=162 Baniachang N=134 at Chunarugh 185 N= Sadar N=188 Lakhai N=159 Madhabpur N=204 Nabiganj N=147 TOTAL N=1374 MBBS doctor 19.5 40.7 35.1 48.7 56.9 38.4 36.3 57.1 41.3 Nurse/midwife 0.5 2.5 0.8 7.0 2.1 1.3 0.5 0.7 2.0 Paramedic 0.0 0.0 0.0 0.0 0.0 0.0 0.5 0.7 0.2 FWV 0.0 1.2 0.0 2.7 0.5 0.6 0.0 0.0 0.7 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.0 0.0 1.0 0.7 0.2 MaMoni health worker 0.0 0.0 1.5 0.0 0.0 0.0 0.0 0.0 0.2 HA 0.0 0.0 0.8 0.5 0.0 0.0 0.0 0.0 0.2 FWA 0.0 0.0 0.8 0.0 0.0 0.0 0.0 0.0 0.1 TTBA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 TBA 0.0 0.0 0.0 0.0 0.0 0.6 0.0 0.0 0.1 Homeopath 5.1 17.9 11.2 10.3 12.8 8.2 37.3 10.2 14.6 Ayurved 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Quack 3.1 3.1 7.5 10.3 2.7 1.9 1.5 2.0 3.9 Village doctor 72.3 35.8 46.3 22.2 28.2 53.5 26.0 29.3 39.0 Spiritual person/Kabiraj 0.5 0.0 0.8 0.5 0.5 0.6 1.5 0.7 0.7 Pharmacy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Family member/relative 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Neighbor/Friend 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other health worker 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.7 0.1 Other 0.0 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Note: Multiple answers were accepted
Table 7.6.5: Percent distribution of sites from where the women sought medical care for the sick baby by upazila, Habiganj.
Facility/Site
Azmeriganj 195 N= Bahubol N=162 N=159 N=204 N=147 Baniachang N=134 Chunarughat Lakhai Madhabpur Nabiganj TOTAL N=1374 N= 185 N= Sadar N=188 At home 4.1 17.9 10.5 8.7 10.1 28.9 10.3 8.2 12.0 Satellite clinic 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 FWC 0.0 0.0 0.8 2.7 0.0 0.6 0.5 0.0 0.6 UHC 5.1 9.3 6.7 12.4 2.7 11.3 2.5 6.1 6.8 Chamber of MBBS doctor 9.2 25.9 17.2 22.2 35.6 17.6 23.0 38.1 23.4 Clinic 1.0 1.9 5.2 6.0 6.4 0.6 5.9 4.8 4.0 Community clinic 0.0 0.0 1.5 0.0 0.5 0.6 0.0 0.0 0.3 Hospital 5.1 6.8 7.5 13.5 13.8 9.4 5.4 10.9 9.0 Pharmacy 75.9 40.1 56.0 36.2 34.6 34.0 54.4 34.0 46.2 Other 0.0 0.0 0.0 0.0 0.0 0.0 0.5 0.7 0.2 Note: Multiple answers were accepted
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Table 7.6.6: Percent of newborns had a danger sign and were referred by HA/FWA/MaMoni HW/CHW by upazila, Habiganj. Multiple responses were accepted AREA
N=
Total referred HA/FWA/MaMoni HW / CHW Family members Relatives friends Neighbors/ TBA TTBA doctor Village Others Total: 1,424 86.9 0.6 83.4 13.7 2.8 0.7 0.3 5.2 0.5 Azmeriganj 204 74.5 0.0 66.5 1.3 3.3 0.0 0.0 29.0 0.0 Bahubol 170 84.7 0.7 88.2 10.4 2.8 0.0 0.0 0.0 0.0 Baniachang 138 79.7 0.0 73.6 22.7 0.0 0.0 0.9 3.6 0.9 Chunarughat 194 90.2 2.3 84.6 20.0 5.7 0.0 0.0 1.1 0.0 Sadar 192 96.4 0.0 93.0 11.9 1.1 1.1 0.5 4.3 0.5 Lakhai 163 90.8 0.0 93.9 9.5 1.4 3.4 0.0 0.0 0.0 Madhabpur 212 91.0 1.0 90.2 7.3 1.0 0.0 1.0 1.6 0.0 Nabiganj 151 86.1 0.0 68.5 33.1 6.9 0.8 0.0 2.3 3.1
Table 7.6.6 shows that around 87 percent of newborns who had complication and were referred for seeking treatment. Among referred, 83 percent were referred by family members, 14 percent by relatives, 3 percent by friends and neighbors and 1 percent by TBA/TTBA. The trend was almost similar across the upazilas except in Azmeriganj where 29 percent sick newborns were referred by village doctors and 4 percent by TBA in Lakhai.
Table 7.6.7: Reason of not seeking care for newborn illness by upazila, Habiganj.
Facility/Site
rughat
Baniachang N=4 Chuna N= 9 Sadar N=4 Lakhai N=4 Madhabpur N=8 Nabiganj N=4 TOTAL N=50 Azmeriganj N= 9 Bahubol N=8 Too far 0.0 0.0 25.0 22.2 0.0 25.0 0.0 25.0 10.0 Service hour is inconvenient 0.0 0.0 0.0 0.0 0.0 0.0 0.0 25.0 2.0 Unpleasant behavior of the service 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 provider Lack of skill of the service provider 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Lack of privacy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Inadequate drug 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Have to wait for a long time 0.0 0.0 0.0 11.1 0.0 0.0 0.0 0.0 2.0 Too expensive 55.6 12.5 25.0 33.3 50.0 75.0 37.5 75.0 42.0 Religious reasons 0.0 12.5 0.0 0.0 0.0 0.0 0.0 0.0 2.0 Not beneficial 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Did not know that it is necessary to go 22.2 87.5 75.0 33.3 25.0 25.0 62.5 0.0 44.0 there Could not/Did not get permission 22.2 0.0 0.0 0.0 25.0 0.0 0.0 25.0 8.0 Did not know that it has health care 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 facility Others 0.0 0.0 0.0 11.1 0.0 0.0 0.0 0.0 2.0
Multiple responses were accepted
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Table 7.6.7 shows the reasons for not seeking care for newborn illness. Among those who did not seek care, 10 percent women said that the facility was too far, 42 percent said that the treatment was expensive, 44 percent of women did not know or feel that treatment was required, 8 percent did not get permission from the family, 2 percent said the time was inconvenient for them and other 2 percent mentioned that waiting time was too long in the health facility. Upazila wise variations were seen and distance was mentioned as a reason in Baniachang, Chunarughat, Lakhai and Nabiganj. Similarly lack of permission was mentioned by respondents in Azmeriganj, Sadar and Nabiganj.
CHAPTER 7 REFERENCES
1. IOM, Improving Birth Outcomes: Meeting the Challenge in the Developing World, ed. J. Bale, B. Stoll, and A. Lucas. 2004, Washington, D.C.: The National Academies Press.
2. Santosham, M., et al., Newborn Thermal Care Practices in Rural India: A community-based program to prevent and improve recognition and management of hypothermia. USAID Project Proposal, 2003.
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Chapter-8 Birth Interval and Contraception:
8.1 Birth Interval:
Information on the length of birth intervals provides insight into birth spacing patterns. Research suggests that children born too soon after a previous birth are at an increased risk of having poor health and, consequently, an increased risk of dying, particularly when the interval between births is less than 24 months. Maternal health is also jeopardized when births are close together.
Table 8.1.1: Percentage of women reported desire to delay next pregnancy for at least two years, by upazila, Habiganj.
AREA < 2 ≥ 2 Soon / Cannot be No desire Don’t N Other years years Just now pregnant for child know anymore Total: 2,541 1.1 41.2 6.1 0.2 49.7 0.5 1.1 Azmeriganj 317 1.6 36.3 5.7 0.3 55.8 0.3 0.0 Bahubol 323 1.2 42.1 7.4 0.0 48.0 1.2 0.0 Baniachang 304 2.0 38.2 10.5 0.3 46.4 0.7 2.0 Chunarughat 302 1.7 45.0 6.3 0.0 45.7 0.3 1.0 Sadar 327 1.5 39.5 5.5 0.0 53.2 0.0 0.3 Lakhai 303 0.0 45.5 3.6 0.3 49.8 0.3 0.3 Madhabpur 334 0.6 41.3 4.8 0.3 48.8 0.6 3.6 Nabiganj 331 0.6 42.3 5.1 0.3 49.6 0.3 1.8
Table 8.1.1 shows that around 50 percent of women had no desire for another child and 41 percent of women desired to delay their next child at least 2 years in the in the MaMoni intervention areas of Habiganj. Seven percent of women desired their next child within a short time (less than 2 years). There was no major difference in the time interval in desiring the next child among the upazilas. However, in Baniachang 11 percent of women desired to have their next child within 2 years while it was low (4-7 percent) in the other seven upazilas. Around 56 percent of women in Azmeriganj had no desire for additional child.
Table 8.1.2 shows that birth intervals were generally long in Habiganj. Around 77 percent of women (excluding women having a first pregnancy) in the intervention area actually delayed their pregnancy for at least 2 years. There was no significant variation among the upazilas, although the situation was better in Bahubol and Chunarughat (around 82 percent). Maternal education and wealth quintile did not seem to have any effect on birth spacing of mothers but there were marked variations by maternal age and parity. Younger women were less likely to delay pregnancy. 42 percent of women less than 20 years of age delayed their pregnancy for at least two years compared to around 90 percent of women aged 35 years or more. Similarly, about 35 percent of women with low parity (1) actually delayed their last pregnancy by at least two years while the rate was around 80 percent among women had two or more children.
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Table 8.1.2: Percentage of women whose recent pregnancies were actually delayed for at least 2 years by upazila and by selected demographic and socio-economic characteristics in Habiganj.
N= Pregnancy delayed for at least 2 years Total: 1,909 77.7 Azmeriganj 248 73.8 Bahubol 243 81.5 Baniachang 225 77.3 Chunarughat 227 81.1 Habiganj Sadar 234 79.1 Lakhai 244 77.1 Madhabpur 232 79.7 Nabiganj 256 73.1 Maternal education No education 776 81.4 Primary 423 76.6 Class 5-9 639 73.4 Class 10+ 71 83.1 Maternal age <20 52 42.3 20 – 24 565 68.5 25 – 29 664 80.6 30 – 34 386 83.2 35 – 39 186 90.9 40 + 56 89.3 Birth order 0 6 33.3 1 99 35.4 2 567 78.0 3 458 80.8 4 314 84.7 5+ 465 79.4 Wealth Quintile Lowest 424 79.3 Second 401 78.3 Middle 383 77.6 Fourth 359 75.2 Highest 342 76.6
8.2 Family Planning:
This section presents information on use of family planning methods after delivery and the sources of contraceptive methods. Contraceptive use within six months after delivery and during the time of the interview was recorded. Knowledge of family planning methods is widespread in Bangladesh and almost all ever-married women know at least one modern method of family planning (BDHS 2007).
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Table 8.2.1: Percent distribution of women used any family planning method during first six months after delivery by upazila, Habiganj.
Contraceptive methods Azmeriganj N= 317 Bahubol N=323 Baniachang N=304 Chunarughat N= 302 Sadar N=327 Lakhai N=303 Madhabpur N=334 Nabiganj N=331 TOTAL N=2541 Did not use any method 63.1 79.0 79.9 68.5 65.4 75.3 73.1 68.9 71.6 Female Sterilization 2.5 0.3 1.3 0.7 0.9 1.0 0.9 0.6 1.0 Male Sterilization 0.0 0.0 0.0 0.7 0.9 0.3 0.3 0.0 0.3 Pill 18.3 13.3 12.5 19.2 15.9 15.8 18.3 19.3 16.6 IUD 1.0 0.0 0.0 0.3 0.0 0.0 0.6 0.3 0.3 Injection 3.2 2.8 1.6 4.6 5.5 1.7 1.2 3.9 3.1 Implant 0.3 0.3 0.0 0.0 0.6 0.0 1.5 0.3 0.4 Condom 4.1 2.8 1.6 2.7 4.6 1.0 2.1 4.2 2.9 Safe Day 7.3 1.6 2.6 3.0 5.2 5.0 2.1 2.1 3.6 Withdrawal 0.0 0.0 0.0 0.3 0.9 0.0 0.0 0.0 0.2 LAM 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Others 0.3 0.0 0.3 0.0 0.0 0.0 0.0 0.3 0.1 Did not mention anything 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Table 8.2.1 shows that around 72 percent women did not use any contraceptive method during the first six months after delivery in the intervention upazilas of Habiganj. The pill continued to be by far the most popular method of contraception after delivery and around 17 percent of women reported using this method in Habiganj; it was followed by injection (3 percent) and condoms (3 percent). Around 4 percent of women also reported using traditional methods. Highest 37 percent of women in Azmeriganj reported used contraceptives during first six months of delivery while the rate was lowest in Baniachong (20 percent). There was no significant variation in the selection of method by upazila.
Table 8.2.2 shows the rate of current use of contraception among recently delivered women aged 15 to 49 years during the time of interview. 40 percent of women were using any method of contraception and 4 percent of women reported were pregnant at that time. less than1 percent of women reported being either widowed or separated. Among women using a modern family planning method, more than half (56 percent) reported using pills followed by injection (11 percent) and condom (9 percent); around 5 percent of women reported either adopted male or female sterilization. Around 17 percent women reported using traditional methods and of them followed safe day method. Among the sources of modern methods contraception in Habiganj, a little less than 50 percent of women collected their contraceptive methods from a pharmacy, followed by 17 percent from FWA, 12 percent from UHC and 7 percent from FWC (Fig: 8.1). Less than 3% of women collected contraceptive methods from other sources (Table 8.2.2 ).
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Table 8.2.2: Percent distribution of women was currently using contraceptive methods by method and source of collection of method, Habiganj.
Use of contraception and method N=2,541 Number % Using any method 1,021 40.2 Did not use any method 1,407 55.4 Currently Pregnant 97 3.8 Widowed/ Separated 16 0.6 Name of the method: Female Sterilization 35 3.4 Male Sterilization 14 1.4 Pill 570 55.8 IUD 8 0.8 Injection 116 11.4 Implant 8 0.8 Condom 87 8.5 Safe Day 166 16.3 Withdrawal 7 0.7 LAM 0 0.0 Others 10 1.0 Sources of receiving Contraceptive methods: Hospital 14 1.7 FWC 60 7.1 UHC 99 11.7 Satellite Clinic 19 2.2 MCWC 11 1.3 FWA 142 16.8 Community Clinic 27 3.2 Other Govt Centre 1 0.1 NGO Clinic 8 0.9 NGO Satellite Clinic 0 0.0 NGO Depot Holder 0 0.0 NGO FW 3 0.4 NGO Other 0 0.0 Private Clinic 20 2.4 MBBS Doctor 5 0.6 Quack 0 0.0 Pharmacy 410 48.4 Shop 0 0.0 Friends/Relatives 21 2.5 Others 8 0.9
Fig 8.1: Sources of receiving contraceptive methods
12 17 2 7 2
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Table: 8.2.3: Percentage of women accepted a contraceptive method within 6 weeks of postpartum by method and by background characteristics, Habiganj.
Characteristics N=
Not use Female sterilization Male sterilization Pill IUD Injection Implants Condom Periodic abstinence With drawl LAM Other % % % % % % % % % % % % Total used 240 0.0 7.1 1.3 59.2 0.8 13.3 1.7 10.0 4.6 1.7 0.0 0.4 Within 1 week 14 0.0 92.9 7.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Week-1 0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Week-2 5 0.0 20.0 0.0 20.0 0.0 20.0 0.0 40.0 0.0 0.0 0.0 0.0 Week-3 2 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Week-4 21 0.0 4.8 4.8 57.1 0.0 14.3 0.0 14.3 0.0 4.8 0.0 0.0 Week-5 78 0.0 1.3 1.3 65.4 1.3 19.2 0.0 10.3 0.0 1.3 0.0 0.0 Week-6 120 0.0 0.8 0.0 63.3 0.8 10.8 3.3 9.2 9.2 1.7 0.0 0.8 Total status within 2,541 90.6 0.7 0.1 5.6 0.1 1.3 0.2 1.0 0.4 0.2 0.0 0.0 6 week Maternal education No education 889 76.7 1.5 0.3 12.0 0.2 2.8 0.1 1.4 4.6 0.1 0.0 0.2 Primary 547 71.7 1.3 0.4 16.6 0.6 3.5 0.4 2.6 2.9 1.2 0.0 0.0 Class 5-9 984 69.6 0.6 0.2 19.9 0.2 3.4 0.6 2.6 2.6 0.1 0.0 0.1 Class 10+ 121 49.6 0.0 0.0 23.1 0.0 0.8 0.8 18.2 6.6 0.8 0.0 0.0 Maternal age <20 268 70.9 0.0 0.0 14.6 0.4 5.6 1.1 2.2 5.2 0.0 0.0 0.0 20 – 24 915 70.1 0.3 0.0 20.3 0.4 3.1 0.4 2.4 2.8 0.1 0.0 0.0 25 – 29 721 73.7 1.4 0.4 14.7 0.3 2.2 0.4 3.2 3.3 0.4 0.0 0.0 30 – 34 395 69.4 2.5 0.0 16.5 0.0 3.3 0.0 3.5 4.3 0.0 0.0 0.5 35 – 39 186 75.8 1.1 1.6 10.2 0.0 2.7 0.0 3.8 4.3 0.0 0.0 0.5 40 + 56 75.0 1.8 1.8 12.5 0.0 1.8 0.0 3.6 3.6 0.0 0.0 0.0 Birth order 0 41 97.6 0.0 0.0 2.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1 694 67.3 0.0 0.0 19.5 0.3 3.0 0.7 4.3 4.5 0.4 0.0 0.0 2 569 70.0 0.4 0.0 20.2 0.5 3.0 0.5 2.5 3.0 0.0 0.0 0.0 3 458 71.6 1.5 0.7 15.1 0.0 4.2 0.4 3.9 2.2 0.2 0.0 0.2 4 314 73.9 1.3 0.3 15.3 0.3 3.8 0.0 1.0 3.8 0.0 0.0 0.3 5+ 465 76.1 2.8 0.7 11.6 0.2 1.9 0.0 1.9 4.5 0.0 0.0 0.2 Wealth Quintile Lowest 509 80.2 1.2 0.2 0.4 0.2 2.6 0.4 0.8 3.7 0.0 0.0 0.4 Second 508 77.4 0.4 0.4 13.0 0.4 2.8 0.4 1.4 3.9 0.0 0.0 0.0 Middle 508 72.1 1.6 0.2 15.9 0.4 3.5 0.2 2.2 3.5 0.2 0.0 0.2 Fourth 508 67.3 1.4 0.4 20.9 0.2 3.4 0.6 2.2 3.7 0.0 0.0 0.0 Highest 508 61.0 0.6 0.2 22.8 0.2 3.2 0.4 8.1 3.0 0.6 0.0 0.0
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Table 8.2.3 shows the distribution of use of contraceptive methods by weeks during 6 weeks of postpartum. Only 240 (9 percent) women reported using a contraceptive method during the first six weeks after delivery. Among those 240 women, 6 percent reported using contraception within 1 week of postpartum and majority (91 percent) women were using contraception after 4 weeks of postpartum; the remaining reported beginning the use of contraception between 2-3 weeks postpartum.
Among the women who used any kind of contraceptive method within one week of birth, 93% selected female sterilization while the remaining 7 percent chose male sterilization. The use of pills started from week 2 and around 60 percent of women reported using pills during week 4-6. More women reported using condoms in week 2, which was lower than 15 percent in women using family planning methods in weeks 4-6.
From Table 8.2.3 we can see women with higher levels of education were more likely to use a family planning method. Fifty percent women with more than secondary levels of education were likely to use contraception compared to one-fourth of women with no education. The use of pills was higher in all women but highest (23 percent) in women with more than secondary or more level of education. Also it was notable that the use of condom was highest among with higher level of education.
Maternal age was correlated with the selection of female sterilization as a method of contraception. Use of female sterilization was zero among women of less than 20 years of age and the rate was increased with age. The use of pills did not follow any pattern but was highest (20 percent) among women aged 20- 24 and lowest among women aged (35-39). Condom use was more frequent among older women compared to younger women. The use of injection method (5 percent) and periodic abstinence (5 percent) were more frequent among younger mothers less than 20 years of age.
The female sterilization was more common among women with parity more than 2 and was thrice among women with parity 5 or more compared to women with parity ‘one’. The use of pills varied but was lowest (12 percent) among women with parity 5 or more and highest among women with parity 1-2. Injections and condoms were more popular among women with lower parity.
There was no notable difference in the selection of contraceptive method by level of wealth quintile. However, women belonging to the higher wealth quintile were more likely to use pills, injections and condoms than women with poorer socio-economic status.
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Chapter-9 Community Action Group (CAG):
Community mobilization is one of the major components of the MaMoni project. The intent of this strategic approach is to ensure environment and community-generated action that leads and enables the practice of maternal and newborn healthy behaviors. It has been proven that community participation towards a program, has got a substantial impact over the achievement of the objectives of that program.
9.1 Existence of CAG and Membership
Table 9.1.1: Percent of women reported aware of the existence of a Community Action Group (CAG) in their villages and percentage of whom held membership of CAG (herself or any family member) by upazila, Habiganj.
AREA N Mothers aware about CAG Member of CAG Total: 2,404 17 ( 0.7) 3 (17.7) Azmeriganj 290 0.0 0.0 Bahubol 311 0.0 0.0 Baniachang 291 1.0 0.0 Chunarughat 283 0.4 0.0 Habiganj Sadar 311 1.0 33.3 Lakhai 295 0.0 0.0 Madhabpur 319 1.9 16.7 Nabiganj 304 1.3 25.0
Table 9.1.1 shows that out of 2,404 RDWs interviewed only, 17 (less than one percent) were aware about community action group (CAG) and among them only 3 (18 percent) women were members of any CAG. Among the upazilas, less than 1 percent women from Chunarughat, 1 percent from Baniachang, Sadar and Nabiganj, and 2 percent from Madhabpur were aware of CAG. Of those who aware of CAG, 17 percent of women from Madhabpur and one-third from Habiganj Sadar were members of CAG.
Table 9.1.2: Percentage of women reported aware of activities of the community action group by upazila, Habiganj.
N
Mother’s health Newborn’s health planning Family Education Transporting sick mother & newborn sick Financing & mother newborn Others Don’t know Total: 17 70.6 64.7 29.4 0.0 5.9 5.9 0.0 5.9 Azmeriganj 0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Bahubol 0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Baniachang 3 66.7 66.7 0.0 0.0 33.3 33.3 0.0 0.0 Chunarughat 1 100.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 Habiganj Sadar 3 66.7 66.7 33.3 0.0 0.0 0.0 0.0 0.0 Lakhai 0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Madhabpur 6 83.3 66.7 16.7 0.0 0.0 0.0 0.0 0.0 Nabiganj 4 50.0 50.0 75.0 0.0 0.0 0.0 0.0 25.0
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Table 9.1.2 shows the distribution of awareness of different activities of CAG among the women who were aware of community action group. Most of the women in Habiganj mentioned three activities of CAG. Seventy-one percent women mentioned about “mother’s health” followed by “Newborn’s health” (65 percent) and “Family planning” (29 percent). Six percent of respondents also mentioned transportation and emergency financing of sick mothers and newborns as activities of CAG. The small number of observations makes it difficult to come to any conclusion about the variation across upazilas. Despite that, Table 9.1.2 shows higher percentage of respondents in Baniachang mentioned emergency transportation and financing as activities compared to other upazilas.
Table 9.1.3: Percentage of women had postpartum complication or the newborn complication, used emergency transport or benefited financing from CAG by upazilas of Habiganj.
Had postpartum or Used transport facility Got financial benefit newborn complication from CAG from CAG (N=2541) Total: 67.9 0.0 0.06 Azmeriganj 71.3 0.0 0.0 Bahubol 64.4 0.0 0.0 Baniachang 54.3 0.0 0.0 Chunarughat 77.5 0.0 0.0 Habiganj Sadar 72.5 0.0 0.0 Lakhai 66.0 0.0 0.0 Madhabpur 76.7 0.0 0.0 Nabiganj 60.1 0.0 0.5
Table 9.1.3 shows the percentage of women reported using emergency transport facility or financing from community action group (CAG) among those who had postpartum complication or newborn complication. Only one woman from Nabiganj upazila reported to have received financial benefit from CAG.
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Chapter-10 Hand washing:
Appropriate hand washing practices are basic necessities for good health and can reduce many diseases particularly in children. Studies have shown that hand washing could also help to reduce respiratory problems by 25 percent, (UNICEF and WHO). Inadequate handwashing can cause transmission of enteric diseases. Despite considerable achievement in water and sanitation, hygiene and behavioural practice is lagging behind. The baseline survey in Habiganj collected information on handwashing practices among RDW in the intervention areas.
Table 10.1.1: Percentage of recently delivered women reported washed their hands before most recent preparation of food for family members by type of material used and by upazila, Habiganj.
N= Percentage of women reported washed their hands before most recent preparation of food by category of material used Not wash Only Ash Soap Earth Others Not prepare water any food Total: 2,541 6.4 63.9 0.2 28.6 0.0 0.0 0.9 Azmeriganj 317 7.9 66.6 0.6 24.6 0.0 0.0 0.3 Bahubol 323 4.6 60.4 0.3 34.1 0.0 0.0 0.6 Baniachang 304 11.5 67.1 0.0 20.7 0.0 0.0 0.7 Chunarughat 302 7.3 58.6 0.3 32.1 0.0 0.0 1.7 Habiganj Sadar 327 9.2 64.2 0.3 26.3 0.0 0.0 0.0 Lakhai 303 2.6 75.9 0.0 20.8 0.0 0.0 0.7 Madhabpur 334 4.8 62.6 0.3 30.5 0.0 0.0 1.8 Nabiganj 331 3.6 56.5 0.0 38.7 0.0 0.0 1.2
Table 10.1.1 presents data on handwashing practices before preparation of food. Around 6 percent of the total number of 2,541 women, only 6% reported not washing their hands before food preparation. Among the rest 94 percent of women, 64 percent washed their hands using only water while around 28 percent reported used soap to wash their hands. The highest percentage of soap users were from Nabiganj (39 percent) followed by Bahubol (34 percent) and Chunarughat (32 percent).
Table 10.1.2 describes status of handwashing before last meal taken among RDW in the study area by category of material used. Overall, about 99% of women washed their hands before the last meal taken. Among them three-fourths used only water while 22% used soap for hand washing. Very few women used ash and earth for cleaning their hands. Use of soap was more common in Madhabpur (31%) and least common in Baniachang (14%).
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Table 10.1.2: Percentage of recently delivered women reported washed their hands before taking their last meal by type of material used and by upazilas of Habiganj.
N= Percentage of women reported washed their hands before taking their last meal by category of material used Only Ash Soap Earth Others Not wash hand before water taking meal Total: 2,541 76.2 0.4 22.2 0.04 0.0 1.1 Azmeriganj 317 76.7 0.3 22.7 0.0 0.0 0.3 Bahubol 323 76.2 0.3 22.6 0.0 0.0 0.9 Baniachang 304 84.5 0.0 13.8 0.0 0.0 1.6 Chunarughat 302 80.8 0.0 18.5 0.0 0.0 0.7 Habiganj Sadar 327 78.3 1.2 19.6 0.0 0.0 0.9 Lakhai 303 82.8 0.7 14.2 0.0 0.0 2.3 Madhabpur 334 67.1 0.0 30.8 0.0 0.0 2.1 Nabiganj 331 65.3 0.6 33.5 0.3 0.0 0.3
Table 10.1.3 reports distribution of hand washing materials used before feeding child among the recently delivered women. The table shows that among 95 percent of women who washed their hands before feeding children, 66 percent used only water, 23 percent used soap. Hand washing with soap was found to be highest in Nabiganj (34 percent) and lowest in Lakhai (14 percent) and Baniachang (15 percent).
Table 10.1.3: Percentage of recently delivered women whose child is still alive reported washed their hands before feed their children by type of material used and by upazila, Habiganj.
N= Percentage of women reported washed their hands before feed their children by category of material used Not Only water Ash Soap Earth Others Not fed baby by their wash own hand/ refuse to gave answer Total: 2315 5.4 65.8 0.4 22.6 0.1 0.0 5.7 Azmeriganj 284 4.6 69.7 0.4 24.3 0.0 0.0 1.1 Bahubol 296 5.7 66.2 0.7 24.3 0.0 0.0 3.0 Baniachang 280 7.1 70.0 0.0 15.0 0.0 0.0 7.9 Chunarughat 271 4.1 64.9 0.0 18.8 0.0 0.0 12.2 Habiganj Sadar 300 7.3 64.3 0.0 21.0 0.3 0.0 7.0 Lakhai 291 3.8 74.2 1.0 14.4 0.3 0.0 6.2 Madhabpur 308 7.5 59.4 1.0 28.6 0.0 0.0 3.6 Nabiganj 285 3.2 57.5 0.0 34.0 0.0 0.0 5.3
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Table 10.1.4: Percentage of recently delivered women whose child is still alive reported washed their hands after cleaning their child’s anus by type of material used and by upazilas of Habiganj.
N= Percentage of women reported washed their hands after cleaning their child’s anus by category of material used
Not Only Ash Soap Earth Others Not clean child’s anus/ wash water refuse to gave answer Total: 2,315 1.4 27.4 1.4 62.0 5.4 0.0 2.3 Azmeriganj 284 3.9 47.5 2.8 42.6 2.1 0.0 1.1 Bahubol 296 1.0 25.3 1.4 68.6 2.4 0.0 1.4 Baniachang 280 2.9 28.9 1.4 58.6 4.6 0.0 3.6 Chunarughat 271 0.7 24.0 1.5 64.2 4.8 0.0 4.8 Habiganj Sadar 300 0.0 29.0 1.0 65.0 3.0 0.0 2.0 Lakhai 291 0.3 20.6 2.1 54.6 21.0 0.0 1.4 Madhabpur 308 1.3 23.4 0.7 70.1 2.6 0.0 2.0 Nabiganj 285 1.4 20.7 0.7 71.6 2.8 0.0 2.8
Table 10.1.4 shows that almost all women (99 percent) washed their hands after cleaning their child’s anus. Use of soap for this purpose was more common (62 percent) followed by only water (27 percent) and ash/earth (7 percent). In Azmeriganj almost half (48 percent) of the respondents reported the use of water only; the use of earth/ash was found to high in Lakhai (23 percent) compared 3-7% in the other upazilas.
Table 10.1.5 shows that almost all RDW women washed their hands after defecation.
Table 10.1.5: Percentage of recently delivered women reported washed their hands after defecations by upazila, Habiganj.
N= Percentage of women reported washed their hands after defecations Total: 2,541 99.3 Azmeriganj 317 99.1 Bahubol 323 99.7 Baniachang 304 99.7 Chunarughat 302 99.7 Sadar 327 99.4 Lakhai 303 99.7 Madhabpur 334 98.5 Nabiganj 331 99.1
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Table 10.1.6: Percentage of recently delivered women reported washed their hands with soap at least 3 times during last 24 hours by upazila and by selected demographic and socio-economic characteristics, Habiganj.
N= Percentage of women reported washed their hands by soap at least 3 times a day Total: 2,541 98.2 Azmeriganj 317 96.2 Bahubol 323 98.1 Baniachang 304 98.4 Chunarughat 302 99.0 Habiganj Sadar 327 100.0 Lakhai 303 98.7 Madhabpur 334 97.3 Nabiganj 331 98.2 Maternal education No education 889 97.1 Primary 547 98.4 Class 5-9 984 99.0 Class 10+ 121 100.0 Maternal age <20 268 98.1 20 – 24 915 98.9 25 – 29 721 98.1 30 – 34 395 97.2 35 – 39 186 97.3 40 + 56 100.0 Birth order 0 41 97.6 1 694 98.6 2 569 99.1 3 458 97.8 4 314 97.8 5 + 465 97.4 Wealth Quintile Lowest 509 96.9 Second 508 97.2 Middle 508 98.4 Fourth 508 99.2 Highest 508 99.4
According to table 10.1.6, more than 98 percent of women reported washed their hands at least 3 times a day. The rates were 96 percent in Azmeriganj and 100 percent in Habiganj Sadar. The rates of hand washing three times a day were almost similar across the upazilas and by maternal education, age, parity and wealth quintiles.
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Table 10.1.7 shows the proportion of women washing their hands with soap after certain activities. It was found that women were least careful about handwashing with soap in all upazilas after handling cowdung, after washing child’s hands, before preparing meal, before feeding a child and before and after meal. Most women wash their hands with soap when bathing themselves, after defecation, after cleaning children’s anus, washing clothes or bathing child. Upazila wise distribution has shown in table 10.1.7
Table 10.1.7: Percentage of recently delivered women reported washed their hands with soap by category of work/activity during last 24 hours by upazila, Habiganj.
Provider
541
34 17 23 04 02 27 03 3 Nabiganj N= 331 Total N= 2, Azmeriganj N= 3 Bahubol N= 3 Baniachong N= 3 Chunarughat N= 3 Sadar N= 3 Lakhai N= 3 Madhabpur N= Use any soap within 24 hour 96.9 99.4 98.0 99.7 99.4 99.3 98.2 99.1 98.7 Washing cloths 53.9 69.4 61.5 64.9 69.1 70.0 68.3 59.8 64.6 Bathing herself 88.6 84.5 85.9 88.4 86.5 89.1 90.7 82.2 87.0 Bathing child 25.9 37.5 46.7 35.4 42.5 43.9 40.4 29.3 37.6 Washing child’s hand 2.2 7.4 2.3 4.6 6.7 1.7 9.9 3.6 4.9 Washing child’s anus 46.1 68.4 57.6 44.4 50.5 49.5 62.6 58.0 54.8 Washing hands after defecation 46.1 65.0 51.0 55.3 57.5 47.2 65.0 57.4 55.7 Washing hands after handling cow- 20.2 18.6 9.2 11.9 8.3 14.5 11.4 9.7 13.0 dung Washing hands before feeding child 13.3 16.1 8.2 11.6 12.8 6.9 11.7 22.1 13.0 Washing hands before preparing food 12.3 28.5 17.4 18.2 12.8 8.9 18.9 21.5 17.4 Washing hands before meal 6.3 22.3 8.2 10.9 10.4 5.0 18.9 14.8 12.2 Washing hands after meal 2.8 5.9 3.0 2.0 3.1 1.7 6.0 6.7 3.9 Others 2.2 4.0 1.3 8.6 6.1 2.0 7.2 4.5 4.5
Table 10.1.8 depicts the type of cleansing materials observed in the households during the time of interview. The table reveals that about 92 percent of the households had soaps while around 46 percent had detergent. Only 7 percent of the households had ash/earth. There was no significant variation in the percentages of household had soap during the time of interview.
Table 10.1.8: Percentage of households had soap/detergent/other cleansing material at home observed during the time of interview by upazila, Habiganj.
N= Soap Detergent Ash Earth/sand Others Total: 2,541 91.5 46.4 4.1 2.5 0.8 Azmeriganj 317 80.8 73.2 0.0 0.0 1.0 Bahubol 323 97.5 40.9 1.9 0.3 0.0 Baniachang 304 97.0 61.8 3.3 0.7 0.0 Chunarughat 302 95.7 47.0 16.2 0.3 2.3 Habiganj Sadar 327 93.3 44.3 0.9 0.0 2.8 Lakhai 303 78.6 34.3 3.3 16.8 0.3 Madhabpur 334 96.4 29.0 5.7 2.1 0.0 Nabiganj 331 92.5 42.0 2.4 0.3 0.0
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Table 10.1.9: Percentage of household was able to show stock of additional soap during the interview by upazila, Habiganj.
N= Percentage of household had a stock of soap Total: 2,541 30.5 Azmeriganj 317 34.4 Bahubol 323 19.8 Baniachang 304 27.0 Chunarughat 302 26.2 Habiganj Sadar 327 36.4 Lakhai 303 31.0 Madhabpur 334 24.6 Nabiganj 331 43.8
Table 10.1.9 on the other hand shows the stock of additional soap available in the households interviewed. According to the table, a little less than one-third of the total households had a stock of soap. The maximum number of households with a stock was from Nabiganj (44 percent) while the minimum number of households belonged to Bahubol (20 percent).
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Chapter-11 Neonatal Mortality:
The reduction of neonatal mortality is one of the major objectives of the MaMoni intervention. Another target is to reduce other adverse pregnancy outcomes, such as stillbirths and perinatal mortality. This chapter presents the levels and differentials in neonatal mortality, stillbirth, and perinatal mortality rates by study areas.
Estimates of neonatal mortality, stillbirth rates are based on information from the pregnancy histories of women who delivered in the 12 months preceding the survey. Age at death was recorded in days for children that died in the first month of life. However, because the births and timing of deaths are based on mother’s reporting, the reliability of mortality estimates is dependent on the extent of accurate reporting. Underreporting of early deaths is a concern for estimating neonatal mortality, however, earlier analysis conducted in the Bangladesh Demographic and Health Survey (BDHS) suggests that early neonatal deaths have not been seriously underreported.1 Mortality estimates presented in this report are measured by following four methods:
Early Neonatal death: Death of Newborn before the seventh day of life. Late Neonatal death: Death of Newborn within 7-28 days of life. Neonatal death: Death of Newborn in the first month of life (0-28 days). The conventional definition of neonatal death is the death of the newborn between 0-28 days of life. However, in many developing countries, including Bangladesh, the exact age at death is not available due to the lack of a vital registration system, and is based on reporting by mothers. This leads to a heaping problem at 30 days. As a result, it is a common practice to include deaths between 0-30 days for the estimation of neonatal mortality in developing countries (BDHS 2000). Perinatal death: Still-birth (born dead) after 28 weeks of pregnancy and neonatal death within 7 days of birth.
In addition, the distribution of mortality risks for each day during the first month of life was examined to determine the proportion of neonatal deaths that occur during the first day, first 3 days, and first 7 days of life. This was done to assess the reliability of the data as well as to examine the significance of early intervention needs in preventing neonatal deaths.
Most of the above mortality rates were estimated with live births as the risk population and expressed as the number of deaths per 1000 live births. Rates of stillbirth and perinatal mortality, which includes both stillbirth and early neonatal death, were estimated with the total births (live births plus stillbirths) as the denominator and are expressed as the deaths per 1000 births.
11.1 Levels of Neonatal Mortality
Table 11.1.1 shows the four measures of neonatal mortality (early neonatal mortality, late neonatal mortality, neonatal mortality and perinatal mortality rates) in Habiganj. The overall neonatal mortality estimate for this study was considerably lower (28.4 per 1000 live births) than the earlier estimate based on the 2007 BDHS for the Sylhet division (53 per 1000 live births), NSDP 2005 for Chittagong and
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Sylhet division (34.6 per 1000 live births) and Projahnmo baseline survey 2003 in Beanibazar, Zakiganj and Kanaighat upazilas of Sylhet (46.9 per 1000 live births). Neonatal mortality rate of ACCESS baseline estimate in Sylhet was 23.1 per 1,000 live-births during 2007. Neonatal mortality rate was estimated from one year of observation data (July 2009– June 2010) in Habiganj MaMoni intervention areas as a baseline.
These observed differences may be partially attributed to methodological differences within the study designs, particularly regarding recall and sampling. Accordingly, it is important to mention that the BDHS rates were based on a 10-year period, whereas the baseline survey rates are based on a one-year period. Studies show that the duration of observations may significantly affect mortality estimates, especially in places with rapid changes. Overall, BDHS results suggests that there has been a rapid decline in neonatal deaths in recent years; it has been estimated that neonatal mortality is declining at a rate of about 2.6 neonatal deaths per 1,000 live births per year, and infant mortality is declining at a rate of about 5.8 infant deaths per 1,000 live births per year (BDHS). Given such an accelerated declining trend in mortality rates, the observed lower rates in baseline survey are not unexpected in the current study period. Table 11.1.1 shows early neonatal mortality rate (within 0-6 days) was almost four times higher than late neonatal mortality rate (within 7-28 days) in the intervention area. Neonatal mortality rate was estimated from one year of observation data (Jul’09 – Jun’10) and it was 28.4 per 1000 live-births in the MaMoni intervention area, Habiganj. Similarly Perinatal mortality rate was estimated from the same year of observation and it was 44.3 per 1000 births in Habiganj study area.
Table 11.1.1: Neonatal Mortality Rate and Perinatal Mortality Rate in Habiganj district. (Births between 01/07/2009 to 30/06/2010)
Area Total # of # of live Early NMR Late NMR NMR CI Still Perinatal pregnancy births (0-6 days) (7-28 days) (0-28 days) (Confidence birth Mortality outcome Interval) Rate* # Rate # Rate # Rate
13,031 25.6 - 295 Habiganj 14,409 296 22.7 74 5.7 370 28.4 44.3 (90.4) 31.4 (2.1)
* Perinatal mortality rate (PNMR): Includes both stillbirth and early neonatal death, were estimated from the total births (live births plus stillbirths) as the denominator and are expressed as the deaths per 1000 births.
Table 11.1.2 shows the mortality rates in Habiganj intervention area. Mortality rates among males were higher and gender ratio among neonatal deaths in the study area was 3.1:2.6 (male:female). Overall neonatal death rate varied by level of education of mother (Fig: 11.1). Early, late and overall neonatal death rates were higher among women who had no education compared to those who had higher levels of education. Neonatal death rate was 3.1 percent in mothers with no education compared to mothers with ten or more years of education (2.1 percent). Neonatal mortality rate was high (around 37 per thousand live-births) among women less than 20 years of age while it was 14 per 1000 LBs among women aged 40 years or more. The mortality rate was low (24 per thousand live-births) among women aged 25-29 years. There was no notable correlation in the early, late and the total neonatal death rates by parity of recently delivered women.
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The most striking differentials in mortality rates are observed with the wealth index variable (Table 11.1.2 and Fig: 11.2). While neonatal mortality rate was 33 deaths per 1,000 live births in the lowest wealth quintile, the rate was 19 per 1,000 live births in the highest wealth quintile. Similarly, early neonatal mortality rate was also very high among families in the lowest wealth quintile (26 deaths per 1,000 live births), compared to families in the highest (16 per 1,000 live births) and late neonatal mortality rate was 8 per thousand live-births in lowest wealth quintile group while it was only 3 deaths per thousand live-births in the highest quintile group. Although there is a peak in the rates among women belonging to the middle quintile, for each neonatal mortality category, the lowest wealth quintile group had almost 2 or more times higher mortality risk compared to the richest group.
Table 11.1.2: Mortality estimates in neonatal period by selected demographic and socio-economic characteristics in Habiganj. (Birth between 01/07/2009 – 30/06/2010)
Late Neonatal Early Neonatal Death Neonatal Death Total Number Death (within 7-28 (within 6 days of birth) (0-28 days) of Live-birth days) # % # % # % Habiganj district 13,031 296 2.3 74 0.6 370 2.8 Sex of the child: Male 6,748 161 2.4 45 0.7 206 3.1 Female 6,283 135 2.2 29 0.5 164 2.6 Maternal education: No education 4,403 96 2.2 40 0.9 136 3.1 Primary 2,664 69 2.6 12 0.5 81 3.0 Class 5-9 5,284 117 2.2 22 0.4 139 2.6 Class 10+ 680 14 2.1 0 0.0 14 2.1 Maternal age: < 20 1,618 51 3.2 9 0.6 60 3.7 20 – 24 4,776 115 2.4 22 0.5 137 2.9 25 – 29 3,528 64 1.8 21 0.6 85 2.4 30 – 34 1,964 42 2.1 16 0.8 58 3.0 35 – 39 857 21 2.5 5 0.6 26 3.0 40 + 288 3 1.0 1 0.4 4 1.4 Birth order (Parity): 1 3,568 110 3.1 16 0.5 126 3.5 2 3,190 48 1.5 15 0.5 63 2.0 3 2,315 46 2.0 15 0.7 61 2.6 4 1,513 34 2.3 13 0.9 47 3.1 5+ 2,554 58 2.4 15 0.6 73 3.0 Wealth Quintile: Lowest 2,612 67 2.6 20 0.8 87 3.3 Second 2,653 67 2.5 17 0.6 84 3.2 Middle 2,585 71 2.8 17 0.7 88 3.4 Fourth 2,607 49 1.9 13 0.5 62 2.4 Highest 2,574 42 1.6 7 0.3 49 1.9
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Fig. 11.1: Early, late and neonatal death rates by maternal education:
No education Primary Class 5-9
Early Neonatal Death Late Neonatal Dea
Fig.11.2: Early, late and neonatal death rates by maternal socio-economic characteristic (Wealth Quintile)
Lowest Second Middle Fourth
Early Neonatal Death Late Neonatal Death Lowest 26 08 Table 11.1.3 presents data on still birth and abortion rates in the study areas of Habiganj. The results show that the rate of still-birth, abortion rate within three months of pregnancy and abortion between 4-7 months of pregnancy were 2.1 percent, 5.3 percent and 2.2 percent respectively. The survey shows that the lower the maternal level of education higher the rate of still-birth. Similarly abortion rate between 4-7 months of pregnancy was more than three times higher among women who had no education than the women having higher secondary level of education. But the rate of abortion within 3 months of pregnancy was found to be highest among women with secondary or higher levels of education. Possibly this was due to increased MR among educated women. No notable pattern was found between rates of still birth and maternal age. However, rates of abortion was lowest in women aged 20-24 and then increased with increasing age. Also rates of abortion was high among women with age <20 years. There was no variation by parity in still-birth and abortion rate but still birth (30%) and abortion rates (27% - abortion between 4-7 months, 43% -abortion within 3 months) were highest among women who had no living child. There was also no such variation in mortality rates by household socio-economic condition (wealth quintile), but abortion rate within 4-7 months of pregnancy decreased with increasing socio-economic status.
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Table 11.1.3: Rate of Still-birth and Abortion by selected demographic and socioeconomic characteristics in Habiganj. (Birth between 01/07/2009 – 30/06/2010)
Total Number Still-birth Abortion between 4-7 Abortion within 3 of pregnancy months months outcome # % # % # % Habiganj district 14,409 295 2.1 316 2.2 767 5.3 Maternal education: No education 4,949 112 2.3 148 3.0 286 5.8 Primary 2,951 61 2.1 62 2.1 164 5.6 Class 5-9 5,766 112 1.9 99 1.7 271 4.7 Class 10+ 743 10 1.4 7 0.9 46 6.2 Maternal age: <20 1,773 38 2.1 43 2.4 74 4.2 20 – 24 5,168 105 2.0 76 1.5 211 4.1 25 – 29 3,861 67 1.7 76 2.0 192 5.0 30 – 34 2,252 57 2.5 72 3.2 159 7.1 35 – 39 999 22 2.2 30 3.0 90 9.0 40 + 354 6 1.7 19 5.4 41 11.6 Birth order (Parity): 0 319 96 30.1 85 26.7 138 43.3 1 3,832 61 1.6 46 1.2 157 4.1 2 3,436 50 1.5 54 1.6 142 4.1 3 2,500 33 1.3 39 1.6 113 4.5 4 1,659 22 1.3 35 2.1 89 5.4 5+ 2,663 33 1.2 57 2.1 128 4.8 Wealth Quintile: Lowest 2,908 51 1.8 83 2.9 162 5.6 Second 2,911 63 2.2 70 2.4 125 4.3 Middle 2,856 61 2.1 61 2.1 149 5.2 Fourth 2,892 68 2.4 55 1.9 162 5.6 Highest 2,842 52 1.8 47 1.7 169 6.0
Table 11.1.4 shows the variations of perinatal death rates by selected demographic and socioeconomic characteristics of women in the MaMoni area. The overall perinatal mortality rate was 44 deaths per 1000 births in the study area an estimated half of which (21 per 1000 births) were due to stillbirths. Perinatal death rate was 4.6 percent among women who had no education, while it was 3.1 percent among women who had secondary or higher level of education. Rates of perinatal death was higher among younger women of less than 20 years of age (5.4 percent) and among older women of 30-39 years of age (5 percent). Rate was lower among women of 25-29 years of age (around 3.6 percent). There was no difference of perinatal death rate by parity but it was highest among women with parity 1. It was also observed that perinatal death rates were almost similar across the different wealth quintiles of the women but was lowest in the highest wealth quintile (3.6 percent).
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Table 11.1.4: Rate of Perinatal death by selected demographic and socioeconomic characteristics in Habiganj. (Birth between 01/07/2009 – 30/06/2010)
Perinatal deaths (Still-births + early Total Number of neonatal death [within 1 week] Births (Live + Still) # % Habiganj district 13,326 591 4.4 Maternal education: No education 4,515 208 4.6 Primary 2,725 130 4.8 Class 5-9 5,396 229 4.2 Class 10+ 690 24 3.5 Maternal age: <20 1,656 89 5.4 20 – 24 4,881 220 4.5 25 – 29 3,595 131 3.6 30 – 34 2,021 99 4.9 35 – 39 879 43 4.9 40 + 294 9 3.1 Birth order (Parity): 0 96 96 100.0 1 3,629 171 4.7 2 3,240 98 3.0 3 2,348 79 3.4 4 1,535 56 3.7 5+ 2,478 91 3.7 Wealth Quintile: Lowest 2,663 118 4.4 Second 2,716 130 4.8 Middle 2,646 132 5.0 Fourth 2,675 117 4.4 Highest 2,626 94 3.6
Table 11.1.5 shows the distribution of neonatal deaths by age in days. Around 40 percent of all neonatal deaths happened within 24 hours of birth in MaMoni study area. Half of all neonatal deaths were reported within 2 days of birth and 80 percent of deaths occurred within 6 days. The rest (20 percent) occurred between 7-28 days of life.
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Table 11.1.5: Distribution of deaths by age of newborn in Habiganj
Age at Death Habiganj (MaMoni area) (in days) # % cum-% 0 150 40.5 40.5 1 34 9.2 49.7 2 24 6.5 56.2 3 38 10.3 66.5 4 22 6.0 72.4 5 18 4.9 77.3 6 10 2.7 80.0 7 10 2.7 82.7 8 7 1.9 84.6 9 8 2.2 86.8 10 2 0.5 87.3 11 3 0.8 88.1 12 6 1.6 89.7 13 2 0.5 90.3 14 2 0.5 90.8 15 5 1.4 92.2 16 2 0.5 92.7 17 4 1.1 93.8 18 2 0.5 94.3 19 0 0.0 94.3 20 3 0.8 95.1 21 5 1.4 96.5 22 3 0.8 97.3 23 1 0.3 97.6 24 0 0.0 97.6 25 2 0.5 98.1 26 4 1.1 99.2 27 1 0.3 99.5 28 2 0.5 100.0 Total 370 100.0
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Chapter-12 Discussion:
The baseline survey aims to serve as the benchmark for the evaluation of MaMoni intervention program. Results from the subsequent final evaluation survey will be compared against the data presented in this document to assess the adequacy of the implementation of the intervention and demonstrate its effectiveness. The following effectiveness measures will be used: (1) improvements in knowledge of maternal and neonatal health care; (2) improvements in maternal health care practices, including antenatal, delivery, and post-partum care; (3) improving care seeking for maternal complications; (4) improving newborn care practices including care seeking for complications; and (5) reducing neonatal mortality.
12.1 Socio-demographic characteristics of the women in the survey:
Baseline survey results have highlighted deficiencies in education and the disproportionate loss of males to abroad employment that are particularly prevalent in Sylhet Division. However, overall, baseline data indicates that the study population maintains comparable socio-demographic and economic characteristics to those observed across Sylhet Division in the BDHS. Across project upazilas of Habiganj, considerable variation was observed, however, the fact that these differences were not present across intervention upazilas indicates that the randomization scheme used is indeed effective in ensuring comparability with regard to population characteristics. Given that health care utilization, health related knowledge, and neonatal health outcomes are known to vary significantly by socioeconomic status, the observed similarity in baseline characteristics across upazilas will be crucial for ensuring validity and generalizability of project results.
12.2 Knowledge of Maternal and Neonatal Health
Maternal knowledge of complications during pregnancy, delivery, and postpartum as well as of neonates, as revealed by the survey, provides crucial information about care-seeking and the conditions under which women are supposed to seek appropriate medical care. Conditions like eclampsia, bleeding, obstructed labor and sepsis require immediate professional medical and emergency obstetrical care services and are the major causes of maternal morbidity and mortality, and of fetal and neonatal deaths. Baseline survey results indicated that ~90% of women were able to name at least one major complication during pregnancy, delivery, and post-partum care. While this figure suggests that a large percentage of women are cognizant of potential complications, it offers little immediate insight into the correlation between knowledge, care-seeking, and health outcomes. Overall, slight differences were observed in maternal knowledge of complications during pregnancy, delivery, post-partum, and for neonates by MaMoni upazilas, however, these differences were not apparent across the upazilas. Direct comparison of baseline levels of maternal knowledge with those reported in the Bangladesh Maternal Health Services and Maternal Morbidity Survey (BMMS) was not possible as results are combined for complications cited during pregnancy, delivery, and post-partum. However, it bears mention that the most frequently cited complications in the BMMS were similar to those observed in the baseline survey.
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12.3 Maternal Health Care
Baseline data on maternal health care focused primarily upon the (1) utilization and content of antenatal care (ANC); (2) nutrition and immunizations; and (3) aspects of birth preparedness, delivery care and postpartum care.
Overall, results indicated that ANC utilization in the intervention area was low; 40 percent of women reported having received any ANC and 10 percent received at least four ANC check-ups from a skilled provider. This finding, while comparable to national estimates observed in the BMMS, demonstrates a considerable gap between service need and receipt. In addition, it highlights the need for further research to identify barriers to ANC utilization (i.e. financial and geographic). In view of these findings, MaMoni activities to increase ANC coverage are particularly timely and appropriate.
Baseline results indicate a low intake rate of iron-folic acid during pregnancy (~35 percent) in the intervention upazilas of Habiganj. This result is a cause for concern, and suggests one or more of the following: (a) the content of advice received is insufficient and/or not convincing; (b) there are barriers to iron tablet access; and/or (c) health workers need to conduct follow-up visits to monitor iron tablet intake. In addition to iron supplementation, overall TT immunization coverage rates was found very high and 85 percent of newborns were protected against neonatal tetanus at birth. Overall, the low ANC utilization rates (40 percent) coupled with the low iron tablet consumption need to improve service linkages within the health system and among the population.
The baseline survey results indicate that the majority of deliveries occurred in the home (85 percent), and over 90 percent of them were conducted by TBAs and TTBAs. While consistent with BDHS results, these findings demonstrate that there are considerable socioeconomic inequalities in institutional delivery care present within MaMoni areas. The overwhelming reliance upon TBAs additionally raises the importance of developing effective strategies to increase utilization of skilled birth attendants. Also in immeditate term when untrained providers continue attending deliveries, interventions are needed to ensure clean delivery and referral for danger signs. Further, particular attention will need to be paid to targeting women with higher parity, lower level of education, and of lower socioeconomic status to counteract their tendency to rely upon unskilled practitioners for care.
12.4 Maternal Health Problems and Treatment Seeking Behaviors
Early recognition of life threatening danger signs and symptoms of pregnancy related complications, and immediate care seeking from trained health professionals are key to reducing risk of maternal morbidity and mortality, miscarriage, stillbirth and early neonatal deaths. The baseline survey examined the occurrences of potentially life threatening complications, and treatment seeking behaviors of the recently delivered women.
Results indicate that the overall number of reported complications (~35 percent) in the intervention areas is almost same as the national estimates reported in the 2004 BDHS, but lower proportion of women (15 percent) reported experienced any maternity complication in the 2007 BDHS. The high proportion of individuals who developed maternal complications and did not seek medical care (40 percent), coupled with the high reliance upon unskilled health workers for care (~30%) highlights the need for further research to identify barriers to medical care access and the overall factors affecting care-seeking.
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Baseline findings on newborn care practices indicate that immediate attention needs to be paid to improving thermal care, cord care and breastfeeding practices, exclusive breastfeeding in particular. Hypothermia prevention efforts are currently grossly deficient as only 5 percent of newborns were dried and wrapped immediately following birth (within 5 minutes). Further, the application of some form of indigenous substance on the umbilical cords of 33 percent of children highlights the need for improved counseling on dry cord care practices. During the neonatal period, mothers reported that ~60 percent of neonates developed some form of illness and less than half of them received medical care from trained providers. Medical care was sought for an estimated 97 percent of sick neonates, with the primary provider being unskilled health professionals (55 percent). Overall, findings on care-seeking immediately following birth and during the first month of life highlight fluctuations in provider preferences at certain periods. Finally, one major area requiring immediate attention is that of breastfeeding. Despite being nearly universally practiced, attention needs to be paid to encouraging immediate initiation of breastfeeding following birth and exclusive breastfeeding throughout the first 6 months of life.
12.6 Neonatal Mortality
With an early neonatal mortality rate in Habiganj of 22.7 deaths per 1000 live births, around 80 percent of all neonatal deaths are estimated to occur within the first 7 days of life. Overall, neonatal (28.3 per 1000 live births) mortality rates within the MaMoni area is lower than that reported in the 2007 BDHS (mid year 2004, 37/1000 live-births as a national rate) and from 39.7 deaths per 1000 live-births reported in the endline survey of 2005 in the comparison area of Projahnmo (three upazilas of Sylhet district), 34.6 deaths per 1000 live-births in NSDP survey 2005 (mid year 2000 of Chittagong and Sylhet division), 27.9/1000 live-births from MNTE LQA-CS, EPI 2008 in Sunamganj were collected and reported. However, despite these declines, mortality rates were observed to vary markedly by wealth index, maternal educational status, gender and parity. Among these demographic parameters, neonatal mortality varied most notably by the wealth index variable as the lowest wealth quintiles had more than a 2 times higher mortality risk, compared to the wealthiest. The wealth index variable was found to exert similar influence on perinatal mortality, which additionally varied by gender. Collectively, these results support previous findings, which identified differentials in quality of care and care-seeking across a variety of characteristics, most namely wealth, maternal education, parity and gender. In further substantiating these findings, results emphasize the need for intervention activities to target vulnerable sub-populations and ensure that these identified gaps in care and health outcomes are bridged.
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Chapter-13 Appendix:
Appendix: A (RDW listing form)
RDW and MWRA Listing Form (Ma-Moni, Habiganj) eZ©gv‡b weevwnZv Ges eqm 50 eQ‡ii Kg gwnjv‡`i ZvwjKv Upazila:______|___| Union: ______|___|___| Cluster #: |___|___|___|___| Village: ______|___|___|___|___| Bari Name Bari location Name of HH head List of currently married Any of them is RDW? If RDW, then date of outcome? evwo evwowUi Lvbv cÖav‡bi women of <50 years old G‡`i g‡a¨ wK †KD RDW n‡j cÖm‡ei ZvwiL cÖav‡bi Ae¯’v‡bi bvg eZ©gv‡b weevwnZv m¤úÖwZ (w`b/gvm/eQi)
Ges eqm 50 eQ‡ii Kg bvg ev eY©bv cÖmeKvix (
evwowU gwnjv‡`i ZvwjKv (bvg) cÖm‡ei ZvwiL
†h bv‡g 01/05/09 – 31/07/10)
Bari # bs evwo HH # bs Lvbv cwiwPZ Serial # 1 Yes |__| No|__| |__|__|-|__|__|-|__|__| 2 Yes |__| No|__| |__|__|-|__|__|-|__|__| 3 Yes |__| No|__| |__|__|-|__|__|-|__|__| 4 Yes |__| No|__| |__|__|-|__|__|-|__|__| 1 Yes |__| No|__| |__|__|-|__|__|-|__|__| 2 Yes |__| No|__| |__|__|-|__|__|-|__|__| 3 Yes |__| No|__| |__|__|-|__|__|-|__|__| 4 Yes |__| No|__| |__|__|-|__|__|-|__|__| 1 Yes |__| No|__| |__|__|-|__|__|-|__|__| 2 Yes |__| No|__| |__|__|-|__|__|-|__|__| 3 Yes |__| No|__| |__|__|-|__|__|-|__|__| 4 Yes |__| No|__| |__|__|-|__|__|-|__|__| 1 Yes |__| No|__| |__|__|-|__|__|-|__|__| 2 Yes |__| No|__| |__|__|-|__|__|-|__|__| 3 Yes |__| No|__| |__|__|-|__|__|-|__|__| 4 Yes |__| No|__| |__|__|-|__|__|-|__|__| Name of Lister: ______|___|___|___| Date: ______Supervisor: ______|___|___|___| Date: ______123 | Page
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Appendix: B (List of indicators for evaluation)
List of ACCESS / MaMoni Indicators by section, Sylhet (Midline Evaluation)
Reproduction and Birth history: 1 Neonatal Mortality Rate in the MaMoni intervention area, Habiganj 2 Percent of recent mothers who want to delay their next pregnancy for at least 2 years. 3 Percent of recent mothers whose recent pregnancy were delayed for at least 2 years 4 Percent of recent mothers who accepted a contraceptive method by 6 weeks postpartum. 5 Number/Percentage of recent mothers who are currently practicing (if baby is >6 months) or practiced (if baby >6 months) LAM as a method of contraception. 6 Number/Percentage of recent mothers who know LAM as a method of contraception (disaggregated by source of information, e.g. AC, FWA, FWV, TBA, Doctors, etc). 7 Percent of recent mothers who know the three conditions that must be met to be able to use LAM as a method of contraception. Knowledge: 8 Percent of recent mothers who can cite the key components of birth plans. 9 Percent of recent mothers who can cite at least three danger signs of pregnancy 10 Percent of recent mothers who can cite at least three danger signs of childbirth 11 Percent of recent mothers who can cite at least three danger signs postpartum 12 Percent of recent mothers who can cite at least three danger signs in newborn babies 13 Percent of recent mothers who are aware of the existence of a Community Action Group (CAG) in their villages 14 Percent of recent mothers who are aware of the existence of an emergency transport system 15 Percent of recent mothers who are aware of the existence of an emergency financing system Antenatal Care: 16 Percent of recent mothers who reported receiving two TT immunizations during their last pregnancy 17 Percent of newborns were protected from neonatal tetanus 18 Percent of recent mothers who consumed iron/folate tablets during their last pregnancy 19 Percent of recent mothers who received at least four ANC visits from a skilled provider during their last pregnancy by type of provider 20 Percent of recent mothers who reported having developed a danger sign during pregnancy and sought care from a skilled provider by type of provider 21 Percent of recent mothers who reported having received at least two home visits by an ACCESS Counselor/MaMoni HW during their last pregnancy 22 Percent of recent mothers who reported receiving counseling from an ACCESS Counselor on the importance of 4 ANC visits by a skilled provider 23 Percent of recent mothers with a danger sign during pregnancy who were referred by an ACCESS Counselor Delivery: 24 Percent of recent mothers who had a birth plan during their last pregnancy 25 Percent of recent mothers whose birth was attended by a skilled provider by type of provider, by place of delivery 26 Percent of recent mothers who reported having developed a danger sign during childbirth and sought care from a skilled provider by type of provider 27 Percent of recent mothers with a home birth (without a skilled provider) who reported having developed a danger sign during childbirth and were referred by the birth attendant by type of birth attendant 28 Percent of recent mothers who received birth kits from ACCESS Counselor MaMoni HW Immediate Newborn Care: 29 Percent of recent mothers who gave birth at home whose newborns were attended by a Newborn Care Person at birth.
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30 Percent of recent mothers who gave birth at home whose newborns’ cord were cut with clean/new instrument or that clean birth kit were used at their last childbirth 31 Percent of newborns who were breastfed within the first hour after childbirth 32 Percent of newborns who were exclusively breastfed in the last 24 hours 33 Percent of newborns whose first bath was delayed for 3 days 34 Percent of newborns who were delivered at home who were dried and wrapped immediately after birth 35 Percent of newborns who had nothing applied on to their umbilical stump after birth 36 Percent of recent mothers who reported using KMC or skin-to-skin with their newborn for their most recent birth Postpartum: 37 Percent of recent mothers who received a PNC visit within 3 days after childbirth 38 Percent of recent mothers who received at least two PNC visits for themselves from a skilled provider after childbirth by type of provider 39 Percent of recent mothers who received at least two PNC visits for their newborns from a skilled provider after childbirth by type of provider 40 Percent of recent mothers who reported having developed a postpartum danger sign and sought care from a skilled provider by type of provider 41 Percent of recent mothers who reported that their newborns developed a danger sign at birth or within 1 month after birth and sought care from a skilled provider by type of provider 42 Percent of recent mothers who reported receiving counseling from an ACCESS Counselor on the importance of 2 PNC visits 43 Percent of recent mothers who reported receiving home visit by an ACCESS Counselor within 24 hours after childbirth 44 Percent of recent mothers who reported receiving home visit by an ACCESS Counselor within 5-7 days after childbirth 45 Percent of recent mothers with a postpartum danger sign who were referred by an ACCESS Counselor 46 Percent of newborns with a danger sign who were referred by an ACCESS Counselor Community Action Group: 47 Percent of recent mothers who are aware of the existence of a Community Action Group (CAG) in their villages 48 Percent of recent mothers who are members of Community Action Group (CAG) 49 Percent of recent mothers who are aware of the existence of an emergency transport system 50 Percent of recent mothers who experienced a pregnancy-related complication, or whose newborns experienced a complication, who used the emergency transport 51 Percent of recent mothers who are aware of the existence of an emergency financing system 52 Percent of recent mothers who experienced a pregnancy-related complication, or whose newborns had a complication, who were benefited from the emergency financing system Hand Washing: 53 Percentage of recent mothers who live in households with soap at the place for hand-washing, by background characteristics 54 Percentage of recent mothers who washed their hands with soap at critical times 24 hours prior to the survey
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Appendix-C (Questionnaire for RDW-Habiganj)
MaMoni Survey 2010 Questionnaire for Recently Delivered Women (RDW), HABIGANJ
IDENTIFICATION Name Code District HABIGANJ Upazila Interview starting time: Union
Cluster # |______|______| : |______|______| Hour Minute Village
BARI name & no. Interview end time: Household number |______|______| : |______|______| Name of RDW Hour Minute
Husband’s name of RDW Name of household head
INTERVIEWER’S VISIT AND STATUS Visit 1 Visit 2 Visit 3 Final Visit
Date |_____|_____|-|_____|_____|-|_____|_____| |_____|_____|-|_____|_____|-|_____|_____| |_____|_____|-|_____|_____|-|_____|_____| Date |_____|_____|-|_____|_____|-|_____|_____| Interviewer’s Interviewer’s Name |_____|_____|_____| code Result code* |_____|_____| |_____|_____| |_____|_____| Result code |_____|_____| Date: Date: Next Visit Total # of visits |_____| Time: Time: RESULT CODES*:
01. Interview Complete 06. Woman who has recently delivered is absent 02. No HH Member or competent respondent were present 07. No recently delivered woman [Pregnncy outcome in the last at home at the time of HH visit 15 months (01 May 2009 to 31 July 2010) 03. Interview cancelled 08. Others ______04. Refused to give interview (Specify) 05. Could not find the residence
Supervision Name Code Date
Reviewed by Supervisor |____|____| |____|____|-|____|____|-|____|____|
Checked by Field Editor |____|____| |____|____|-|____|____|-|____|____| Reviewed by Office
Editor |____|____| |____|____|-|____|____|-|____|____|
Keyed by |____|____| |____|____|-|____|____|-|____|____|
International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B)
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Information sheet to obtain verbal consent from participants
Title of Project: Evaluation of the ACCESS/MaMoni Bangladesh program: population based surveys in Sylhet division of Bangladesh.
Principal Investigator: Shams El Arifeen Head, Child Health Unit PHSD, ICDDR,B
Description of the project:
We are working on behalf of Save the Children, USA to conduct household surveys for the project entitled ‘ACCESS/MaMoni’ aiming to reduce morbidity and mortality of newborn babies. The project is implemented in seven upazilas of Sylhet, and all the eight upazilas in Habiganj by government and NGO health workers under the financial support of Save the Children USA. ACCESS/MaMoni needs to know the health status of babies and mothers during pregnancy, delivery and during postnatal period. The findings will be utilized in a way that, it will be more effective and acceptable to you and the members of your communities. The information will also help to ascertain rates of newborn deaths and improvement of the newborn health practices in this community. In this regard, we are interviewing women with pregnancy outcomes in the last one-year or married women of 15-49 years to know these important information. So, we seek your permission for your participation in this survey. If you agree to participate in this survey, we will ask you questions regarding your family, how you/your family provided/received cares for health during pregnancy, delivery and in the neonatal period. You will be interviewed once and it would take only 30-45 minutes.
We hope you will take part in this survey voluntarily. You have the right to withdraw yourself from taking part in the survey at any time. You can also avoid answering any question that you think sensitive. Even if you do not want to take part in the survey, or if you withdraw yourself, you will still receive the same quality of services and care from health workers.
Your identity will remain confidential. Only project staff will have access to these forms.
If you think that you’ve been treated unfairly or been hurt by joining this survey or if you have questions, you may contact Dr. Shams El Arifeen, Principal Investigator and head of Child Health Unit, ICDDR,B, Mohakhali,
Dhaka, Tel# 880-2-8860523-32, Ext 3800 and/or Mr. M. A. Salam Khan, Committee Coordination Secretariat,
ICDDR,B, Mohakhali, Dhaka, Tel # 880-2-9886498.
Do you agree? Yes |___| No |___|
Signature of the Interviewer: ______Date: ______
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Section A: Household Section
Interview starting time - Hour Minute Now we would like to know some information about you and your household. NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 11 How many members usually live in your household? Total # of HH member...... Please give the number of household member 12 Now tell me how many male and female Male Female members are there in your household: 0-4 years ......
5-14 years...... If none, write ‘00’ in box. 15-29 years ......
Calculate the total number of male and female 30-49 years ......
and write in the Total box 50 and Above ......
Total ...... 13 Write the total of male and female members Total number of male and female ...... from Q12 in the box and reconcile with Q11 14 What is the main source of water your Piped water: household used for dish washing? Piped inside dwelling ...... 11 Piped outside dwelling ...... 12 Well water: Tubewell ...... 21 Shallow Tubewell ...... 22 Deep Tubewell ...... 23 Surface Well/Other Well ...... 24 Surface water: Pond/Tank/Lake ...... 31 River/Stream ...... 32 Rain water ...... 41 Other ______96 (Specify) 15 What kind of toilet facility does your household Septic Tank/Modern Toilet 11 have? Pit Toilet/Latrine: Water sealed/Slab Latrine ...... 21 Pit Latrine ...... 22 Open/Hanging Latrine ...... 23 No Facility/Bush/Field ...... 31 Other ______96 (Specify) 16 Does your household have electricity? Yes ...... 1 No ...... 2 17 How many (OBJECT) does your household (or Item Number any member of your household) have? A Almirah or Wardrobe ...... B Table ...... C Chair/Bench ...... CHECK EVERY ITEM. D Functioning watch/Clock ...... If none enter ‘00’ E Cot/Bed ...... F Functioning radio ...... G Functioning television ...... H Quilt (lep or kombol) ...... I Mattress ...... J Functioning refrigerator ...... K Bicycle ...... L Motorcycle ...... M Functioning Sewing machine ...... N Functioning telephone ...... O Functioning mobile phone ...... P Car/Microbus/Tempo ...... Q Rickshaw/Rickshaw-van ...... R Boat ...... 18 How many of the following animals are owned Animal Number
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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP by your household? A Cow ...... B Buffalo ......
C Goat ...... If don’t know enter ‘97’. D Sheep ...... E Chicken ...... If none enter ‘00’. F Duck ...... G Pigeon ...... 19 Main Material of the Roof: Natural Roof: Katcha (Bamboo/Thatch) ...... 11 (Record observation.) Rudimentary Roof: Tin ...... 21 Finished roof (Pukka): Cement/Concrete/Tiled ...... 31 Other ______96 (Specify) 20 Main material of the Walls: Natural Walls: Jute/Bamboo/Mud (Katcha) ...... 11 (Record observation.) Rudimentary Walls: Wood...... 21 Finished Walls: Brick/Cement ...... 31 Tin ...... 32 Other ______96 (Specify) 21 Main material of the Floor: Natural floor: Bamboo/Earth (Katcha) ...... 11 (Record observation.) Rudimentary floor: Wood...... 21 Finished floor (pukka): Cement/Concrete ...... 31 Other ______96 (Specify) 22 Does your household own any homestead? Yes ...... 1 IF ‘NO’, PROBE: Does your household own homestead at any No ...... 2 other places? 23 Does your household own any land (other than Yes ...... 1 the homestead land)? No ...... 2 101 24 How much land does your household own (other than the homestead land)? Amount______ACRE DECIMALS Specify Unit______(1 KIYAR = 30 DECIMALS) 25 Do you have any relative living or working Yes ...... 1 outside of Bangladesh? No ...... 2 101 26. 27. 28. 29. Does any of them in ______? Do they send you Can you use How many times have they (COUNTRY) money? this money sent you money in last one (Ask for each country) when you are year? in need? YES ...... 1 YES ...... 1 Number of times ...... NO ...... 2 NO...... 2 YES ...... 1 A. UK/LOndon (SKIP TO B) (SKIP TO B) Never Send Money ...... 00 NO ...... 2 DON’T KNOW ...... 97 YES ...... 1 YES ...... 1 Number of times ...... NO ...... 2 NO...... 2 YES ...... 1 B. Middle east (SKIP TO C) (SKIP TO C) Never Send Money ...... 00 NO ...... 2 DON’T KNOW ...... 97 YES ...... 1 YES ...... 1 Other country: Number of times ...... NO ...... 2 NO...... 2 YES ...... 1 C. Never Send Money ...... 00 (SKIP TO 101) (SKIP TO 101) NO ...... 2 specify DON’T KNOW ...... 97
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Section B: Respondent’s and her Husband’s Background
First I would like to ask some questions about you and your husband
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 101 In what month and year were you born? Month ...... Don’t know month ...... 97 Year ...... Don’t know year...... 9997 102 How old were you at your last birthday? (Compare and correct 102 and/or 101 if Age in completed years ...... inconsistent) 103 Have you ever attended school or madrasha? Yes, School ...... 1 Yes, Madrasa ...... 2 Yes, Both ...... 3 No ...... 4 104 103a What level of schooling (Name) have you last Primary ...... 1 attended? Secondary ...... 2 College/University ...... 3 103b What is the highest grade/class (Name) completed at that schooling? Grade/Class...... (Write ‘00’ if no class completed) 104 What is your religion? Islam ...... 1 Hinduism ...... 2 Buddhism ...... 3 Christianity ...... 4 Other ______6 (Specify) 105 As you know, some women take up jobs for Yes ...... 1 which they are paid in cash or kind. Others sell things, have a small business or work on the 2 family farm or in the family business. No ...... 106 Are you doing any of this things or any work? 105a What is your primary occupation, that is, what Physical work: kind of work do (did) you mainly do? 01 Work on own farm or as a share cropper ...... Day/unskilled laborer (domestic, agricultural 02 and migrant) ...... Skilled worker (long term contracted laborer 03 /carpenter /mason /fishermen ...... Rickshaw/Van puller/Boat ...... 04 Non physical work: Own business shopkeeper, vendor, artisan ...... 05 Service holder/Professionals (Doctor /Engineer 06 /Lawyer /Teacher) ...... Other ...... 96 (specify) 106 Are you now married, separated, deserted, Currently married ...... 1 widowed, or divorced? Separated ...... 2 201 Deserted ...... 3 201 Divorced ...... 4 201 Widowed ...... 5 201 Never married ...... 6 END 107 In what month and year was your husband Month ...... born? Don’t know month ...... 97 Year ...... Don’t know year...... 9997
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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 107a How old was your husband at his last birthday? COMPARE AND CORRECT 107a AND /OR 107 IF Age in completed years ...... INCONSISTENT CORRECT 107a AND/OR 107. 108 Has your husband ever attended school or Yes, School ...... 1 madrasha? Yes, Madrasha ...... 2 Yes, Both ...... 3 No ...... 4 109 108a What level of schooling your husband has last Primary ...... 1 attended? Secondary ...... 2 College/University ...... 3 108b What is the highest grade your husband completed at that schooling? Grade/Class...... (Write ‘00’ if no class completed) 109 Does your husband do anything for living? Yes ...... 1 No ...... 2 201 109a What is his primary occupation? Physical work:
(IF MORE THAN ONE OCCUPATION, RECORD Work on own farm or as a share cropper ...... 01 THE MAIN ONE) Day/unskilled laborer (domestic, agricultural 02 and migrant) ...... Occupation: ______Skilled worker (long term contracted laborer 03 /carpenter /mason /fishermen ...... Write the occupation here and circle the correct 04 code in the next column Rickshaw/Van puller/Boat ...... Non physical work: Own business shopkeeper, vendor, artisan ...... 05 Service holder/Professionals (Doctor 06 /Engineer /Lawyer /Teacher) ...... Other ...... 96 (specify)
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Section C: Reproduction and Birth History
Now I would like to ask about all the births you have had during your life. NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
201 Have you ever given birth? Yes...... 1 No ...... 2 206 202 Do you have any sons or daughters to whom you Yes...... 1 have given birth who are now living with you? No ...... 2 204 203 How many sons live with you? And how many Sons living with respondent ...... daughters live with you? IF NONE, RECORD ‘00'. Daughters living with respondent ...... 204 Do you have any sons or daughters to whom you Yes...... 1 have given birth who are alive but do not live with you? No ...... 2 206 205 How many sons are alive but do not live with you? Sons elsewhere ...... And how many daughters are alive but do not live with you? IF NONE, RECORD ‘00'. Daughters elsewhere ...... 206 Have you ever given birth to a boy or girl who was Yes...... 1 born alive but later died? IF NO, PROBE: Any baby who cried or showed signs of life but did not No ...... 2 208 survive? 207 How many boys have died? And how many girls Person have died? IF NONE, RECORD ‘00'. Boys dead ...... Girls dead ...... 208 Some pregnancies end before full term as Yes...... 1 miscarriage or an abortion or MR, while others may result in a stillbirth. 2 Have you had any pregnancies that did not result in No ...... 210 live births? 209 In all, how many pregnancies did not result in a live Pregnancy Loss ...... birth? 210 SUM ANSWERS TO 203, 205, 207 AND 209, and Total number of pregnancies ...... ENTER TOTAL number of pregnancies in the box. 210a Check Q210 and circle appropriate code. Total pregnancy 01 or more ...... 1 Stop Total pregnancy 00 ...... 2 Intervie w 211 CHECK 210 and ask: Just to make sure that I have this OK you have had in TOTAL _____ pregnancies during your
life. Is that correct?
Yes No P ROBE AND CORRECT 201-209, IF NECESSARY.
Interviewer: You have to collect information about the recent pregnancy outcome during the period of 01 MAY 2009 TO 31 JULY 2010. So, make sure that the respondent understand and identify the pregnancy. Then ask questions.
Now I would like to talk to you about your most recent birth, (outcome during 01 MAY 2009 TO 31 JULY 2010) whether the child was born alive or born dead or the pregnancy was lost before full term, which is as a miscarriage or abortion.
Think back to your most recent pregnancy outcome or birth (between 01 MAY 2009 TO 31 JULY 2010) and the time you were pregnant leading to that birth. 212 In what day, month and year the outcome or birth occurred? PROBE: Appropriately for date of birth or DD MM YYYY the date of pregnancy outcome. 212a How long this pregnancy continued? Months…………………………………….. (Write in completed months) 212b Interviewer: Pregnancy continued 3 months or less ...... 1 223 133 | Page
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Check Question 212a and encircle appropriately. Pregnancy continued more than 3 months ..... 2 212c Was that a single or a multiple birth? Single ...... 1 Multiple ...... 2 Don’t Know ...... 7 Interviewer: Record Twins and Triplets in separate columns (infant1, infant 2, infant 3) 213 Was the baby born alive, born Infant-1 Infant-2 Infant-3 dead, or lost before full-term, Born Alive ...... 1 Born Alive ...... 1 Born Alive ...... 1 that is, as a miscarriage or an (skip to 215) (skip to 215) (skip to 215) abortion? Born Dead ...... 2 Born Dead ...... 2 Born Dead ...... 2 Lost before 7 Lost before 7 Lost before 7 months ...... 3 months ...... 3 months ...... 3 skip to 223 skip to 223 skip to 223 214 Did that baby cry, move, or Yes ...... 1 Yes ...... 1 Yes ...... 1 breathe at all when it was No ...... 2 No ...... 2 No ...... 2 born? skip to 223 skip to 223 skip to 223 215 What name was given to that Name: Name: Name: child? ______IF NO NAME WAS GIVEN, RECORD ‘NO NAME’. 216 Is/Was (NAME) a boy or a Boy ...... 1 Boy ...... 1 Boy ...... 1 girl? Girl ...... 2 Girl ...... 2 Girl ...... 2 218 Is (NAME) still alive? Alive ...... 1 Alive ...... 1 Alive ...... 1 Dead ...... 2 Dead ...... 2 Dead ...... 2 skip to 220 skip to 220 skip to 220
219 If alive: Month ...... Month ...... Month ...... How old is (NAME)? skip to 223 skip to 223 skip to 223 Record in months. Check against question 212 and correct if necessary. 220 ASK if born alive but now dead: Infant-1 Infant-2 Infant-3 How old was he/she when he/she died? day ...... day ...... day ...... IF ‘1 YR’, PROBE: How many months old was
(NAME)? IF ‘1 month’, PROBE: How many days Month Month Month old was (NAME)? Record days if less than 1 month, otherwise record in months. If age is less than 1 day, record ‘00’. Now I would like to talk about pregnancy and birth spacing. Think back to the time before the pregnancy we have just discussed. (Pregnancy ended between 01 MAY 2009 to 31 JULY 2010) 223 Have you been pregnant before your recent birth or Yes ...... 1 pregnancy? No...... 2 226 224 In what day, month and year did that pregnancy end? Day Month Year 224a What was the length of that pregnancy? (Completed months) Month ...... Now I am going to ask you about the future pregnancy. 226 Are you pregnant now? Put tick in the appropriate box below.
Not pregnant or Pregnant Month ...... 1 unsure Year ...... 2
How long would you like After the birth of the Soon/Now ...... 93 to wait from now before child you are expecting Says She Can’t Get Pregnant ...... 94 the birth of (a/another) now, how long would Don’t want anymore children ...... 95 child? you like to wait before Other ______...... 96 the birth of another (Specify) child? Don’t know ...... 97 Now I am going to ask you about your menstruation after your last pregnancy (in between 01 May 2009 to 31 July 2010) 226a Did you have a menstrual period after the delivery Yes...... 1 of your last baby (NAME) or end of the pregnancy No ...... 2 226c and before getting pregnant again? 226b When have you started menstruating (following delivery of NAME)? Day Month Year
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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
How long after the birth of NAME you have started Month ...... 1 menstruating? Year ...... 2 226c Have you ever heard information and counseling Yes...... 1 about LAM (the lactational amenorrhea method which is a method of using breastfeeding, to delay No ...... 2 226f menstruation in order to plan the family) as a method of family planning?
By counseling it means given detailed information on or had detailed discussion on a method of using breastfeeding to plan the family 226d Who told you about this method? Health Professional:
MBBS doctor ...... A Do not read the answers. Nurse/Midwife ...... B
Paramedic ...... C Ask: Anything else? Family Welfare Visitor ...... D
MA/SACMO ...... E Write down all the answers. ACCESS Counselor/MaMoni Health Worker ..... F
Health Assistant ...... G
Family Welfare Assitant ...... H Other professional: Trained TBA ...... I TBA ...... J Homeopath ...... K Ayurved ...... L Quack ...... M Village doctors ...... N Spiritual person/Kabiraj ...... O Pharmacy...... P Family member/relative...... Q Neighbor or friend ...... R Other ______...... X (Specify) Don’t Know/Can’t say ...... Y 226e Can you tell me what you have been told about Amenorrhea (period has not returned) ...... A LAM (the lactational amenorrhea method which is Breastfeeding (exclusive or nearly full) ...... B a method of family planning in breastfeeding Baby is less than 6 months ...... C women who follow certain characteristics? Use other method when LAM is not possible .... D Other ______...... X Do not read responses. (Specify)
226f Did you receive information and counseling ever in Yes ...... 1 your life about family planning/birth spacing 227 No ...... 2 methods, the various ways or methods that a 227 couple can use to delay or avoid a pregnancy? Don’t know ...... 7
226g Which ways or methods have you heard about to Female Sterilization ...... A plan your family? Male Sterilization...... B Do not read out the options. Combined Pill (Shukhi) ...... C Ask: anything else? IUD ...... D Depo-Provera (Progestin Only) ...... E Record all the responses mentioned. Implants/Norplants ...... F Condom ...... G Periodic Abstinence ...... H Withdrawal ...... I LAM ...... J Other ______X (Specify)
226h Did you receive information, from where the Yes...... 1
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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP family planning/birth spacing methods can be No ...... 2 227 obtained? 226i From where did you receive the information? Govt. Sector: Any other place? Hospital/Medical college ...... A ªFWC ...... B PROBE TO IDENTIFY EACH TYPE OF SOURCE AND MCWC ...... C CIRCLE THE APPROPRIATE CODE(S) Upazila Health Complex ...... D IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH Satellite clinic/EPI out reach site ...... E CENTER OR CLINIC IS PUBLIC OR PRIVATE FWA ...... F MEDICAL, WRITE THE NAME OF THE PLACE. Community clinic ...... G (IF HEALTH WORKER, GET THE NAME AND NGO Sector: VERIFY THE DESIGNATION) NGO Static Clinic ...... H
NGO Satellite Clinic ...... I
NGO Depot holder ...... J
NGO Field Worker ...... K
Private Medical Center: [NAME OF PLACE(S)] Private clinic/Hospital ...... L MBBS doctor ...... M Traditional healer ...... N Pharmacy...... O Other sources: Shop ...... P Friends/Relatives ...... Q TBA ...... R Other ______X (Specify) Now I would like to know about family planning /contraceptive use during first six months after delivery of (Name) or end of pregnancy. 227 Did you or your husband use any method of family Yes ...... 1 planning during the first 6 months after the birth 228 No ...... 2 of (NAME) or outcome of pregnancy to delay or 228 Don’t Know ...... 7 avoid next pregnancy? 227a What method of family planning are you or your Female Sterilization ...... 01 husband using within 6 months after the birth of Male Sterilization...... 02 NAME to delay or avoid next pregnancy? Combined Pill (Shukhi) ...... 03 IUD ...... 04 Depo-Provera (Progestin Only) ...... 05 Implants/Norplants ...... 06 Condom ...... 07 Periodic Abstinence ...... 08 Withdrawal ...... 09 LAM ...... 10 Other ...... 96 (Specify) No method used ...... 95 227b How many weeks or months after the birth or end of pregnancy did you or your husband start use of Week ...... contraceptive? 228 Are you currently doing something or using any Yes...... 1 method to delay or avoid getting pregnant? No ...... 2 303 Currently pregnant ...... 3 303 Not currently married (widowed/separated) .. 4 303 228a Which method are you using now? Female Sterilization ...... 01 Male Sterilization...... 02 Combined Pill (Shukhi) ...... 03 IUD ...... 04 Depo-Provera (Progestin Only) ...... 05 Implants/Norplants ...... 06 Condom ...... 07 Periodic Abstinence ...... 08 303 Withdrawal ...... 09 303 LAM ...... 10 303 Other ...... 96 (Specify)
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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 228b Last time, from where did you get this (current) Govt. Sector: method. ______Hospital/Medical college ...... 11 (Answer of FWC ...... 12 228a) Upazila Health Complex ...... 13 Satellite clinic/EPI out reach site ...... 14 In case of sterilization, ask from where did you get MCWC ...... 15 the service? ______FWA ...... 16 Community clinic ...... 17 (Answer of 228a) Other ______18 (Specify) NGO Sector: NGO Static Clinic ...... 21 NGO Satellite Clinic ...... 22 NGO Depot holder ...... 23 NGO Field Worker ...... 24 Other ______26 (Specify) Private Medical Center: Private clinic/Hospital ...... 31 MBBS doctor ...... 32 Traditional healer ...... 33 Pharmacy...... 34 Other ______36 (Specify) Other sources: Shop ...... 41 Friends/Relatives ...... 42 Other ______96
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Section D: Knowledge
Now I would like to ask you about the care and complications during pregnancy, delivery and post delivery period of a mother and a newborn. NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
303 Please tell me what are the complications that Severe Headache ...... A may occur during pregnancy that need medical Blurred Vision ...... B support? Fetal movement reduced/absent ...... C High Blood Pressure ...... D Do not read out the answers. Oedema of the face/swelling ...... E Oedema of the hands/swelling ...... F ASK: Anything else? Convulsions/fits ...... G Excessive Vaginal Bleeding ...... H Severe abdominal pain ...... I Record all the answers. Oedema of the legs ...... J Fever...... K Premature rupture of membrane ...... L Loss of consciousness ...... M Difficulty breathing ...... N Severe weakness ...... O Excessive vomiting ...... P Excessive whitish vaginal discharge ...... Q Others ______X (Specify) Don’t know/None mentioned ...... Y
305 Now tell me what are the problems / Excessive Vaginal Bleeding ...... A complications in a woman during childbirth that Foul-Smelling Discharge ...... B needs medical support? High Fever ...... C
Baby’s Hand or Feet Coming out First ...... D Do not read out the answers. Baby is in abnormal position ...... E
Prolong Labor (>12 hours) ...... F ASK: Anything else? Retained Placenta (placenta not delivered 30 minutes after the baby is born) ...... G Rupture uterus/Cervical tear/Vaginal tear...... H Write down all the answers. Cord prolapsed ...... I Cord around neck ...... J Convulsion ...... K Severe Headache ...... L Greenish vaginal discharge ...... M Loss of consciousness ...... N Neonatal injuries ...... O Blurring of vision ...... P Others ______X (Specify) Don’t know/None mentioned ...... Y Deciding where to deliver ...... A 306 Can you tell us what measures or preparations
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are needed to be taken for safe delivery? (Birth Deciding who will assist birth ...... B plan) Ensure a person for newborn care ...... C Do not read out the answers. To purchase/procure a safe delivery kit ...... D ASK: Anything else? Ensure emergency transport...... E Write down all the answers. Savings for emergency ...... F Approval to seek care ...... G Check up during pregnancy ...... H TT vaccination ...... I To take Iron tablet ...... J Know danger signs for mother ...... K Know danger signs for newborn ...... L Extra food ...... M Take adequate rest ...... N Not to do heavy work ...... O Ensure a trained TBA ...... P A well lighted and airy delivery place ...... Q Prepare two pieces of cloth ...... R Identify Blood Donor ...... S Prepare boiled blade ...... T Prepare boiled thread ...... U Others ______X ( (Specify) Can’t remember/Don’t know ...... Y Excessive Vaginal Bleeding ...... A 314 Now tell me what are the problems / complications or situation that may arise after delivery for which a woman should seek medical Foul-Smelling Discharge ...... B support? Fever...... C Do not read out the answers. Inverted nipples...... D ASK: Anything else? Tetanus ...... E Write down all the answers. Retained Placenta ...... F Severe lower abdominal pain ...... G Convulsions/fits ...... H Engorged breasts/ swelling of breasts ...... I Fainting ...... J Difficulty breathing ...... K Severe weakness ...... L Severe headache ...... M Blurred Vision ...... N Swollen hands/face ...... O Others ______X (Specify) Don’t know /None mentioned ...... Y Now I would like to ask you a few questions about the health of newborn babies.
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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Difficult or fast breathing ...... A 315 Now, I would like to ask you a few questions Pneumonia ...... B about the health of newborn babies. Cold/cough ...... C In your opinion, what are some serious health Yellow skin/palm/feet/eye color (jaundice) ...... D problems that can occur during the first 7 days Poor sucking or feeding ...... E after birth that could endanger the life of a Pus, bleeding, or discharge from around the newborn baby and for which treatment is umbilical cord ...... F required? Skin lesions or blisters ...... G Do not read out the answers. Convulsions/spasms/rigidity ...... H Lethargy/unconsciousness ...... I PROBE: Any others? Red or swollen eyes with pus...... J Write down all the answers. Baby feels cold ...... K Baby doesn’t cry ...... L Fever...... M Doesn’t pass urine ...... N Doesn’t pass stool ...... O Continuous vomiting ...... P Distention of abdomen ...... Q Difficult to wake ...... R Skin rash/‘Mashipishi’ ...... S Measles ...... T Others ______X (Specify) Don’t know/None mentioned ...... Y Difficult or fast breathing ...... A 315a What are the problems or symptoms that may Pneumonia ...... B arise in a newborn within 1 month after birth for Cold/cough ...... C which treatment is required? Yellow skin/palm/feet/eye color (jaundice) ...... D Poor sucking or feeding ...... E Pus, bleeding, or discharge from around the Do not read out the answers. umbilical cord ...... F Skin lesions or blisters ...... G Convulsions/spasms/rigidity ...... H ASK: Anything else? Lethargy/unconsciousness ...... I Red or swollen eyes with pus...... J Baby feels cold ...... K Write down all the answers. Baby doesn’t cry ...... L Fever...... M Doesn’t pass urine ...... N Doesn’t pass stool ...... O Continuous vomiting ...... P Distention of abdomen ...... Q Difficult to wake ...... R Skin rash/‘Mashipishi’ ...... S Measles ...... T Diarrhoea ...... U Chest indrawing ...... V Others ______X (Specify) Don’t know/None mentioned ...... Y
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Secion E: Antenatal Care
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 400 Interviewer: Check Question 212a and circle Pregnancy last less than 3 months ...... 1 1001 appropriate code. Pregnancy last more than 3 months ...... 2 Interviewer: You have to collect information about the pregnancy outcome during the period of 01 May 2009 to 31 July 2010. So, make sure that the respondent understand and identify the pregnancy then ask questions. 401 Did you see any health worker for ANC when you Yes ...... 1 were pregnant with (NAME) (during pregnancy)? No ...... 2 402 Interviewer: make sure that you make the respondent understand that you mean all levels of health worker including doctors. 401a How many times in total did you go to receive No. of times ...... antenatal care from a health worker during your Don’t know/Don’t remember ...... 97 pregnancy? As you mentioned that during the pregnancy without having illness, you seek ANC / medical check-up for ____ times; now tell me from where you have taken 1st ANC, 2nd ANC, 3rd ANC and 4th ANC?
401b To whom you went for ANC? Do not read out the answers. ASK: Anything else? Write down all the answers.
ANC 1 ANC2 ANC 3 ANC 4 MBBS doctor ...... 01 01 01 01 Nurse/midwife ...... 02 02 02 02 Paramedic ...... 03 03 03 03 FWV ...... 04 04 04 04 Medical Assistant/SACMO ...... 05 05 05 05 ACCESS Counselor/MaMoni Health Worker ...... 06 06 06 06 HA ...... 07 07 07 07 FWA ...... 08 08 08 08 Trained TBA...... 09 09 09 09 TBA...... 10 10 10 10 Homeopath ...... 11 11 11 11 Ayurved ...... 12 12 12 12 Quack ...... 13 13 13 13 Village doctors ...... 14 14 14 14 Spiritual person/Kabiraj ...... 15 15 15 15 Community Clinic ...... 16 16 16 16 Other health worker ...... 17 17 17 17 Others ...... 18 18 18 18 (Specify) Don’t know/Don’t remember ...... 19 19 19 19 401c As part of your antenatal care during this pregnancy, were any of the following done at Yes No least once? Ask about each item. Weight ...... 1 2 Blood pressure ...... 1 2 Were you weight? Urine test ...... 1 2 Was your blood pressure measured? Blood test ...... 1 2 Did you give a urine sample? Ultra sonogram ...... 1 2 Did you give a blood sample? Abdominal examination...... 1 2 Did you have an ultra sonogram? Did you have an abdominal examination? 401d How many months pregnant were you when you Months...... first received antenatal care for this pregnancy? Don’t know ...... 97 402 Did any health worker come to your home for Yes ...... 1 checkup/advice when you were pregnant with No ...... 2 420 (NAME) (during pregnancy)? Don’t know/Don’t remember ...... 7 420 Interviewer: make sure that you make the respondent understand that you mean all levels of health worker in including doctors. 402a How many times in total did the health Times...... worker(s) come to your home for antenatal care/ advice during this pregnancy? Don’t know ...... 97 402b Which health worker(s) came to your place? MBBS doctor ...... A Nurse/midwife ...... B 141 | Page
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Do not read out the answers. Paramedic ...... C FWV ...... D ASK: Anything else? Medical Assistant/SACMO ...... E MaMoni Health Worker/CHW ...... F Write down all the answers. HA ...... G FWA ...... H Trained TBA...... I TBA...... J Homeopath ...... K Ayurved ...... L Quack ...... M Village doctors ...... N Spiritual person/Kabiraj ...... O Other health worker ...... P Others ...... X (Specify) Don’t know/Can’t say ...... Y 402c During the visit by health worker in this Yes No pregnancy, were any of the following done at Weight ...... 1 2 least once? Blood pressure ...... 1 2 Ask about each item. Urine test ...... 1 2 Were you weight? Blood test ...... 1 2 Was your blood pressure measured? Did you give a urine sample? Ultra sonogram ...... 1 2 Did you give a blood sample? Abdominal examination 1 2 Did you have an ultra sonogram? Did you have an abdominal examination? 404 Interviewer: Check Question 401b and 402b, 6 code is circled any one in 401b and also F code then circle appropriate code. is circled in Q402b ...... 1 6 code is circled in any one of Q401b or F code is circled in Q402b...... 2 6 code is not circled in Q401b and F code is not circled in Q402b...... 3 420 405 How many months pregnant were you when the Months...... Government Health Worker (HA, FWA) or Don’t know /Can’t remember ...... 97 MaMoni Health Worker/CHW first visited you (in this pregnancy)? 406 How many months pregnant were you when the Months...... Government Health Worker (HA, FWA) or Don’t know /Can’t remember ...... 97 MaMoni Health Worker/ CHW last visited you (in this pregnancy)? 407 Did the Government Health Worker (HA, FWA) Yes ...... 1 or MaMoni Health Worker/CHW who visited you No ...... 2 409 provide any advice regarding care during pregnancy? Don’t know/Can’t remember ...... 7 409
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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 408 Can you recall what advice the Government Check up during pregnancy ...... A Health Worker (HA, FWA) or MaMoni Health TT vaccination ...... B Worker/CHW gave you regarding care during To take Iron tablet ...... C pregnancy? Regarding danger signs during pregnancy ...... D Extra food ...... E Do not read the answers. Take rest ...... F Not to do heavy work ...... G Ask: Anything else? Savings for emergency ...... H Ensure emergency transport...... I Record all the answers. To deliver at a health facility ...... J Ensure a trained TBA ...... K Ensure a person for newborn care ...... L To use safe delivery kit...... M A well lighted and airy delivery place ...... N Prepare two pieces of cloth ...... O Family planning ...... P Breastfeeding ...... Q LBW baby care...... R Others ______X (Specify) Can't remember ...... Y 409 Did the Government Health Worker (HA, FWA) Yes ...... 1 or MaMoni Health Worker/ CHW counsel you No ...... 2 about the importance of antenatal care by a Don’t know ...... 7 skilled provider? 410 Did the Government Health Worker (HA, FWA) Yes ...... 1 or MaMoni Health Worker/CHW counsel you No ...... 2 where to go for antenatal care? Don’t know ...... 7 410a Did the Government Health Worker (HA, FWA) Yes ...... 1 or MaMoni Health Worker/CHW tell you how No ...... 2 419 many times to go for ANC? 410b Government Health Worker (HA, FWA) or Times...... MaMoni Health Worker/CHW told you to receive Don’t know ...... 97 ANC for how many times? 419 Did the Government Health Worker (HA, FWA) Yes ...... 1 or MaMoni Health Worker/CHW tell you how to No ...... 2 419c take care of the newborn immediately after Don’t know ...... 7 419c birth? 419a Can you recall the issues the Government Health Clean/dry the baby immediately after birth ...... A Worker (HA, FWA) or MaMoni Health Wrap the baby immediately after birth ...... B Worker/Community Health Worker told you Put the baby to breast before delivery of the regarding newborn care immediately after birth? placenta...... C Nothing to be applied to the umbilicus ...... D Do not read out the answers. Not to remove the vernix or the white skin ...... E Ask: Anything else? First bath should be given 72 hrs/3 days after delivery ...... F Write down all the answers. Not to give anything before breast milk ...... G Exclusive Breastfeeding ...... H Skin-to-skin (KMC) ...... I About family planning ...... J About LAM ...... K Others ______X (Specify) Don’t know/cant remember ...... Y Interviewer: In question 419c circle 1 in the first column, if the respondent mentions the items spontaneously. After she finishes, show the ACCESS/MaMoni samples that she did not mention and circle 2 in the second column if she replied positively. If she still does not mention those things then circle 3 in the third column. 419c What did the Government Health Worker (HA, FWA) or MaMoni health worker/CHW give you while she visited you during your pregnancy? Before showing After showing Yes Yes No Mother card (Preparation for safe delivery and 1 2 3 complication) Clean delivery kit 1 2 3
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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
420 Record all the TT vaccination of the woman, either from the TT card or from recalling the event. If TT is received, then circle ‘1’ by dose of TT, put date of TT received by dose. PROBE for date, if not certain then put’99’ in the day. Month and Year for the dose is very important, try to get the date if not found then put ‘99’ in month and year boxes. Did the woman Date of TT received by dose Dose interval Have you received Date of TT Date of TT receive any TT Dd/mm/yy (Difference of any TT during this received from received from vaccine? time in month pregnancy History Card from previous) Yes=1, No=2 Yes=1, No=2 Yes=1, No=2 TT No Yes |__|__|-|__|__|-|__|__| |__|__| TT1 0 1 |__|__|-|__|__|-|__|__| |__|__| TT2 0 1 |__|__|-|__|__|-|__|__| |__|__| TT3 0 1 |__|__|-|__|__|-|__|__| |__|__| TT4 0 1 |__|__|-|__|__|-|__|__| |__|__| TT5 0 1 |__|__|-|__|__|-|__|__| |__|__| TT6 0 1 |__|__|-|__|__|-|__|__| |__|__| TT7 0 1 |__|__|-|__|__|-|__|__| |__|__| TT8 0 1 |__|__|-|__|__|-|__|__| |__|__| TT9 0 1 |__|__|-|__|__|-|__|__| |__|__| TT10 0 1 |__|__|-|__|__|-|__|__| |__|__| 422 Did you take iron tablets or iron syrup (to Yes ...... 1 increase blood) during this pregnancy? No ...... 2 Don’t know ...... 7 [If necessary then show the tablet or bottle of syrup and then ask] 424 When you were pregnant with Name did you or Yes ...... 1 your family selects someone to help you during No ...... 2 426 delivery? Don’t know ...... 7 426 425 What kind of a birth attendant did you or your Health professional: family select? MBBS doctor ...... A Nurse/midwife ...... B Interviewer: Ask for the name of the person who Paramedic ...... C FWV ...... D was principally selected to assist delivery and Medical Assistant/SACMO ...... E record the name. ACCESS Counselor/MaMoni Health Worker/CHW ...... F Write down the name______HA ...... G FWA ...... H Do not read out the answers. Others: TTBA...... I TBA...... J Write down all the answers. Homeopath ...... K Ayurved ...... L Quack ...... M Village Doctors ...... N Spiritual person/Kabiraj ...... O Mother/Mother in law ...... P Pharmacy ...... Q Family member/relative ...... R Neighbor or friend ...... S Others ______X (Specify) Don’t know/Can’t remember ...... Y 426 When you were pregnant with (Name) did you Yes ...... 1 or your family selects a person for newborn No ...... 2 428 care? Don’t know ...... 7 428 427 Who was pre selected as newborn care person? Health professional: Interviewer: Ask for the name of the person who MBBS doctor ...... A was principally selected to assist delivery and Nurse/midwife ...... B record the name. Paramedic ...... C Name: ______FWV ...... D Do not read out the answers. Medical Assistant/SACMO ...... E
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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Write down all the answers. ACCESS Counselor/MaMoni Health F Worker/CHW ...... HA ...... G FWA ...... H Others: TTBA...... I TBA...... J Homeopath ...... K Ayurved ...... L Quack ...... M Village Doctors ...... N Spiritual person/Kabiraj ...... O Mother/Mother in law ...... P Pharmacy ...... Q Family member/relative ...... R Neighbor or friend ...... S Others ______X (Specify) Don’t know/Can’t remember ...... Y 428 During the pregnancy with (Name) did you Yes ...... 1 develop any problem/complication that required No ...... 2 500 medical treatment? Don’t know/Can’t remember ...... 7 500 428a Please tell me what was that Severe Headache ...... A problem/complication? Blurred Vision ...... B Do not read out the answers. Fetal movement reduced/absent ...... C Ask: Anything else? High Blood Pressure ...... D Write down all the answers. Oedema of the face/swelling ...... E Oedema of the hands/ swelling ...... F Convulsions/fits ...... G Excessive Vaginal Bleeding ...... H Severe abdominal pain ...... I Oedema of the legs ...... J High Fever ...... K Premature rupture of membrane ...... L Loss of consciousness ...... M Difficulty breathing ...... N Severe weakness ...... O Others ______X (Specify) Can’t remember/None mentioned ...... Y 428b Did anyone ask you/ advise you to seek care for Yes ...... 1 this problem/complication? No ...... 2 428d Don’t know/Can’t remember ...... 7 428d 428c Who asked you/advised you to take care of the ACCESS Counselor/MaMoni Health Worker ...... A problem/complication? Family members ...... B Relatives ...... C Neighbors/friends ...... D TBA (Dai/Dhorni/Chauni) ...... E TTBA...... F Others ______X (Specify) 428d Did you seek any sort of treatment for this Yes ...... 1 problem/complication? No ...... 2 500 Don’t know/Can’t remember ...... 7 500 428e From whom you received treatment for this Health professional: problem/complication? MBBS doctor ...... A Do not suggest any answers. Nurse/midwife ...... B Ask: Anything else? Paramedic ...... C Write down all the answers. FWV ...... D Medical Assistant/SACMO ...... E ACCESS Counselor/MaMoni Health Worker ...... F
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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP HA ...... G FWA ...... H Others: TTBA...... I TBA (Dai/Dhorni/Chauni) ...... J Homeopath ...... K Ayurved ...... L Quack ...... M Village Doctors ...... N Spiritual person/Kabiraj ...... O Mother/Mother in law ...... P Pharmacy ...... Q Family member/relative ...... R Neighbor or friend ...... S Others ______X (Specify) Don’t know/Can’t remember ...... Y 428f From where did you receive care for this Home ...... A problem/complication? Satellite clinic ...... B
FWC...... C Do not suggest any answers. UHC ...... D Ask: Anything else? Qualified Doctor's chamber ...... E Write down all the answers. Clinic ...... F
Community clinic ...... G
Hospital ...... H Pharmacy ...... I
Others ______X
(Specify)
Don’t know/Can’t remember ...... Y
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Section F: Delivery
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 500 Check question 213 (What was the outcome of her Live birth ...... 1 last pregnancy?) Still birth ...... 2 Lost before 7 months ...... 3 508 Now I shall ask few questions about delivery of (NAME) born between 01 May 2009 to 31 July 2010 500a When you were pregnant with (NAME) did you Yes ...... 1 take any preparation for its delivery/birth? No ...... 2 501 PROBE –where the delivery should take place, who should attend baby and mother during Don’t know/Can’t remember ...... 7 501 delivery, arrangement of money and transport, etc.) 500b What preparations did you make? Selected place of delivery ...... A Selected the person to attend the delivery ...... B 501 Do not read out the answers. Selected a newborn care person to attend the ASK: Anything else? newborn ...... C 501 Record all the answers. Purchase/procure a safe delivery kit/CDK ...... D 501 Arranged emergency transport ...... E 501 Saved money to pay emergency care ...... F 501 Took approval to seek care ...... G 501 Check up during pregnancy ...... H 501 Took TT vaccine ...... I 501 Took Iron tablet/syrup ...... J 501 Know danger signs for mother ...... K 501 Know danger signs for the new born ...... L 501 Took extra food ...... M 501 Took adequate rest ...... N 501 Did not perform heavy work ...... O 501 Ensure a trained TBA ...... P 501 Selected a well lighted and airy delivery place ...... Q 501 Prepare two pieces of cloth ...... R 501 Identify Blood Donor ...... S 501 Others ______X 501 ( (Specify) Can’t remember ...... Y 501 500c Which place have you selected for delivery? Own home ...... 01 In-laws home ...... 02 My natal home (Parents’ home) ...... 03 FWC ...... 04 UHC ...... 05 Medical College Hospital ...... 06 Private hospital/clinic ...... 07 NGO Hospital ...... 08 Others ______96 (Specify) 501 Actually where did the birth of (NAME)/delvery Own home ...... 01 take place? In-laws home ...... 02
My natal home (Parents’ home) ...... 03 FWC ...... 04 508 UHC ...... 05 508 Medical College Hospital ...... 06 508 Private hospital/clinic ...... 07 508 NGO Hospital ...... 08 508 Others ______96 (Specify) 501a Address of delivery place Name of upazila______Name of district ______
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502 Who from outside (not a family member) assisted Health professional: in your delivery? MBBS doctor ...... 01 Record the name who was mainly responsible or Nurse/midwife ...... 02 mostly involved in assisting the delivery. Paramedic ...... 03 Interviewer: Ask and record the name of the FWV ...... 04 person who assisted in delivery Medical assistant/SACMO ...... 05 Name ------ACCESS Counselor/MaMoni Health 06 Worker/CHW ...... Circle only one from the list HA ...... 07 FWA ...... 08 Others: TTBA ...... 09 TBA (Dai/Dhorni/Chauni) ...... 10 Homeopath ...... 11 Ayurved ...... 12 Quack ...... 13 Village doctors ...... 14 Spiritual person/Kabiraj ...... 15 Neighbor/friend ...... 16 Others(Specify) ______96 None ...... 95 502a Did the person who assisted with the delivery of Yes ...... 1 (NAME) wash hands with soap prior to delivery of No ...... 2 (NAME)? Don’t know/Can’t remember ...... 7 504 Did you have a delivery bag / birth kit? Yes ...... 1 No ...... 2 508 Don’t know/Can’t remember ...... 7 508 505 Where did you get birth kit? FWC ...... 01 Satellites clinic ...... 02 Community Clinic ...... 03 NGO clinics ...... 04 Shop...... 05 ACCESS Counselor/MaMoni Health Worker ...... 06 TBA home ...... 07 NGO Volunteer home ...... 08 Others (specify) ______96 Don’t know/Can’t remember ...... 97 505a Did you pay for it or was it free? Pay for it ...... 1 It was free ...... 2 Don’t know ...... 7 505b What were the items from the birth kit that were Stated Stated after Not stated used during your delivery? promptly showing At first write down all the answers. After she finishes, show the CDK items one by one and ask Plastic sheet 1 2 3 again whether she has received any of these. Blade 1 2 3 Record unprompted answers in the first column and the prompted answers in the second column. Thread 1 2 3 If she still does not mention the item then circle Soap 1 2 3 third column. 508 During the time of the birth of (Name) or Problem/Complication Yes No
abortion did you have any problem or a. Excessive Vaginal Bleeding ...... 1 2 complication like: b. Foul-Smelling Discharge ...... 1 2 c. High Fever ...... 1 2 Excessive Vaginal Bleeding? Foul-Smelling Discharge? d. Baby’s Hand or Feet Coming out First? ...... 1 2 High Fever? e. Baby is in abnormal position? ...... 1 2 Baby’s Hand or Feet Coming out First? f. Prolong Labor (>12 hours) ...... 1 2 Baby is in abnormal position? g. Retained Placenta ...... 1 2 Prolong Labor (>12 hours)? Retained Placenta? h. Rupture uterus/Cervical tear/Vaginal 1 2 Rupture uterus/Cervical tear/Vaginal tear? tear ...... Cord Prolapse? i. Cord Prolapse ...... 1 2 Cord around neck ? j. Cord around neck ...... 1 2 Convulsion? Severe headache? k. Convulsion ...... 1 2 Greenish vaginal discharge? l. Severe headache ...... 1 2 Swelling of feet or face? m. Greenish vaginal discharge ...... 1 2 Any other problem? n. Swelling of feet or face ...... 1 2
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o. Any other problem (specify) 1 2 ______ 508a Interviewer: Check Question 508 and circle One or more codes circled 1 ...... 1 appropriate code. All codes circled 2 ...... 2 600 508c With whom you have discussed about the ACCESS Counselor/MaMoni Health Worker ...... A problems? TTBA ...... B Do not read out the answers. TBA (Dai/Dhorni/Chauni) ...... C ASK: Anything else? Family member/relative ...... D Record all the answers. Neighbor or friend...... E Village doctor ...... F Community Health Worker ...... G Spiritual person/Kabiraj ...... H did not consult with anyone ...... I Others ______X (Specify) 509 Did you seek assistance for this Yes ...... 1 complication? No ...... 2 600 Don’t know/Can’t remember ...... 7 600 510 Whom did you see? Health professional: Do not suggest any answers. Ask: Anyone else? MBBS doctor...... A Write down all the answers. Nurse/midwife...... B Paramedic ...... C FWV ...... D Medical Assistant/SACMO ...... E ACCESS Counselor/MaMoni Health Worker/CHW ...... F HA ...... G FWA ...... H Others: TTBA ...... I TBA (Dai/Dhorni/Chauni) ...... J Homeopath ...... K Ayurved ...... L Quack ...... M Village Doctors ...... N Spiritual person/Kabiraj ...... O Mother/Mother in law ...... P Pharmacy ...... Q Family member/relative ...... R Neighbor or friend...... S Others ______X (Specify) Don’t know/Can’t say ...... Y 510a Where did you seek assistance for the Home ...... A complication? Satellite clinic ...... B Do not suggest any answers. FWC ...... C Ask: Anywhere else? Community Clinic ...... D Write down all the answers. UHC ...... E
Doctor's chamber (MBBS) ...... F
Clinic ...... G
Hospital ...... H Pharmacy ...... I Others ______X (Specify) Don’t remember/Can’t remember ...... Y
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Section G: Immediate Newborn Care
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 600 Check question 213 (What was the outcome of her Live birth ...... 1 last pregnancy?) Still birth ...... 2 700 Lost before 7 months ...... 3 700 After the birth of a baby there is something essential to do. Now I would ask you few questions regarding what was done immediately after the birth of (NAME ). 601 Interviewer: Check Question 501 and encircle Code 01 or 02 or 03 or 96 encircled ...... 1 appropriate code. Code 04 or 05 or 06 or 07 or 08 encircled ...... 2 606 601a What was the very first thing done immediately Cut cord ...... 01
after delivery? Placed the child on mother's abdomen/ chest ...... 02 Left alone ...... 03 Probe adequately. Dried ...... 04 Wrapped ...... 05 Circle only one answer. Bathed ...... 06 Let the baby sleep ...... 07 Breast fed...... 08 Fed sugar water or other thing ...... 09 Other ______96 (Specify) Don’t know/Can’t remember ...... 97 601b How many minutes after delivery of (Name) the Minutes ...... placenta was delivered? Placenta was not delivered, I was moved to the hospital ...... 95 Don't know...... 97 602 When the baby’s body was wiped (dried), before Before delivery of placenta ...... 1 delivery of placenta or after delivery of placenta? After delivery of placenta ...... 2
Wasn't wiped ...... 3 604 Don’t know/Can’t remember ...... 7 604 602a How many minutes after delivery of (Name) Minutes ...... he/she was wiped/dried/cleaned? Don't know...... 97
Health professional: 603 Who wiped (dried) the baby? MBBS doctor ...... 01
Nurse/midwife ...... 02 Paramedic ...... 03 Name: ______FWV ...... 04
Medical assistant/SACMO ...... 05 Circle only one code. MaMoni Health Worker/ CHW ...... 06 HA ...... 07
FWA ...... 08 Others: TTBA ...... 09
TBA (Dai/Dhorni/Chauni) ...... 10 Homeopath ...... 11 Ayurved ...... 12
Quack ...... 13 Village doctors ...... 14 Spiritual person/Kabiraj ...... 15
Mother/Mother in law ...... 16 Family Member/Relative ...... 17 Neighbor/Friend ...... 18
Mother herself ...... 19 Others ______96 (Specify)
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Don’t know/Can’t remember ...... 97
603b
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 603a Was this person (Answer of Q-603) selected before Yes ...... 1 for taking care of (drying) the newborn? No ...... 2 Don’t know/can’t remember ...... 7 603b Check Q-427 and Q-603 and circle appropriate Answer of 427 and 603 same person ...... 1 code. Take name from that answer and ask by Answer of 427 and 603 different person ...... 2 using that name (Interviewer: Are the person of 603 and the person No answer in 427 and 603 or mentioned about of 427 the same person?) single person...... 3
604 After delivery when was the baby (NAME) Before delivery of the placenta ...... 1 wrapped with a cloth? Before delivery of placenta or after delivery of placenta? After delivery of the placenta ...... 2 Wasn't wrapped ...... 3 606 Don’t know/can’t remember ...... 7 606 604a How many minutes after delivery of (Name) was Minutes ...... wrapped? Don't know...... 97
605 Who wrapped the baby with a cloth? Health professional: MBBS doctor ...... 01 Name: ______Nurse/midwife ...... 02 Paramedic ...... 03 Circle only one code. FWV ...... 04 Medical assistant/SACMO ...... 05 MaMoni Health Worker / CHW ...... 06 HA ...... 07 FWA ...... 08 Others: TTBA ...... 09 TBA (Dai/Dhorni/Chauni) ...... 10 Homeopath ...... 11 Ayurved ...... 12 Quack ...... 13 Village doctors ...... 14 Spiritual person/Kabiraj ...... 15 Mother/Mother in law ...... 16 Family Member/Relative ...... 17 Neighbor/Friend ...... 18 Mother herself ...... 19 Others ______96 (Specify) Don’t know/Can’t remember ...... 97 605a Was this person Answer Q-605 selected before for Yes ...... 1 taking care of (wrapping) the newborn? No ...... 2 606 Don’t know/Can’t remember ...... 7 606 605b Check Q-425 and Q-605 and circle appropriate Answer of 425 and 605 same person ...... 1 code. Answer of 425 and 605 different person ...... 2 (Interviewer: Are the person of 605 and the person No answer in 427 and 603 or mentioned about of 425 the same person?) single person...... 3
606 What was used to cut the cord? Blade from the delivery bag ...... 01 151 | Page
New blade ...... 02 Old blade in the house ...... 03 Bamboo strips/bata/toll ...... 04 Scissor ...... 05 Other ...... 96 (Specify) Cord was not cut ...... 95 60 8 Don’t know/can’t remember ...... 97 607 606a Was the instrument boiled before cutting the Yes ...... 1 cord? No ...... 2 607 Was anything applied to the cord immediately Yes ...... 1 after cutting and tying it? No ...... 2 607b Don’t know/can’t remember ...... 7 607b NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 607a What was applied to the cord after cutting and Antibiotics(Powder/Ointment,specify______A tying the cord? Antiseptic (Detol/savlon/hexisol) ...... B Spirit/Alcohol ...... C Do not suggest any answers. Mustard oil (with or without garlic) ...... D Chewed rice ...... E Ask: Anything else was used? Turmeric juice/powder ...... F Ginger juice ...... G Record all the answers. Shidur ...... H Boric powder ...... I Gentian violet ...... J Talcum Powder...... K Ash ...... L Coconut oil ...... M Dust of earth-burner ...... N Other ______X (Specify) Don’t know ...... Y 607b Was anything applied to the cord within seven Yes ...... 1 days after cutting and tying it? No ...... 2 608 Baby died before 7 days ...... 3 608 Don’t know ...... 7 608 607c What was applied to the cord within seven days Antibiotics(Powder/Ointment (Specify) A after cutting and tying the cord? Antiseptic (Detol/savlon/hexisol) ...... B Spirit/Alcohol ...... C Do not suggest any answers. Mustard oil (with or without garlic) ...... D Chewed rice ...... E Ask: Anything else was used? Turmeric juice/powder ...... F Ginger juice ...... G Circle all the answers. Shidur ...... H Boric powder ...... I Gentian violet ...... J Talcum Powder...... K Ash ...... L Coconut oil ...... M Dust of earth-burner ...... N Other ______X (Specify) Don’t know ...... Y 608 Did your baby cry/ breathe normally immediately Yes ...... 1 609b after birth? No ...... 2 Don’t know/can’t remember ...... 7
608a Was anything done to help the baby cry or breath Didn’t give any answer...... A immediately after birth? Dried the baby ...... B Do not suggest any answers.
Wrapped the baby ...... C
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ASK: Anything else? Rubbed the back for stimulation ...... D
Write down all the answers. Rubbed the feet for stimulation...... E
Mouth to mouth respiration ...... F
Heated the cord ...... G
Slapped the baby ...... H
Hold the baby upside down ...... I
Other ______X
(Specify)
Don’t know/can’t remember ...... Y
Nothing done ...... Z 609b NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Health professional: 608b Who took initiative to resuscitate or to help the MBBS doctor ...... 01 baby cry? Nurse/midwife ...... 02
Paramedic ...... 03 Circle only one code. FWV ...... 04 Medical assistant/SACMO ...... 05 MaMoni Health Worker/CHW ...... 06 HA ...... 07 FWA ...... 08 Others: TTBA ...... 09 TBA (Dai/Dhorni/Chauni) ...... 10 Homeopath ...... 11 Ayurved ...... 12 Quack ...... 13 Village doctors ...... 14 Spiritual person/Kabiraj ...... 15 Mother/Mother in law ...... 16 Family Member/Relative ...... 17 Neighbor/Friend ...... 18 Mother herself ...... 19 Others ______96 (Specify) Don’t know/Can’t remember ...... 97 609b Can you tell me what the size of (NAME) was? Much samller than usual ...... 1 Smaller than usual...... 2 Normal/Usual ...... 3 Larger than usual ...... 4 Don’t know/Can’t decide ...... 7 610 When was (NAME) given a bath for the first time? Immediately ...... 000
Hours ...... 1 Days ...... 2 Did not give bath ...... 996 Don’t know ...... 997 611 Have you ever breastfed (NAME)? Yes ...... 1 No ...... 2 611e 611a Was the baby put to breast before delivery of the Yes ...... 1 placenta? No ...... 2 Don’t know/can’t remember ...... 7 Immediately after birth ...... 000 611b When was the baby breast-fed for the first time after birth? How many hours after birth ...... 1
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How many days after birth ...... 2 If before/within an hour circle "000”, If before/ within 24 hours then circle 1 and write in the space for hour, If 24 hours/after 24 hours then circle 2 and write in the space for days.
611c Was (NAME) given colostrum immediately after Yes ...... 1 his/her birth? No ...... 2 611d Before giving breastfeeding or in the first three Yes ...... 1 days after delivery was (NAME) given any other No ...... 2 611f food or liquid? Don’t know/can’t remember ...... 7 611f NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 611e What other food or liquid was given besides Honey ...... A breast milk at any point during first 3 days? Misri water ...... B Sugar water ...... C Ask: Did you feed any other things? Water ...... D Fruit juice ...... E Write down all the answers. Tinned milk/ infant formula from shop ...... F Cow’s milk ...... G Other liquids ...... H Powdered rice with water (Lei) ...... I Banana ...... J Papaya/mango ...... K Green leafy vegetable ...... L Rice/bread ...... M Lentil/pulse/dal ...... N Other ...... X (Specify) 611m Was (NAME) given any other food or liquid before Honey ...... A starting breast milk? Misri water ...... B Sugar water ...... C Ask: Did you feed any other things? Water ...... D Fruit juice ...... E Write down all the answers. Tinned milk/ infant formula from shop ...... F Cow’s milk ...... G Other liquids ...... H Powdered rice with water (Lei) ...... I Banana ...... J Papaya/mango ...... K Green leafy vegetable ...... L Rice/bread ...... M Lentil/pulse/dal ...... N Other ...... X (Specify) 611f Interviewer: Check question 218 and encircle Alive ...... 1 appropriate code. Dead ...... 2 612
611g Interviewer: Check question 219 and encircle Baby less than 6 months ...... 1 appropriate code. Baby more than 6 months ...... 2 611j
611h Are (Name) still breast-feeding? Yes ...... 1
No ...... 2 611j 611i For how many months did (NAME) breastfeed? Months ...... 611k
Don’t know ...... 97 611k
611j Do you give (Name) anything else to eat beside Yes ...... 1 breast milk in the last 24 hours? No ...... 2 612
611k Food item Yes No
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Now I will ask you about the type of solid, liquid a. Cow’s or goat milk? 1 2 or semi-solid food you have given to (NAME) in b. Other liquid food? 1 2 last 24 hours. c. Baby formula/baby food? 1 2 Among the following liquid, solid and semi-solid food what have you given to (NAME)? (Ask for d. Shuji/lei? 1 2 every item). e. Rice, bread, khichuri? 1 2 f. Water? 1 2 g. Honey, sugar water or fruit juice? 1 2 h. Mango, ripe papaya? 1 2 i. Green vegetable? 1 2 j. Other fruits or vegetables? 1 2 k. Fish, meat or egg? 1 2 l. Pulses (dal)? 1 2 m. Others? 1 2 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 611l How many times did (Name) eat solid, semi-solid, liquid food other than breast milk in last 24 Number of extra feeding in last 24 hours hours?
IF 7 OR MORE TIMES , RECORD 07, IF NONE , RECORD 00. 612 What have you done to keep (NAME) warm Dried the baby ...... A following delivery Wrapped the baby with clean cloths/‘katha’ ...... B
Kept the baby on bare skin to skin contact ...... C Do not read out the answer Conducted delivery at kitchen ...... D Ask: Anything else was used? Lighted some fire at delivery room...... E Rubbed the baby with hot oil ...... F Circle all the answers. Kept newborn on my lap ...... G
Kept newborn at others lap ...... H Other ...... X (Specify) Nothing done ...... Z 613 In the first fifteen days of life how frequently per Always ...... 1 day did you hold (NAME) skin-to-skin against Very often ...... 2 your breasts during the daytime and nighttime? Often ...... 3
A few times ...... 4
Never ...... 5
Baby died before 15 days ...... 6 700
614 In the first fifteen days do you sleep with (NAME) Sleep with baby ...... 1 against you at night, or do you lay him/her on the Lay baby on cot ...... 2 bed/cot, or elsewhere? Sleep with baby and cot/elsewhere ...... 3 Elsewhere ...... 4 Don’t know ...... 7
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Section H: Postnatal visits by Health Workers
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 700 To prevent excessive bleeding after delivery Yes ...... 1 of (NAME), where you given 2/3 tablets? No ...... 2 701 700a Did you use the tablets just after delivery? Yes ...... 1 No ...... 2 701 After the birth of NAME did you visit any Yes ...... 1 health worker for PNC for yourself? No ...... 2 701d 701a To whom you went for PNC? MBBS doctor ...... A Nurse/midwife ...... B Do not read out the answers. Paramedic ...... C FWV ...... D ASK: Anybody else? Medical Assistant/SACMO ...... E MaMoni Health Worker/CHW ...... F Write down all the answers. HA ...... G FWA ...... H TTBA ...... I TBA (Dai/Dhorni/Chauni) ...... J Homeopath ...... K Ayurved ...... L Quack ...... M Village doctors ...... N Spiritual person/Kabiraj ...... O Other health worker ...... P Others ______X (Specify) Don’t know/Can’t say ...... Y 701b How many times in total you visit any health worker for PNC for yourself? No. Of times ...... 701c How many days after delivery you visit any health worker for first PNC for yourself? Days after...... 701d Check question 213 (What was the outcome Live birth ...... 1 of her last pregnancy?) and circle Still birth ...... 2 702 appropriate code. Lost before 7 months ...... 3 702 701e After the birth of (NAME) did you visit any Yes ...... 1 health worker for PNC for your baby? No ...... 2 701h 701j How many days/months/year later after the Day ...... birth of (NAME) did you visit? Record in Month ...... days if less than 1 month, record in months if less than 1 year. If age is less than 1 day, Year ...... record ‘00’. 701f To whom you went for PNC for your baby? MBBS doctor ...... A Do not read out the answers. Nurse/midwife ...... B ASK: Anything else? Paramedic ...... C Write down all the answers. FWV ...... D Medical assistant/SACMO ...... E MaMoni Health Worker/CHW ...... F HA ...... G FWA ...... H TTBA ...... I TBA (Dai/Dhorni/Chauni) ...... J Homeopath ...... K Ayurved ...... L Quack ...... M Village doctors ...... N Spiritual person/Kabiraj ...... O Other health worker ...... P Others ...... X (Specify) Don’t know/ Can’t say ...... Y 701g How many times in total you visit any health No. Of times ...... worker for PNC for your baby?
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MaMoni_Questionnaire_RDW_Habiganj_English version_June 2011 Survey 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 701h Did any health worker/workers come to your Yes ...... 1 house for checkup/advice after (NAME) was No ...... 2 702 born? Interviewer: Make sure that you make the respondent understand that you mean all Don’t know/ Can’t say ...... 7 702 level of health worker including doctors. 701k How many days/months/year later after the Day ...... 1 birth of (NAME) did any health worker visit Month ...... 2 your baby? Record in days if less than 1 month, record in months if less than 1 year. If age is Year ...... 3 less than 1 day, record ‘00’. 701i Which health worker/workers come to your house to visit your baby? MBBS doctor ...... A Nurse/midwife ...... B Do not read out the answers. Paramedic ...... C ASK: Anything else? FWV ...... D Medical assistant/SACMO ...... E Write down all the answers. MaMoni Health Worker/CHW ...... F HA ...... G FWA ...... H TTBA...... I TBA (Dai/Dhorni/Chauni) ...... J Homeopath ...... K Ayurved ...... L Quack ...... M Village doctors ...... N Spiritual person/Kabiraj ...... O Other health worker ...... P Others ...... X (Specify) 702 After delivery of the baby did any health Yes ...... 1 worker/workers come to your house to visit No ...... 2 702b you? Don’t know/ Can’t say ...... 7 702b 702a After delivery of the baby which health MBBS doctor ...... A worker/workers came to your house to visit Nurse/midwife ...... B you? Paramedic ...... C Ask: Any other health worker came? FWV ...... D Identify all the health workers. Medical Assistant/SACMO ...... E MaMoni Health Worker/CHW ...... F HA ...... G FWA ...... H TTBA...... I TBA (Dai/Dhorni/Chauni) ...... J Homeopath ...... K Ayurved ...... L Quack ...... M Village doctors ...... N Spiritual person/Kabiraj ...... O Other health worker ...... P Others ______X (Specify) Don’t know/Can’t say ...... Y 702b Interviewer: Check Question 701i and circle Code F/G/H circled ...... 1 appropriately? Other code circled except F,G & H ...... 2 706a No code circled ...... 3 706a
703 After the birth of the baby how many times in No. Of times ...... total the health worker with the gray bag came Don’t know/Can’t say ...... 97 706a to visit you and the newborn within the first Never came ...... 00 706a week of delivery?
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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 703a You mentioned that HA/FWA/MaMoni 1st time after _ days of delivery Health Worker/CHW visited you ……. times during the first seven days. Please specify the nd timing of those visits? 2 time after _ days of delivery ______3rd time after _ days of delivery When was 1st visit made after delivery by HA/FWA/MaMoni Health Worker/CHW? 4th time after _ days of delivery ______nd When was 2 visit made after delivery by 5th time after _ days of delivery HA/FWA/MaMoni Health Worker/CHW? ______6th time after _ days of delivery When was 3rd visit made after delivery by HA/FWA/MaMoni Health Worker/CHW? 7th time after _ days of delivery ______When was 4th visit made after delivery by HA/FWA/MaMoni Health Worker/CHW? ______When was 5th visit made after delivery by HA/FWA/MaMoni Health Worker/CHW? ______When was 6th visit made after delivery by HA/FWA/MaMoni Health Worker/CHW? ______When was 7th visit made after delivery by HA/FWA/MaMoni Health Worker/CHW? 704a What did the health worker do while visiting Asked about the health of the mother ...... A you or your baby? Asked about the health of the newborn ...... B Do not read the answers. Ask: Anything else? Examined the mother ...... C Interviewer: circle all responses. Examined the newborn ...... D
Took weight of the newborn ...... E
Gave treatment to the mother ...... F
Treated the newborn ...... G
Referred the mother to health center for illness ...... H
Referred the newborn to health center for illness ... I
Demonstrated and gave advice regarding proper
technique of breastfeeding ...... J
Demonstrated and gave advice to the mother regarding drying wrapping of the newborn immediately after birth ...... K Watch me breastfeed ...... L Asked if I have any danger signs ...... M
Asked if baby had any danger signs...... N Counseled on danger signs for baby...... O
Counseled on danger signs for mother ...... P Counseled on LAM ...... Q Counseled on what family planning method to use after completing LAM ...... R Counseled about family planning ...... S Others ______X (Specify) 706a Check question 213 (What was the outcome Live birth ...... 1 of her last pregnancy?) Still birth ...... 2 712 Lost before 7 months ...... 3 712
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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
Now I will discuss about the health problems of your baby. 707 After the birth of (Name) did s/he suffer Difficult or fast breathing ...... A from any sort problem/complication within Pneumonia ...... B first month of life? Cold/cough ...... C Do not read out, Ask anything else? Yellow skin/palm/feet/eye color (jaundice) ...... D Record all the answers she mentions. Poor sucking or feeding ...... E Pus, bleeding, or discharge from around the umbilical cord ...... F Skin lesions or blisters ...... G Convulsions/spasms/rigidity ...... H Lethargy/unconsciousness ...... I Red or swollen eyes with pus ...... J Baby feels cold ...... K Baby doesn’t cry ...... L Fever ...... M Doesn’t pass urine ...... N Doesn’t pass stool ...... O Continuous vomiting ...... P Distention of abdomen...... Q Difficult to wake ...... R Skin rash/‘Mashipishi’ ...... S Measles ...... T Diarrhoea ...... U Chest in drawing ...... V Others ______X (Specify) No illness/None mentioned ...... Y 712 707a Did anyone told/gave you advice for the Yes ...... 1 treatment of (NAME) for this illness? No ...... 2 708 Don’t know/ Can’t say ...... 7 708 707b Who advised you to seek treatment for your ACCESS Counselor/MaMoni Health Worker/CHW ...... A sick baby? Family members ...... B 708 Relatives ...... C 708 Neighbors/friends...... D 708 TBA (Dai/Dhorni/Chauni) ...... E 708 Trained TBA ...... F 708 Village doctor ...... G 708 Others ______X 708 (Specify) 708 Did you seek any treatment for this Yes ...... 1 710 problem/complication? No ...... 2 Don’t know/ Can’t say ...... 7 712 709 Why did you not seek any treatment for this Too far ...... A 712 problem/complication? Service hour is inconvenient ...... B 712 Don’t suggest any answer. Unpleasant behavior of the service provider ...... C 712 Ask: Any other reason? Lack of skill of the service provider ...... D 712 Write down all the answers. Lack of privacy ...... E 712 Inadequate drug ...... F 712 Have to wait for a long time ...... G 712 Too expensive ...... H 712 Religious reasons ...... I 712 Not beneficial ...... J 712 Did not know that it is necessary to go there ...... K 712 Could not/Did not get permission ...... L 712 Did not know that it has health care facility ...... M 712 Others ______X 712 (Specify)
710 From whom you received treatment for your MBBS doctor ...... A baby? Nurse/midwife ...... B 159 | Page
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Do not suggest any answers. Paramedic ...... C Ask: Anything else? FWV ...... D Write down all the answers. Medical Assistant/SACMO ...... E MaMoni Health Worker/CHW ...... F HA ...... G FWA ...... H TTBA ...... I TBA (Dai/Dhorni/Chauni) ...... J Homeopath ...... K Ayurved ...... L Quack ...... M Village doctors ...... N Spiritual person/Kabiraj ...... O Other health worker ...... P Others ______X (Specify) Don’t know/Can’t say ...... Y 711 From where did you receive care for this Home...... A problem/complication? Satellite clinic ...... B FWC ...... C After the birth of (Name) did you have any UHC ...... D of the following problem/complication? MBBS Doctor's chamber ...... E Clinic ...... F Community Clinic ...... G Hospital ...... H Pharmacy ...... I Others ______X (Specify) Now I shall ask you whether you have any problem/complication at the period after delivery.
712 After the birth of (Name) did you have any of Problem Yes No the following problem/complication? A. Fever 1 2 B. Excessive vaginal bleeding, large 1 2 clots or tissue passed. C. Foul smelling vaginal discharge 1 2 D. Severe lower abdominal pain 1 2 E. Breathlessness, tiredness, palpitation 1 2 and weakness F. Fainting 1 2 G. Fits and convulsion 1 2 H. Other problem 1 2 712a Interviewer: Check Question 712 and circle One or more codes circled 1 ...... 1 appropriate code. All codes circled 2 ...... 2 801 712e Did you seek any sort of treatment for this Yes ...... 1 problem/complication? No ...... 2 801 Don’t know/ Can’t say ...... 7 801 712g From where did you receive care for this Home ...... A problem/complication? Satellite clinic...... B FWC ...... C
UHC ...... D
MBBS Doctor's chamber ...... E Clinic ...... F
Community Clinic ...... G
Hospital ...... H
Pharmacy ...... I Others ______X (Specify)
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Section I: Community Action Groups You may know that there are local networks and committees in many communities. Now I will be discussing about such formations in your communities.
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 801 Do you know about any committees, or network Yes ...... 1 or group in your community that works towards improving you or your babies’ health? No ...... 2 1001 801a Are you and/or any of your family member is a Yes ...... 1 member of any such group? No ...... 2 802
801b How long ago did you become member of this Month ...... group? Interviewer: If respondent answer in years Don’t rememberCan’t remember ...... 97 convert it into months. If less than one month write ‘00’ in the box.
802 What issues do the committee/group deal with? Mother’s health ...... A Baby’s health ...... B
Family planning ...... C Education ...... D Transporting sick mother & babies ...... E
Financing sick mother & babies ...... F Others ______X (Specify) Don’t know ...... Y
803 PLEASE CHECK 707 and 712 and encircle Code ‘Y’ in Q707 and all 2 codes in Q712 circled ...... 1 1001 appropriate code. Code ‘Y’ in Q707 and any ‘1’ code in Q712 circled .... 2 Other than ‘Y’ in Q707 and all 2 codes in Q712 circled ...... 3 Other than ‘Y’ in Q707 and any ‘1’ code in Q712 circled ...... 4 803a Did you take any sort of help from this group Yes ...... 1 for this/these problems? (MENTION THE No ...... 2 1001 PROBLEMS FROM Q707 and Q712) 803b Have you received any sort of help from this Yes ...... 1 group? No ...... 2 1001
803c What kind of support you and/or a newborn get Transport support ...... A from this village group/CAG? Financial support ...... B 803 g Informed Health Worker ...... C 1001 Ensured visit of Health Worker ...... D 1001 Others ______X 1001 (Specify) 803d What kind of transport support you got from Helped to find a transport ...... 1 them? Provided with a transport ...... 2 803e Do you consider this as beneficial? Yes ...... 1
No ...... 2 803f CHECK Question 803c and circle appropriate Code B circled ...... 1 code. Code B not circled ...... 2 1001
803g Did they give you money directly from their Gave money from their fund ...... 1 fund or arranged money from the community? Arranged from community ...... 2 Don’t know ...... 7
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Section K: Hand Washing NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 1001 When did you wash your hands with soap Before preparing food ...... A yesterday? Before eating ...... B After eating ...... C Do not PROBE, circle the appropriate answer. Before feeding a child ...... D After feeding a child ...... E After cleaning child’s anus ...... F After disposal child feces ...... G After defecation ...... H After handling cow-dung ...... I After returning from outside compound ...... J After changing the baby’s diaper ...... K Never ...... L Others ______X (Specify) 1002 When did you wash your hands with ash Before preparing food ...... A
yesterday? Before eating ...... B After eating ...... C Do not PROBE, circle the appropriate answer. Before feeding a child ...... D After feeding a child ...... E After cleaning child’s anus ...... F After disposal child feces ...... G After defecation ...... H After handling cow-dung ...... I After returning from outside compound ...... J After changing the baby’s diaper ...... K Never ...... L Others ______X (Specify) 1003 When did you last prepare food? Today ...... 1 Yesterday ...... 2 Before 2 or more days back ...... 3 Never/Can’t remember ...... 8 1004 Refused to answer ...... 9 1004 1003a Did you wash hands before preparing food? Yes ...... 1 No ...... 2 1004 1003b Did you wash your both hands before Yes ...... 1
preparing food? No ...... 2
1003c What type of materials did you use for hand Only water ...... 1
washing before preparing food? Ash ...... 2 Soap ...... 3 Earth ...... 4 Others ______6 (Specify) 1004 When did you last eat with hands? Today ...... 1 Yesterday ...... 2 Before 2 or more days back ...... 3 Never/Can’t remember ...... 8 1005 Refused to answer ...... 9 1005 1004a Did you wash hands before eating? Yes ...... 1 No ...... 2 1005 1004b Did you wash your both hands before eating? Yes ...... 1
No ...... 2
1004c What type of material did you use for hand Only water ...... 1
washing before eating? Ash ...... 2 Soap ...... 3 Earth ...... 4 Others ______6 Specify)
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1005 When did you last feed your child with hands? Today ...... 1 Yesterday ...... 2 Before 2 or more days back ...... 3 Never/Can’t remember ...... 8 1006 Refused to answer ...... 9 1006 1005a Did you wash your hands before feeding child? Yes ...... 1 No ...... 2 1006 1005b Did you wash your both hands before feeding Yes ...... 1 child? No ...... 2 1005c What type of material did you use for hand Only water ...... 1 washing before feeding child? Ash ...... 2 Soap ...... 3 Earth ...... 4 Others ______6 (Specify) 1006 When did you last clean your child’s anus? Today ...... 1 Yesterday ...... 2 Before 2 or more days back ...... 3 Never/Can’t remember ...... 8 1006d Refused to answer ...... 9 1006d 1006a Did you wash your hands after cleaning your Yes ...... 1 child’s anus? No ...... 2 1006d 1006b Did you wash your both hands after cleaning Yes ...... 1 your child’s anus? No ...... 2 1006c What type of material you use for hand Only water ...... 1 washing after cleaning your child’s anus? Ash ...... 2 Soap ...... 3 Earth ...... 4 Others ______6 (Specify) 1006d When did you last defecate? Today ...... 1 Yesterday ...... 2 Before 2 or more days back ...... 3 Never/Can’t remember ...... 8 1007 Refused to answer ...... 9 1007 1006e Did you wash hands after defecation? Yes ...... 1 No ...... 2 1007 1006f Did you wash your both hands? Yes ...... 1 No ...... 2 1007 How many times did you wash your hands Number throughout the day yesterday? 1008 Have you used soap today or yesterday? Yes ...... 1 No ...... 2 1009 1008a When did you use soap yesterday, what did Washing cloths ...... A
you use for it? Washing my body ...... B Washing my children ...... C Instruction: Ask for what purposes the mother Washing my children’s hands ...... D used soap in last 24 hours. Washing child’s anus...... E Washing hands after defecating ...... F Washing hands after handling cow-dung ...... G Washing hands before feeding child ...... H Washing hands before preparing food...... I Washing hands before eating ...... J Washing hands after eating ...... K Others ______X (Specify) 1009 Do you have separate soap available for hand Yes ...... 1
washing? No ...... 2 Don’t know/can’t remember ...... 7 1009a Observe: Is there soap or detergent or locally Soap ...... A
used cleansing agent? Detergent ...... B Ash ...... C Mud/Sand ...... D Others ______X (Specify) 163 | Page
1009b Do you have available water for hand Yes ...... 1
washing? (Observe) No ...... 2
1010 Do you have spare soap available in the Yes ...... 1
household? No ...... 2 Ask mother to show the soap. Don’t know/Can’t remember ...... 7 1011 Before leaving the place check the Interview ending time:
questionnaire properly then : END THE SURVEY WITH THANKS H H : M M and record the time.
Thank you.
Name, Signature of FRA: Checked by FRO:
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