Final Report_MaMoni midline evaluation_Sylhet_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
Mid-line Evaluation on Maternal & Newborn Health, 2010 Sylhet
Report prepared by:
Child Health Unit of Public Health Sciences Division ICDDR,B
Acknowledgements
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Final Report_MaMoni midline evaluation_Sylhet_Maternal & Newborn Health 2010
We would like to acknowledge the large number of people and organizations that provided support in the completion of midline evaluation survey on the maternal and newborn health indicators of the ‘MaMoni’ project in Sylhet. 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 midline evaluation_Sylhet_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 Sylhet ...... 20 1.4 Chapter References ...... 21
Chapter-2: Methodology of the survey ...... 23
2.1 Respondent ...... 23 2.2 Midline Survey Design ...... 23 2.3 Selection of sample ...... 24 2.4 Sample size ...... 24 2.5 Household survey (data collection) ...... 25 2.5.1 Recruitment and training of field staff ...... 25 2.5.2 Survey method ...... 26 2.6 Survey instrument (Questionnaire) ...... 26 2.7 Survey implementation ...... 27 2.8 Quality assurance (QA) ...... 28 2.9 Data management and analysis ...... 29
Chapter-3: Demographic & Socio-economic status ...... 30
3.1 Demographic Characteristics of Households ...... 30 3.2 Pregnancy outcome ...... 32 3.3 Parity ...... 32 3.4 Educational Attainment of RDW ...... 33 3.5 Household characteristics ...... 35 3.6 Household Possessions ...... 36 3.7 Land ownership ...... 38 3.8 Religion...... 39
Chapter – 4: Knowledge of Mother on Maternal and Neonatal Health ...... 40
4.1 Key components of birth plan ...... 40 4.4 Knowledge of Complications during Pregnancy ...... 41 4.5 Knowledge of Complications during Delivery ...... 42 4.6 Knowledge of Complications during Postpartum Period ...... 43 4.7 Knowledge of Neonatal Health Problems ...... 44
Chapter 5 Maternal Health ...... 46
5.1 Antenatal Care ...... 46 5.2 Components of Antenatal Care Checkup ...... 52 5.3 Information Received during Antenatal Care ...... 55 5.4 Birth Plan & Delivery ...... 57 5.5 Post Partum ...... 62
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Final Report_MaMoni midline evaluation_Sylhet_Maternal & Newborn Health 2010
Chapter 6: Maternal Health Problems & Treatment Seeking Behavior ...... 65
6 Women’s Reporting of Maternal Complications ...... 65 6.1 Complications during Pregnancy ...... 66 6.2 Complications during delivery ...... 70 6.3 Complication during Postpartum ...... 73
Chapter 7 Newborn Health ...... 77
7.1 Prevention of Hypothermia ...... 77 7.2 Umbilical Cord Care ...... 81 7.3 Breast Feeding ...... 83 7.4 Bathing ...... 86 7.5 Postnatal Care (PNC) ...... 88 7.6 Newborn complication and care seeking ...... 90
Chapter 8: Birth Interval and Contraception ...... 95
8.1 Birth Interval ...... 95 8.2 Family Planning ...... 96
Chapter 9: Community Action Group (CAG) ...... 101
9.1 Existence of CAG and Membership ...... 101
Chapter 10: Hand washing ...... 103
Chapter 11: Discussion ...... 108
Chapter 12 Appendix 109
Appendix-A RDW listing form ...... 109 Appendix-B Evaluation indicators for midline survey ...... 110 Appendix-C Midline questionnaire on maternal and newborn health ...... 112
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Final Report_MaMoni midline evaluation_Sylhet_Maternal & Newborn Health 2010
List of Tables
Page # Chapter-2: Methodology of the survey ...... 23
Table 2.1 Calculation of sample size ...... 25 Table 2.2 Distribution of samples (RDW) by upazila ...... 25 Percent distribution of women (RDW) by results of household and individual Table 2.3 27 interviews by upazila, Sylhet,2010 ......
Chapter-3: Demographic & Socio-economic status ...... 30
Percent distribution of the household members by age group & sex, among Table 3.1.1 households with women that had pregnancy outcome during 01 July 2009 to 30 June 30 2010 in seven intervention upazilas of Sylhet ...... Percent distribution of household size (number of usual members), among Table 3.1.3 households with a women who had a pregnancy outcome during 01 July 2009 to 30 31 June 2010 in the MaMoni –Sylhet...... 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 July 2009 to 30 June 32 2010) ...... Percent distribution of women with different birth orders by MaMoni upazila of Table 3.3.1 32 Sylhet 2010 ...... Percent distribution of women by level of education and age who had a pregnancy Table 3.4.1 33 outcome during July’09 to June’10 by upazila in Sylhet ...... Percent distribution of households by housing characteristics by upazilas of Sylhet Table 3.5.2 36 ...... Percentage of households possessing various durable consumer goods by upazilas Table 3.6.2 for households with a woman had a pregnancy outcome during the period Jul2009 – 37 Jun2010 ...... Table 3.6.3 Distribution of wealth index quintile by upazilas of Sylhet ...... 38 Percent distribution of households with own land, among households with a woman Table 3.7.1 39 had a pregnancy outcome during Jul2009 – June2010 by upazilas of Sylhet... Table 3.8.1 Distribution of religion of RDW households by upazilas of Sylhet ...... 39
Chapter – 4: Knowledge of Mother on Maternal and Neonatal Health...... 40
Table 4.1.2 Percentage of women cited the key components of birth plan by upazila, Sylhet 40 Percent of recent mothers reported knowing danger signs of pregnancy by upazila, Table 4.4.1 42 Sylhet...... Percent of recent mothers reported knowing danger signs during child birth by Table 4.5.1 43 upazila, Sylhet ...... Percent of recent mothers reported knowing danger signs of post partum by upazila, Table 4.6.1 44 Sylhet...... Percent of recent mothers reported knowing danger signs of newborn baby within 7 Table 4.7.1 45 days of birth by upazila, Sylhet ......
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Final Report_MaMoni midline evaluation_Sylhet_Maternal & Newborn Health 2010
Chapter- 5: Maternal Health ...... 46
Percentage of women received 4 ANCs from a skilled provider during their last Table:5.1.1 47 pregnancy by upazila,Sylhet ...... 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 48 characteristics ...... Percent distribution of women who received at least 4 ANC visits during their last Table 5.1.3 49 pregnancy by type of providers and by upazilla, Sylhet ...... Percent distribution of women received ANC during their last pregnancy by type of Table 5.1.3a 50 provider in Sylhet. (2010) ...... Percent distribution of ANC provider, who provided ANC-1 to the women during Table 5.1.4 their last pregnancy by upazila and according to background characteristics, Sylhet 51 2010 ...... Percent distribution of TT doses received (from card and history) by MaMoni Table 5.2.1 52 upazilas of Sylhet ...... Percent distribution of women received valid doses of TT (from card and history) Table 5.2.1a 53 during their lifetime by upazilas of Sylhet ...... Percentage of children born protected from neonatal tetanus among live-births Table 5.2.1b 53 during last pregnancy by upazila of Sylhet ...... Percentage of women consumed Iron-folic acid tablets during their last pregnancy Table 5.2.2 54 by upazila and by background characteristics in Sylhet ...... Percentage of women received counseling/advice from ACCESS counselor / Table 5.3.1 MaMoni health worker and percentage of whom received counseling by component 55 during pregnancy and by upazila, Sylhet. (2010) ...... Percentage of women received at least 2 home visits by an ACCESS counselor / Table 5.3.2 56 MaMoni health worker during their last pregnancy by upazilas of Sylhet ...... Percent of women reported receiving counseling from an ACCESS Table 5.3.4 56 Counselor/MaMoni health worker on the importance of 4 ANC visits by upazila Percentage of women reported receiving counseling from an ACCESS Counselor / Table 5.3.5 57 MaMoni health worker 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 58 ...... Percent of recent mothers reported had a birth plan with 5 components during their Table 5.4.2 58 last pregnancy by upazila, Sylhet ...... Percent distribution of place of delivery during last pregnancy by background Table 5.4.3 59 characteristics and by upazila, Sylhet ...... Percent distribution of type of birth attendant who assisted delivery at home (Except Table 5.4.4 61 family member) by upazilla and by background characteristics in Sylhet ...... Percent of women who had birth kits for delivery and distribution of source from Table 5.4.5 62 where birth kits were received by upazilas of Sylhet ...... Percentage of women reported receiving any PNC visit for themselves and Table 5.5.1 percentage of whom received a PNC within 3 days after child birth by upazila, 62 Sylhet...... Percentage of women reported received at least two PNC visits for themselves from Table 5.5.2 63 a skilled provider after child birth by MaMoni upazilas ...... Percentage of women received PNC visits for themselves from a skilled provider Table 5.5.3 63 within 3 days after child birth by upazila, Sylhet ...... Percentage of women reported receiving home visit by a ACCESS Table 5.5.5 counselor/MaMoni health worker by timing of home visit after child birth and by 64 upazila, Sylhet ......
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Final Report_MaMoni midline evaluation_Sylhet_Maternal & Newborn Health 2010
Chapter- 6: Maternal Health Problems & Treatment Seeking Behavior ...... 65
Among women with reported danger signs during last pregnancy, percent Table 6.1.1 66 distribution of danger signs by MaMoni upazilas of Sylhet ...... Percent distribution of number of danger signs reported during last pregnancy by Table 6.1.2 66 upazila, Sylhet ...... 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 67 characteristics, Sylhet ...... Among women with reported danger signs during pregnancy and sought care, the Table 6.1.5 68 percent distribution of provider (by category) by upazila, Sylhet ...... Among women with reported danger signs during pregnancy and sought care, the Table 6.1.6 69 percent distribution of place of care by upazila, Sylhet ...... 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, 69 Sylhet...... Percentage of women reported danger signs during delivery and percentage of whom Table 6.2.1 70 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 71 danger signs by upazila, Sylhet ...... Percent distribution of number of danger signs reported during delivery by upazilla, Table 6.2.3 71 Sylhet...... Women who had complication during delivery and sought care, the percent Table 6.2.5 72 distribution of provider by upazila, Sylhet ...... Women reported had complications during delivery and sought care, the percent Table 6.2.6 72 distribution of place of care by intervention upazillas in Sylhet ...... 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 73 provider in Sylhet ...... Percent of women reported danger signs during post-partum and percentage of Table 6.3.1 whom sought care from a skilled provider by upazila and by background 74 characteristics ...... Percent distribution of danger signs reported during post partum period by upazila, Table 6.3.2 75 Sylhet...... Percent distribution of number of danger signs reported during post partum period Table 6.3.3 75 by upazilla ...... Women reported had complications and sought care during post partum period, the Table 6.3.6 76 percent distribution of place of care by upazila ......
Chapter -7: Newborn Health ...... 77
Women gave birth at home and had newborn care person (NBC) at birth; percent Table 7.1.1 78 distribution of type of newborn care person by upazila, Sylhet ...... Percent distribution of type of immediate care that newborn received first after birth Table 7.1.2 78 by upazila ...... Percentage of newborns were dried and wrapped before the delivery of placenta in Table 7.1.3 79 home deliveries by upazila ...... Timing of both drying and wrapping of the newborn immediately after birth among Table 7.1.4 79 home deliveries by upazila ...... Percent distribution of time of delivery of placenta in minutes by intervention Table 7.1.5 80 upazilas of Sylhet (home delivery only) ......
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Final Report_MaMoni midline evaluation_Sylhet_Maternal & Newborn Health 2010
Percent distribution of individual timing of immediate drying and wrapping of Table 7.1.6 80 newborns after birth in Sylhet (Home delivery only) ...... Percent of recent mothers who gave birth at home and whose newborns’ cords were Table 7.2.1 81 cut by type of instruments and by upazila ...... Percent distribution of women had CDK during child birth and used materials from Table 7.2.3 82 birth kit among home deliveries by upazila ...... Percentage of women applied specific substances to the umbilical cord of the Table 7.2.4 82 newborn within seven days after birth among home deliveries by upazila ...... Percentage of women applied specific substances to the umbilical cord after birth Table 7.2.5 83 among home deliveries by upazila ...... Percentage of women reported initiating breast feeding immediately following birth Table 7.3.1 (home delivery) by time since birth, placental delivery and by baseline/midline 83 surveys...... Percent of recent mothers delivered at home reported initiating breast feeding within Table 7.3.2 84 1 hour of birth by upazila ...... Table 7.3.3 Percentage of newborns received colostrum by upazila ...... 84 Table 7.3.4 Percentage of newborns received prelacteal feed by upazila ...... 85 Percentage of newborns received solid or liquid food other than breast milk within 3 Table 7.3.5 85 days after birth by upazila ...... Table 7.4.1 Timing of first bathing of newborns after birth by upazila. (Home delivery only) 86 Percentage of newborns bathed after 3 days of birth for the first time by upazila and Table 7.4.2 87 selected demographic and socio-economic characteristics (Home Delivery Only) Percentage of women reported receiving at least 2 PNC visits for their newborns by Table 7.5.1 88 upazila ...... Percent distribution of women received PNC by timing of first PNC received by Table 7.5.2 88 upazila ...... Percentage of women reported receiving at least two PNCs from a skilled provider Table 7.5.4 89 by upazila and selected demographic and socio-economic characteristics...... Percent of women reported their newborns developed a danger sign at birth or within Table 7.6.1 28 days after birth and percentage of whom sought care from a skilled provider by 90 upazila and by background characteristics ...... Percent distribution of signs and symptoms of newborns reported sick during first Table 7.6.2 91 month of life by intervention upzila ...... Percent distribution of number of danger signs reported during 1st month of life of Table 7.6.3 92 newborns by upazila ...... Newborns (within 28 days of birth) had complications and sought care, percent Table 7.6.4 92 distribution of heath care provider by upazila ...... Percent distribution of sites from where a woman sought medical care for the sick Table 7.6.5 93 newborn by upazila ...... Percent of newborns who had a danger sign and were referred by an ACCESS Table 7.6.6 94 Counselor by upazila ...... Table 7.6.7 Reason of not seeking care for newborn illness by upazila ...... 94
Chapter -8: Birth Interval and Contraception ...... 95
Percentage of women reported desire to delay next pregnancy for at least two years Table 8.1.1 95 by upazila ...... Percentage of women whose recent pregnancies were actually delayed for at least Table 8.1.2 96 two years by upazila and by background characteristics ...... Percent distribution of women used any family planning method during first six Table 8.2.1 97 months after delivery by upazila, Sylhet ......
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Final Report_MaMoni midline evaluation_Sylhet_Maternal & Newborn Health 2010
Percent distribution of women currently using contraceptive methods by ACCESS Table 8.2.2 baseline and MaMoni mid-line survey by method and source of collection of method 98 ...... Percentage of women accepted a contraceptive method within 6 weeks of Table 8.2.3 postpartum by method and by selected demographic and socio-economic 99 characteristics in Sylhet ......
Chapter -9: Community Action Group (CAG) ...... 101
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 101 or any family member), by upazila ...... Percentage of women reported aware of activities of the community action group by Table 9.1.2 101 upazila ...... Percentage of women had postpartum complication or the newborn complication, Table 9.1.3 used emergency transport or benefited financing from CAG by intervention upazila 102 of Sylhet ......
Chapter -10: Hand washing ...... 103
Percentage of recently delivered women reported washed their hands before most Table 10.1.1 recent preparation of food for family members by type of material used and by 103 upazila ...... Percentage of recently delivered women reported washed their hands before taking Table 10.1.2 103 their last meal by type of material used and by upazila ...... Percentage of recently delivered women whose child is still alive reported washed Table 10.1.3 104 their hands before feed their children by type of material used and by upazila Percentage of recently delivered women whose child is still alive reported washed Table 10.1.4 their hands after cleaning their child’s anus by type of material used and by upazila 104 ...... Percentage of recently delivered women reported washed their hands after Table 10.1.5 105 defecations by upazila ...... Percentage of recently delivered women reported washed their hands with soap at Table 10.1.6 least 3 times during last 24 hours by upazila and by selected demographic and socio- 105 economic characteristics ...... Percentage of recently delivered women reported washed their hands with soap by Table 10.1.7 106 category of work/activity during last 24 hours by upazila...... Percentage of households had soap/detergent/other cleansing material at home Table 10.1.8 106 observed during the time of interview by upazila ...... Percentage of household was able to show stock of additional soap during the Table 10.1.9 107 interview by upazila ......
Chapter-11 Discussion 108
Table 11.1 Comparison between baseline-2007 and midline-2010 surveys ...... 108
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Final Report_MaMoni midline evaluation_Sylhet_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 Sylhet district showing ACCESS/MaMOni areas ...... 23
Chapter-3 Demographic & Socio-economic status ...... 30 Fig 3.1 Population pyramid in MaMoni area of Sylhet ...... 31 Fig 3.2 Level of maternal education by MaMoni upazila, Sylhet ...... 34 Fig 3.3 Level of maternal education by baseline and endline surveys, Sylhet ...... 34 Fig 3.4 Level of education by age of mother, Sylhet ...... 35
Chapter-5 Maternal Health ...... 46 Fig 5.1 Percentage of women received ANC during their last pregnancy by upazila ... 47 Percentage of women delivered their baby at health facility by level of maternal Fig 5.6 60 education and baseline/midline surveys, Sylhet ......
Chapter-6 Maternal Health Problems & Treatment Seeking Behavior ...... 65 Percentage of women reported had complication during pregnancy, delivery and Fig 6 65 postpartum and compare with baseline 2007 survey, Sylhet ......
Chapter-7 Newborn Health ...... 77 Percentage of women had CDK during child birth by baseline and midline Fig 7.1 81 surveys in Sylhet ...... Timing of first bathing (bathed after 3 days of birth) of newborns after birth by Fig 7.2 86 baseline and midline surveys, Sylhet ......
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Final Report_MaMoni midline evaluation_Sylhet_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 midline evaluation_Sylhet_Maternal & Newborn Health 2010
Preface
The midline household survey was carried out in the seven upazilas of Sylhet 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 midline survey 2010 provides updated estimates of levels of maternal and newborn complications, and information on care seeking and delivery practices.
The information concerning maternal and newborn health in Sylhet will be useful to assess the effectiveness and adequacy of the intervention and 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 midline evaluation_Sylhet_Maternal & Newborn Health 2010
Summary of the findings:
Back ground: 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 ACCESS/MaMoni programme in terms of programme coverage and improvements in key practices of maternal and newborn health. As part of this evaluation, a midline survey was conducted to measure current levels of indicators on knowledge and practices and compare data with baseline findings.
Methods: The midline survey was conducted in the seven intervention upazillas of Sylhet district (Balaganj, Biswanath, Companiganj, Fenchuganj, Golapganj, Gowainghat and Jaintapur). To estimate programme coverage and improvements in key practices of maternal and newborn health, we estimated a sample size of 304 recently delivered women (RDW) as samples per upazila for interview. Samples were selected from 15 clusters (population of each cluster was 1000-1500) from each upazila selected using probability proportion to size (PPS). “Bari” list was generated from ACCESS/MaMoni register and from there 22 bari (House) were selected randomly as a starting point to search for a RDW. One RDW from one starting point or house was selected by following a definite method which has mentioned in detail in the methodology section.
Findings: Socio-demographic characteristics of the women in the survey: About 65% of women interviewed were between 20-29 years old. Around 12% of the women were <20 years and the remaining 23% were 30 years or older. About 93% of women interviewed were Muslim. Around 33% of the women in the survey had no education, and 49% had five or more years of schooling, including secondary or higher education. The rest had less than 5 years of education. In women 15-24 years old, more than 55% women had five or more years of schooling. 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 there was no such variability in wealth among the selected samples in Sylhet. Incidentally it was twenty percent households in each of the five different quintiles. There was slight variation found in Companiganj and Gowainghat upazilas where percentage in the lowest quintile group was little high.
Regarding demographic characteristics, proportion of female population (51%) was slightly higher than the male population (49%) at midline. In particular, for age groups 30-49, the proportion of females in the population was almost twice that of males. This is attributed to the large proportion of males in this age group working and residing 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-2007, little discrepancy is observed except that nationally the numbers of women and men were more or less similar in all age
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groups including 30-49 years of age. This indicated that the large numbers of males working abroad is a more prominent feature of Sylhet than in other parts of Bangladesh. Maternal health and care-seeking: Around 50% of the women in the ACCESS/MaMoni intervention area reported receiving any ANC during their last pregnancy, 14% received four or more ANCs and 13% received four or more ANCs with at least one from a skilled provider. About a third (35%) of the women in the highest wealth quintile reported receiving four ANCs during their last pregnancy, while it was only 1.4% in the lowest wealth quintile group. Around 88% of the women reported receiving at least two doses of TT immunization on or before their last pregnancy. Percentages were similar across upazilas but found a little high (>90%) in the Biswanath and Golapganj upazilas. Eighty percent of deliveries in the ACCESS/MaMoni area were at home. Home deliveries were most common in Companiganj and Gowainghat upazilas (>90%). The percentage of women delivering in a health facility was the highest in Fenchuganj and Golapganj (around 30%), followed by 21% in Balaganj. There were significant variations in the percentage of health facility delivery by maternal education, birth order and wealth quintile. 2.4% of women who delivered at home were attended by a skilled provider. The rate of SBA attendance in home deliveries was comparatively high (5%) in Fenchuganj and Golapganj and 0% in Companiganj. Around 19% women in the ACCESS/MaMoni upazilas reported receiving any PNC after the termination of their last pregnancy. The rate was higher (>25%) in Fenchuganj and Golapganj upazilas. Around 26% of the women reported a complication during their last pregnancy, 23% during delivery and 29% during the post partum period. Among the women had complication, the most common complications reported during pregnancy included severe abdominal pain (34%) severe weakness (26%). Prolonged labour (45%) and excessive vaginal bleeding (18%) were the most common complications during delivery. Post-partum complications included severe lower abdominal pain (48%), fever (38%) and breathlessness/weakness (33%). Almost 82% of women with reported complication during pregnancy sought care from a skilled provider and seeking care from a skilled provider for a pregnancy complication was more than 90% in Fenchuganj and Golabganj upazilas. Care-seeking from a skilled provider for delivery complications was around 65% in Sylhet but the rate was high (around 80%) in Fenchuganj and Golabganj and low (55%) in Companiganj. Around 27% of women with reported post partum complications sought care from a skilled provider. The rate of seeking care from a skilled provider was high (>35%) in Fenchuganj and Golabganj and low in Gowainghat (14%). Immediate newborn care: Around 40 percent of newborns were reported to be dried and wrapped within ten minutes of birth while it was only 7% within five minutes. Almost three-fourths of the babies were dried and wrapped within 15 minutes of birth. Initiation of breast feeding within an hour after birth occurred with 88% of newborns in home deliveries. Around 85% of women reported cutting the umbilical cord with a blade from a birth-kit and 14% by a new blade. Around one-thirds of women reported used various substances to the umbilical stump and of them most frequently used materials were mustard oil with or without garlic, ginger juice and antiseptics like savlon, dettol, hexisol etc. More than 40% newborns were bathed for the first time after 3 days after birth. Only 11% of neonates received two or more PNC visits and of them around 98% received PNC from a skilled provider. Rate of receiving two or more PNCs was higher in Golabganj (23%) and Balaganj (16%) and lower in Companiganj and Jaintapur (around 4%). 14 | Page
Final Report_MaMoni midline evaluation_Sylhet_Maternal & Newborn Health 2010
Newborn complications and care seeking: Neonatal complications were reported in 43% of neonates and the rate was almost similar across MaMoni upazilas. Most commonly reported complications included fever (22%), cough & cold (17%) and pneumonia (8%). Almost all (97%) mothers reported seeking care for their sick newborns and of them 52% sought care from a skilled provider. Among women sought care for their newborns, 43% received care from pharmacies (drug store), 32% from a chamber of a qualified (MBBS) doctor, 13% from hospital/clinics and 8% from upazila health complex. Care-seeking for neonatal complications from a skilled provider was highest in Fenchuganj (70%) and lowest in Gowainghat (27%).
Conclusion: We note that certain recommended practices, e.g., maternal and neonatal health care practices, including ante-natal care, delivery care, post-natal care, newborn care and care-seeking from skilled providers for maternal or neonatal complications were higher than baseline coverage. Among the seven ACCESS/MaMoni upazilas, almost all indicators were much better for Balaganj, Biswanath, Fenchuganj and Golapganj compared with the other three upazilas of Companiganj, Gowainghat and Jaintapur.
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Final Report_MaMoni midline evaluation_Sylhet_Maternal & Newborn Health 2010
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)
ARI+Diarr, 1% N.Tetanus, 4% Diarrhea, 1% ARI, 10% Birth asphyxia, 21%
Possible LBW/PMB, 11% serious infection, Birth injury, 4% 34% Cong.abnormality, Others 2%
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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 seven out of total eleven upazilas (sub-districts) of Sylhet district of the north eastern region of Bangladesh. The MaMoni intervention upazilas are Balaganj, Biswanath, Companiganj, Fenchuganj, Golabganj, Gowainghat and Jaintapur.
Fig-2.1: Map of Sylhet district: Shaded 7 upazilas (sub-district) are MaMoni upazilas.
2.1 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’.
2.2 Survey Design: A population file of 2001 was prepared from BBS 2001 census report by village, union and upazila for the seven intervention upazilas of Sylhet 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 1000-1500 with the prediction that at least 22 women are available who delivered during the last one year in each cluster. We followed single procedure to select recently delivered women (RDW) and currently married women of reproductive age (CMWRA) from a cluster. 15 clusters from each upazila 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).
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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.
2.3 Selection of sample:
Total 198 villages (full or part) were in the selected 105 (15 X 7) clusters. House (Bari) list by village was gathered from ACCESS register to produce table for systematic random selection of house (Bari). From each cluster, 22 (Twenty two) houses were randomly selected as a starting point to search for RDW. We selected only one RDW from each starting point following definite procedure. Flow chart (2.2) below has shown the procedure to select and interview RDW from a starting point (house). Flow-chart: 2.2 Starting point
(house/Bari)
Listed all house-holds of the “Bari” One male enumerator used form-2 for and gave serial number household listing Selected a serial number from the list of HHs by lottery in each house Search from the selected serial number of HH for RDW When RDW found, then interview was If there is no RDW in the randomly done or made revisit plan if found selected HH, then search in the next HH absent. (serial) If there are more than one RDW in the Interview RDW same HH, then select one by lottery Completed remaining households for a RDW If no RDW found in the remaining HHs, then start from serial 1 to complete the whole house (Bari) If there is no RDW found in the HHs of that house, then data collector will move to the next house which is nearest to the selected house (starting point). Same procedure will follow until one RDW is found.
2.4 Sample size: (Sample size estimated to evaluate knowledge, practice and coverage indicators by upazila level) 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 recently delivered women (RDW) per measurement unit (Upazila). 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 once, the RDW sample required for estimating measures
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for indicators related to knowledge, practice and coverage for a upazila became 243 (194 x 1.25). Assuming 20 percent absent or refusal, the required sample size would be 304 (243 / .80).
Table-2.1: Calculation of sample size
Sample Size by Upazila
Sample size at upazila level 243 (194 x 1.25 ) Assuming 20% absent and refusal 304 (243 / .80)
Table-2.2: Distribution of samples (RDW) by upazila:
Name of # Population Population 2009, Total # of cluster # of RDW
upazila unions 2001 (BBS projected from 2001 RDW per upazila sample census) BBS census using sample (Pop. Range per cluster
Upazila code growth rate by upazila 1000-1500) 01 Balaganj 14 291,464 316,866 304 15 22 02 Biswanath 8 215,864 235,981 304 15 22 03 Companiganj 6 129,426 163,190 304 15 22 04 Fenchuganj 3 108,243 122,416 304 15 22 05 Golapganj 11 300,239 336,355 304 15 22 06 Goainghat 8 235,650 276,102 304 15 22 07 Jaintapur 6 138,155 163,657 304 15 22 Total: 56 1,419,041 1,614,567 2,126 105
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.
2.5.1 Recruitment and training of field staff:
ACPR recruited 24 field staff (16 Female interviewers, 4 Female supervisors and 4 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. The training for the interviewers and supervisors was held from July 26 to August 05, 2010 including two days of field practice. The training sessions were facilitated by training section of ACPR and study team of ICDDR,B. 2.5.2 Survey method:
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supervisors accompanied the data collectors inside the households and facilitated data collection, observed interviews and edited questionnaires to assure data quality in the field. It is relevant to mention here that the team was also engaged to select and interview currently married women of reproductive age (CMWRA) in the same cluster. Separate questionnaires were used for RDW and CMWRA.
2.6 Survey instrument (Questionnaire):
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 outcome 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 instrument included a section on community action group (CAG) which is a component of ACCESS community intervention package.
The following box gives an over view of the three questionnaires consisting of 10 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 history Section - G Newborn care practice including drying, wrapping, applying substances to the umbilicus, bathing and feeding 26 | Page
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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-K Hand washing practices among recently delivered women
2.7 Survey Implementation:
Data were collected by interviewing RDW through a set of questionnaire from August 07 to October 05, 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 four teams and they completed interview of 524 currently married women of reproductive age (15-49 years) in the selected 105 clusters in the seven intervention upazilas (15 clusters in each upazila) during the mentioned time period (two months). Following table 2.3 shows the status of implementation.
Table 2.3: Percent distribution of women (RDW) by results of household and individual interviews by upazila, Sylhet,2010
0
Balaganj N= 330 Bishwanath N= 33 Companiganj N= 330 Fenchuganj N=330 Golapganj N=330 Gowainghat N=316 Jaintapur N= 330 Total 2,296 N= Interview Complete 329 330 328 330 330 310 326 2,283 (99.7) (100.0) (99.4) (100.0) (100.0) (98.1) (98.8) (99.4) No HH member OR competent 0 0 2 0 0 3 1 6 respondent were present at home at (0.0) (0.0) (0.6) (0.0) (0.0) (1.0) (0.3) (0.3) time of HH visit Interview cancelled 0 0 0 0 0 0 0 0 (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) Refused to give interview 0 0 0 0 0 0 0 0 (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) Could not find the residence 0 0 0 0 0 0 1 1 (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.3) (0.0) Woman who has recently delivered 0 0 0 0 0 2 0 2 is absent (0.0) (0.0) (0.0) (0.0) (0.0) (0.6) (0.0) (0.1) No recently delivered woman 1 0 0 0 0 1 2 4 (Pregnancy outcome in the last 12 (0.3) (0.0) (0.0) (0.0) (0.0) (0.3) (0.6) (0.2) month 01 Jul’09 to 30 Jun’10) found Others 0 0 0 0 0 0 0 0 (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0)
2.8 Quality assurance
There were rigorous embedded quality assurance inputs in the implementation of the survey. In addition to the embedded quality assurance procedures of ACPR, there was an independent additional umbrella approach from ICDDR,B. Data analysis and report generation, sharing of findings were the specific responsibilities of ICDDR,B.
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The quality assurance (QA) procedures included:
1. Verification & Identification of sample: Four 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 seven upazilas of Sylhet district. 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 collectors so that if there were any need for repeating the incorrect survey they could do it easily as they were nearby. During two months of survey period in Sylhet district, the team completed 113 verifications of Bari, HH and RDW (5% of total). All the verification checks revealed consistent and correct administration of the surveys, in terms of the Bari, household and individual respondents. 100% samples was correctly identified including the household and bari (house).
2. On-site observation of interview: Data Collectors (QA) were able to observe 119 interviews (5% of total survey) on site. The performance was scored using a scale 1-4 (one being poor and 4 being very good). After analysis it shows that average score was 3.60 and scores by component were:- 1. Explained objective 3.60 2. Identified correct RDW 4.00 3. Consent taken 4.00 4. Face sheet found correct 3.58 5. Section-A 3.80 6. Section-B 3.80 7. Section-C 3.40 8. Section-D 3.40 9. Section-E 3.40 10. Section-F 3.50 11. Section-G 3.50 12. Section-H 3.50 13. Section-I 3.70 14. Section-K 3.60 15. Respondent understood Ques 3.40 16. Questionnaire checked 3.52 Mean 3.60
3. Repeat interviews: The Quality Assurance team collected the list of RDWs (interview completed within preceding 3 days) from the survey teams by cluster. Data Collector (QA) randomly selected RDW by cluster and by DC from that list and interviewed the same as a repeat. QA data collector collected photocopy of the completed questionnaire of the particular 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 was shared with ACPR for immediate remedies. For speedy feedback, mobile phones were used. Total 116 (5%) repeat interviews were done in Sylhet and 10 percent questions were found mis-matched with the original data collected by main team. Mis-matched report by section has shown below:- Section-A 7.60 Section-B 5.70 Section-C 6.20 Section-D 5.80
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Section-E 14.0 Section-F 6.70 Section-G 12.0 Section-H 9.40 Section-I 2.90 Section-K 16.0 Mean 10.0
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.
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.
Demographic and socioeconomic characteristics of the study population in the intervention areas were examined. 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 baseline 2007 and the overall population of the country. Therefore, whenever possible, baseline survey results have been compared to 2007 Bangladesh Demographic and Health Surveys (BDHS) data, ACCESS baseline survey data 2007 and when appropriate, to the Bangladesh Maternal Health Services and Maternal Mortality Survey (BMMS) data 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.
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3.1 Demographic Characteristics of Households
This study covers a population of 16,136 persons in the 2,283 households sampled among the all MaMoni area population, 51% of which were females and 49% 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 16-30 years of age, the proportion of females in the population was almost 1.7 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: Percent distribution of the household members by age group & sex, among households with women that had pregnancy outcome during 01 July 2009 to 30 June 2010 in seven intervention upazilas of Sylhet.
Age Group Intervention upazilas of Sylhet (in years) Male % of total male Female % of total Female Total % by age 0 – 4 1,971 24.9 1,902 23.1 3,873 24.0 5 – 14 1,815 22.9 1,777 21.6 3,592 22.3 15 – 29 1,664 21.0 2,752 33.5 4,416 27.4 30 – 49 1,848 23.4 978 11.9 2,826 17.5 > 50 613 7.7 816 9.9 1,429 8.9 Total 7,911 49.0 8,225 51.0 16,136 100.0
Fig:3.1 Population pyramid in the MaMoni area of Sylhet, 2010
Table 3.1.1 shows the distribution of the population by age category among the households surveyed; around 24% was 0-4 year age, 22% was 5-14 years, 27% was 15-29 years, 18% was 30-49 years and 9% was more than 49 years in the study area. The male female ratio in each age group was almost same except 21:33 in 15-29 years age group and 23:12 in the 31-49 years age group. In total, the ratio of male- to- female was 49:51. Table 3.1.3 shows that average household size was 7.1 across the study area. The highest mean of household member is 7.4 in Golapganj and Goainghat Upazilla and lowest is 6.7 in Jaintpur Upazilla.
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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 July 2009 to 30 June 2010 in the MaMoni –Sylhet
Number of usual members < 3 4 5 6 7 8 9+ Total Mean ± Std; (Median) Total area # 224 296 351 330 263 235 584 2283 7.1±3.5 % 9.8 13.0 15.4 14.5 11.5 10.3 25.6 100.0 6,(2-36) Upazila # 22 42 62 43 37 32 91 329 7.1±3.3 Balaganj % 6.7 12.8 18.8 13.1 11.3 9.7 27.7 100.0 6,(3-29) # 38 44 51 43 40 32 82 330 6.8±3.0 Biswanath % 11.5 13.3 15.5 13.0 12.1 9.7 24.9 100.0 6,(2-17) # 26 40 53 49 36 39 85 328 7.1±3.1 Companiganj % 7.9 12.2 16.2 14.9 11.0 11.9 25.9 100.0 6,(2-20) # 40 32 54 45 33 39 87 330 7.1±3.4 Fenchuganj % 12.1 9.7 16.4 13.6 10.0 11.8 26.4 100.0 6,(2-24) # 30 49 43 48 40 34 86 330 7.4±4.0 Golabganj % 9.1 14.9 13.0 14.6 12.1 10.3 26.1 100.0 6,(2-36) # 25 45 38 47 41 31 83 310 7.4±4.1 Gowainghat % 8.1 14.5 12.3 15.2 13.2 10.0 26.8 100.0 6.5,(2-32) # 43 44 50 55 36 28 70 326 6.7±3.4 Jaintapur % 13.2 13.5 15.3 16.9 11.0 8.6 21.5 100.0 6,(2-30)
3.2 Pregnancy outcome:
Table 3.2.1: Percentage of recent pregnancy outcomes and male/female ratio among live-births in the MaMoni upazilas of Sylhet (Pregnancy outcome period: 01 July 2009 to 30 June 2010)
Upazila Total Live birth Still-birth Abortion Abortion within Outcome within 4-7 3 months Male Female Total months Balaganj 332 52.3 47.7 92.2 0.3 1.2 6.3 Bishwanath 337 54.7 45.3 91.1 0.9 2.1 5.9 Companigonj 330 55.2 44.9 91.2 3.0 0.9 4.9 Fenchugonj 335 53.9 46.1 95.2 0.6 0.6 3.6 Golapgonj 333 56.7 43.3 91.6 1.2 1.2 6.0 Gowainghat 312 49.7 50.3 93.6 1.3 1.3 3.9 Jaintapur 332 52.7 47.3 95.5 0.3 2.4 1.8 Total: 2,311 53.6 46.4 92.9 1.1 1.4 4.6
During the period of 1st July 2009 to 30th June 2010, a total of 2,311 pregnancy outcomes were recorded among sampled RDW. Table 3.2.1 shows around 93% of all pregnancy outcomes were live-births and it was almost similar across seven intervention upazilas of Sylhet (96 percent in Jaintpur being the highest and 91 percent in Bishwanath being the lowest. The percentage of still-births among all pregnancies was 1.1%; abortions within 3 months were 4.6%. Abortion between 4-7 months of pregnancy was 1.4% in the study area. The Male/Female ratio among all live-births was 54:46. The percentage of abortions within 3 months of pregnancy was highest in Balaganj (6.3%) and lowest in Jaintpur (1.8%). 31 | Page
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3.3 Parity
Table 3.3.1: Percent distribution of women with different birth orders by MaMoni upazila of Sylhet 2010.
Upazila N= Birth order
0 1 2 3 4 5 or more Total: 2,283 1.5 25.5 23.9 15.2 12.6 21.3 Balaganj 329 1.5 19.8 26.8 18.8 11.6 21.6 Biswanath 330 3.0 27.3 23.3 15.8 12.1 18.5 Companiganj 328 1.5 22.3 20.1 15.9 13.1 27.1 Fenchuganj 330 1.2 32.7 22.4 15.2 11.5 17.0 Golapganj 330 0.9 30.0 28.5 14.6 9.1 17.0 Gowainghat 310 1.3 24.8 23.9 11.9 14.8 23.2 Jaintapur 326 0.9 21.8 22.1 14.1 16.3 24.9
Table 3.3.1 shows the distribution of women by parity. About 1.5% 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 study area. Around 26% women had one living child; while 24% had two living children; 16% had three and 13% had four in the study area. The percentage of women having five or more living children was 21% among the study population. Less than 1% women had no children only Jaintpur Upazilla while more than 27% of women had five or more children in Companiganj Upazilla. The difference of parity among MaMoni upazilas was not very significant.
3.4 Educational Attainment of RDW
Table 3.4.1 shows the distribution of women interviewed according to their education level by area and maternal age. Results indicate that almost 33% women had no education, while 5% of women had either secondary or higher level of education. 19% had attended school less than five years (primary) and around 44% had education level in between primary and secondary. Fig 2.2 shows level of maternal education by intervention upazila. The comparison of education level shows that more than 40% women in Companiganj, Gowainghat & Jaintapur had no formal education, while in the other four upazilas it was around 20%. However, there was marked variability in education level by age: younger women were more educated than older women in the study area (Fig: 3.4). The Level of maternal education by baseline (ACCESS-2007) and Midline (MaMoni-2010) in Sylhet were compared in figure 3.3.
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Table 3.4.1: Percent distribution of women by level of education and age who had a pregnancy outcome during July’09 to June’10 by upazila in Sylhet.
No Education Primary Class 5 - 9 Class 10 + Total number (N) Upazila Balaganj 24.0 19.8 51.7 4.6 329 Biswanath 22.7 20.0 53.6 3.6 330 Companiganj 51.2 20.4 26.5 1.8 328 Fenchuganj 21.5 15.8 52.7 10.0 330 Golabganj 20.6 16.7 55.2 7.6 330 Gowainghat 47.4 18.4 29.0 5.2 310 Jaintapur 41.4 21.2 35.3 2.2 326 Maternal age and level of education <20 24.0 21.2 53.8 1.1 279 20 – 24 20.5 20.2 54.0 5.3 863 25 – 29 36.4 17.6 38.4 7.6 604 30 – 34 45.7 19.3 30.3 4.8 337 35 – 39 60.4 13.2 24.5 1.9 159 40 + 70.7 14.6 14.6 0.0 41
Total: 743 (32.5) 431 (18.9) 995 (43.6) 114 (5.0) 2,283
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Fig:3.2 Level of maternal education by MaMoni upazilas of Sylhet, 2010
60
50
40
30
20
10
0 No education Primary Class 5-9 Class Balaganj 24 19.8 51.7 4. Biswanath 22.7 20 53.6 3. Companiganj 51.2 20.4 26.5 1. Fenchuganj 21.5 15.8 52.7 10 Golapganj 20 6 16 7 55 2 7 Fig:3.3 Level of maternal education by baseline (ACCESS-2007) and Midline (MaMoni-2010) in the intervention upazilas of Sylhet
50 45 40 35 30 25 20 15 10 5 0 No education Primary Class 5-9 Class 10+ ACCESS,2007 44.9 13.9 37.2 4 MaMoni, 2010 32.5 18.9 43.6 5
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Fig:3.4 Level of education by age of mother (MaMoni, 2010)
80 70 60 50 40 30 20 10 0 <20 yrs 20-24 yrs 25-29 yrs 30-34 yrs 35-39 yrs 40+ yrs No education 24 20.5 36.4 45.7 60.4 70.7 Primary 21.2 20.2 17.6 19.3 13.2 14.6 Class 5-9 53.8 54 38.4 30.3 24.5 14.6 Class 10+ 1.1 5.3 7.6 4.8 1.9 0 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 56% of households had electricity in the study area. Variability found in the distribution of electricity among different upazillas of the study area. More than half of the households in Balaganj, Biswanath, Fenchuganj & Golabganj had electricity, while it was around 40% in Companiganj, Gowainghat and Jaintapur. Around 53% households in the study area had access to a Tap/tube-well as source of drinking water. In Golapganj 83% household use Tap/tube-well as source of drinking water while in Companygonj 66.2% household use surface water for drinking purpose. In the Study area, 37.4% of households use hygienic latrines. Non- water seal latrines are available in 39.7% household. Open latrines were found in 22.9% of households in the study area. In Golapgonj, the highest number (61.5%) of household used sanitary latrine; incase of pit latrine (without water seal) the number was 58% in Jaintpur. In companygonj and in Gowainghat, highest number of household use open type of latrine (around 41%). In rural Bangladesh, tin is the main roofing material, and walls are usually constructed with natural materials, such as bamboo and mud. In the study area, almost 80% of houses had tin roofs, and 51% of houses had bamboo and mud walls, 39% houses had brick/cement walls and 76% had mud floors. Roofs made by bamboo/thatch were found most frequently in Gowainghat (28.4%), Jaintapur (26.1%) and Companiganj (18%), while in the other four upazilas they were found in less than 1% of houses. Cement/concrete wall were more prevalent in Golabganj (60.9%) followed by Balaganj (48.6%); the number were around 22-24% in companyganj, Gowainghat and in Jaintpur. Pucca floor with cement was found more frequently (25% or more) in Balaganj, Biswanath, and Fenchuganj, while only they were around 10% in the other four upazillas.
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Table 3.5.2: Percent distribution of households by housing characteristics by upazilas of Sylhet.
Characteristic
Balaganj N=329 Biswanath N=330 Companigan j N=328 Fenchuganj N=330 Golapganj N=330 Gowainghat N=310 Jaintapur N=326 Total N=2283 Electricity: Yes 55.9 69.4 40.6 68.2 74.9 40.3 42.3 56.1 Source of water to clean household utensils: Tap 1.8 4.2 0.9 11.2 4.2 0.3 5.2 4.0 Tube well 40.7 40.0 32.9 73.6 78.8 33.6 41.7 48.9 Surface water 57.5 55.8 66.2 15.2 17.0 66.1 53.1 47.0 Other 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Sanitation facility: Septic tank, modern 3.7 10.0 1.5 7.3 13.0 1.6 3.4 5.8 Water sealed / Slab lat. 40.7 38.5 14.9 36.4 48.5 23.6 17.8 31.6 Pit Latrine / not sealed 36.5 40.9 42.1 40.0 26.7 33.6 58.0 39.7 Open / hanging latrine 11.6 7.6 29.3 13.3 11.5 29.7 16.3 16.9 No facility / bush, field 7.3 3.0 12.2 3.0 0.3 11.6 4.6 6.0 Other 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Roof material: Katcha bamboo/thatch 0.0 0.3 18.0 0.9 0.0 28.4 26.1 10.3 Tin 83.0 84.9 77.4 89.4 92.4 69.0 72.1 81.3 Cement / concrete / tile 17.0 14.9 4.6 9.7 7.6 1.9 1.8 8.3 Other 0.0 0.0 0.0 0.0 0.0 0.7 0.0 0.1 Wall material: Jute / bamboo / mud 39.2 46.1 54.9 42.1 29.4 67.4 66.9 49.2 Wood 0.0 0.0 0.0 0.0 0.3 1.0 0.6 0.3 Brick / cement 48.6 43.3 22.9 47.9 60.9 22.9 24.2 38.9 Tin 12.2 10.6 22.3 10.0 9.4 8.7 8.3 11.7 Floor material: Earth / bamboo 73.3 75.2 89.3 62.7 59.7 86.1 87.4 76.1 Wood / others 0.0 0.0 0.0 0.0 0.0 1.9 0.3 0.3 Cement / concrete 26.8 24.9 10.7 37.3 40.3 11.9 12.3 23.6
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 by study area. Results indicate that 90% of households had at least one cot or bed in the study area, the most common durable goods; around 39% households had at least one almirah/wardrobe and about 78% had a table and/or a chair. Thirty five perecent households had at least one TV, and about only 6% of households had a radio.. Across the study areas 66% households had telephone/cell phone.
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Table 3.6.2: Percentage of households possessing various durable consumer goods by upazilas for households with a woman had a pregnancy outcome during the period Jul2009 – Jun2010
Goods
Balaganj N=329 Biswanath N=330 Companiganj N=328 Fenchuganj N=330 Golapganj N=330 Gowainghat N=310 Jaintapur N=326 Total N=2,283 Almirah / wardrobe 49.2 53.3 18.0 49.7 62.4 21.6 20.3 39.4 Table / Bench / chair 79.6 80.3 66.5 82.7 86.7 69.0 77.6 77.6 Watch / clock 51.7 45.8 38.7 62.1 63.3 41.6 46.9 50.1 Cot / bed 92.7 90.3 76.8 92.7 94.6 85.5 94.5 89.6 Functioning Radio 8.2 4.2 2.7 9.1 7.3 5.5 4.9 6.0 Functioning Television 42.0 40.9 20.1 50.0 50.0 18.4 19.0 34.5 Quilt (kombol) 83.3 87.6 60.7 85.8 93.0 78.4 74.9 80.6 Refrigerator 21.3 17.9 2.7 20.9 23.9 3.6 3.1 13.5 Bicycle 5.5 7.6 3.7 9.4 9.7 9.7 5.8 7.3 Motorcycle 4.3 4.6 1.5 6.1 8.8 3.2 3.1 4.5 Sewing machine 5.5 6.1 4.3 9.7 8.2 4.8 4.0 6.1 Telephone/ Mobile 71.4 70.6 55.5 73.6 79.1 56.8 54.9 66.1 Car / Micro-bus / tempo 3.0 3.0 2.4 2.7 3.3 1.6 1.8 2.6 Rickshaw / Van 0.9 2.4 0.6 1.2 1.5 1.6 3.4 1.7 Boat 16.1 2.4 31.7 13.0 8.2 18.4 4.9 13.5
Categorization of ACCESS / MaMoni upazilas: We grouped the 7 ACCESS / MaMoni upazilas into two categories based on the mean wealth index of the upazila (source: ACCESS baseline survey data, 2007)
Category-A: Four upazilas with higher wealth index
Upazila: Mean and Standard deviation of wealth index 1. Golapganj Mean: 1.54 SD: 3.16 2. Fenchuganj Mean: 1.26 SD: 3.48 3. Balaganj Mean: 0.75 SD: 3.23 4. Biswanath Mean: 0.84 SD: 3.24
Category-B: Three upazilas with lower wealth index
Upazila: Mean and Standard deviation of wealth index 1. Companiganj Mean: -1.15 SD: 2.42 2. Gowainghat Mean: -1.36 SD: 2.41 3. Jaintapur Mean: -0.71 SD: 2.64
Table 3.6.2 shows the percentage of possession of durable consumer goods were relatively higher in Balaganj, Biswanath, Fenchuganj and Golapganj (A category) compared to Companiganj, Gowainghat and Jaintapur (B category), in general. More than 40 percent households in A category upazilas possessed a functioning TV, while it was around 20 percent in the B category upazilas. Similarly, around 20% households of A category upazila possessed a Refrigerator, while it was around 3 percent in the B category upazilas. Around 4-9 percent of households had motorcycle in A category upazilas compared to 1-2% in the B category. Most striking was the possession of a telephone (mostly cell phone): around 70- 80 percent households had a telephone/cell phone in A category upazilas and 50-60 percent household had 37 | Page
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cell phone in B category upazilas. Possession of a boat was more common in Balaganj, Companiganj and Gowainghat (16-32%) upazilas because of the low lying area. Around 50-60% of households in the A category possessed an Almirah, and only 18-22% in B category upazilas.
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, 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.
Table 3.6.3: Distribution of wealth index quintile by upazilas of Sylhet.
Upazila Lowest Second Middle Fourth quintile Highest quintile N quintile quintile quintile # % # % # % # % # % Balaganj 64 19.5 60 18.2 76 23.1 57 17.3 72 21.9 329 Biswanath 61 18.5 64 19.4 83 25.2 72 21.8 50 15.2 330 Companiganj 75 22.9 66 20.1 55 16.8 68 20.7 64 19.5 328 Fenchuganj 62 18.8 69 20.9 60 18.2 79 23.9 60 18.2 330 Golabganj 42 12.7 77 23.3 79 23.9 58 17.6 74 22.4 330 Gowainghat 89 28.7 55 17.7 39 12.6 50 16.1 77 24.8 310 Jaintapur 64 19.6 66 20.3 64 19.6 73 22.4 59 18.1 326 Total: 457 20.0 457 20.0 456 20.0 457 20.0 456 20.0 2,283
Table 3.6.3 shows that the distribution of wealth quintiles is homogeneous and very similar across the upazilas except Gowainghat.
3.7 Land ownership
Table 3.7.1 shows the percent distribution of homestead and other land ownership in study area. Among the households 95% had their own homestead and 35% possessed lands other than homestead, while 5% had neither homestead for living nor other land (for cultivation). In Jaintpur, 10% households had neither their own homestead nor any other lands.
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Table 3.7.1: Percent distribution of households with own land, among households with a woman had a pregnancy outcome during Jul2009 – June2010 by upazilas of Sylhet.
Upazila Owns homestead Owns other land Neither Total households # % # % # % N
Balaganj 315 95.7 127 38.6 14 4.3 329
Biswanath 317 96.1 79 23.9 13 3.9 330
Companiganj 313 95.4 144 43.9 15 4.6 328
Fenchuganj 308 93.3 98 29.7 22 6.7 330
Golabganj 318 96.4 126 38.2 11 3.3 330
Gowainghat 291 93.9 136 43.9 18 5.8 310
Jaintapur 296 90.8 93 28.5 29 8.9 326
Total: 2,158 94.5 803 35.2 122 5.3 2,283
3.8 Religion
The population of the study areas were predominantly Muslim (93%), and the rest were Hindu, only 0.3% were from other religion (Table 3.8.1). The proportions of Hindu population in Jaintpur & Fenchuganj were slightly higher (13% and 10% respectively).
Table 3.8.1: Distribution of religion of RDW households by upazilas of Sylhet.
Upazila Religion Total Number of Islam Hinduism Others households # % # % # % N Balaganj 319 97.0 10 3.0 0 0.0 329
Biswanath 318 96.4 12 3.6 0 0.0 330
Companiganj 312 95.1 16 4.9 0 0.0 328
Fenchuganj 298 90.3 32 9.7 0 0.0 330
Golapganj 309 93.6 21 6.4 0 0.0 330
Gowainghat 282 91.0 22 7.1 6 1.9 310
Jaintapur 285 87.4 41 12.6 0 0.0 326
Total: 2,123 93.0 154 6.8 6 0.3 2,283
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Chapter-4 Knowledge of Mother on Maternal and Neonatal Health
The midline survey 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 knowledge at midline will help to evaluate the adequacy 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, Sylhet Multiple answers were accepted
Knowledge of RDW about the
components of Birth plan
Balaganj N=329 Biswanath N=330 Companiganj N=328 Fenchuganj N=330 Golabganj N=330 Gowainghat N=310 Jaintapur N=326 Total N=2283 Deciding where to deliver 6.4 3.9 0.9 5.5 7.6 7.4 3.4 5.0 Deciding who will assist birth 24.0 20.3 17.1 21.2 27.3 30.0 12.3 21.7 Ensure a person for newborn care 7.0 2.4 2.1 2.1 4.6 4.5 3.1 3.7 Purchase /procure a safe delivery kit 22.8 19.4 24.4 27.3 14.9 13.2 12.3 19.2 Ensure emergency transport 17.0 18.2 5.5 14.6 20.3 8.1 5.5 12.8 Savings for emergency 28.0 29.4 20.1 29.7 34.6 19.4 16.9 25.5 Approval to seek care 0.6 1.5 0.6 0.0 0.3 0.7 0.9 0.7 Check up during pregnancy 11.3 25.8 12.2 12.7 17.6 11.0 16.9 15.4 TT vaccination 0.9 5.2 4.6 2.1 0.9 0.7 9.5 3.4 To take Iron tablet 0.3 0.9 1.8 0.9 0.3 2.6 2.2 1.3 Know danger signs for mother 1.8 2.1 2.4 0.3 0.0 0.7 2.2 1.4 Know danger signs for newborn 0.0 0.3 1.2 0.0 0.0 0.7 0.6 0.4 Extra food 38.6 47.3 21.3 23.9 33.6 16.1 37.1 31.3 Take adequate rest 33.4 33.9 24.1 28.2 29.1 10.7 35.0 27.9 Not to do heavy work 45.3 46.1 40.9 36.1 33.6 17.7 42.9 37.7 Ensure a trained TBA 0.6 3.3 1.5 4.2 8.5 4.8 1.2 3.5 A well lighted and airy delivery place 0.0 0.0 0.9 0.3 0.6 1.9 0.6 0.6 Prepare two pieces of cloth 34.4 40.0 53.4 57.3 56.7 56.1 49.1 49.5 Identify Blood Donor 2.4 1.5 2.1 2.1 4.6 2.6 2.8 2.6 Prepare boiled blade 51.4 48.2 67.4 63.6 60.0 63.6 59.2 59.0 Prepare boiled thread 49.2 47.3 64.6 62.7 57.6 61.0 55.2 56.8 Others 7.9 5.5 9.8 20.3 13.0 13.9 4.3 10.6 Can’t remember/Don’t know 0.0 0.0 0.9 0.0 0.0 0.0 1.2 0.3
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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 (50-65%). Around 10-30 percent of women had knowledge about the selection of a birth attendant, high in Gowainghat, Golabganj and Balaganj (>20percent) and low in Jaintpur and Comapaniganj (15 percent); 17-35 percent knew about savings for an emergency (Golabganj was the highest around 35 percent and the lowest reporting of knowledge was in Jaintpur, 17 percent); 11-26 percent had knowledge about having a medical check-up during pregnancy (highest in Biswanath 26 percent and lowest in Gowainghat at 11 percent); 34-57 percent had knowledge about the preparation of the two pieces of cloths for drying/wrapping of newborn, high in Fenchganj, Golabganj and Jaintpur (>50 percent) and low in Balaganj (34 percent). Around 4 percent of women reported knowledge of the importance of trained TBAs for delivery. Knowledge of the need for TT (tetanus toxoid) vaccination during pregnancy was low across all upazilas; 10 percent women in Jaintapur mentioned TT as an important part of the birth plan, whereas less than 1 percent women in Balaganj, Golapganj and Goainghat mentioned about TT.
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 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 97% of recently delivered women (RDW) in the intervention areas named at least one condition, including severe headache (60 percent), convulsion/fits (43 percent), severe weakness (37 percent), excessive vomiting (34 percent), and severe abdominal pain (32 percent). The percentage of women citing more than three complications was 78 percent in the MaMoni intervention areas. 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 15 percent of women also 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 43 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, one fourth of all RDW 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, Sylhet
Multiple answers were accepted
Danger signs
intapur Balaganj N=329 Biswanath N=330 Companiganj N=328 Fenchuganj N=330 Golabganj N=330 Gowainghat N=310 Ja N=326 Total N=2283 Severe Headache 66.0 69.4 67.1 62.4 61.5 35.2 55.2 59.8 Blurred Vision 40.7 27.0 19.2 45.5 30.3 14.5 25.8 29.1 Fetal movement reduced/absent 7.0 4.9 2.7 7.3 6.4 10.7 7.4 6.6 High Blood Pressure 4.0 3.3 0.3 3.6 6.1 3.6 3.4 3.5 Edema of the face/swelling 7.0 4.9 7.0 6.1 3.9 1.3 5.8 5.2 Edema of the hands/ swelling 17.0 17.3 16.8 10.9 12.1 8.1 11.4 13.4 Convulsions/fits 38.6 31.5 39.3 60.3 41.2 40.3 46.9 42.6 Excessive Vaginal Bleeding 21.0 23.3 19.8 32.1 29.7 20.3 24.9 24.5 Severe abdominal pain 31.3 34.6 30.2 30.6 30.0 39.0 28.8 32.0 Edema of the legs 13.1 13.3 15.6 7.0 3.9 4.2 11.7 9.9 Fever 24.0 29.7 33.8 35.8 31.8 29.7 29.8 30.7 Premature rupture of membrane 0.6 1.2 1.2 1.2 4.6 1.9 2.2 1.8 Loss of consciousness 0.9 0.3 0.0 0.9 0.9 1.9 0.9 0.8 Difficulty breathing 0.3 1.2 0.3 0.0 1.5 1.0 0.3 0.7 Severe weakness 39.8 42.7 46.7 25.8 36.1 31.9 36.2 37.1 Excessive vomiting 33.7 31.8 36.3 36.7 44.2 27.1 27.6 34.0 Excessive whitish vaginal discharge 0.3 0.6 0.3 0.3 0.9 1.0 0.0 0.5 Others 0.0 0.0 0.0 0.0 0.6 3.6 0.6 0.7 Don’t know 0.0 0.0 0.0 0.6 0.0 0.0 0.6 0.2 Number of complication cited Did not mention any complication 0.0 0.0 0.0 0.6 0.0 0.0 0.6 0.2 Mentioned <3 Complication 15.2 23.6 19.8 10.0 16.7 44.8 27.6 22.3 Mentioned ≥3 Complications 84.8 76.4 80.2 89.4 83.3 55.2 71.8 77.5
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. Less than 1 percent of respondents were not able to mention the name of any adverse condition during the delivery that required immediate medical attention. Among all of women 54 percent were able to name three or more adverse condition, 41 percent able to name less than three complications. The most frequently cited conditions were convulsion (64 percent), excessive bleeding (56 percent), prolong labour (45 percent); 28 percent mentioned about the baby’s hands or feet coming out first. High fever, and retained placenta were additionally mentioned by around 15 percent of women. Very few women mentioned a rupture of the uterus, cord prolapsed and loss of consciousness (1-5 percent).
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Table 4.5.1: Percent of recent mothers reported knowing danger signs during child birth by upazila, Sylhet
Multiple answers were accepted
Danger signs
Balaganj N=329 Biswanath N=330 Companiganj N=328 Fenchuganj N=330 Golabganj N=330 Gowainghat N=310 Jaintapur N=326 Total N=2283 Excessive Vaginal Bleeding 66.6 52.4 58.5 78.2 53.0 34.5 50.9 56.5 Foul-Smelling Discharge 4.3 1.8 0.0 2.7 0.3 1.3 0.6 1.6 High Fever 15.2 11.8 22.3 23.9 17.6 11.6 18.1 17.3 Baby’s Hand or Feet Coming out first 20.7 22.7 41.5 41.2 16.4 19.7 31.6 27.7 Baby is in abnormal position 21.0 24.9 31.4 29.1 23.0 21.0 18.7 24.2 Prolong Labor (>12 hours) 41.3 43.6 46.3 38.8 40.9 51.6 49.4 44.5 Retained Placenta 13.7 12.1 11.6 17.3 19.1 16.1 14.1 14.9 Rupture uterus/Cervical/Vaginal tear 1.5 1.8 0.9 0.3 0.9 0.3 1.2 1.0 Cord Prolapse 0.0 0.6 0.0 0.0 0.3 0.0 0.0 0.1 Cord around neck 0.6 0.3 0.3 0.3 0.0 0.7 0.3 0.4 Convulsion 63.8 62.7 66.5 71.8 62.1 55.2 63.8 63.8 Severe headache 12.2 11.5 6.4 9.7 13.9 5.8 8.9 9.8 Greenish vaginal discharge 0.0 0.0 0.0 0.3 0.3 0.0 0.0 0.1 Loss of consciousness 2.7 2.4 2.7 1.2 3.0 2.9 1.8 2.4 Neonatal injuries 0.9 0.3 0.0 0.0 1.8 0.0 0.0 0.4 Blurring of vision 5.5 4.2 0.9 0.9 4.2 0.7 1.8 2.6 Others 0.3 1.8 0.0 0.0 2.1 1.3 0.3 0.8 Don’t know 0.0 0.3 0.6 0.6 0.0 0.7 2.8 0.7 Number of complication cited Did not mention any complication 0.0 0.3 0.6 0.6 0.0 0.7 2.8 0.7 Mentioned <3 Complication 40.7 50.6 39.0 23.9 50.6 67.7 47.6 40.7 Mentioned ≥3 Complications 59.3 49.1 60.4 75.5 49.4 31.6 49.7 53.8
4.6 Knowledge of Complications during Postpartum Period:
Around 99% of women in the intervention areas were able to name at least one complication during the postpartum period. Results indicate that while hemorrhage is the leading cause of maternal mortality, 69 percent of respondents cited excessive bleeding as a postpartum complication in the intervention areas. In contrast, 53 percent reported as convulsion/fits, 34 percent of women reported severe weakness and 27 percent abdominal pain as one of the major life threatening conditions. Fever was cited by 37 percent of women and 20 percent mentioned tetanus as additional complication. Only 14 percent of women could mention retained placenta as a complication. Table 4.6.1 enumerated the knowledge on danger sign in post partum period.
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Table 4.6.1: Percent of recent mothers reported knowing danger signs of post partum by upazila, Sylhet.
Multiple answers were accepted
Danger signs
Balaganj N=329 Biswanath N=330 Companiganj N=328 Fenchuganj N=330 Golabganj N=330 Gowainghat N=310 Jaintapur N=326 Total N=2283 Excessive Vaginal Bleeding 76.0 74.2 71.0 82.1 67.0 43.9 65.3 68.7 Foul-Smelling Discharge 4.0 3.6 2.1 2.4 0.9 2.6 0.9 2.4 Fever 26.8 34.2 51.8 40.9 33.6 31.9 41.7 37.3 Inverted nipples 0.6 0.0 0.3 0.6 1.2 0.7 0.6 0.6 Tetanus 27.7 27.3 22.3 18.2 13.6 17.4 13.2 20.0 Retained Placenta 14.0 11.2 10.4 10.9 19.7 17.1 9.8 13.3 Severe lower abdominal pain 22.8 22.7 31.1 31.8 23.6 27.7 25.8 26.5 Convulsions/fits 47.1 36.1 45.4 75.5 55.8 55.2 58.6 53.4 Engorged breast/ swelling of breast 0.3 0.3 0.3 0.0 0.6 1.0 1.5 (0.6 Fainting 0.9 0.6 2.1 2.1 3.0 6.1 3.1 2.5 Difficulty breathing 0.9 0.9 0.3 (0.3 0.0 0.7 0.6 0.5 Severe weakness 34.4 37.6 4.9 32.1 30.3 23.9 35.6 33.6 Severe headache 12.8 8.5 9.8 8.8 18.2 12.9 12.3 11.9 Blurred Vision 4.9 2.1 2.1 3.0 3.0 2.9 4.0 3.2 Swollen hands/face 1.5 2.7 1.8 1.8 1.8 3.2 1.2 2.0 Others 0.0 0.0 0.0 0.0 0.6 1.3 0.3 (0.3 Don’t know 0.0 0.0 0.6 0.9 0.0 0.7 2.5 0.7 Number of complication cited : Did not mention any complication 0.0 0.0 0.3 0.9 0.0 0.7 2.5 0.6 Mentioned <3 Complication 38.0 48.2 32.0 16.7 44.6 55.8 37.7 38.9 Mentioned ≥3 Complications 62.0 51.8 67.7 82.4 55.5 43.6 59.8 60.5
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.
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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, Sylhet.
Multiple answers were accepted
Danger signs of new born
Balaganj N=329 Biswanath N=330 Companiganj N=328 Fenchuganj N=330 anj Golabg N=330 Gowainghat N=310 Jaintapur N=326 Total N=2283 Difficult and fast breathing 63.2 46.1 43.6 60.9 39.7 40.3 40.5 47.8 Pneumonia 90.9 85.5 89.6 92.1 81.8 71.0 77.9 84.2 Cough/Cold 82.4 75.8 90.6 89.7 67.0 59.0 71.2 76.7 Yellow skin/palm/feet/eye 33.4 30.3 21.3 41.8 43.0 19.7 24.9 30.8 Poor sucking or feeding 4.6 6.7 3.4 7.3 15.8 14.2 3.7 7.9 Pus, bleeding/ discharge from around cord 4.0 2.7 4.3 8.5 7.9 7.7 4.9 5.7 Skin lesions or blisters 3.0 3.0 0.6 0.6 1.5 2.6 2.8 2.0 Convulsion/ spasms/rigidity 11.9 13.6 14.3 13.6 9.4 12.9 14.1 12.8 Lethargy/ unconsciousness 0.6 0.6 0.0 0.0 0.9 0.3 0.6 0.4 Red or swollen eyes with pus 0.6 0.0 0.9 0.9 0.6 0.7 1.5 0.7 Baby feels cold 0.6 0.0 0.6 0.3 0.3 0.3 1.2 0.5 Baby doesn’t cry 1.2 1.2 0.9 2.1 3.0 1.3 2.8 1.8 Fever 72.3 64.9 79.3 76.7 65.8 61.0 77.9 71.2 Doesn’t pass urine 0.9 2.7 1.8 3.0 5.2 3.6 1.8 2.7 Doesn’t pass stool 1.2 2.1 2.7 3.0 4.9 3.9 3.4 3.0 Continuous vomiting 2.4 4.6 4.0 3.3 5.2 4.5 8..6 4.6 Distention abdomen 4.9 5.5 5.5 5.8 7.3 10.3 12.3 7.3 Difficult to make woke from sleep 0.0 0.0 0.6 0.6 0.6 0.0 0.3 0.3 Skin rash/Mashipishi 3.7 5.5 5.2 6.7 9.4 12.6 8.9 7.4 Measles 0.9 2.1 4.6 6.1 6.4 4.5 4.0 4.1 Others 0.0 0.0 0.3 0.3 1.2 3.2 0.0 0.7 Don’t know 0.0 0.0 0.0 0.0 0.0 0.3 0.0 0.0 Number of complication cited Did not mention any complication 0.0 0.0 0.0 0.0 0.0 0.3 0.0 0.0 Mentioned <3 Complication 9.7 16.7 7.3 3.0 11.2 24.2 12.3 12.0 Mentioned ≥3 Complications 90.3 83.3 92.7 97.0 88.8 75.5 87.7 88.0
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, 100 percent of women mentioned at least one adverse neonatal condition, including fever (71 percent), cough & cold (77 percent), pneumonia (84 percent), difficulty in breathing (48 percent), and yellow skin in palm/feet/eye (31 percent). A small percentage of women (8 percent) reported convulsions and poor sucking/feeding.
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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 percent 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 percent), eclampsia (12 percent), and obstructed labor (8 percent).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 shows percent distribution of ANC during pregnancy by RDW. Results indicate that 14 percent of mothers received at least four ANC check-ups during their last pregnancy, while 34 percent women did not receive any ANC in the MaMoni intervention areas. This latter estimate of the percent of pregnancies that did not receive antenatal care is comparable to the estimate (47.4 percent) observed from the 2001 Bangladesh Maternal Health Services and Maternal Morbidity Survey (BMMS), and the rate (45.6 percent) observed from the 2007 Demographic and Health urvey (BDHS) in Sylhet division and the rate (51 percent) reported in the ACCESS baseline survey 2007.
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Table 5.1.1 shows the highest percentage of women receiving any ANC during their last pregnancy was in Golabganj upazila (70 percent) and the lowest was in Companiganj (30 percent). Around 13 percent of women reported receiving 4 ANCs from a skilled provider. Around 27 percent of women received ANC from a skilled provider in Golapganj upazila, while the percentage was low (2 percent) in Companiganj.
Table 5.1.1: Percentage of women received 4 ANCs from a skilled provider during their last pregnancy by upazila,Sylhet.
Upazila N= Received any Received 4 Received 4 ANCs from a skilled ANC ANCs provider (at least 1 ANC received from a skilled provider) Balaganj 308 46.1 9.1 8.8 Biswanath 310 55.2 15.5 15.5 Companiganj 312 30.1 1.9 1.9 Fenchuganj 318 61.3 19.2 19.2 Golabganj 310 70.0 27.1 26.5 Gowainghat 297 42.1 11.5 11.5 Jaintapur 320 43.1 10.0 8.8 Total: 2,175 49.8 13.5 13.1 Notes: Skilled provider: MBBS, Nurse/Midwife, Paramedic, FWV, SACMO/MA
Fig:5.1 Percentage of women received ANC during their last pregnancy by upazila, Sylhet.
80
70
60
50
40
30
20
10
0 Balaganj Biswanath Companiganj Fenchuganj Golapganj Gowainghat Jaintapur Total
Received any ANC Received 4 ANCs Received 4 ANCs from skilled provider
Table 5.1.2 shows the distribution of ANC by number of ANC check-ups according to demographic and socioeconomic variables. Younger, educated and low-parity mothers were more likely to receive higher numbers of antenatal care check-ups. Educational level and economic status, as measured by a wealth index from durable goods and household structure, demonstrated the most striking differences in ANC. Among women with no education, 73% did not receive ANC, compared to 9% with a secondary or above level of education. Among the lowest wealth quintile, 77% of the women did not receive ANC as compared to 38% in the highest wealth quintile. Overall, highly educated women were nearly ten times more likely to receive at least four or more ANC check-ups than the women with no education (48% and 47 | Page
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4.4% of women with secondary or above level of education and women with no education, respectively). More strikingly, women in the highest wealth quintile were more than twenty times likely to receive 4 ANC visits than the women in the lowest quintile (34.9% versus 1.4%).
Table 5.1.2: Percentage of women who received ANC by number of ANC visits during their last pregnancy, by MaMoni upazilla and selected demographic and socio-economic characteristics.
Characteristics N Did not Received Received Received 3 Received 4 or receive 1 ANC 2 ANC ANC visits more ANC ANC visit visits visits Upazila Balaganj 308 53.9 11.4 14.6 11.0 9.1 Bishwanath 310 44.8 9.4 15.2 15.2 15.5 Companiganj 312 69.9 9.6 9.9 8.7 1.9 Fenchuganj 318 38.7 14.2 13.2 14.8 19.2 Golabganj 310 30.0 14.2 14.2 14.5 27.1 Gowainghat 297 57.9 12.5 10.1 8.1 11.5 Jaintapur 320 56.9 9.4 9.4 14.4 10.0 Total: 2,175 50.3 11.5 12.4 12.4 13.5 Maternal education No education 708 72.5 8.5 8.6 6.1 4.4 Primary 404 60.2 12.1 12.6 9.9 5.2 Class 5-9 952 34.4 14.2 14.6 17.1 19.8 Class 10+ 111 9.0 5.4 16.2 21.6 47.8 Maternal age <20 262 49.2 14.9 11.1 13.4 11.5 20-24 836 42.9 14.5 14.2 13.8 14.6 25-29 580 53.8 9.8 10.9 10.9 14.7 30-34 317 57.1 6.6 11.7 12.6 12.0 35-39 142 61.3 7.8 10.6 10.6 9.9 40 + 38 65.8 2.6 15.8 5.3 10.5 Birth order 0 11 63.6 9.1 0.0 9.1 18.2 1 557 33.2 14.9 13.6 16.5 21.7 2 529 44.2 12.3 12.5 13.6 17.4 3 337 52.5 12.5 12.5 12.2 10.4 4 281 63.0 10.0 11.0 10.0 6.1 5+ 460 68.0 6.7 11.7 7.8 5.7 Wealth Quintile Lowest 435 77.2 9.7 6.7 5.1 1.4 Second 435 67.4 10.6 9.2 8.1 4.8 Middle 435 49.7 12.4 16.1 13.1 8.7 Fourth 435 37.9 15.4 13.8 15.4 17.5 Highest 435 19.1 9.4 16.1 20.5 34.9
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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. If a women received any one ANC from a skilled provider, considered as “ANC received from skilled provider” In the intervention areas, 86 percent women received ANC from an MBBS doctor, 1.4 percent from nurse/midwives, 5 percent from a paramedic, 12 percent from FWV, 0.3 percent from FWA and 3 percent from other providers. Traditional birth attendants (TBAs), trained or untrained, rarely provided ANC check-ups. More than 90 percent women received any ANC from MBBS doctor in Balaganj and Golapganj, while the rate was low in Jaintapur (62 percent). In Gowainghat, 30 percent of women received ANC from a FWV, while the rate was low in Balaganj and Companiganj (5 percent). No one reported received ANC from a FWA. It was significant that 1 percent women reported receiving ANC from a village doctor. No women reported receiving ANC from TBA across all seven upazilas.
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, Sylhet
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
1 Balaganj N=28 Biswanath N=48 Companiganj N=6 Fenchuganj N=6 Golabganj N=84 Gowainghat N=34 Jaintapur N=32 Total N= 293
MBBS doctor 92.9 87.5 83.3 88.5 91.7 82.4 62.5 86.0 Nurse/midwife 0.0 2.1 16.7 1.6 1.2 0.0 0.0 1.4 Paramedic 7.1 6.3 0.0 3.3 1.2 0.0 18.8 4.8 FWV 3.6 8.3 0.0 13.1 7.1 29.4 18.8 12.0 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 ACCESS Counselor 3.6 0.0 0.0 0.0 2.4 0.0 3.1 1.4 HA 0.0 0.0 0.0 0.0 0.0 2.9 0.0 0.3 FWA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 TTBA 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 Homeopath 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Herbalist (Ayurved) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Traditional healer/Quack 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Village doctor 3.6 2.1 0.0 0.0 0.0 0.0 0.0 1.0 Community Clinic 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 Other health worker 0.0 0.0 0.0 0.0 0.0 0.0 12.5 1.4 Other 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
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In table 5.1.3a shows that around 75-80 percent women got ANC during their last pregnancy from MBBS doctors. Other major providers were FWV (around 10 percent) and paramedics (around 5 percent). Contribution of rest of the providers was less than 5 percent.
Table 5.1.3a: Percent distribution of women received ANC during their last pregnancy by type of provider in Sylhet. (2010)
Women received ANC by visit and by ANC-1 ANC-2 ANC-3 ANC-4 type of provider N=1,082 N=832 N=563 N=293 MBBS doctor 75.1 76.1 79.6 80.2 Nurse/midwife 2.5 2.0 1.2 1.4 Paramedic 4.9 5.5 5.0 4.8 FWV 13.8 12.7 11.3 8.9 Medical assistant/SACMO 0.0 0.1 0.0 0.0 ACCESS Counselor/MaMoni health worker 1.0 1.0 0.7 1.4 HA 0.0 0.0 0.4 0.3 FWA 0.4 0.2 0.2 0.0 TTBA 0.1 0.0 0.0 0.0 TBA 0.0 0.1 0.0 0.0 Homeopath 0.1 0.0 0.0 0.0 Herbalist (Ayurved) 0.0 0.0 0.0 0.0 Traditional healer/Quack 0.1 0.1 0.0 0.0 Village doctor 0.9 1.0 0.4 0.7 Community Clinic 0.1 0.1 0.0 0.0 Spiritual Person/ Kabiraj 0.0 0.0 0.0 0.0 Other health worker 1.1 0.8 1.1 1.4 Other 0.0 0.0 0.0 0.0 Data missing 0.0 0.10 0.4 1.0
Table 5.1.4 shows that among the women who received ANCs, 75 percent of them in the seven intervention upazilas received 1st ANC from an MBBS doctor during their last pregnancy. Around 60 percent recently delivered women who had no education got 1st ANC from MBBS doctor while the rate was 94 percent who had secondary education. The mother who were having first child had more chance of getting 1st ANC from MBBS doctor (around 100 percent) in comparison to the mother who were having 5+ child (around 70 percent). Chance of having 1st ANC was almost double if we compare highest wealth quintile with lowest wealth quintile (93 and 51 percent). In Balaganj, highest 87 percent mother got their 1st ANC from MBBS doctor and the rate was low (about 53 percent) in Jaintpur.
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Final Report_MaMoni midline evaluation_Sylhet_Maternal & Newborn Health 2010
Table 5.1.4: Percent distribution of ANC provider, who provided ANC-1 to the women during their last pregnancy by upazila and according to background characteristics, Sylhet 2010
N= MBBS Nurse / Paramedic FWV SACMO Others doctor Midwife / MA (non- skilled) Upazila Balaganj 142 86.6 0.7 2.8 7.8 0.0 2.1 Bishwanath 171 82.5 0.6 4.7 10.5 0.0 1.8 Companiganj 94 68.1 5.3 2.1 23.4 0.0 1.1 Fenchuganj 195 80.5 2.6 5.1 9.7 0.0 2.1 Golabganj 217 82.0 3.2 3.2 8.3 0.0 3.2 Gowainghat 125 60.8 3.2 0.8 25.6 0.0 9.6 Jaintapur 138 52.9 2.9 15.2 21.0 0.0 8.0 Total: 1,082 75.1 2.5 4.9 13.8 0.0 3.8 Maternal education No education 195 60.0 3.6 6.7 23.6 0.0 6.2 Primary 161 67.7 5.0 4.4 15.5 0.0 7.5 Class 5-9 625 78.6 1.8 5.3 11.7 0.0 2.7 Class 10+ 101 94.1 1.0 0.0 5.0 0.0 0.0 Maternal age <20 133 61.6 3.0 9.8 19.6 0.0 6.0 20-24 477 75.5 1.7 5.2 14.3 0.0 3.4 25-29 268 78.7 4.5 1.9 11.6 0.0 3.4 30-34 136 78.7 2.2 5.2 12.5 0.0 1.5 35-39 55 74.6 0.0 5.5 10.9 0.0 9.1 40 + 13 84.6 0.0 0.0 7.7 0.0 7.7 Birth order 0 4 100.0 0.0 0.0 0.0 0.0 0.0 1 372 78.2 1.6 6.2 11.0 0.0 3.0 2 295 77.0 1.4 3.4 14.3 0.0 4.1 3 160 70.0 3.1 5.0 17.5 0.0 4.4 4 104 72.1 5.8 4.8 14.4 0.0 2.9 5+ 147 70.1 4.1 4.8 15.7 0.0 5.4 Wealth Quintile Lowest 100 51.0 4.0 13.0 29.0 0.0 3.0 Second 139 57.6 4.3 5.8 23.4 0.0 8.6 Middle 229 66.4 2.2 7.4 18.3 0.0 5.7 Fourth 269 78.1 3.0 3.7 12.3 0.0 3.0 Highest 345 92.5 1.2 1.5 3.5 0.0 1.5
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Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
5.2 Components of Antenatal Care Checkup
TT vaccine and Iron-folic acid tablet
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. Table 5.2.1 shows the distribution of women by TT immunization status. Midline survey results shows that over 90 percent of women received at least one dose of TT injection during their life time and almost 76 percent received at least two or more doses. There were no significant differences in TT immunization coverage by intervention upazilas of MaMoni. 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 midline survey could explore lifetime TT vaccination status with validity of the doses, hence there was very little chance of underestimation of protection of newborn against neonatal tetanus. Results in Table 5.2.1 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. Around 88 percent of women who were interviewed received at least two doses of TT in study areas, while it was only 26 percent when documented from Vaccination Card.
Table 5.2.1: Percent distribution of TT doses received (from card and history) by MaMoni upazilas of Sylhet
Upazila N= Received at Received at Received at Received at Received at least 1 TT least 2 TT least 3 TT least 4 TT least 5 TT
No TT TT No card Card + card Card + card Card + card Card + card Card + received history history history history history Balaganj 308 8.4 27.9 91.6 26.6 88.3 22.4 72.4 18.2 61.0 12.3 42.5 Bishwanath 310 5.8 40.7 94.2 38.1 93.2 31.3 81.0 24.5 71.0 18.1 55.8 Companiganj 312 12.8 25.6 87.2 22.4 84.0 17.3 70.2 10.3 55.5 5.5 40.4 Fenchuganj 318 10.1 28.6 89.9 24.2 86.8 19.2 73.9 15.1 64.2 10.7 45.9 Golabganj 310 4.5 37.4 95.5 32.9 91.0 23.2 81.3 16.8 68.1 11.3 49.0 Gowainghat 297 10.4 22.9 89.6 19.5 87.9 13.5 77.4 9.8 66.7 8.1 50.5 Jaintapur 320 11.3 25.3 88.8 19.7 85.6 13.4 74.7 10.6 60.9 6.3 43.4 Total 2,175 9.1 29.8 90.9 26.2 88.1 20.1 75.8 15.0 63.9 10.3 46.8 TT Card retention rate was 30%
At least 2 doses of TT received in space one month is taken as proactive. In table 5.2.1.a, shows overall 88 percent mother in Sylhet had valid doses of TT for first two doses. It was highest in Biswanath (about 93 percent) and lowest in Companiganj (about 84 percent). Only 36 percent women received valid 5 doses of TT vaccine in the intervention upazilas of Sylhet. The rate was more than 40 percent in Biswanath and Golabganj while it was around 28 percent in Companiganj.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 5.2.1a: Percent distribution of women received valid doses of TT (from card and history) during their lifetime by upazilas of Sylhet.
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 N= TT-2 TT-3 TT-4 TT-5 Card + history Card + history Card + history Card + history # % # % # % # % Balaganj 308 272 88.3 223 72.4 157 51.0 109 35.4 Bishwanath 310 289 93.2 251 81.0 194 62.6 137 44.2 Companiganj 312 262 84.0 219 70.2 150 48.1 86 27.6 Fenchuganj 318 276 86.8 235 73.9 175 55.0 117 36.8 Golapganj 310 282 91.0 252 81.3 186 60.0 124 40.0 Gowainghat 297 261 87.9 230 77.4 160 53.9 113 38.1 Jaintapur 320 273 85.3 239 74.7 168 52.5 91 28.4 Total 2,175 1915 88.1 1649 75.8 1190 54.7 777 35.7
In table 5.2.1.b shows that 81 percent newborns were protected from neonatal tetanus among total livebirths. The highest 90 percent newborns were protected in Golabganj while it was less than 80 percent in Companiganj and Jaintpur.
Table 5.2.1b Percentage of children born protected from neonatal tetanus among live-births during last pregnancy by upazila of Sylhet.
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 TT2 within 3 years of last delivery then the child is considered protected. If mother received 3 doses of TT and received TT3 with 5 years of last delivery then the child is considered protected and similar for TT4 and TT5.
Upazila Live-births Newborn was protected from tetanus N= (calculated from date of birth) # % Balaganj 306 246 80.4 Bishwanath 307 266 86.6 Companiganj 301 231 76.7 Fenchuganj 319 257 80.6 Golapganj 305 274 89.8 Gowainghat 292 231 79.1 Jaintapur 317 243 76.7 Total: 2,147 1,748 81.4
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 that 48 percent women received iron tablets during their last pregnancy. The rate was almost similar across the upazilas except Golabganj (60 percent). The use of iron tablets during pregnancy varied markedly by the selected demographic and socio- economic variables. Younger, educated women with low parity and high economic status were more likely to consume iron tablets during their pregnancy. Women with at least secondary level of education were almost three times more likely to take iron tablets, compared to uneducated women (85% and 33%, respectively). Similarly, women in the highest wealth quintile were about two times more likely to take iron tablets than the women in the lowest wealth quintile (29% vs. 68%). Table 5.2.2: Percentage of women consumed Iron-folic acid tablets during their last pregnancy by upazila and by background characteristics in Sylhet.
N= Consumed Iron-folic acid tablet # % Total: 2,175 1,039 47.8 Balaganj 308 126 40.9 Bishwanath 310 149 48.1 Companiganj 312 131 42.0 Fenchuganj 318 141 44.3 Golapganj 310 186 60.0 Gowainghat 297 152 51.2 Jaintapur 320 154 48.1 Maternal education No education 708 238 33.6 Primary 404 190 47.0 Class 5-9 952 517 54.3 Class 10+ 111 94 84.7 Maternal age <20 262 124 47.3 20-24 836 428 51.2 25-29 580 273 47.1 30-34 317 146 46.1 35-39 142 55 38.7 40 + 38 13 34.2 Birth order 0 11 6 54.6 1 557 293 52.6 2 529 295 55.8 3 337 151 44.8 4 281 119 42.4 5+ 460 175 38.0 Wealth Quintile Lowest 435 124 28.5 Second 435 163 37.5 Middle 435 226 52.0 Fourth 435 232 53.3 Highest 435 294 67.6
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 TT immunization, intake of iron-folic acid (IFA) tablet, rest and nutrition. Delays 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 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 ACCESS counselor / MaMoni health worker and percentage of whom received counseling by component during pregnancy and by upazila, Sylhet. (2010)
Component of Antenatal counseling by
an ACCESS Counselor / MaMoni health worker
Balaganj N=308 Biswanath N=310 Companiganj N=312 Fenchuganj N=318 Golabganj N=310 Gowainghat N=297 Jaintapur N=320 Total N=2175 Women received ante-natal counseling 283 284 271 297 293 215 254 1,897 from MaMoni health worker (91.9) (91.6) (86.9) (93.4) (94.5) (72.4) (79.4) (87.2) Check up during pregnancy 55.5 54.9 55.7 60.9 58.4 40.0 40.9 53.0 TT vaccination 1.8 4.2 7.0 2.0 1.4 2.3 11.4 4.2 To take Iron tablet 0.7 2.5 2.2 0.7 3.1 4.7 3.5 2.4 Regarding danger signs during pregnancy 14.1 15.5 8.9 14.1 7.9 6.1 2.8 10.2 Extra food 70.3 64.4 64.6 82.2 68.3 55.8 62.2 67.4 Take rest 73.1 64.1 75.7 82.5 63.1 47.9 69.3 68.7 Not to do heavy work 71.4 70.4 82.3 87.5 75.4 58.6 74.0 74.9 Savings for emergency 17.7 16.9 28.0 24.6 23.9 15.8 17.3 20.8 Ensure emergency transport 5.3 7.4 3.3 10.8 11.3 2.3 3.9 6.6 To deliver at a health facility 0.0 0.4 0.4 0.3 0.3 2.3 2.0 0.7 Ensure a trained TBA 0.4 4.6 3.3 1.7 3.8 6.5 5.1 3.5 Ensure a person for newborn care 0.7 4.6 1.5 0.7 3.4 6.1 5.1 3.0 To use safe delivery kit 9.2 10.6 7.4 8.4 16.0 10.7 12.6 10.7 A well lighted and airy delivery place 0.0 0.0 0.0 0.3 0.0 0.0 0.0 0.1 Prepare two pieces of cloth 24.4 27.5 16.2 18.5 17.4 19.1 18.9 20.4 Family planning 5.7 4.9 1.1 0.3 (4.8 1.4 3.2 3.1 Breastfeeding 7.1 8.1 8.5 5.1 12.6 23.3 12.6 10.5 LBW baby care 0.7 0.7 0.0 0.0 0.7 0.5 0.4 0.4 Others 0.0 0.0 0.0 0.3 0.0 0.5 0.4 0.2 Can't remember 0.0 0.4 0.0 0.0 0.0 0.0 0.0 0.1
Table 5.3.1 shows that very few women in the MaMoni intervention areas reported received information on birth preparedness. Only 53 percent women received advice on having a check-up during pregnancy, 4 percent on TT vaccination, 2 percent on iron-folate, 70 percent on extra food, 69 percent to take adequate rest; around 35 percent of women reported on a few preparedness activities for delivery and birth.
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 practices can significantly reduce neonatal infections and mortality. Acute respiratory infections (ARIs)
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 27%) reported receiving information on infection prevention methods through safe delivery practices. Almost two-thirds of women reported received advices on adequate rest and nutrition; while the 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. Counseling is one of the main components of ANC checkup. Table 5.3.2 shows the percent distribution of women received information and advice from an ACCESS counselor (AC) / MaMoni health worker during their home visits. About 81 percent women received two counseling visits by AC/MaMoni HWs in the area. It was highest in Biswanath (91%) and lowest in Gowainghat (62%). Table 5.3.2: Percentage of women received at least 2 home visits by an ACCESS counselor / MaMoni health worker during their last pregnancy by upazilas of Sylhet.
Upazila N= Did not receive any Received one visit by Received two visits visit by AC/HW AC/HW by AC/HW Balaganj 308 7.5 92.5 85.4 Biswanath 310 8.4 91.6 91.0 Companiganj 312 10.3 89.7 79.5 Fenchuganj 318 5.7 94.3 89.9 Golabganj 310 5.2 94.8 87.4 Gowainghat 297 24.9 75.1 61.6 Jaintapur 320 18.8 81.3 73.1 Total 2,175 11.5 88.6 81.2
Tables 5.3.4 shows that only 15 percent women mentioned the name of ACCESS counselor/MaMoni HW as a source of 4 ANC visit information. It was highest 22 percent in Golabganj and lowest 5 percent in Companiganj. Table 5.3.4: Percent of women reported receiving counseling from an ACCESS Counselor/MaMoni health worker on the importance of 4 ANC visits by upazila.
Upazilla N AC / MaMoni HW counsel about 4 ANC visits # % Balaganj 308 40 13.0 Bishwanath 310 43 13.9 Companiganj 312 16 5.1 Fenchuganj 318 61 19.2 Golabganj 310 68 21.9 Gowainghat 297 38 12.8 Jaintapur 320 61 19.1 Total 2,175 327 15.0
Table 5.3.5 shows that around 86 percent women reported received counseling from an ACCESS counselor (AC) or MaMoni health worker (HW). Among the different component of counseling, 77 percent women told about ‘wrapping the baby immediately after birth’, 59 percent clearly mentioned that newborn should be bathed 3 days after birth, 52 percent mentioned about cleaning and drying the baby immediately after birth, 35 percent mentioned about exclusive breast feeding and around 30 percent mentioned to keep the newborn warm by skin ti skin contact. There was no remarkable difference across the upazilas.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 5.3.5: Percentage of women reported receiving counseling from an ACCESS Counselor / MaMoni health worker by component of newborn care and by upazila.
Components of newborn care
=312 Balaganj N=308 Biswanath N=310 Companiganj N Fenchuganj N=318 Golabganj N=310 Gowainghat N=297 Jaintapur N=320 Total N=2175 Received counseling from AC/MaMoni health 228 283 274 296 293 214 237 1,879 worker (74.0) (91.3) (87.8) (93.1) (94.5) (72.1) (74.1) (86.4) Clean/dry the baby immediately after birth 77.2 54.1 56.6 61.8 41.0 32.7 51.9 52.2 Wrap the baby immediately after birth 96.1 67.1 86.9 84.1 67.6 67.8 84.8 76.6 Put the baby to breast before delivery of placenta 4.0 3.9 0.4 4.1 3.8 2.3 5.1 3.3 Nothing to be applied to the umbilicus 3.1 7.8 6.2 0.7 4.4 2.3 3.0 3.9 Not to remove the vernix or the white skin 0.4 1.1 0.4 0.0 1.0 1.9 0.0 0.6 First bath should be given 3 days after delivery 71.5 58.0 65.0 74.3 58.9 51.9 43.9 59.2 Not to give anything before breast milk 18.0 15.9 16.4 13.2 17.4 18.2 8.0 14.9 Exclusive Breastfeeding 31.1 27.9 36.1 26.4 41.6 47.2 46.4 35.1 KMC, Skin-to-skin contact 26.3 42.1 30.7 32.1 36.2 26.6 17.3 29.9 About family planning 1.3 1.1 0.7 0.0 0.0 0.0 3.8 0.9 About LAM 0.0 0.0 0.0 0.0 0. 0.9 0.4 0.2 Others 0.0 0.0 0.0 0.0 0.0 0.5 0.0 0.1 Don’t know/ Can't remember 0.0 0.4 0.0 0.0 0.0 0.0 0.0 0.1
5.4 Birth Plan and Delivery
Table 5.4.1 shows that around 48% of women had any component of a birth plan. Highest 47 percent of women selected a person to attend the delivery. Around 35 percent women mentioned that they selected the place for delivery, procured birth-kit and saved money for emergency. Around 15 percent women said that they selected newborn care person before the delivery, arranged a transport for any emergency, had extra food and adequate rest and did not perform heavy work. About one-fourth of them prepared two pieces of cloths to dry and wrap baby just after birth.
Very few women (less than 5 percent) mentioned about check-up during pregnancy, TT vaccination and consumption of iron-folic acid tablets.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 5.4.1 Percent of women reported having a birth plan during their last pregnancy by upazila.
Multiple answers were accepted
Birth Plan
paniganj Balaganj 304 N= Biswanath 303 N= Com 309 N= Fenchuganj 316 N= Golabganj 306 N= Gowainghat 294 N= Jaintapur 312 N= Total 2144 N= Selected place for delivery 40.5 49.8 25.6 29.7 30.1 23.5 30.8 32.8 Selected person to attend the delivery 47.7 42.6 46.9 51.6 52.3 50.7 39.7 47.3 Selected person to take the newborn 17.1 10.9 14.9 17.7 17.6 17.0 16.3 16.0 Purchase/procure a safe delivery kit 28.0 28.7 36.6 46.2 29.7 24.1 35.3 32.8 Arranged emergency transport 15.8 15.2 4.2 23.1 27.5 15.3 3.8 15.0 Saved money for emergency 34.9 39.3 23.3 41.1 55.2 42.9 27.6 37.7 Took approval to seek care 0.3 0.0 0.6 1.6 0.7 0.3 1.0 0.7 Check up during pregnancy 4.6 7.9 7.1 3.5 3.3 2.7 5.8 5.0 Took TT vaccine 0.3 0.3 2.9 0.6 0.7 0.3 5.4 1.5 Took Iron tablet/syrup 0.3 0.3 0.6 0.3 0.3 0.0 0.3 0.3 Knew danger signs for women 0.0 0.0 1.0 0.0 0.0 0.3 0.6 0.3 Knew danger signs about new born 0.3 0.0 0.6 0.0 0.3 0.3 0.0 0.2 Took extra food 21.4 22.4 6.5 10.8 25.2 7.1 12.5 15.1 Took adequate rest 19.7 19.1 10.0 15.2 21.6 4.1 13.1 14.7 Did not perform heavy work 21.7 19.5 14.2 19.0 21.2 8.2 15.7 17.1 Ensure a trained TBA 2.6 3.3 1.9 8.5 12.4 7.8 2.2 5.6 Selected a well lighted and Airy 0.7 0.0 0.3 0.3 1.0 0.3 0.0 0.4 delivery place Prepare two pieces of cloth 15.8 21.8 26.2 23.1 24.8 23.8 25.6 23.0 Identify Blood Donor 0.0 0.3 0.0 0.0 1.3 0.3 0.0 0.3 Others 0.3 3.0 0.0 0.6 2.6 4.1 0.3 1.5
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, Sylhet.
N= % reported all 5 selected components of birth plan
Total: 2,144 0.33 Balaganj 304 0.99 Bishwanath 303 0.33 Companiganj 309 0.65 Fenchuganj 316 0.32 Golapganj 306 0.00 Gowainghat 294 0.00 Jaintapur 312 0.00
Table 5.4.2 shows that the percentage of women reported all five selected components of a birth plan was very low (less than 1 percent) across the intervention upazilas.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Place of delivery
Overall, results indicate that 80 percent women delivered their last child at home, this was proportionally lower than results from Projahnmo-1 in Sylhet (around 93 percent), Access baseline in 2007 (around 88 percent) and what was observed in the BDHS and DHS for Sylhet Division (2007).
Table 5.4.3: Percent distribution of place of delivery during last pregnancy by background characteristics and by upazila, Sylhet. (Heath facility includes FWC, UHC, medical college hospital, private/NGO hospital or clinic and specified hospital in other code)
N= Delivery at Home Delivery at Health facility Other places Total: 2,144 80.4 19.2 0.4 Balaganj 304 79.3 20.7 0.0 Bishwanath 303 82.2 17.2 0.7 Companiganj 309 90.6 9.4 0.0 Fenchuganj 316 69.6 29.4 1.0 Golapganj 306 64.4 35.0 0.7 Gowainghat 294 90.1 9.5 0.3 Jaintapur 312 86.9 12.8 0.3 Maternal education: No education 699 92.0 7.7 0.3 Primary 401 87.3 12.7 0.0 Class 5-9 934 74.0 25.4 0.6 Class 10+ 110 35.5 63.6 0.9 Maternal age: <20 262 82.4 16.8 0.8 20-24 828 77.4 22.0 0.6 25-29 569 79.8 20.0 0.2 30-34 310 83.6 16.1 0.3 35-39 137 86.1 13.9 0.0 40 + 38 92.1 7.9 0.0 Birth order: 0 7 42.9 42.9 14.3 1 551 66.1 33.2 0.7 2 524 77.7 22.0 0.4 3 331 86.4 13.6 0.0 4 279 88.2 11.5 0.4 5+ 452 92.3 7.5 0.2 Wealth Quintile: Lowest 429 95.8 3.7 0.5 Second 430 91.6 8.4 0.0 Middle 431 85.6 13.9 0.5 Fourth 427 73.8 26.0 0.2 Highest 427 54.8 44.3 0.9
Table 5.4.3 shows that highest 90 percent of women had the delivery at home in Gowainghat while it was 64 percent in Golabganj. Health facility delivery was highest in Golabganj (35 percent) and lowest in Companiganj (9 percent). A high maternal education was correlated with a lower rate of home delivery. Among women having no education, 92% of deliveries occurred at home while the rate was 36 percent among women with an education level of class 10+. There was no such variability by maternal age but there was a marked
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
difference by parity of women. Lower parity correlated with a higher percentage of health facility deliveries: 43 percent of deliveries took place at a health facility among women of ‘0’ parity, 33 percent with parity ‘1’, 22 percent with parity ‘2’, 14 percent with parity ‘3’, 12 percent with parity ‘4’ and 8 percent with parity ‘5+’. Similarly, marked differences were found by wealth quintile. A lower quintile correlated with a lower percentage of health facility deliveries. Only 4 percent of deliveries took place at a health centre among lowest quintile group while it was 8 percent among women in the second quintile, 14 percent among women in the middle quintile, 26 percent among the fourth quintile and 44 percent among the highest quintile group. In sum, health facility delivery took place among women of ‘0’ and ‘1’ parity, education level 10+ and among women in the high quintile group.
Fig:5.6 Percentage of women delivered their baby at health facility by level of education and by baseline/midline
70 63.6 60 ACCESS baseline MaMoni midline 50 46.6
40
30 25.4 18.2 20 12.7 7.7 8 10 4.7
0 No education Primary Class 5-9 Class 10+
Table 5.4.4 shows around 91 percent of deliveries at home were conducted by TBA/TTBA in the intervention upazilas of Sylhet. The rate of delivery attended by a skilled birth attendant was very low (2.4 percent); the rate of home deliveries attended by a skilled birth attendant was highest in Fenchuganj (6 percent) and lowest in Gowainghat, jaintapur (around 1 percent) and 0 percent in Companiganj. Women’s educational and economic status was related to the type of provider who assisted during delivery. There were variations in percentage of deliveries attended by a skilled birth attendant by maternal education, parity and wealth quintile. Around 3 percent of women with no education or primary education reported having a skilled birth attendant during delivery at home, while it was around 10 percent among women had education level of class 10+. There were no significant variations in rate of attendance of skilled birth attendant by maternal age and parity. Only 0.5 percent women in lowest quintile group reported having a skilled birth attendant, 0.8 percent in second quintile, 3.8 percent in middle, 3.2 percent in fourth and 5.1 percent in the highest quintile group.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 5.4.4: Percent distribution of type of birth attendant who assisted delivery at home (Except family member) by upazilla and by background characteristics in Sylhet.
N= Skill Other health TTBA TBA Other*** No-one provider* professional** Total 1,723 2.4 0.4 41.8 50.6 2.4 2.5 Balaganj 241 3.3 0.4 32.0 62.7 0.4 1.2 Bishwanath 249 2.4 0.4 44.6 0.2 2.0 0.4 Companiganj 280 0.0 0.0 37.9 56.1 2.8 3.2 Fenchuganj 220 5.9 0.5 51.4 39.6 0.5 2.3 Golapganj 197 4.1 0.0 52.3 36.6 3.6 3.6 Gowainghat 265 1.1 1.1 36.6 54.3 3.8 3.0 Jaintapur 271 1.1 0.4 41.7 49.8 3.3 3.7 Maternal education: No education 643 0.9 0.3 36.1 57.2 2.6 2.8 Primary 350 2.3 0.3 39.4 52.3 2.9 2.9 Class 5-9 691 3.3 0.6 47.6 44.6 1.9 2.0 Class 10+ 39 10.3 0.0 53.9 30.8 2.6 2.6 Maternal age: <20 216 2.8 0.9 43.5 48.2 2.3 2.3 20-24 641 2.7 0.3 42.3 49.5 2.3 3.0 25-29 454 1.3 0.2 44.5 48.7 2.4 2.9 30-34 259 2.3 0.0 37.8 56.8 2.7 0.4 35-39 118 3.4 1.7 37.3 51.7 1.7 4.2 40 + 35 5.7 0.0 31.4 60.0 2.9 0.0 Birth order: 0 3 0.0 0.0 0.0 100.0 0.0 0.0 1 364 3.6 0.6 45.6 46.4 1.9 1.9 2 407 2.7 0.5 42.5 48.4 2.5 3.4 3 286 1.1 0.0 42.3 51.8 1.1 3.9 4 246 2.0 0.4 43.9 50.4 2.0 1.2 5+ 417 2.2 0.5 36.5 55.2 3.8 1.9 Wealth Quintile: Lowest 411 0.5 0.7 35.8 56.9 2.9 3.2 Second 394 0.8 0.5 40.4 51.3 3.6 3.6 Middle 369 3.8 0.0 47.2 46.3 1.9 0.8 Fourth 315 3.2 0.6 40.3 51.4 1.6 2.9 Highest 234 5.1 0.0 48.3 43.6 1.3 1.7
Note: *Skiledl provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO **Other health professional includes HA, FWA and ACCESS Counselor *** Others includes Village doctor, Quack, Ayurved, Homeopathy, Spiritual, Neighbor
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 5.4.5: Percent of women who had birth kits for delivery and distribution of source from where birth kits were received by upazilas of Sylhet.
Birth-kit
Balaganj N= 241 Biswanath N= 249 Companiganj N= 280 Fenchuganj N= 220 Golabganj N= 197 Gowainghat 265 N= Jaintapur 271 N= Total N= 1723 Had Birth-kit 90.0 91.2 82.5 90.9 90.4 76.6 84.9 86.2 Source of birth-kit received: FWC 0.0 0.0 0.9 0.0 0.0 0.0 0.4 0.2 Satellite clinic 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Community clinic 0.0 0.0 0.0 0.0 0.0 0.0 1.4 0.1 NGO clinic 0.0 0.0 0.4 0.0 0.6 0.5 0.0 0.2 Shop 0.0 0.0 0.0 1.0 2.3 1.5 1.3 0.8 AC/MaMoni HW 99.5 99.1 97.8 99.0 97.2 96.6 94.4 97.6 Untrained TBA 0.5 0.9 0.9 0.0 0.0 1.0 0.4 0.5 NGO Volunteer 0.0 0.0 0.0 0.0 0.0 0.0 2.6 0.4 Others 0.0 0.0 0.0 0.0 0.0 0.5 0.4 0.1 Don’t know/ can’t remember 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Almost 86 percent of women had birth-kit during their last delivery. More than 90 percent women had birth-kit in Balaganj, Biswanath, Fenchuganj and Golabganj upazilas while it was 77 percent in Gowainghat. The main source of collection of birth-kit was ACCESS counselor or Mamoni health worker (around 98 percent) and the rate was almost similar across seven intervention upazilas. Less than 1 percent women reported that they procure birth-kit from shop, TBA or NGO volunteer.
5.5 Post Partum
Table 5.5.1 shows that only 19 percent of women reported were received at least one PNC and of them 86 percent received PNC within 3 days, 90 percent within 6 days and about 95 percent within 14 days after child birth. The rate of receiving any PNC was highest in Golapganj (34 percent) while it was around 10 percent in Companiganj, Gowainghat and jaintapur upazilas. Considering the timing of the first PNC received, around 94% of women received PNC within 3 days of delivery in Balaganj, while it was lowest (67%) in Jaintapur. 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, Sylhet.
Upazila N= Received Time of first PNC received any PNC Within 3 4-6 days 7-13 14-27 28-41 >41 days days days days days Total 2,175 409 (18.8) 86.1 3.4 5.1 2.2 2.7 0.5 Balaganj 308 65 (21.1) 93.9 1.5 3.1 1.5 0.0 0.0 Bishwanath 310 60 (19.4) 85.0 1.7 5.0 3.3 3.3 1.7 Companiganj 312 29 (9.3) 82.8 6.9 10.3 0.0 0.0 0.0 Fenchuganj 318 82 (25.8) 92.7 3.7 3.7 0.0 0.0 0.0 Golapganj 310 104 (33.6) 86.5 4.8 1.9 3.9 2.9 0.0 Gowainghat 297 34 (11.4) 76.5 0.0 8.8 2.9 8.8 2.9 Jaintapur 320 35 (10.9) 68.6 5.7 14.3 2.9 8.6 0.0 Table 5.5.2 shows that only 11 percent of women received at least two PNC visits during their last pregnancy. The rate was highest in Golapganj (22 percent), 12-15 percent in Balaganj, Biswanath and Fenchuganj and lowest in Companiganj (4 percent). 4-8 percent women reported received at least two
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
PNC visits in Gowainghat and Jaintapur. Among women who received two or more PNCs, around 99 percent reported received from a skilled provider. The rate was almost similar across the upazilas.
Table 5.5.2: Percentage of women reported received at least two PNC visits for themselves from a skilled provider after child birth by MaMoni upazilas. (Multiple answers were accepted)
Area N= Received 2 Type of PNC provider or more PNC *Skilled TTBA **Other Health ***Others Don’t know/cant provider and TBA professional remember
Total: 2,175 244 (11.2) 99.2 0.0 0.4 0.8 0.0 Balaganj 308 49 (15.9) 100.0 0.0 0.0 0.0 0.0 Bishwanath 310 41 (13.2) 97.6 0.0 2.4 2.4 0.0 Companiganj 312 12 (3.9) 100.0 0.0 0.0 0.0 0.0 Fenchuganj 318 38 (12.0) 100.0 0.0 0.0 0.0 0.0 Golapgonj 310 67 (21.6) 100.0 0.0 0.0 0.0 0.0 Gowainghat 297 23 (7.7) 95.7 0.0 0.0 4.4 0.0 Jaintapur 320 14 (4.4) 100.0 0.0 0.0 0.0 0.0
*Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO **Other health professional includes HA, FWA, ACCESS Counselor, Village doctor, Quack, Ayurved, Homeopath. other health worker *** Others includes: Kabiraj, other
Table 5.5.3 shows around 16% of women reported receiving their first PNC within 3 days after child birth from a skilled provider in the intervention upazilas. The situation was slightly better in Golapganj, Fenchuganj and Balaganj (20-30 percent). The percentage was lowest (8 percent) in Jaintapur upazila.
Table 5.5.3: Percentage of women received PNC visits for themselves from a skilled provider within 3 days after child birth by upazila, Sylhet.
Area N= Received PNC within 3 days after child birth from a skilled provider Total 2,175 16.0 Balaganj 308 19.5 Bishwanath 310 16.1 Companiganj 312 7.7 Fenchuganj 318 23.9 Golapganj 310 29.0 Gowainghat 297 8.4 Jaintapur 320 7.5
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 5.5.5 shows that about 43 percent mothers reported receiving a home visit by a ACCESS counselor / MaMoni health worker within 7 days after child birth. Only 5 percent of women reported visited by an AC/MamOni HW within 24 hours after delivery and 35 percent of women reported visited an AC / MaMoni HW within 3 days after delivery.
Table 5.5.5: Percentage of women reported receiving home visit by a ACCESS counselor/MaMoni health worker by timing of home visit after child birth and by upazila, Sylhet.
Area N= Timing of home visit by ACCESS Counselor after child birth Within 24 hours Within 3 days Within 7 days Not visited
Balaganj 308 3.6 30.5 39.3 60.7 Bishwanath 310 9.7 46.5 56.8 43.2 Companiganj 312 3.5 32.4 41.4 58.7 Fenchuganj 318 8.5 49.1 58.2 41.8 Golapganj 310 3.9 34.5 43.6 56.5 Gowainghat 297 4.0 22.6 26.6 73.4 Jaintapur 320 2.2 26.9 33.8 66.3 Total: 2,175 5.1 34.7 42.9 57.1
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 percent of maternal deaths are due to hemorrhage, 15 percent due to sepsis, 12 percent due to eclampsia, and 8 percent 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 abruptio (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’s Reporting of Maternal Complications
Recently delivered women in the intervention areas 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 27 percent of women reported that they experienced problems during their last pregnancy and the most cited problems were abdominal pain, weakness, headache and edema in hands. During delivery, 23 percent of women reported developing at least one complication and the most cited problems were prolong labour, excessive vaginal bleeding and baby was in abnormal position. Around 29 percent of women developed at least one postpartum complication and the most cited problems were severe abdominal pain, fever, weakness/tiredness/palpatition and severe vaginal bleeding.
Fig: 6 Percentage of women reported having complication during pregnancy, delivery and postpartum and comparison with baseline-2007
Reported Complications during Pregnancy, Delivery & Post-partum and comparison with baseline-2007 50 45.1 40 31.3 30.3 26.5 28.8 30 22.7 20 10 0 Complication during Complication during delivery Complication at post-partum pregnancy
Baseline 2007 Midline 2010
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 (34 percent) and severe weakness (26 percent). Around 13 percent of women reported edema of the legs, 12 percent reported of severe headache, and another 12 percent had edema of hands/swelling during antenatal period. Almost same percentage of women reported severe abdominal pain in all seven upazilas.
Table 6.1.1 Among women with reported danger signs during last pregnancy, percent distribution of danger signs by MaMoni upazilas of Sylhet. (Multiple answers were accepted)
Danger signs during pregnancy
aganj Bal N= 71 Biswanath N= 84 Companiganj N= 73 Fenchuganj N= 78 Golabganj 105 N= Gowainghat N= 95 Jaintapur N= 70 Total N= 576 Severe Headache 14.1 9.5 13.7 10.3 11.4 11.6 10.0 11.5 Blurred Vision 2.8 2.4 2.7 9.0 11.4 10.5 1.4 6.3 Fetal movement reduced/absent 11.3 2.4 2.7 5.1 4.8 4.2 2.9 4.7 High Blood Pressure 1.4 1.2 0.0 5.1 1.0 1.1 1.4 1.6 Edema of the face/swelling 9.9 10.7 1.4 6.4 3.8 3.2 5.7 5.7 Edema of the hands/ swelling 9.9 20.2 15.1 10.3 9.5 12.6 8.6 12.3 Convulsions/fits 7.0 1.2 4.1 3.8 3.8 3.2 2.9 3.6 Excessive Vaginal Bleeding 5.6 4.8 9.6 10.3 2.9 0.0 5.7 5.2 Severe abdominal pain 32.4 29.8 35.6 35.9 32.4 34.7 35.7 33.7 Edema of the legs 15.5 9.5 20.5 11.5 10.5 2.1 22.9 12.5 Fever 5.6 7.1 15.1 7.7 7.6 14.7 5.7 9.2 Premature rupture of membrane 2.8 3.6 4.1 3.8 7.6 5.3 5.7 4.9 Loss of consciousness 0.0 1.2 0.0 1.3 0.0 1.1 0.0 0.5 Difficulty breathing 0.0 1.2 1.4 0.0 6.7 1.1 0.0 1.7 Severe weakness 18.3 29.8 30.1 16.7 24.8 36.8 20.0 25.7 Others 4.2 13.1 2.7 9.0 13.3 9.5 2.9 8.3 Can’t remember/None mentioned 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Table 6.1.2: Percent distribution of number of danger signs reported during last pregnancy by upazila, Sylhet.
AREA N= No Complication 1 Complication 2 Complications ≥3 Complications
Balaganj 308 77.0 15.3 6.2 1.6 Bishwanath 310 72.9 18.7 6.1 2.3 Companiganj 312 76.6 13.1 7.4 2.9 Fenchuganj 318 75.5 14.8 8.2 1.6 Golapganj 310 66.1 21.6 8.4 3.9 Gowainghat 297 68.0 19.5 9.1 3.4 Jaintapur 320 78.1 16.9 3.8 1.3 Total: 2,175 73.5 17.1 7.0 2.4
Table 6.1.2 shows that around 17 percent women reported single complication and which was almost similar across the seven intervention upazilas. Around 7 percent of women reported two complications
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010 which was also very similar in all upazilas except in Jaintapur (3.8 percent). Only around 2 percent women experienced three or more complications. The table also shows that about 74 percent women did not experience any complication during their last pregnancy in all upazilas and it did not largely vary among these seven upazilas.
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, Sylhet.
N Reported danger Sought care for Sought care from a sign complication skilled provider* Total: 2,175 576 (26.5) 499 (86.6) 408 (70.8) Upazila Balaganj 308 23.1 88.7 77.5 Bishwanath 310 27.1 82.1 64.3 Companiganj 312 23.4 84.9 63.0 Fenchuganj 318 24.5 89.7 82.1 Golapganj 310 33.9 88.6 80.0 Gowainghat 297 32.0 86.5 56.8 Jaintapur 320 21.9 85.7 72.9 Maternal education No education 708 26.0 77.2 49.5 Primary 404 26.0 89.5 74.3 Class 5-9 952 26.3 90.8 81.2 Class 10+ 111 33.3 97.3 97.3 Maternal age <20 262 26.7 74.3 58.6 20-24 836 25.6 93.0 77.1 25-29 580 26.0 84.8 69.5 30-34 317 26.8 87.1 69.4 35-39 142 32.4 82.6 69.6 40 + 38 26.3 80.0 60.0 Birth order 0 11 72.7 87.5 75.0 1 557 27.3 88.8 75.0 2 529 27.2 88.2 77.8 3 337 24.0 88.9 76.5 4 281 27.4 85.7 59.7 5+ 460 24.8 80.7 59.7 Wealth Quintile Lowest 435 26.2 66.7 63.1 Second 435 21.6 84.0 60.0 Middle 435 26.7 90.5 73.1 Fourth 435 28.1 94.3 78.0 Highest 435 29.9 95.4 81.7 Note: *Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO
Table 6.1.3 shows around 27 percent of women reported complication during their last pregnancy in the intervention area and of them 87 percent sought care from any health care provider and 71 percent from a skilled provider in the intervention area. There was no significant variation in reporting complications among the seven upazilas. More than 80 percent women in all upazilas sought care for pregnancy complications. The pattern of seeking care from
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
a skilled health provider was around 80 percent in Fenchuganj, Gopalganj and Balaganj; while the rate was around 60 percent in Biswanath and Gowainghat. The rate of care seeking was much higher among educated women who had at least 10 years of schooling (around 97 percent) and lowest among women with no education (77 percent). The table shows a noticeable result that women with education level of Class 10+, who sought care for complication, 100 percent of them sought care from a skilled health care provider. Women with no education level who sought care for their complication, 50 percent of them sought care from a skilled care provider. No remarkable variability is found in care seeking from a skilled provider by maternal age, parity and wealth quintiles across the upazilas.
Table 6.1.5: Among women with reported danger signs during pregnancy and sought care, the percent distribution of provider (by category) by upazila, Sylhet.
Multiple responses were accepted AREA Had danger sign Skill Other health TTBA TBA Other*** Don’t know and sought care provider* professional** Balaganj 63 55 (87.3) 0 (0.0) 0 (0.0) 0 (0.0) 8 (12.7) 0 (0.0) Bishwanath 69 54 (78.3) 0 (0.0) 0 (0.0) 0 (0.0) 17 (24.6) 0 (0.0) Companiganj 62 46 (74.2) 1 (1.6) 0 (0.0) 0 (0.0) 16 (25.8) 0 (0.0) Fenchuganj 70 64 (91.4) 0 (0.0) 0 (0.0) 0 (0.0) 7 (10.0) 0 (0.0) Golapganj 93 84 (90.3) 1 (1.1) 0 (0.0) 0 (0.0) 9 (9.7) 0 (0.0) Gowainghat 82 54 (65.9) 1 (1.2) 0 (0.0) 0 (0.0) 36 (43.9) 0 (0.0) Jaintapur 60 51 (85.0) 1 (1.7) 0 (0.0) 0 (0.0) 9 (15.0) 0 (0.0) Total: 499 408 (81.8) 4 (0.8) 0 (0.0) 0 (0.0) 102 (20.4) 0 (0.0)
Note: *Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO **Other health professional includes HA, FWA and ACCESS Counselor *** Others includes Village doctor, Quack, Ayurved, Homeopathy, Spiritual, Neighbor/ relative, pharmacy
Table 6.1.5 shows that seeking care from skilled provider by the women during pregnancy was around 82 percent which did not vary largely across the intervention upazilas. None sought care from TTBA and TBA. Around 20 percent of women sought care from other local health care providers includes village doctor/ quack/ ayurved/ homeopathy/ spiritual/ neighbor/ relative/ pharmacy. The rate of sought care from other category was high (44 percent) in Gowainghat.
Table 6.1.6 shows that women had pregnancy complications and sought care, around 6 percent of them received care at home, the rate was 13 percent in Gowainghat while no one received care at home in Balaganj. Vast majority of women (46 percent) sought care from chamber of MBBS doctor. The rate was around 65 percent in Balaganj and Golabganj while it was less than 30 percent in Companiganj and gowainghat. Around 15 percent of women sought care from UHC, while it was highest (29 percent) in Companiganj and lowest (3 percent) in Balaganj. Almost same scenario was found in care receiving from pharmacy and clinic which were around 15 percent and 10 percent respectively. Around 8 percent women sought care from hospitals other than UHC. Only 3 percent women received care from FWC.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 6.1.6: Among women with reported danger signs during pregnancy and sought care, the percent distribution of place of care by upazila, Sylhet.
Place of care
Balaganj N=63 Biswanath N=69 Companiganj N=62 Fenchuganj N=70 Golapganj N=93 Gowainghat N=82 Jaintapur N=60 Total N=499 At home 0.0 8.7 3.2 2.9 3.2 13.4 6.7 5.6 Satellite clinic 0.0 0.0 0.0 0.0 2.2 0.0 0.0 0.4 FWC 0.0 2.9 0.0 1.4 5.4 6.0 3.3 3.0 UHC 3.2 4.4 29.0 25.7 8.6 15.9 25.0 15.4 Chamber of MBBS doctor 63.5 52.2 27.4 42.9 64.5 29.3 38.3 46.1 Clinic 7.9 11.6 8.1 15.7 7.5 6.1 11.7 9.6 Community clinic 1.6 0.0 0.0 1.4 0.0 0.0 1.7 0.6 Hospital 11.1 8.7 8.1 4.3 6.5 11.0 5.0 7.8 Pharmacy 11.1 15.9 25.8 7.1 6.5 30.5 10.0 15.2 Other 0.0 0.0 0.0 0.0 1.1 1.2 3.3 0.8 Don't know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Multiple answers were accepted
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 upazilla, Sylhet. (Multiple answers were accepted)
AREA N= ACCESS Family Relative Neighbo TBA TTBA Others counselor member s r/friend s Balaganj 71 2.8 76.1 22.5 7.0 0.0 0.0 0.0 Bishwanath 84 4.8 72.6 22.6 8.3 2.4 2.4 1.2 Companiganj 73 2.7 76.7 12.3 4.1 1.4 4.1 0.0 Fenchuganj 78 12.8 76.9 14.1 2.6 1.3 0.0 0.0 Golapganj 105 9.5 82.9 21.0 9.5 1.0 1.9 1.0 Gowainghat 95 10.5 65.3 14.7 13.7 0.0 0.0 1.1 Jaintapur 70 7.1 41.4 17.1 5.7 1.4 1.4 1.4 Total: 576 7.5 71.0 17.9 7.6 1.0 1.4 0.7
Table 6.1.7 shows the percentage of women who had danger signs during pregnancy and were referred for treatment. The proportion referred has shown by area and category of person who referred the women. It was found that 71 percent of women reported receiving advice from their family members about referral to a health care provider for necessary treatment. Besides, around 18 percent of women were referred by their relatives, 8 percent by their neighbors/friends, 8 percent by an ACCESS counselor / MaMoni HW and 1 percent by TBA.
6.2 Complications during delivery
Table 6.2.1 shows around 23 percent of women reported complication during their last delivery. Among them, around 86 percent sought care from any health care provider and 56 percent from a skilled
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010 provider. Seeking care from any health care provider was almost same in all upazilas. But there were significant variations in seeking care from a skilled provider; around 70 percent sought care from Fenchuganj, Golabganj and Balaganj while it was 22 percent in Gowainghat. Women had delivery complications and had an education level of secondary or higher, all of them sought care from a skilled provider. On the other hand, women had complication and had zero level of education, only 38 percent of them sought care from a skilled provider. There was no such variation in reporting a danger sign by level of maternal education, age and wealth quintile. But reporting delivery complication among women with parity ‘0’ was around 72 percent compare to other categories (around 20 percent).
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
N= Reported delivery Sought care for Sought care from complication complication a skilled provider Total: 2,175 494 (22.7) 426(86.2) 278(56.3) Balaganj 308 20.1 93.6 67.7 Bishwanath 310 26.1 86.4 54.3 Companiganj 312 21.5 80.6 44.8 Fenchuganj 318 21.1 95.5 74.6 Golapganj 310 25.5 88.6 69.6 Gowainghat 297 24.5 69.9 21.9 Jaintapur 320 20.3 90.8 63.1 Maternal education No education 708 18.5 84.0 38.2 Primary 404 22.3 83.3 51.1 Class 5-9 952 26.1 87.1 64.1 Class 10+ 111 22.5 100.0 92.0 Maternal age <20 262 27.1 80.3 53.5 20-24 836 24.2 90.1 63.4 25-29 580 21.6 84.0 52.8 30-34 317 19.2 86.9 52.5 35-39 142 18.3 84.6 46.2 40 + 38 23.7 77.8 22.2 Birth order 0 11 72.7 100.0 87.5 1 557 31.6 89.8 67.1 2 529 18.9 82.0 63.0 3 337 17.5 84.8 49.2 4 281 22.4 87.3 41.3 5+ 460 19.1 83.0 39.8 Wealth Quintile Lowest 435 17.7 79.2 60.5 Second 435 21.4 79.6 54.8 Middle 435 22.8 86.9 55.1 Fourth 435 27.6 87.5 52.7 Highest 435 24.1 95.2 58.9 Note: *Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 6.2.2 Among women with reported danger signs during delivery, percent distribution of danger signs by upazila, Sylhet.
Multiple answers were accepted
Danger signs during delivery
anj
Balag N= 62 Biswanath N= 81 Companiganj N= 67 Fenchuganj N= 67 Golapganj N= 79 Gowainghat N= 73 Jaintapur N= 65 Total N= 494
Excessive Vaginal Bleeding 4.8 16.0 20.9 7.5 15.2 27.4 32.3 17.8 Foul-Smelling Discharge 0.0 0.0 3.0 1.5 2.5 8.2 3.1 2.6 High Fever 0.0 3.7 19.4 3.0 6.3 17.8 6.2 8.1 Baby’s Hand or Feet Coming out first 1.6 2.5 4.5 6.0 0.0 2.7 0.0 2.4 Baby is in abnormal position 19.4 8.6 9.0 14.9 7.6 9.6 10.8 11.1 Prolong Labor (>12 hours) 54.8 55.6 46.3 44.8 51.9 27.4 32.3 44.9 Retained Placenta 6.5 4.9 3.0 7.5 10.1 8.2 9.2 7.1 Rupture uterus/Cervical/Vaginal tear 0.0 0.0 0.0 4.5 5.1 4.1 0.0 2.0 Cord Prolapsed 0.0 1.2 0.0 0.0 0.0 4.1 0.0 0.8 Cord around neck 0.0 0.0 0.0 1.5 2.5 5.5 0.0 1.4 Convulsion 6.5 6.2 7.5 1.5 3.8 11.0 3.1 5.7 Severe headache 0.0 1.2 3.0 0.0 2.5 8.2 7.7 3.2 Greenish vaginal discharge 0.0 0.0 0.0 0.0 0.0 0.0 1.5 0.2 Swelling of feet or face 4.8 7.4 9.0 11.9 11.4 11.0 13.8 9.9 Others 9.7 13.6 4.5 17.9 5.1 6.8 12.3 9.9
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 (45 percent) and excessive vaginal bleeding (18 percent), which were almost similar in all the seven upazilas. Around 11 percent of women reported that their baby was in abnormal position, 10 percent reported swelling of feet or face, 8 percent reported high fever, 7 percent reported retained placenta, and 6 percent reported convulsion.
Table 6.2.3: Percent distribution of number of danger signs reported during delivery by upazilla, Sylhet.
AREA N No Complication 1 Complication 2 Complications ≥3 Complications Balaganj 308 79.9 18.5 1.6 0.0 Bishwanath 310 73.9 21.6 3.6 1.0 Companiganj 312 78.5 16.4 4.2 1.0 Fenchuganj 318 78.9 17.3 3.1 0.6 Golapganj 310 74.5 20.3 4.5 0.7 Gowainghat 297 75.4 16.5 5.4 2.7 Jaintapur 320 79.7 15.0 4.1 1.3 Total: 2,175 77.3 17.9 3.8 1.0
Table 6.2.3 shows that around 18 percent women reported single complication during their last delivery, 4 percent with two complications and 1 percent with three or more complications. The distribution of rates in each category was almost similar across the upazilas. About 77 percent of women reported had no complication during their last pregnancy and the rate was similar across the seven upazilas.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 6.2.5: Women who had complication during delivery and sought care, the percent distribution of provider by upazila, Sylhet.
N Skilled Other health TTBA TBA Other*** Don’t provider* professional** know Balaganj 58 72.4 0.0 3.5 10.3 20.7 0.0 Bishwanath 70 62.9 0.0 7.1 8.6 28.6 0.0 Companiganj 54 55.6 0.0 1.9 1.9 38.9 0.0 Fenchuganj 64 78.1 0.0 1.6 1.6 18.8 0.0 Golapganj 70 78.6 1.4 8.6 5.7 17.1 0.0 Gowainghat 51 31.4 2.0 7.8 11.8 52.9 0.0 Jaintapur 59 69.5 0.0 1.7 5.1 23.7 0.0 Total: 426 65.3 0.5 4.7 6.3 27.7 0.0
Note: *Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO **Other health professional includes HA, FWA and ACCESS Counselor *** Others includes Village doctor, Quack, Ayurved, Homeopathy, Spiritual, Neighbor
Table 6.2.5 shows that among women reported had any complication during delivery and sought care, 65 percent of them sought care from a skilled health care provider. The rate of seeking care from skilled provider was high in Fenchuganj and Golabganj (around 78 percent) while it was very low (31 percent) in Gowainghat. 28 percent women received care from village doctor/ quack/ ayurved/ homeopath/ Kabiraj and/or neighbor in the intervention area and the rate was high in Gowainghat (53 percent) while low in Fenchuganj and Golabganj (18 percent). Less than 1% of women sought care from HA and FWA or AC, and around 11 percent from TBA or TTBA.
Table 6.2.6 Women reported had complications during delivery and sought care, the percent distribution of place of care by intervention upazillas in Sylhet. Multiple answers were accepted
Place of care for delivery
complication
Total N= 426 Balaganj N= 58 Biswanath N= 70 Companiganj N= 54 Fenchuganj N= 64 Golapganj N= 70 Gowainghat N= 51 Jaintapur N= 59 At home 33.3 31.0 45.7 29.6 23.4 27.1 52.9 25.4 Satellite clinic 0.2 0.0 0.0 0.0 0.0 1.4 0.0 0.0 FWC 1.2 0.0 0.0 0.0 0.0 1.4 3.9 3.4 Community clinic 0.2 0.0 0.0 0.0 0.0 0.0 0.0 1.7 UHC 17.8 12.1 5.7 14.8 32.8 20.0 3.9 33.9 Chamber of MBBS doctor 4.9 5.2 7.1 0.0 6.3 5.7 3.9 5.1 Clinic 21.6 34.5 27.1 24.1 20.3 25.7 11.8 5.1 Hospital 15.3 15.5 14.3 13.0 15.6 18.6 7.8 20.3 Pharmacy 7.0 1.7 4.3 18.5 3.1 1.4 19.6 5.1 Other 0.5 0.0 1.4 0.0 0.0 1.4 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
Table 6.2.6 shows that around 33 percent of women received care at home. The rate was higher in Biswanath (46 percent) and Gowainghat (53 percent) while low in Fenchuganj, Golabganj and jaintapur (about 25 percent). 22 percent of women received care from clinic, 18 percent from UHC 15 percent from hospital and 7 percent from pharmacy. The care seeking pattern was almost similar in all upazilas.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 6.2.7: Women with a home delivery (without a skilled provider) had danger sign during delivery and received advice to seek care by type of birth attendant / health service provider in Sylhet.
Birth attendant/ Health service provider MaMoni survey 2010 (N=241)
ACCESS counselor / MaMoni health worker 5.0 TTBA 10.8 TBA 17.0 Family member/relative 60.6 Neighbor or friend 6.2 Village doctor 3.7 Community Health Worker 0.0 Spiritual person/ Kabiraj 0.0 Others 0.8 Don’t discuss 12.5
Table 6.2.7 shows the distribution of birth attendants/health care providers who were present at the time of childbirth and advised the mother to get treatment for the complication. 61 percent of women reported receiving advice from family members or relatives to seek care for the complication during childbirth. Around 28 percent women received advice from a TBA/TTBA, 5 percent of women received advice from ACCESS counselor / MaMoni health worker and 4 percent from a village doctor.
6.3 Complication during post-partum:
Table 6.3.1 shows around 29 percent of women reported had complication during post-partum. Among them, around 85 percent sought care from any health care provider and 27 percent from a skilled provider. Care seeking pattern was almost similar across the upazilas but there were variations in seeking care from a skilled by upazila. Around 36 percent of women sought care from a skilled provider in Fenchuganj and Golabganj while it was only 14 percent in Gowainghat upazila. 82 percent of women who had an education level of secondary or higher sought care for their complication from a skilled provider, while the rate of seeking care from a skilled provider was only 18 percent among women had no education There was no such variation in reporting a danger sign by level of maternal education, age, parity and wealth quintile and which remained around 30 percent in all seven upazilas. Seeking care from a skilled provider among women had no children was 80 percent but the rate dropped down as the parity went-up. It was very interesting to see that women with one children or more had almost same rate of care seeking (about 25 percent).
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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.
N= Reported danger Sought care for Sought care from a sign complication skilled provider Total: 2,175 625 (28.8) 528(84.5) 167(26.7) Balaganj 308 15.6 83.3 27.1 Bishwanath 310 30.3 89.4 30.9 Companiganj 312 31.4 79.6 28.6 Fenchuganj 318 18.2 94.8 36.2 Golapganj 310 26.1 90.1 35.8 Gowainghat 297 49.2 80.1 14.4 Jaintapur 320 31.3 81.0 26.0 Maternal education No education 708 29.8 79.2 17.5 Primary 404 31.7 83.6 21.1 Class 5-9 952 28.3 88.1 33.1 Class 10+ 111 15.3 100.0 82.4 Maternal age <20 262 33.6 76.1 18.2 20-24 836 27.2 84.6 26.0 25-29 580 27.4 86.2 37.1 30-34 317 31.2 84.9 22.2 35-39 142 31.7 91.1 22.2 40 + 38 18.4 100.0 14.3 Birth order 0 11 45.5 100.0 80.0 1 557 24.8 79.7 29.0 2 529 27.0 86.7 31.5 3 337 30.3 80.4 21.6 4 281 29.2 92.7 30.5 5+ 460 33.7 84.5 20.0 Wealth Quintile Lowest 435 31.5 70.8 21.2 Second 435 34.7 84.1 23.8 Middle 435 28.5 87.1 27.0 Fourth 435 29.0 92.1 27.7 Highest 435 20.0 92.0 32.8
The proportion of women that reported each specific complication during post-partum period has shown in Table 6.3.2. The most commonly cited complication was severe lower abdominal pain (48 percent) which was almost same in all upazilas, 38 percent of women reported had fever and the rate was low (around 25 percent) in Balaganj and Biswanath. 33 percent women had Breathlessness, tiredness, palpitation and weakness and that varied very little across the upazilas. Around 14 percent of women reported that they had excessive vaginal bleeding, 12 percent reported fainting, 5 percent of women experienced fits and convulsion and 4 percent had foul smelling vaginal discharge.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 6.3.2 Percent distribution of danger signs reported during post partum period by upazila, Sylhet.
Reported danger signs during
j
post partum
Balaganj N= 48 Biswanath N= 94 Companiganj N= 98 Fenchuganj N= 58 Golapgan N= 81 Gowainghat N= 146 Jaintapur N= 100 Total N= 625 Fever 16.7 25.5 50.0 44.8 39.5 43.8 32.0 37.6 Excessive vaginal bleeding 10.4 24.5 18.4 19.0 17.3 1.4 17.0 14.4 Foul smelling vaginal discharge 2.1 0.0 4.1 6.9 3.7 6.2 3.0 3.8 Severe lower abdominal pain 43.8 53.2 51.0 41.4 46.9 44.5 52.0 48.0 Breathlessness, tiredness, palpitation and weakness 33.3 39.4 33.7 22.4 35.8 37.0 25.0 33.1 Fainting 6.3 8.5 14.3 6.9 16.0 15.8 9.0 11.8 Fits and convulsion 8.3 4.3 13.3 3.4 2.5 4.1 3.0 5.4 Others 0.0 1.1 1.0 5.2 6.2 2.7 1.0 2.4
Multiple answers were accepted
Table 6.3.3 shows that around 17% of women reported single complication during post-partum period across the seven intervention upazilas which was almost similar in all upazilas. Around 7% of women reported two complications which do not largely vary across the upazilas. Around 4% women experienced more than three complications. The table also shows that about 71% women did not experience any complication during post-partum period in all upazilas and it does not largely vary across these seven upazilas.
Table 6.3.3: Percent distribution of number of danger signs reported during post partum period by upazilla.
AREA N No Complication 1 Complication 2 Complications ≥3 Complications
Balaganj 308 84.4 12.7 2.6 0.3 Bishwanath 310 69.7 19.4 6.8 4.2 Companiganj 312 68.6 12.8 12.5 6.1 Fenchuganj 318 81.8 12.9 2.8 2.5 Golapganj 310 73.9 14.8 6.1 5.2 Gowainghat 297 50.8 26.9 14.8 7.4 Jaintapur 320 68.8 22.8 5.3 3.1 Total: 2,175 71.3 17.4 7.2 4.1
Table 6.3.6 shows that for post-partum complicacy around 28 percent of women received care at home, 41 percent received care from pharmacy, 13 percent from doctor’s chamber, 7 percent from hospital and 6 percent from clinics. Distribution pattern across upazilas was very similar except that only 6 percent women received care from MBBS doctor in Gowainghat upazila. None sought care from FWC in Balaganj, Biswanath, Companiganj and Fenchuganj.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 6.3.6: Women reported had complications and sought care during post partum period, the percent distribution of place of care by upazila.
Place of care
Balaganj N=40 Biswanath N=84 Companiganj N=78 Fenchuganj N=55 Golapganj N=73 Gowainghat N=117 Jaintapur N=81 Total N=528 At Home 40.0 31.0 12.8 27.3 46.6 27.4 16.1 27.7 Satellite clinic 0.0 0.0 0.0 0.0 0.0 0.0 1.2 0.2 FWC 0.0 0.0 0.0 0.0 1.4 2.6 1.2 1.0 UHC 7.5 0.0 6.4 10.9 6.9 4.3 4.9 5.8 Doctor's chamber 12.5 15.5 12.8 10.9 16.4 6.0 16.1 12.5 Clinic 10.0 11.9 7.7 10.9 4.1 2.6 0.0 6.1 Community clinic 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Hospital 2.5 7.1 9.0 5.5 13.7 2.6 9.9 7.2 Pharmacy 27.5 34.5 51.3 34.6 15.1 58.1 49.4 41.3 Others 0.0 0.0 0.0 0.0 0.0 0.0 1.2 0.2
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Chapter-7: Newborn Health
One of the primary goals of the 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 percent of children acquire an infection during the neonatal period, and infection contributes to 30-40 percent 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 study area 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 [foot note]
In an effort to prevent neonatal hypothermia and promote thermal care practice, two methods of preventing hypothermia are being promoted in the ACCESS/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.
Tables 7.1.1 shows that more than 95% of women reported had a newborn care person at birth in all upazilas (except in Gowainghat 89 percent). Around 88 percent women reported that TBA/TTBA was the newborn care person in the home deliveries, which was similar across the upazilas, 4 percent was the mother/mother in law and another 4 percent was family member/relative. Only 2 percent women reported that nurse/midwife/FWV was the newborn care person in the deliveries and the rate was found high (4-5 percent) in Fenchuganj and Golabganj upazilas while it was almost zero percent in Companiganj, Gowainghat and Jaintapur upazilas.
Foot note: Low birth weight infants are at a particular risk of hypothermia, given their further limitations of decreased subcutaneous fat stores, lowered ability for cold-induced thermogenesis, and increased surface-to-volume ratio.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 7.1.1: Women gave birth at home and had newborn care person (NBC) at birth; percent distribution of type of newborn care person by upazila, Sylhet.
Newborn Care Person
ghat
708 , mpaniganj Balaganj N=241 Biswanath N=246 Co N=274 Fenchuganj N=219 Golapganj N=195 Gowain N=262 Jaintapur N=271 Total N=1 Had newborn care person 231 245 267 211 190 233 263 1640 (95.9) (99.6) (97.5) (96.4) (97.4) (88.9) (97.1) (95.2) Type of NBC person: MBBS doctor 0.0 0.0 0.0 0.5 0.0 0.0 0.0 0.1 Nurse/midwife 0.9 1.2 0.0 5.2 3.7 0.4 0.4 1.5 Paramedic 0.9 0.0 0.0 0.0 0.0 0.0 0.0 0.1 FWV 0.0 0.8 0.0 0.5 0.5 0.0 0.4 0.3 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 ACCESS Counselor 0.0 0.4 0.4 0.0 0.5 0.9 0.4 0.4 HA 0.4 0.4 0.0 0.0 0.0 0.0 0.0 0.1 FWA 0.0 0.4 0.0 0.0 0.0 0.0 0.0 0.1 TTBA 31.6 42.5 37.1 51.7 49.0 40.8 38.8 41.2 TBA 62.8 45.7 50.6 36.5 33.2 48.9 46.8 46.9 Homeopath 0.0 0.0 0.4 0.0 0.0 0.0 0.0 0.1 Ayurved 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 Village doctors 0.0 0.0 0.0 0.0 0.0 0.4 0.0 0.1 Spiritual person/Kabiraj 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Mother/mother in law 2.2 2.9 6.4 2.4 4.2 5.2 6.5 4.3 Family members/relatives 0.9 4.1 3.8 3.3 5.8 1.7 4.9 3.5 Neighbors/friends 0.4 1.2 0.8 0.0 2.1 1.3 1.9 1.1 Mother herself 0.0 0.4 0.8 0.0 1.1 0.4 0.0 0.4 Others 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Table 7.1.2: Percent distribution of type of immediate care that newborn received first after birth by upazila.
chuganj Balaganj N=241 Biswanath N=246 Companiganj N=274 Fen N=219 Golapganj N=195 Gowainghat N=262 Jaintapur N=271 Total N=1,708 Cut the umbilical cord 95.9 86.2 78.1 94.1 95.4 93.9 94.8 90.9 Kept the baby over chest/abdomen with 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 bare skin to skin contact Left the baby alone 0.0 2.0 1.1 0.0 0.0 0.0 0.0 0.5 Dried the baby 4.2 11.4 14.2 5.0 4.1 4.6 4.8 7.1 Wrapped the baby with cloths 0.0 0.4 5.1 0.0 0.0 0.4 0.0 0.9 Bathed the baby 0.0 0.0 0.0 0.0 0.0 0.4 0.0 0.1 Let the baby sleep 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Breast fed 0.0 0.0 0.4 0.0 0.0 0.4 0.0 0.1 Fed sugar water or other thing 0.0 0.0 0.0 0.0 0.0 0.4 0.0 0.1 Others 0.0 0.0 0.0 0.0 0.5 0.0 0.0 0.1 Don’t know/Can’t remember 0.0 0.0 1.1 0.9 0.0 0.0 0.4 0.4
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 7.1.2 shows more than 90 percent women reported cord cutting as the immediate care that newborn received just after birth. The rate was highest (96 percent) in Balaganj and lowest (78 percent) in Companiganj, besides the rate was similar across the seven intervention upazilas. The practice of immediate drying of newborns just after birth was 7.1 percent and was high (12-14 percent) in Biswanath and Companiganj and around 4 percent in other upazilas. A very low percentage (1 percent) of women reported wrapping their newborns immediately after birth.
Table 7.1.3: Percentage of newborns were dried and wrapped before the delivery of placenta in home deliveries by upazila.
AREA N Both dried & wrapped before the delivery of placenta Balaganj 241 1.7 Bishwanath 246 4.1 Companiganj 274 6.9 Fenchuganj 219 4.6 Golapganj 195 8.7 Gowainghat 262 7.3 Jaintapur 271 7.8 Total: 1,708 5.9
Table 7.1.3 shows that only about 6% of women reported both dried and wrapped their newborns before the delivery of the placenta. Among the upazilas, it was 2 percent in Balaganj as lowest and 9 percent in Golapganj as highest.
Table 7.1.4 shows that 7 percent of women reported their newborns were dried and wrapped within 5 minutes, 40 percent within 10 minutes, 72 percent within 15 minutes and around 95 percent within 30 minutes after birth. 11-13 percent women from Biswanath and Golabganj reported their newborns were dried and wrapped within 5 minutes while the rate was very low (1 percent) in Fenchuganj. Two-thirds of women reported their newborns were dried and wrapped between 6-15 minutes and one-fifth after 15 minutes, although it was reported that the placenta was delivered within 5 minutes after birth in 68 percent of all deliveries. (Table 7.1.5).
Table 7.1.4: Timing of both drying and wrapping of the newborn immediately after birth among home deliveries by upazila
Area N <5 6-10 11-15 16-30 >30 Don’t know Don’t Don’t dry minutes minutes minutes minutes minutes the timing know and wrap Balaganj 241 5.4 21.6 36.9 31.1 0.8 0.0 0.0 4.2 Biswanath 246 10.6 33.3 28.5 25.2 1.6 0.4 0.0 0.4 Companiganj 274 3.3 31.0 37.2 19.7 5.1 0.7 0.0 2.9 Fenchuganj 219 1.4 22.8 41.6 28.8 1.4 0.5 0.0 3.7 Golapganj 195 13.3 35.4 30.8 15.9 1.5 0.0 0.0 3.1 Gowainghat 262 8.8 40.8 19.1 13.0 5.8 0.0 0.4 12.2 Jaintapur 271 4.1 43.2 34.0 12.9 2.6 0.4 0.7 2.2 Total: 1,708 6.5 32.9 32.4 20.7 2.8 0.3 0.2 4.2
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 7.1.5 Percent distribution of time of delivery of placenta in minutes by intervention upazilas of Sylhet (home delivery only).
Timing of placental delivery MaMoni area, Sylhet N= 1708 Number % Within 5 minutes 1,161 68.0 6-10 minutes 347 20.3 11-15 minutes 79 4.6 16-30 minutes 98 5.7 >30 minutes 15 0.9 Was not delivered 3 0.2 Did not know 5 0.3
Table 7.1.5 shows around two-thirds of women reported that the placenta was delivered within 5 minutes after child birth at home in the intervention areas. Placenta was delivered within 10 minutes after birth in 88 percent deliveries and 93 percent within 15 minutes. Only 1 percent of women reported that the delivery of placenta took more than 30 minutes after child birth.
Table 7.1.6 shows the timing of drying and wrapping separately. Almost 31 percent of women reported that their newborns were dried within 5 minutes, 78 percent within 10 minutes and 93 percent within 15 minutes after child birth. About 2 percent reported dried their babies after 30 minutes of child birth. In the case of wrapping of the newborn, around 7 percent of women reported wrapped their newborns within 5 minutes, 41 percent within 10 minutes, 75 percent within 15 minutes and 98 percent within 30 minutes after child birth. Around 2% of women reported their newborns wrapped after 30 minutes of child birth.
Table 7.1.6 Percent distribution of individual timing of immediate drying and wrapping of newborns after birth in Sylhet (Home delivery only)
Drying & wrapping of newborn immediately MaMoni area, Sylhet after birth Number % Drying the baby 1,640 Within 5 minutes 505 30.8 6-10 minutes 767 46.8 11-15 minutes 253 15.4 16-30 minutes 74 4.5 >30 minutes 37 2.3 Don’t know/can’t remember 4 0.2 Wrapping the baby 1,688 Within 5 minutes 116 6.9 6-10 minutes 575 34.1 11-15 minutes 566 33.5 16-30 minutes 381 22.6 >30 minutes 45 2.7 Don’t know/can’t remember 5 0.3
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 around 14 percent women reported cut their umbilical cords with a new blade and about 85 percent used a birth-kit (CDK) to cut their umbilical cords. Bamboo slices were used for cutting the umbilical cord in 1 percent of cases.
Table 7.2.1: Percent of recent mothers who gave birth at home and whose newborns’ cords were cut by type of instruments and by upazila.
AREA N= Blade New Old Bamboo Scissors Others Umbilicus was Don’t from birth blade blade strip not cut know kit Balaganj 241 88.8 10.4 0.0 0.4 0.4 0.0 0.0 0.0 Bishwanath 246 89.0 10.6 0.0 0.4 0.0 0.0 0.0 0.0 Companiganj 274 81.0 16.8 0.7 1.5 0.0 0.0 0.0 0.0 Fenchuganj 219 89.5 9.6 0.0 0.0 0.0 0.0 0.0 0.5 Golapganj 195 86.7 11.3 0.0 0.0 1.5 0.0 0.5 0.0 Gowainghat 262 74.4 21.8 0.0 3.1 0.0 0.0 0.8 0.0 Jaintapur 271 84.1 13.3 0.7 1.1 0.7 0.0 0.0 0.0 Total: 1,708 84.5 13.6 0.2 1.0 0.4 0.1 0.2 0.1
Use of birth-kit was highest in Fenchiganj (90 percent) and lowest in Gowainghat (74 percent). On the other hand, use of new blade for cord cutting was highest in Gowainghat (22 percent) and lowest in Fenchuganj, Balaganj and Biswanath (around 10 percent). Figure 7.1 shows percentage of women had birth-kit (CDK) during their last deliveries by upazila and by survey (Baseline 2007 Vs Midline 2010)
Fig: 7.1 Percentage of women had CDK during child birth by baseline (2007) and Midline (2010) surveys
100 90 91.1 90.9 90.3 90 82.5 84.9 76.7 80 70 60 50 40 30 20 5.9 6 3.6 10 2.6 2.4 0.6 3 0 3.2 0 Balaganj Bishwanath Companiganj Fenchuganj Golapganj Gowainghat Jaintapur To
Baseline (2007) Midline (2010)
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 7.2.3: Percent distribution of women had CDK during child birth and used materials from birth kit among home deliveries by upazila.
Upazila N= Had CDK (%) Balaganj 241 90.0 Bishwanath 246 91.1 Companiganj 274 82.5 Fenchuganj 219 90.9 Golapganj 195 90.3 Gowainghat 262 76.7 Jaintapur 271 84.9 Total: 1,708 86.2
Table 7.2.3 shows that more than 90 percent of women had a birth kit during their last child birth in Fenchuganj and Golapganj upazila, while it was 82 percent in Companiganj and 77 percent in Gowainghat.
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.
Specific substances applied to the
umbilical cord within 7 days of birth Balaganj 241 N= Biswanath 246 N= Companiganj 274 N= Fenchuganj 219 N= Golapganj 195 N= Gowainghat 262 N= Jaintapur N=271 Total N=1708
59 68 88 72 45 78 125 535 Total: (24.5) (27.6) (32.1) (32.9) (23.1) (29.8) (46.1) (31.3) Antibiotics (Powder / Ointment) 18.6 8.8 4.6 18.1 28.9 5.1 1.6 9.9 Antiseptic (Detol/savlon/hexisol) 18.6 39.7 10.2 6.9 6.7 6.4 6.4 12.7 Spirit/Alcohol 3.4 1.5 1.1 0.0 2.2 1.3 0.8 1.3 Mustard oil (with/ without garlic) 47.5 19.1 18.2 13.9 8.9 24.4 40.0 26.2 Chewed rice 0.0 2.9 0.0 9.7 2.2 2.6 4.0 3.2 Turmeric juice/powder 1.7 1.5 0.0 18.1 11.1 2.6 16.0 7.9 Ginger juice 0.0 2.9 33.0 15.3 11.1 30.8 20.8 18.1 Shidur 6.8 2.9 11.4 5.6 8.9 12.8 12.0 9.2 Boric powder 3.4 10.3 8.0 4.2 8.9 2.6 4.8 5.8 Gentian violet (Blue ink) 1.7 0.0 1.1 1.4 6.7 0.0 1.6 1.5 Talcom Powder 0.0 0.0 0.0 1.4 2.2 3.9 1.6 1.3 Ash 0.0 0.0 8.0 8.3 4.4 10.3 3.2 5.1 Coconut oil 0.0 1.5 0.0 2.8 4.4 2.6 1.6 1.7 Dust of earth-burner 5.1 10.3 8.0 4.2 0.0 2.6 0.0 4.1 Other thing 0.0 0.0 5.7 4.2 2.2 1.3 2.4 2.4 Don’t know 0.0 0.0 1.1 0.0 0.0 0.0 0.0 0.2 Multiple answers were accepted
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 shows that around 31 percent of women in the intervention upazilas applied medications or some other substances to the umbilical cords of newborns. The most commonly used substances were mustard oil (26 percent), ginger juice (18 percent), and antiseptic (13 percent).
Table 7.2.5: Percentage of women applied specific substances to the umbilical cord after birth among home deliveries by upazila.
AREA N Applied something Applied nothing Don’t know
Balaganj 241 10.8 87.6 1.7 Bishwanath 246 17.1 79.7 3.3 Companiganj 274 21.2 77.7 1.1 Fenchuganj 219 19.6 79.0 1.4 Golapganj 195 27.2 71.8 1.0 Gowainghat 262 40.1 58.4 1.5 Jaintapur 271 38.0 60.5 1.5 Total: 1,708 25.2 73.2 1.6
Table 7.2.5 shows around 40 percent of women applied specific substances or material to the umbilical cord in Gowainghat and jaintapur upazilas while the rate was less than 20 percent in Balaganj, Biswanath and Fenchuganj.
7.3 Breast Feeding:
Table 7.3.1: Percentage of women reported initiating breast feeding immediately following birth (home delivery) by time since birth, placental delivery and by baseline/midline surveys.
Initiation of breast feeding ACCESS baseline 2007 MaMoni survey 2010 N=16,272 N=1,708 Number % Number % Commencement of breast feeding Within 1 hour 11,938 73.4 1,495 87.5 1 hour 1,635 10.1 28 1.6 2 hours 1,537 9.5 131 7.7 3+ hours 1,009 6.2 42 2.5 Never Breastfed 153 0.9 12 0.7 Placental delivery and breast feeding Before delivery of placenta 566 3.5 54 3.2 After delivery of placenta 15,535 95.5 1,642 96.1 Don’t know /can’t remember 20 0.1 0 0.0 Never gave breast milk 151 0.9 12 0.7
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
In addition to thermal care practices, immediate breastfeeding patterns were evaluated. Findings suggested that the initiation of breastfeeding immediately following birth was rarely practiced overall. 3.2 percent of women reported initiated breast feeding before the delivery of the placenta and the rate was similar in the baseline. About 88 percent of women reported commencing breast feeding within an hour after birth in the midline while it was 73 percent in the baseline. Table 7.3.2 shows that at least 88 percent of women reported initiated breast feeding within an hour after birth in all the upazilas except Jaintapur (79 percent).
Table 7.3.2: Percent of recent mothers delivered at home reported initiating breast feeding within 1 hour of birth by upazila.
Upazila N Within 1 hour 1 hour 2 hours 3+ hours Never breastfed
Balaganj 241 93.8 0.4 4.2 1.7 0.0 Bishwanath 246 94.3 0.0 4.1 1.2 0.4 Companiganj 274 84.3 0.4 11.3 3.3 0.7 Fenchuganj 219 91.3 0.0 5.5 3.2 0.0 Golapganj 195 87.7 0.0 7.7 3.6 1.0 Gowainghat 262 84.0 4.6 8.0 2.3 1.2 Jaintapur 271 79.3 5.2 11.8 2.2 1.5
Total: 1,708 87.5 1.6 7.7 2.5 0.7
Table 7.3.3 Percentage of newborns received colostrum by upazila.
Area N= Newborn received colostrum Balaganj 303 97.0 Bishwanath 300 97.7 Companiganj 301 91.7 Fenchuganj 314 90.5 Golapganj 302 94.4 Gowainghat 290 82.1 Jaintapur 311 90.7 Total: 2,121 92.0
Table 7.3.3 indicates that about 92 percent of women in the intervention areas reported that their newborns received colostrums. The rate of newborns received colostrums was highest (97 percent) in Balaganj and Biswanath upazilas while it was low (82 percent) in Gowainghat upazila.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 7.3.4 Percentage of newborns received prelacteal feed by upazila.
Prelacteal food
Balaganj N=303 Biswanath N=300 Companiganj N=301 Fenchuganj N=314 Golapganj N=302 Gowainghat N=290 Jaintapur N=311 Total N=2121 62 44 56 45 43 61 27 338 Gave pre-lacteal food after birth (20.5) (14.7) (18.6) (14.3) (14.2) (21.0) (8.4) (15.9) Honey 8.1 9.1 16.1 26.7 16.3 16.4 22.2 15.7 Misri water 16.1 27.3 55.4 35.6 39.5 19.7 11.1 29.9 Sugar water 33.9 22.7 25.0 24.4 27.9 63.9 44.4 35.2 Plain water 43.6 36.4 5.4 6.7 4.7 9.8 11.1 17.8 Fruit juice 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Baby formula (Tin food) 3.2 6.8 5.4 0.0 18.6 8.2 7.4 6.8 Cow milk 0.0 0.0 8.9 2.2 0.0 4.9 0.0 2.7 Other liquid 1.6 2.3 0.0 0.0 0.0 0.0 0.0 0.6 Smashed rice/flour 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 Papaya / Mango 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 Boiled rice / Bread 0.0 0.0 1.8 0.0 0.0 0.0 0.0 0.3 Gram / cereal/ Dal 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other thing 1.6 2.3 7.1 8.9 2.3 1.6 0.0 3.6
Table 7.3.4 shows about 16 percent of newborns received prelacteal feed in the intervention areas. Among the feeds, 16 percent children received honey, 30 percent received misri water, 35 percent received sugar water while 18 percent received plain water.
Table 7.3.5 Percentage of newborns received solid or liquid food other than breast milk within 3 days after birth by upazila.
Additional food/drink other
than breast milk
Balaganj N=62 Biswanath N=44 Companiganj N=56 Fenchuganj N=45 Golapganj N=43 Gowainghat N=61 Jaintapur N=27 Total N=338 Honey 6.5 9.1 16.1 26.7 16.3 18.0 22.2 15.7 Misri water 17.7 27.3 55.4 33.3 44.2 21.3 11.1 30.8 Sugar water 32.3 22.7 26.8 26.7 23.3 57.4 55.6 34.6 Plain water 43.6 36.4 5.4 6.7 4.7 13.1 18.5 18.9 Fruit juice 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Baby formula (Tin food) 3.2 6.8 5.4 0.0 18.6 4.9 7.4 6.2 Cow milk 0.0 0.0 8.9 2.2 0.0 4.9 0.0 2.7 Other liquid 1.6 2.3 0.0 0.0 0.0 0.0 0.0 0.6 Smashed rice/flour 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 Papaya / Mango 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 Boiled rice / Bread 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 Other thing 1.6 0.0 5.4 8.9 2.3 1.6 0.0 3.0
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 7.3.5 shows that around 35 percent women reported their newborns were receiving sugar water, 31 percent receiving misri water, 19 percent plain water and 16 percent honey other than breast-milk within 3 days after birth. More than 55 percent newborns were receiving sugar water in Gowainghat and jaintapur and Misri water in Companiganj.
7.4 Bathing:
Table 7.4.1: Timing of first bathing of newborns after birth by upazila. (Home delivery only)
AREA N=
Bathed immediately within Bathed 24 hours Bathed on 2nd day on 3rd Bathed day Bathed after 3 days yet bathe Not Don’t know Balaganj 241 12.5 6.6 5.0 29.9 45.6 0.4 0.0 Bishwanath 246 7.3 7.3 5.7 28.1 49.6 2.0 0.0 Companiganj 274 16.4 4.7 1.5 37.6 38.3 1.5 0.0 Fenchuganj 219 9.6 8.2 1.8 32.4 46.6 0.9 0.5 Golapganj 195 13.3 9.7 6.7 28.2 40.5 1.5 0.0 Gowainghat 262 21.4 11.5 3.4 22.9 38.9 1.9 0.0 Jaintapur 271 10.3 18.1 5.9 24.4 39.5 1.5 0.4 Total: 1,708 13.1 9.5 4.2 29.0 42.6 1.4 0.1
Table 7.4.1 shows that 13 percent women reported bathed their newborns immediately after birth and 23 percent within 24 hours. About 44 percent of women reported bathed their newborns after 3 days of child birth. There was no much variation by upazila in terms of timing of bathing. Around 52 percent of women reported bathed their newborns after 3 days of birth in Biswanath upazila. There was a remarkable improvement of practice of delayed bathing (after 3 days of birth) compare to baseline 2007 data. (Figure: 7.2)
Fig:7.2 Timing of first bathing (Bathed after 3 days of birth) of newborns after birth by baseline and midline surveys
60 49.6 50 45.6 46.6 38.3 40.5 38.9 39.5 40
30
20 7.5 9.2 10 5.4 3.3 4.3 4.3 3.2 0 0 Balaganj Bishwanath Companiganj Fenchuganj Golapganj Gowainghat Jaintapur
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 7.4.2 shows that the percentage of newborns were bathed after three days of birth was higher (64 percent) among women who had secondary or higher level of education, while it was 37 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, 37 percent of women in the lowest wealth quintile group reported bathed their newborns after 3 days of child birth, while it was 52 percent among women in highest wealth quintile group. 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 (Home Delivery Only)
N= Bathed first time after 3 days of birth Total 1,708 42.6 Balaganj 241 45.6 Biswanath 246 49.6 Companiganj 274 38.3 Fenchuganj 219 46.6 Golapganj 195 40.5 Gowainghat 262 38.9 Jaintapur 271 39.5 Education: No education: 633 37.4 Primary 349 41.0 Class 5 - 9 687 46.9 Class 10+ 39 64.1 Maternal Age: 14 – 19 241 44.9 20 – 24 635 43.0 25 – 29 451 44.1 30 – 34 258 39.9 35 – 39 115 33.9 40+ 35 48.6 Birth Order: 1 362 46.4 2 403 42.7 3 285 42.5 4 244 39.8 5+ 414 40.8 Wealth Quintile: Lowest 407 36.9 Second 392 41.8 Middle 364 40.1 Fourth 312 47.1 Highest 233 51.5
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
7.5 Postnatal Care (PNC)
The survey result shows that 82 percent women reported not received any post natal care visit for their newborns after birth (Table 7.5.1). Around 90 percent women reported not received any PNC in Companiganj, Jaintapur and Gowainghat while the rate of not receiving any PNC was 67 percent in Golapganj and 75 percent in Fenchuganj.
Table 7.5.1: Percentage of women reported receiving at least 2 PNC visits for their newborns by upazila.
AREA N= Did not receive any PNC Received 1 PNC Received 2 or more PNC
Balaganj 303 79.2 4.6 16.2 Bishwanath 300 81.3 6.7 12.0 Companiganj 301 91.4 4.7 4.0 Fenchuganj 314 75.2 13.7 11.2 Golapganj 302 67.2 10.3 22.5 Gowainghat 290 87.9 4.1 7.9 Jaintapur 311 90.7 5.1 4.2 Total: 2,121 81.8 7.1 11.1
On the other hand, around 11% of women reported receiving two or more PNC visits for their newborns. The percentage was higher in Golapganj (23 percent), Balaganj (16 percent) and Biswanath (12 Percent) and lower in Companiganj and Jaintapur (each 4 percent).
Table 7.5.2: Percent distribution of women received PNC by timing of first PNC received by upazila.
Area Received Within 3 4-6 days 7-13 14-27 28-41 After 41 PNC (N=) days days days days days Balaganj 63 95.2 0.0 3.2 1.6 0.0 0.0 Biswanath 56 87.5 1.8 5.4 3.6 1.8 0.0 Companiganj 26 80.8 7.7 11.5 0.0 0.0 0.0 Fenchuganj 78 92.3 1.3 5.1 1.3 0.0 0.0 Golapganj 99 87.9 5.1 2.0 3.0 2.0 0.0 Gowainghat 35 74.3 2.9 5.7 5.7 8.6 2.9 Jaintapur 29 72.4 6.9 10.3 0.0 6.9 3.5 Total: 386 87.1 3.1 4.9 2.3 2.1 0.5
Table 7.5.2 shows the timing of first PNC visit among those women who received any PNC visit for their newborns. Around 97 percent women reported receiving PNC for their newborns within 28 days of birth, while it was 87 percent for receiving PNC within three days after birth. More than 90 percent women received PNC for their newborns within 3 days after birth in Balaganj and Fenchuganj, while the rate was less than 75 percent in Gowainghat and jaintapur upazilas.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 7.5.4 shows the distribution of PNC providers by category. Around 98% of women reported receiving PNC visits from a skilled provider, among those who received any PNC for their newborns during postpartum. There was no report of receiving PNC from TBA or TTBA. There was no significant difference in the distribution of PNC providers by upazila. Education level of mother, age, parity and wealth quintile has got no effect on receiving PNC from a skilled provider.
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. Multiple answers were accepted N= Skilled Other health TTBA TBA Other*** Don’t provider* professional** know
Total 236 97.5 0.9 0.0 0.0 1.7 0.0 Balaganj 49 98.0 2.0 0.0 0.0 0.0 0.0 Bishwanath 36 100.0 0.0 0.0 0.0 0.0 0.0 Companiganj 12 100.0 0.0 0.0 0.0 0.0 0.0 Fenchuganj 35 100.0 0.0 0.0 0.0 0.0 0.0 Golapganj 68 98.5 1.5 0.0 0.0 0.0 0.0 Gowainghat 23 87.0 0.0 0.0 0.0 13.0 0.0 Jaintapur 13 92.3 0.0 0.0 0.0 7.7 0.0 Education: No education: 24 95.8 0.0 0.0 0.0 4.2 0.0 Primary 27 96.3 0.0 0.0 0.0 3.7 0.0 Class 5 - 9 134 98.5 0.0 0.0 0.0 1.5 0.0 Class 10+ 51 96.1 3.9 0.0 0.0 0.0 0.0 Maternal Age: 14 – 19 18 88.9 0.0 0.0 0.0 11.1 0.0 20 – 24 94 98.9 0.0 0.0 0.0 1.1 0.0 25 – 29 82 98.8 1.2 0.0 0.0 0.0 0.0 30 – 34 36 94.4 2.8 0.0 0.0 2.8 0.0 35 – 39 5 100.0 0.0 0.0 0.0 0.0 0.0 40+ 1 100.0 0.0 0.0 0.0 0.0 0.0 Birth Order: 1 94 98.9 0.0 0.0 0.0 1.1 0.0 2 80 95.0 2.5 0.0 0.0 2.5 0.0 3 32 100.0 0.0 0.0 0.0 0.0 0.0 4 15 100.0 0.0 0.0 0.0 0.0 0.0 5+ 15 93.3 0.0 0.0 0.0 6.7 0.0 Wealth Quintile: Lowest 6 83.3 0.0 0.0 0.0 16.7 0.0 Second 14 85.7 0.0 0.0 0.0 14.3 0.0 Middle 29 96.6 0.0 0.0 0.0 3.5 0.0 Fourth 53 98.1 1.9 0.0 0.0 0.0 0.0 Highest 134 99.3 0.8 0.0 0.0 0.0 0.0
Note: *Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO **Other health professional includes HA, FWA and ACCESS Counselor *** Others includes Village doctor, Quack, Ayurved, Homeopathy, Spiritual, Neighbor
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
7.6 Newborn complication and care seeking
Table 7.6.1 shows the percentage of newborns developed danger signs and the percentage of parents who sought care from any provider and sought care from a skilled provider. Almost 43 percent women reported that their newborns developed danger signs within the first 28 days of life. Among those women, around 52 percent sought care from a skilled provider in the intervention areas. 85 percent of women who had secondary or higher level of education received care for their newborns from a skilled provider while the rate was very low (37 percent) among women had no education. In terms of parity, 64 percent of women had one children reported sought care from a skilled provider; the percentage decreased as parity increased and 38 percent of women with a parity of 5 or more reported sought care from a skilled provider. There were no marked differences in care seeking from a skilled provider by wealth quintile and maternal age, it was almost 50 percent across all maternal age groups and five wealth quintile groups.
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. (Skilled provider includes MBBS doctor, Nurse/midwife, Paramedic, FWV, Medical assistant/SACMO)
N= Reported danger Sought care for Sought care from a sign complication skilled provider Total: 2,121 907 (42.8) 882 (97.2) 467 (51.5) Balaganj 303 37.0 98.2 59.8 Bishwanath 300 36.0 99.1 59.3 Companiganj 301 47.2 95.1 44.4 Fenchuganj 314 43.6 97.8 70.1 Golapganj 302 43.4 98.5 58.0 Gowainghat 290 49.0 97.9 26.8 Jaintapur 311 43.4 94.8 46.7 Education No education: 684 41.7 95.4 37.2 Primary 400 43.8 95.4 42.9 Class 5 - 9 928 43.2 99.0 61.6 Class 10+ 109 42.2 100.0 84.8 Maternal Age 14 – 19 258 42.6 97.3 48.2 20 – 24 820 44.4 97.3 55.0 25 – 29 565 41.2 98.3 49.8 30 – 34 308 41.6 96.1 46.9 35 – 39 132 42.4 98.2 53.6 40+ 38 42.1 87.5 50.0 Birth Order 1 549 47.0 99.6 64.0 2 520 40.4 96.7 55.7 3 330 42.4 95.7 47.1 4 276 42.0 96.6 43.1 5+ 446 41.0 96.2 37.7 Wealth Quintile: Lowest 422 41.7 96.6 54.0 Second 432 43.1 97.3 50.0 Middle 421 41.3 96.6 48.9 Fourth 424 42.0 98.9 53.4 Highest 422 45.7 96.9 51.3
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 7.6.2 shows the distribution of the most commonly cited danger signs of the newborns as reported by the respondents. Most commonly cited danger signs mentioned were fever (22 percent), cough and cold (17 percent), pneumonia (8 percent), difficult/fast breathing (5 percent), yellow skin/ palm/ feet/ eye (5 percent) and distension of abdomen (3 percent) and diarrhea (2 percent).
Table 7.6.2 Percent distribution of signs and symptoms of newborns reported sick during first month of life by intervention upzila
Danger sign of newborn
Balaganj 303 N= Biswanath 300 N= Companiganj 301 N= Fenchuganj 314 N= Golapganj 302 N= Gowainghat 290 N= Jaintapur 311 N= Total 2121 N= Difficult and fast breathing 3.6 5.0 4.0 4.1 4.0 7.9 3.9 4.6 Pneumonia 6.6 7.3 11.0 9.9 6.6 10.7 7.1 8.4 Cough/Cold 13.9 10.0 25.6 18.8 12.9 18.3 15.8 16.5 Yellow skin/palm/feet/eye 5.6 2.7 1.3 4.8 8.9 2.8 4.2 4.3 Poor sucking or feeding 1.7 2.7 0.7 1.0 1.3 2.4 0.0 1.4 Pus, bleeding/ discharge from around cord 3.0 1.0 0.7 1.0 1.0 1.7 1.9 1.5 Skin lesions or blisters 1.7 1.0 0.7 0.3 0.7 1.0 0.3 0.8 Convulsion/ spasms/rigidity 0.7 0.3 0.7 0.0 0.3 0.7 0.0 0.4 Lethargy/ unconsciousness 0.0 0.0 0.3 0.0 0.0 0.3 0.0 0.1 Red or swollen eyes with pus 0.7 0.3 0.3 1.6 2.0 0.3 0.6 0.9 Baby feels cold 0.0 0.3 0.3 0.0 0.3 0.0 0.3 0.2 Baby doesn’t cry 0.0 0.7 1.3 0.6 0.3 1.0 1.0 0.7 Fever 17.8 20.3 27.9 23.3 17.2 22.8 24.8 22.0 Doesn’t pass urine 0.0 0.3 0.3 0.6 1.0 0.7 1.0 0.6 Doesn’t pass stool 0.0 0.3 0.3 0.3 1.3 0.3 0.6 0.5 Continuous vomiting 1.0 1.0 0.7 2.9 1.3 1.7 1.9 1.5 Distention abdomen 1.3 2.3 3.0 4.8 4.0 6.2 2.6 3.4 Difficult to wake from sleep 0.0 0.3 0.0 0.0 0.0 0.0 0.0 0.1 Skin rash/Mashipishi 1.3 2.3 1.7 1.0 2.0 4.1 1.9 2.0 Measles 0.0 0.7 0.3 1.6 1.3 0.0 0.0 0.6 Diarrhoea 0.0 0.7 2.0 1.9 1.0 5.5 2.3 1.9 Chest in drawing 0.0 0.0 0.3 0.0 0.0 0.0 0.0 0.1 Problem in ear 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Others 0.7 1.0 2.0 0.3 1.7 2.4 0.3 1.2
Multiple answers were accepted
Table 7.6.3 shows about 43 percent of women reported having any type or more than one complication with their newborns during the neonatal period (within 28 days of life). Among them around 21 percent reported having one complication, while 4 percent had two complications and about 7 percent reported that their newborns had developed more than two complications.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 7.6.3: Percent distribution of number of danger signs reported during 1st month of life of newborns by upazila.
AREA N No Complication 1 Complication 2 Complication ≥3 Complication
Balaganj 303 63.0 21.5 9.9 5.6 Bishwanath 300 64.0 18.3 12.3 5.3 Companiganj 301 52.8 20.3 17.6 9.3 Fenchuganj 314 56.4 19.8 14.3 9.6 Golapganj 302 56.6 22.9 15.9 4.6 Gowainghat 290 51.0 21.4 16.6 11.0 Jaintapur 311 56.6 23.8 13.5 6.1 Total: 2,121 57.2 21.1 4.3 7.4
Table 7.6.4 shows the distribution of health care providers among mothers whose babies had a complication and who sought care. Around 52 percent reported sought care from an MBBS doctor while 25 percent sought care from village doctors. 20 percent mothers reported sought care from homeopaths and 3 percent from Kabiraj/fakir in the intervention areas.
Table 7.6.4: Newborns (within 28 days of birth) had complications and sought care, percent distribution of heath care provider by upazila.
Provider
Balaganj N=110 Biswanath N=107 Companiganj N=135 Fenchuganj N=134 Golapganj N=129 Gowainghat N=139 Jaintapur N=128 Total N=882 MBBS doctor 60.9 59.8 46.7 70.9 56.6 25.9 46.1 51.8 Nurse/midwife 3.6 1.9 0.0 0.0 2.3 0.7 0.8 1.3 Paramedic 0.0 0.0 0.0 0.8 0.0 0.7 0.0 0.2 FWV 0.0 0.9 0.0 0.8 0.8 1.4 2.3 0.9 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.8 0.0 0.0 0.1 ACCESS Counselor 0.0 0.0 0.0 0.0 0.8 0.0 0.0 0.1 HA 0.0 0.0 0.7 0.0 0.0 0.7 1.6 0.5 FWA 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 TTBA 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 Homeopath 10.9 13.1 23.7 17.2 20.9 32.4 21.1 20.4 Ayurved 0.0 0.0 0.0 0.8 0.8 0.0 0.0 0.3 Quack 3.6 0.9 1.5 0.8 1.6 2.9 0.0 1.6 Village doctor 23.6 29.0 27.4 13.4 17.8 39.6 27.3 25.5 Spiritual person/Kabiraj 3.6 1.9 2.2 0.8 2.3 3.6 5.5 2.8 Pharmacy 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 Neighbor/Friend 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 0.0 Other 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Multiple answers were accepted
Around 71 percent of women in Fenchuganj reported sought care from a MBBS doctor for the complications of their babies, while it was only 26 percent in Gowainghat. Around 40 percent women
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010 sought care for their newborns from a village doctor in Gowainghat while it was only 13 percent in Fenchuganj. 32 percent women in Gowainghat sought care from a homeopath doctor while it was 11 percent in Balaganj.
Table 7.6.5 shows the distribution of sites / places where women sought care for their sick newborns; 43 percent women reported sought care from a pharmacy, 32 percent from chamber of MBBS doctor, 8 percent from UHC, 7 percent from private clinics, 6 percent from hospital and 8 percent reported seeking care at home. Only 1 percent women reported sought care from FWC for their sick newborns. Around 40 percent women from Balaganj, Biswanath, Fenchuganj and Golapganj reported sought care for their sick newborns from MBBS doctor while the rate was only 13 percent in Gowainghat. Seeking care from UHC was high in Companiganj (16 percent), Fenchuganj (14 percent) and Jaintapur (11 percent) while it was less than 1 percent in Biswanath. More than half of all women sought care from a pharmacy in the Companiganj, Goainghat and Jaintapur upazilas.
Table 7.6.5: Percent distribution of sites from where a woman sought medical care for the sick newborn by upazila.
Facility/Site
aganj Bal N=110 Biswanath N=107 Companiganj N=135 Fenchuganj N=134 Golapganj N=129 Gowainghat N=139 Jaintapur N=128 Total N=882 At home 7.3 6.5 4.4 6.7 9.3 14.4 5.5 7.8 Satellite clinic 0.0 0.0 0.7 0.0 0.0 0.0 0.0 0.1 FWC 0.0 0.0 0.0 0.0 0.0 2.9 3.9 1.0 UHC 3.6 0.9 16.3 14.2 3.9 3.6 10.9 7.9 Chamber of MBBS doctor 39.1 43.0 24.4 42.5 41.1 13.0 24.2 31.9 Clinic 8.2 11.2 3.7 6.7 4.7 6.5 7.0 6.7 Community clinic 0.0 0.0 0.0 0.0 0.0 0.0 1.6 0.2 Hospital 4.6 6.5 3.7 6.0 8.5 5.0 6.3 5.8 Pharmacy 34.6 37.4 51.1 28.4 34.1 62.6 46.9 42.6 Other 1.8 0.0 0.0 0.0 0.0 0.0 0.8 0.3
Note: Multiple answers were accepted
Table 7.6.6 shows around 92 percent women reported that their sick newborns were referred by different agents / health care providers among the newborns who had a complication. Majority of cases (88 percent) were referred by family members, 4 percent by ACCESS counselor or MaMoni health worker, 15 percent by their relatives, 5 percent by neighbors or friends and 2 percent by village doctors. Around 5 percent sick newborns were referred by AC/MaMoni HW in Fenchuganj, Golapganj and Jaintapur upazilas.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 7.6.6: Percent of newborns who had a danger sign and were referred by an ACCESS Counselor by upazila.
Multiple responses were accepted
AREA N=
Total referred AC / MaMoni health worker Family members Relatives Neighbors/ friends TBA TTBA doctor Village Others Balaganj 112 98.2 0.9 95.5 10.0 2.7 0.0 0.9 0.0 0.0 Bishwanath 108 95.4 1.9 92.2 20.4 1.9 0.0 0.0 1.0 1.0 Companiganj 142 95.8 3.7 90.4 15.4 2.9 0.0 0.0 0.0 1.5 Fenchuganj 137 97.8 4.5 92.5 14.2 2.2 0.0 0.0 0.0 0.0 Golapganj 131 97.0 4.7 89.0 13.4 3.9 0.8 0.8 2.4 1.6 Gowainghat 142 88.0 3.2 76.8 12.8 15.2 0.8 0.8 7.2 0.0 Jaintapur 135 73.3 6.1 77.8 16.2 5.1 1.0 1.0 1.0 0.0 Total: 907 92.0 3.6 87.9 14.5 4.9 0.4 0.5 1.7 0.6
Table 7.6.7 below explains the reason for not seeking care for newborn illness. Number of not seeking care was very low. Among them, about 60 percent of women did not know that it was necessary to go to the doctor while 24 percent found it too expensive. Unawareness of the necessity of going to the doctor was 100% in Balaganj and Biswanath while it was as low as 29% in Companiganj.
Table 7.6.7: Reason of not seeking care for newborn illness by upazila.
Facility/Site
Balaganj N=2 Biswanath N=1 Companiganj N=7 Fenchuganj N=3 Golapganj N=2 Gowainghat N=3 Jaintapur N=7 Total N=25 Too far 0.0 0.0 0.0 0.0 50.0 0.0 0.0 4.0 Service hour is inconvenient 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Unpleasant behavior of the service provider 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Lack of skill of the service provider 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 Inadequate drug 0.0 0.0 0.0 0.0 0.0 0.0 14.3 4.0 Have to wait for a long time 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Too expensive 0.0 100.0 28.6 33.3 0.0 33.3 14.3 24.0 Religious reasons 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Not beneficial 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 there 100.0 100.0 28.6 66.7 50.0 66.7 71.4 60.0 Could not/Did not get permission 0.0 0.0 14.3 0.0 0.0 0.0 0.0 4.0 Did not know that it has health care facility 0.0 0.0 0.0 0.0 0.0 0.0 14.3 4.0 Others 0.0 0.0 28.6 0.0 0.0 0.0 14.3 12.0
Multiple responses were accepted
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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.
Area N < 2 ≥ 2 Soon / Cannot be No desire for Other Don’t years years Just pregnant child know % % % % % % % % Balaganj 329 0.6 34.0 6.1 2.4 54.7 1.5 0.6 Bishwanath 330 0.9 42.1 6.4 1.2 47.9 0.0 1.5 Companiganj 328 0.3 45.4 9.2 0.3 43.3 0.3 1.2 Fenchuganj 330 0.6 49.7 2.4 0.6 45.8 0.6 0.3 Golapganj 330 0.9 45.3 3.6 0.3 48.5 0.6 0.9 Gowainghat 310 1.9 43.6 6.5 0.0 46.8 0.3 1.0 Jaintapur 326 1.2 42.3 9.2 0.6 44.8 0.0 1.8 Total: 2,283 0.9 43.2 6.2 0.8 47.4 0.5 1.1
Table 8.1.1 shows that around 47 percent of women had no desire for another child and about 43 percent of women desired to have their next child at least 24 months apart. Almost 7 percent of women desired their next child within a short time (less than 24 months) while 9 percent desired a child within a short time (less than 24 months) in Companiganj and Jaintapur. Around 55 percent of women in Balaganj had no desire for a next child, while it was 43 percent in Companiganj.
Table 8.1.2 shows that birth intervals were generally long in all upazilas. More than 70 percent of women in the intervention areas actually delayed their pregnancies for at least 2 years. There was no significant variation in birth intervals across the upazilas except Fenchuganj where 82 percent women actually delayed their next pregnancy. There was no variation by level of maternal education, but significant variations were observed by maternal age. Younger women were less likely to delay pregnancy (34 percent) while around 88 percent women of 40+ age delayed their next pregnancies for at least 2 years. Similarly, two-thirds of women with low parity (1) had a tendency to go for pregnancy sooner (less than 2 years), while it was much lower among women with higher parities (3 or more).
Around three-fourths of all women (excluding women having their first pregnancy) actually delayed their next pregnancy for at least two years irrespective of categories of wealth quintile.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 8.1.2: Percentage of women whose recent pregnancies were actually delayed for at least two years by upazila and by background characteristics. (Denominator is the number of women who had at least 2 births)
N=1733 Pregnancy delayed for at least 2 years Balaganj 271 76.4 Bishwanath 240 72.1 Companiganj 263 72.6 Fenchuganj 228 81.6 Golapganj 231 71.4 Gowainghat 243 71.6 Jaintapur 257 76.3 Maternal education No education 667 75.6 Primary 343 74.6 Class 5-9 660 72.7 Class 10+ 63 82.5 Maternal age <20 87 34.5 20 – 24 559 65.8 25 – 29 554 81.6 30 – 34 333 83.2 35 – 39 159 81.1 40 + 41 87.8 Birth order (Parity):= 0 4 25.0 1 77 36.4 2 533 72.1 3 346 77.5 4 287 78.4 5+ 486 79.4 Wealth Quintile Lowest 400 75.8 Second 359 75.2 Middle 342 74.0 Fourth 317 69.4 Highest 315 78.1
8.2 Family Planning:
Table 8.2.1 shows that around 70% women did not use any contraceptive method during the first six months after delivery in the study areas. The pill continues to be by far the most popular method of contraception after delivery and around 12% reported using this method; injection users constituted 6% while 4% relied on condoms and around 5% of women used the traditional method of periodic abstinence (safe day).
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 8.2.1: Percent distribution of women used any family planning method during first six months after delivery by upazila, Sylhet.
Contraceptive methods
Balaganj 329 N= Biswanath N= 330 Companiganj 328 N= Fenchuganj 330 N= Golapganj 330 N= Gowainghat 310 N= Jaintapur 326 N= Total 2283 N= Did not use any method 71.7 65.5 81.1 66.7 53.9 71.9 74.2 69.3 Female Sterilization 2.7 1.5 1.8 2.4 2.7 1.0 0.9 1.9 Male Sterilization 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Pill 11.3 17.9 6.1 11.8 15.8 11.6 12.0 12.4 IUD 0.3 0.3 0.3 0.6 0.3 0.0 0.0 0.3 Injection 6.1 7.0 4.6 7.0 6.4 4.2 7.7 6.1 Implant 0.9 0.9 0.3 0.0 0.3 0.0 0.0 0.4 Condom 2.7 3.6 0.9 3.6 12.4 4.5 1.5 4.2 Safe Day 4.3 2.7 4.6 7.3 7.6 5.8 3.4 5.1 Withdrawal 0.0 0.3 0.3 0.3 0.3 1.0 0.3 0.4 LAM 0.0 0.0 0.0 0.3 0.3 0.0 0.0 0.1 Others 0.0 0.3 0.0 0.0 0.0 0.0 0.0 0.0 Did not mention anything 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Current contraception use among recently delivered women aged 15 to 49 years has presented in Table 8.2.2. Around one-third of women were using any method of contraception during the time of interview in the intervention upazilas. 3 percent women reported being pregnant during the time of the interview and 1 percent of women reported being either widowed or separated.
Use of pill among women living in the intervention areas decreased 10 percent points from baseline 2007. 47 percent of women were using pill during the baseline and 37 percent in the midline. Female sterilization increased from 4 percent in baseline to 6 percent in midline. There was no change on the use of the injectables between baseline and midline (around 22 percent). Use of condoms has increased from 8 percent in baseline to 12 percent in midline. The safe day method (periodic abstinence) was used by 16 percent of women during baseline, which has increased to 19 percent in the midline survey.
There was no remarkable change between baseline and midline data in the choice of sources of contraception. Around 50 percent of women collected their contraceptive methods from a pharmacy, 10 percent from FWC, 11 percent from UHC and about 10 percent from satellite and NGO clinics.
Table 8.2.2: Percent distribution of women currently using contraceptive methods by ACCESS baseline and MaMoni mid-line survey by method and source of collection of method
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Contraceptive methods ACCESS baseline 2007 MaMoni survey 2010 N=19,566 N=2283 number % number % Using any method 5,947 30.4 847 37.1 Did not use any method 11,299 57.8 1360 59.6 Currently Pregnant 2,189 11.2 63 2.8 Widowed/ Separated 131 0.7 13 0.6 Name of the method Female Sterilization 269 4.5 52 6.1 Male Sterilization 46 0.8 0 0.0 Pill 2,813 47.3 313 37.0 IUD 52 0.9 8 0.9 Injection 1,237 20.8 184 21.7 Implant 53 0.9 10 1.2 Condom 490 8.2 104 12.3 Safe Day 932 15.7 162 19.1 Withdrawal 37 0.6 11 1.3 LAM 0 0.0 2 0.2 Others 18 0.3 1 0.1 Sources of receiving Contraceptive methods Hospital 256 5.1 14 2.1 FWC 609 12.2 67 10.0 UHC 455 9.1 76 11.3 Satellite Clinic 150 3.0 50 7.4 MCWC 24 0.5 0 0.0 FWA 423 8.5 81 12.1 Community Clinic 15 0.3 9 1.3 Other Govt Centre 7 0.1 0 0.0 NGO Clinic 100 2.0 18 2.7 NGO Satellite Clinic 40 0.8 9 1.3 NGO Depot Holder 24 0.5 4 0.6 NGO FW 56 1.1 9 1.3 NGO Other 1 0.0 0 0.0 Private Clinic 82 1.7 7 1.0 MBBS Doctor 40 0.8 2 0.3 Quack 27 0.5 0 0.0 Pharmacy 2,508 50.4 321 47.8 Shop 137 2.8 1 0.2 Friends/Relatives 14 0.3 4 0.6 Others 10 0.2 0 0.0
Table 8.2.3 shows the distribution of use of contraceptive methods by weeks during 6 weeks of postpartum. Only 14 percent women reported using a contraceptive method during the first six weeks after delivery. Among those women, only 6.3 percent reported using contraception within 1 week of postpartum and 84 percent women were using contraception during 5-6 week of postpartum; the remaining women reported beginning the use of contraception between 2-5 weeks postpartum.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table: 8.2.3: Percentage of women accepted a contraceptive method within 6 weeks of postpartum by method and by selected demographic and socio-economic characteristics in Sylhet.
N=
ection Not use Female sterilization Male sterilization Pill IUD Inj Implants Condom Periodic abstinence With drawl LAM Other Total used 316 0.0 8.2 0.0 39.2 0.3 20.6 1.0 12.4 16.1 1.6 0.3 0.3 Within 1 week 20 0.0 95.0 0.0 5.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Week-1 3 0.0 33.3 0.0 33.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 33.3 Week-2 4 0.0 25.0 0.0 25.0 0.0 0.0 0.0 50.0 0.0 0.0 0.0 0.0 Week-3 5 0.0 20.0 0.0 40.0 0.0 20.0 0.0 20.0 0.0 0.0 0.0 0.0 Week-4 19 0.0 10.5 0.0 52.6 0.0 15.8 0.0 5.3 15.8 0.0 0.0 0.0 Week-5 109 0.0 0.9 0.0 36.7 0.0 23.9 0.9 13.8 21.1 1.8 0.9 0.0 Week-6 156 0.0 0.6 0.0 44.2 0.6 22.4 1.3 12.8 16.0 1.9 0.0 0.0 Total status within 6 2,283 86.2 1.1 0.0 5.4 0.1 2.9 0.1 1.7 2.2 0.2 0.1 0.1 week Maternal education No education 743 76.5 2.2 0.0 7.7 0.3 6.3 0.1 0.9 5.5 0.3 0.1 0.1 Primary 431 71.5 1.9 0.0 13.7 0.2 5.6 0.2 2.3 4.4 0.2 0.0 0.0 Class 5-9 995 65.7 1.6 0.0 14.3 0.3 6.6 0.6 5.4 4.9 0.5 0.0 0.0 Class 10+ 114 44.7 2.6 0.0 21.1 0.0 2.6 0.0 21.9 6.1 0.0 0.9 0.0 Maternal age <20 279 68.1 0.0 0.0 13.3 0.0 9.3 0.4 2.9 5.0 1.1 0.0 0.0 20 – 24 863 67.8 0.7 0.0 13.7 0.7 5.8 0.7 5.2 5.1 0.4 0.0 0.0 25 – 29 604 70.2 2.5 0.0 12.6 0.0 5.3 0.2 4.1 4.8 0.3 0.0 0.0 30 – 34 337 73.9 3.3 0.0 8.9 0.0 5.9 0.0 3.3 3.9 0.0 0.6 0.3 35 – 39 159 64.8 5.7 0.0 10.7 0.0 6.3 0.0 3.8 8.8 0.0 0.0 0.0 40 + 41 73.2 4.9 0.0 9.8 0.0 4.9 0.0 2.4 4.9 0.0 0.0 0.0 Birth order 0 34 91.2 0.0 0.0 5.9 0.0 0.0 0.0 2.9 0.0 0.0 0.0 0.0 1 583 66.2 0.2 0.0 13.2 0.5 6.5 0.3 6.2 6.4 0.5 0.0 0.0 2 545 62.0 0.0 0.0 16.5 0.6 7.5 0.7 6.8 5.1 0.7 0.0 0.0 3 347 72.9 4.3 0.0 9.5 0.0 5.5 0.3 2.9 4.0 0.3 0.3 0.0 4 288 74.7 3.5 0.0 11.1 0.0 4.9 0.0 1.4 4.5 0.0 0.0 0.0 5+ 486 73.7 3.5 0.0 9.9 0.0 5.8 0.2 1.7 4.9 0.0 0.2 0.2 Wealth Quintile Lowest 457 81.2 1.8 0.0 6.6 0.4 4.8 0.2 0.4 4.4 0.0 0.2 0.0 Second 457 75.7 1.3 0.0 9.4 0.2 6.8 0.4 0.7 5.0 0.2 0.0 0.2 Middle 456 66.2 2.6 0.0 14.0 0.2 7.9 0.0 3.7 4.6 0.7 0.0 0.0 Fourth 457 63.7 1.3 0.0 16.6 0.4 6.6 0.9 4.2 6.1 0.2 0.0 0.0 Highest 456 59.4 2.4 0.0 15.1 0.0 4.6 0.2 12.1 5.3 0.7 0.2 0.0
Among the women who used any kind of contraceptive method within one week of birth, 95 percent women selected for female sterilization while the remaining 5 percent chose pills. Around 40 percent of women reported using pills during the subsequent weeks (week 4-6), 5-12 percent selected condoms as a contraceptive method and 16-24 percent injections.
Maternal age was related with the selection of female sterilization as a method of contraception. Use of female sterilization was nil among women of less than 20 years of age, 0.7 percent among women 20-24 years and between 2-6 percent among women of less than 30 years of age. Similarly the percentage of pill users was greater in younger mothers (14 percent), while around 10 percent among women of more
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
than 40 years of age. Condom use was more or less similar across all age groups (2-5 percent). The injection method and periodic abstinence showed no remarkable difference across age groups of women. The combined pill was more popular among lower and higher parity groups. Female sterilization on the other hand was used more by women with higher parity (3+). There was no significant difference in the selection of contraceptive method by level of wealth quintile: In total 14-16 percent of women selected pill across the three highest wealth quintiles. 5-8 percent of women used injection in all the groups, In terms of using condom, 12 percent women belonging to the higher wealth quintiles reported its use, while condom’s use was less than 1 percent among women having poorer socio-economic conditions.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Chapter-9: Community Action Group (CAG)
(Analysis has been done only for villages where CAG implemented) Community mobilization is one of the major components of the study. 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.
AREA N Mothers aware about CAG Member of CAG Balaganj 261 0.0 0.0 Bishwanath 229 0.4 0.0 Companiganj 108 2.8 33.3 Fenchuganj 253 1.2 0.0 Golapganj 206 0.5 100.0 Gowainghat 209 4.3 0.0 Jaintapur 132 3.8 60.0 Total: 1,398 22(1.6) 5(22.7)
Table 9.1.1 shows that only 1.6 percent women in the intervention areas reported aware of community action group (CAG) and among them around 23 percent reported having membership of CAG. There was no woman reported aware of CAG in Balaganj upazila while it was around 4 percent in Gowainghat and Jaintapur upazilas. Women who reported aware of CAG, 100 percent of them were the member of CAG in Golapganj, 60 percent in Jaintapur and 33 percent in Companiganj. There was no woman reported as member of CAG in the Balaganj, Biswanath, Fenchuganj and Gowainghat upazilas.
Table 9.1.2: Percentage of women reported aware of activities of the community action group by upazila. Multiple answers were accepted
N
’s health
Mother health Newborn’s planning Family Education sick Transporting mother newborn & sick Financing mother newborn & Others know Don’t Balaganj 0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Bishwanath 1 100.0 100.0 0.0 0.0 0.0 0.0 0.0 0.0 Companiganj 3 66.7 33.3 33.3 33.3 0.0 0.0 0.0 0.0 Fenchuganj 3 33.3 33.3 0.0 0.0 100.0 66.7 0.0 0.0 Golapganj 1 0.0 0.0 0.0 100.0 100.0 100.0 0.0 0.0 Gowainghat 9 55.6 66.7 0.0 0.0 0.0 0.0 0.0 33.3 Jaintapur 5 80.0 80.0 80.0 0.0 20.0 20.0 0.0 0.0 Total: 22 59.1 59.1 22.7 9.1 22.7 18.2 0.0 13.6 Table 9.1.2 shows the distribution of different activities of CAG among the women who were aware of community action group. Most of the women (around 60 percent) could tell about maternal and newborn health. 23 percent women who were aware of CAG could tell about family planning and emergency transportation of sick mother and newborn to a health facility. 18 percent of them mentioned about
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emergency financing for necessary treatment and 14 percent could not mention anything. There were variations of awareness of different activities of CAG by upazilla. Higher proportion of women in Bishwanath, Companiganj, Fenchuganj and Gowainghat were aware of “mother and newborn health” while women in Golapganj were aware of education, emergency transportation and emergency financing for sick mother and newborn.
Table 9.1.3: Percentage of women had postpartum complication or the newborn complication, used emergency transport or benefited financing from CAG by intervention upazila of Sylhet
Had postpartum or Used transport facility Got financial benefit newborn from CAG from CAG complication (N)
Balaganj 119 0.0 0.0 Bishwanath 114 0.0 0.0 Companiganj 69 0.0 0.0 Fenchuganj 131 0.0 0.0 Golapganj 124 0.0 0.0 Gowainghat 153 0.0 0.0 Jaintapur 67 0.0 0.0 Total 777 0.0 0.0
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. None reported to accrue any benefit from CAG.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Chapter 10: Hand washing
Studies show that hand washing could also help to reduce respiratory problems by 25 percent, (UNICEF and WHO). Despite considerable achievement in water and sanitation, hygiene and behavioural practice is lagging behind. Inadequate handwashing can cause transmission of enteric diseases. The intervention related to handwashing in this study mostly involved counseling related activities. The following tables elaborate the situation of handwashing among women in the intervention upazilas of Sylhet.
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.
Washed with N= Not wash Only water Ash Soap Earth Others Not prepare any food Balaganj 329 20.4 70.2 1.2 7.6 0.0 0.0 0.6 Bishwanath 330 19.7 61.5 0.0 17.9 0.0 0.0 0.9 Companiganj 328 11.3 70.1 0.9 15.6 0.0 0.0 2.1 Fenchuganj 330 4.6 70.6 0.3 23.9 0.0 0.0 0.6 Golapganj 330 13.0 55.5 0.9 30.0 0.0 0.0 0.6 Gowainghat 310 17.7 51.3 0.7 28.7 0.0 0.3 1.3 Jaintapur 326 6.4 56.1 0.3 36.5 0.0 0.0 0.6 Total: 2,283 13.3 62.3 0.6 22.8 0.0 0.0 1.0
Table 10.1.1 shows practice of hand washing by type of material used before preparing food. 86 percent of women interviewed in the survey, reported washed their hands before preparing any food. Practice of hand washing using materials shows that almost two-thirds women (62 percent) washed their hands with only water, 23 percent used soap to wash their hands and less than 1 percent mentioned that they washed hands with ash. 1 percent women reported that they did not prepare any food. The highest percentage of soap users were from Jaintapur (37 percent), followed by Golapganj (30 percent) and Gowainghat (29 percent).
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 upazila.
N= Only Ash Soap Earth Others Not wash hand water before taking meal
Balaganj 329 94.5 0.3 4.6 0.3 0.0 0.3 Bishwanath 330 82.7 0.0 16.1 0.3 0.0 0.9 Companiganj 328 83.5 0.3 15.6 0.0 0.0 0.6 Fenchuganj 330 80.6 0.3 17.9 0.0 0.0 1.2 Golapganj 330 77.6 0.0 21.8 0.0 0.0 0.6 Gowainghat 310 80.3 0.3 16.8 0.0 0.0 2.6 Jaintapur 326 81.0 0.6 17.5 0.3 0.0 0.6 Total: 2,283 82.9 0.3 15.7 0.1 0.0 1.0
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 10.1.2 shows that 83 percent women washed their hands with water only before taking their last meal before the interview had taken place. 16 percent of women reported washed their hands with soap before taking their meal. Rate of washing hand with ash was very low (less than 1 percent) across the upazilas. Almost 22 percent women of Golapganj reported washed their hands with soap while it was only 5 percent in Balaganj and around 17 percent in Gowainghat and Jaintapur. Around 1 percent women did not wash their hands before taking their meal and the rate was 3 percent in Gowainghat.
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. (Taken live-birth in the last outcome)
Washed hand with N= Not wash Only Ash Soap Earth Others Not fed baby by their own water hand/ refuse to gave answer Balaganj 303 5.9 80.9 0.7 10.6 0.0 0.0 2.0 Bishwanath 300 4.3 73.7 0.0 18.0 0.0 0.0 4.0 Companiganj 301 12.0 74.1 0.7 11.0 0.7 0.0 1.7 Fenchuganj 314 8.0 69.8 0.0 18.5 0.0 0.0 3.8 Golapganj 302 5.0 63.3 0.0 28.5 0.3 0.0 3.0 Gowainghat 290 13.1 65.2 0.7 14.8 0.0 0.0 6.2 Jaintapur 311 3.9 76.5 1.0 16.4 0.0 0.0 2.3 Total: 2,121 7.4 72.0 0.4 16.8 0.1 0.0 3.3
Table 10.1.3 shows hand washing practice among recently delivered women those had live-births and the child was still alive at the time of interview. Around 7 percent women did not wash their hands before feeding their children and 3.3 percent did not feed their children by their hands or refused to give answer. Almost three-fourths women (72 percent) reported washed their hands with only water before feed their children and 17 percent with soap. The rate of using soap was high in Golapganj (29 percent) and low in Balaganj and Companiganj (around 11 percent). Less than 1 percent women reported washed their hands with ash in Balagnaj, Companiganj, Gowainghat and jaintapur. There was no women reported washed their hands with ash in Biswanath, Fenchuganj and Golapganj upazilas.
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 upazila. (Last outcome was live-birth)
Washed hands with N= Not wash Only Ash Soap Earth Others Not clean child’s anus/ water refuse to gave answer Balaganj 303 0.7 37.3 0.3 57.4 3.3 0.0 1.0 Bishwanath 300 0.7 37.3 0.3 58.7 2.3 0.0 0.7 Companiganj 301 2.7 44.5 0.7 46.8 4.3 0.0 1.0 Fenchuganj 314 0.3 24.5 0.3 71.0 2.6 0.0 1.3 Golapganj 302 1.3 16.9 0.7 75.5 4.3 0.0 1.3 Gowainghat 290 3.5 27.2 2.1 61.4 2.8 0.3 2.8 Jaintapur 311 1.3 37.3 0.6 57.2 1.6 0.0 1.9 Total: 2,121 1.5 32.2 0.7 61.2 3.0 0.1 1.4
Table 10.1.4 shows that around 98 percent women reported washed their hands after cleaning their child’s anus. 61 percent women washed their hands with soap, 32 percent with only water and 3 percent with earth. More than 70 percent women washed their hands with soap in Fenchuganj and Golapganj upazilas while it was less than 50 percent in Companiganj.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 10.1.5: Percentage of recently delivered women reported washed their hands after defecations by upazila.
N= Percentage of women reported washed their hands after defecations Balaganj 329 99.4 Bishwanath 330 100.0 Companiganj 328 99.4 Fenchuganj 330 98.5 Golapganj 330 100.0 Gowainghat 310 99.0 Jaintapur 326 98.8 Total: 2,283 99.3
Table 10.1.5 shows almost all women (more than 99 percent) washed their hands after defecation and the rate was almost similar across the upazilas.
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.
N= Percentage of women reported washed their hands by soap at least 3 times a day Upazila Balaganj 329 97.6 Bishwanath 330 99.4 Companiganj 328 99.7 Fenchuganj 330 95.5 Golapganj 330 98.2 Gowainghat 310 97.7 Jaintapur 326 95.7 Maternal education No education 743 96.4 Primary 431 97.0 Class 5-9 995 98.7 Class 10+ 114 100.0 Maternal age <20 279 97.9 20 – 24 863 98.8 25 – 29 604 97.5 30 – 34 337 96.4 35 – 39 159 95.6 40 + 41 92.7 Birth order 0 34 100.0 1 583 98.8 2 545 98.9 3 347 98.9 4 288 96.9 5 + 486 94.4 Wealth Quintile Lowest 457 96.1 Second 457 97.6 Middle 456 97.2 Fourth 457 98.5 Highest 456 99.1
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 10.1.6 shows that almost all women in the intervention upazilas washed their hands by soap at least 3 times in last 24 hours before the interview was held and the rate was similar across the upazilas. There were no variations in practicing hand washing with soap by level of education of the women, age, parity and socio-economic status of the household.
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.
Provider
2,283 329 330 328 330 330 310 326
= Balaganj N= Biswanath N= Companiganj N= Fenchuganj N= Golapganj N= Gowainghat N= Jaintapur N= Total N Use any soap within 24 hour 99.1 99.7 97.9 99.4 99.4 99.7 99.4 99.2 Washing cloths 69.9 78.8 64.3 70.3 68.8 55.5 72.4 68.7 Bathing herself 90.6 91.2 91.8 87.6 90.0 86.1 87.1 89.2 Bathing child 41.0 43.6 59.8 60.6 39.7 32.6 58.9 48.1 Washing child’s hand 3.7 1.5 4.0 7.9 5.8 1.6 3.1 3.9 Washing child’s anus 33.4 27.0 36.6 47.9 46.7 33.9 43.6 38.5 Washing hands after defecation 36.5 29.7 36.3 59.1 57.3 40.0 42.3 43.1 Washing hands after handling cow-dung 3.7 1.8 1.5 0.6 4.2 7.1 4.3 3.3 Washing hands before feeding child 0.6 1.5 3.7 1.8 9.4 4.5 6.4 4.0 Washing hands before preparing food 1.5 3.3 3.1 5.2 10.9 6.8 9.8 5.8 Washing hands before meal 0.6 3.0 2.7 3.0 7.9 4.8 5.8 4.0 Washing hands after meal 0.9 1.2 0.3 0.9 3.6 1.6 2.8 1.6 Others 1.8 8.2 1.8 2.7 10.9 14.2 2.2 5.9
Table 10.1.7 shows 99 percent women reported washed their hands with soap in the last 24 hours before the interview was held. It is very interesting that around 90 percent women reported used soap during bathing herself while it was 48 percent when they bathed their children. The rate of hand washing before bathe their children was more (around 60 percent) in Companiganj, Fenchuganj and Jaintapur. Around 40 percent women reported washed their hands with soap after defecation or washing child’s anus. Only 3 percent women reported washed their hands with soap after handling cow-dung, perhaps the rate was low because the survey did not check that how many of the women used to handle cow-dung. Only 4 percent women reported washed their hands with soap before meal and 2 percent after meal and the rates were similar across the upazilas. 6 percent women reported washed their hands with soap before preparing food and the rate was high (around 10 percent) in Golapganj and Jaintapur upazilas.
Table 10.1.8: Percentage of households had soap/detergent/other cleansing material at home observed during the time of interview by upazila.
N Soap Detergent Ash Earth/sand Others Balaganj 329 98.2 51.7 7.3 0.0 1.5 Bishwanath 330 98.2 58.8 11.5 0.0 0.9 Companiganj 328 98.5 42.1 15.9 0.3 0.0 Fenchuganj 330 96.1 54.9 0.9 0.0 3.9 Golapganj 330 93.9 40.6 0.9 0.3 0.9 Gowainghat 310 85.8 26.1 2.9 0.3 2.3 Jaintapur 326 97.6 43.6 6.4 0.3 0.0 Total: 2,283 95.5 45.6 6.6 0.2 1.4
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Table 10.1.8 depicts the type of cleansing materials that households possessed which was observed during the time of interview. Around 96 percent of the households had soap and the rate was almost similar across the upazilas except Gowainghat (86 percent). 46 percent households had detergent and 7 percent had ash for hand washing purposes.
Table 10.1.9 below on the other hand shows the stock of additional soap available in the households at the time of interview. About 32 percent of the households had a stock of soap. The maximum number of households in Golapganj had a stock of soap (45 percent) while it was lowest in Companiganj (20 percent)
Table 10.1.9: Percentage of household was able to show stock of additional soap during the interview by upazila.
N= Percentage of household had a stock of soap
Balaganj 329 29.8 Bishwanath 330 30.3 Companiganj 328 20.4 Fenchuganj 330 43.6 Golapganj 330 45.2 Gowainghat 310 27.1 Jaintapur 326 28.5 Total: 2283 32.2
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Chapter 11: Discussion
The midline survey aims to assess the changes in (1) knowledge of maternal and neonatal health care; (2) maternal health care practices, including antenatal, delivery, and post-partum care; (3) care seeking for maternal complications; (4) newborn care practices including care seeking for complications in the seven intervention upazilas of Sylhet. 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. Midline data were compared with ACCESS baseline data of seven intervention upazilas of Sylhet. However, the comparison of project findings should be treated with caution due to differences in survey methodology and sampling.
Following table 11.1 has shown the differences of data on important variables between ACCESS baseline-2007 and MaMoni midline-2010 surveys:
Table: 11.1 Important Variable Baseline Midline Status Comment 2007 2010 1 Received 4 ANCs from a skilled provider 10% 13% Slight improvement 2 Consumed Iron-folic acid tablet 39% 48% Slight improvement 3 Delivered at health facility 12% 19% Slight improvement a. Among women had no education 5% 8% Slight improvement b. Women primary completed 8% 13% Slight improvement c. Women in class 5-9 18% 25% Slight improvement d. Women completed secondary 47% 64% Significant change 4 Home delivery attended by skilled birth attendant 1.6% 2.4% No marked change 5 Used birth-kit (CDK) in delivery 3% 86% Very significant change 6 PNC within 3 days from skilled provider 1% 16% Significant change 7 Sought care from skilled provider for pregnancy 59% 71% Significant change complication 8 Sought care from skilled provider for delivery complication 36% 56% Significant change 9 Sought care from skilled provider for post-partum 36% 27% Declined complication 10 Dried & wrapped newborn before delivery of placenta 1% 6% Slight improvement 11 Dried & wrapped newborn within 5 minutes 4% 7% Slight improvement 12 Umbilical cord was cut by CDK blade 2% 85% Very significant change 13 Applied substance/chemical to umbilical stump 66% 25% Positive change 14 Commencement of breast-feeding within 1 hour of birth 73% 88% Significant change 15 Bathed newborn within 3 days of birth 95% 57% Marked positive change 16 Received 2 PNCs for newborn from a skilled provider 80% 98% Significant change 17 Sought care from a skilled provider for sick newborn 44% 52% Slight improvement 18 Pregnancy actually delayed for 2 years 70% 70% No change 19 Using any contraceptive during post-partum period 30% 37% Slight improvement
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Chapter-12: Appendix Appendix: A (RDW listing form)
Form-2 Searching and identification of Recently Delivered Women (RDW)
Name of upazila: Name of union: Name of village:
Cluster # |____|____|____|____| Name of the house/Bari: Address and location of the house:
House # |____|____|____|
Name of household Identified Name of RDW Husband’s name of Comment head RDW RDW please () tick Serial # of Household Yes No
Note: Use one form for each house (Bari), Use extra sheet if needed MaMoni survey_Sylhet_sample selection_RDW_Form-2_August 03, 2010
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Appendix: B (List of indicators for evaluation)
List of ACCESS / MaMoni Indicators by section, Sylhet (Midline Evaluation)
Reproduction and Birth history: 1 Percent of recent mothers who want to delay their next pregnancy for at least 2 years. 2 Percent of recent mothers whose recent pregnancy were delayed for at least 2 years 3 Percent of recent mothers who accepted a contraceptive method by 6 weeks postpartum. 4 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. 5 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). 6 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: 7 Percent of recent mothers who can cite the key components of birth plans. 8 Percent of recent mothers who can cite at least three danger signs of pregnancy 9 Percent of recent mothers who can cite at least three danger signs of childbirth 10 Percent of recent mothers who can cite at least three danger signs postpartum 11 Percent of recent mothers who can cite at least three danger signs in newborn babies 12 Percent of recent mothers who are aware of the existence of a Community Action Group (CAG) in their villages 13 Percent of recent mothers who are aware of the existence of an emergency transport system 14 Percent of recent mothers who are aware of the existence of an emergency financing system Antenatal Care: 15 Percent of recent mothers who reported receiving two TT immunizations during their last pregnancy 16 Percent of newborns were protected from neonatal tetanus 17 Percent of recent mothers who consumed iron/folate tablets during their last pregnancy 18 Percent of recent mothers who received at least four ANC visits from a skilled provider during their last pregnancy by type of provider 19 Percent of recent mothers who reported having developed a danger sign during pregnancy and sought care from a skilled provider by type of provider 20 Percent of recent mothers who reported having received at least two home visits by an ACCESS Counselor/MaMoni HW during their last pregnancy 21 Percent of recent mothers who reported receiving counseling from an ACCESS Counselor on the importance of 4 ANC visits by a skilled provider 22 Percent of recent mothers with a danger sign during pregnancy who were referred by an ACCESS Counselor Delivery: 23 Percent of recent mothers who had a birth plan during their last pregnancy 24 Percent of recent mothers whose birth was attended by a skilled provider by type of provider, by place of delivery 25 Percent of recent mothers who reported having developed a danger sign during childbirth and sought care from a skilled provider by type of provider 26 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 27 Percent of recent mothers who received birth kits from ACCESS Counselor MaMoni HW Immediate Newborn Care: 28 Percent of recent mothers who gave birth at home whose newborns were attended by a Newborn Care Person at birth. 29 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 30 Percent of newborns who were breastfed within the first hour after childbirth 31 Percent of newborns who were exclusively breastfed in the last 24 hours
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
32 Percent of newborns whose first bath was delayed for 3 days 33 Percent of newborns who were delivered at home who were dried and wrapped immediately after birth 34 Percent of newborns who had nothing applied on to their umbilical stump after birth 35 Percent of recent mothers who reported using KMC or skin-to-skin with their newborn for their most recent birth Postpartum: 36 Percent of recent mothers who received a PNC visit within 3 days after childbirth 37 Percent of recent mothers who received at least two PNC visits for themselves from a skilled provider after childbirth by type of provider 38 Percent of recent mothers who received at least two PNC visits for their newborns from a skilled provider after childbirth by type of provider 39 Percent of recent mothers who reported having developed a postpartum danger sign and sought care from a skilled provider by type of provider 40 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 41 Percent of recent mothers who reported receiving counseling from an ACCESS Counselor on the importance of 2 PNC visits 42 Percent of recent mothers who reported receiving home visit by an ACCESS Counselor within 24 hours after childbirth 43 Percent of recent mothers who reported receiving home visit by an ACCESS Counselor within 5-7 days after childbirth 44 Percent of recent mothers with a postpartum danger sign who were referred by an ACCESS Counselor 45 Percent of newborns with a danger sign who were referred by an ACCESS Counselor Community Action Group: 46 Percent of recent mothers who are aware of the existence of a Community Action Group (CAG) in their villages 47 Percent of recent mothers who are members of Community Action Group (CAG) 48 Percent of recent mothers who are aware of the existence of an emergency transport system 49 Percent of recent mothers who experienced a pregnancy-related complication, or whose newborns experienced a complication, who used the emergency transport 50 Percent of recent mothers who are aware of the existence of an emergency financing system 51 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: 52 Percentage of recent mothers who live in households with soap at the place for hand-washing, by background characteristics 53 Percentage of recent mothers who washed their hands with soap at critical times 24 hours prior to the survey
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
Appendix-C: RDW Questionnaire
MaMoni Survey 2010 Questionnaire for Recently Delivered Women (RDW), SYLHET
IDENTIFICATION Name Code District SYLHET 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 07. No recently delivered woman [Pregnncy outcome in the last present at home at the time of HH visit 12 months (1 July 2009 to 30 June 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 |____|____| |____|____|-|____|____|-|____|____|
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B)
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: ______
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 ......
30-49 years ...... Calculate the total number of male and female 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 by your household? A Cow ...... B Buffalo ......
C Goat ......
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 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______Specify Unit______ACRE DECIMALS
(1 KIYAR = 30 DECIMALS)
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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 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) 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 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)
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 ......
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
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 JULY 2009 TO 30 JUNE 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 JULY 2009 TO 30 JUNE 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 JULY 2009 TO 30 JUNE 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 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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 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. 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 Says She Can’t Get Pregnant ...... 94 the birth of (a/another) expecting now, how Don’t want anymore children ...... 95 child? long would you like to Other ______...... 96 wait before the birth (Specify) of another child? Don’t know ...... 97 Now I am going to ask you about your menstruation after your last pregnancy (in between 01 July 2009 to 30 June 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
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
Ask: Anything else? Paramedic ...... C Family Welfare Visitor ...... D Write down all the answers. MA/SACMO ...... E ACCESS Counselor/MaMoni Health Worker ..... F
Health Assistant ...... G Family Welfare Assitant ...... H Other professional: Trained TBA ...... I TBA ...... J
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 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 Do not read responses. Other ______...... X (Specify) 226f Yes ...... 1 Did you receive information and counseling ever in your life about family planning/birth spacing No ...... 2 227 methods, the various ways or methods that a Don’t know ...... 7 227 couple can use to delay or avoid a pregnancy? 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 Record all the responses mentioned. Depo-Provera (Progestin Only) ...... E 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 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)
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 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) 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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Friends/Relatives ...... 42 Other ______96
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 Oedema of the face/swelling ...... E Do not read out the answers. Oedema of the hands/swelling ...... F Convulsions/fits ...... G Excessive Vaginal Bleeding ...... H ASK: Anything else? Severe abdominal pain ...... I Oedema of the legs ...... J Fever...... K Record all the answers. 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 Write down all the answers. Rupture uterus/Cervical tear/Vaginal tear...... H 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 306 Can you tell us what measures or preparations Deciding where to deliver ...... A 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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 314 Now tell me what are the problems / Excessive Vaginal Bleeding ...... A complications or situation that may arise after Foul-Smelling Discharge ...... B delivery for which a woman should seek medical Fever...... C support? Inverted nipples...... D Do not read out the answers. Tetanus ...... E ASK: Anything else? Retained Placenta ...... F Write down all the answers. 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. 315 Now, I would like to ask you a few questions Difficult or fast breathing ...... A about the health of newborn babies. Pneumonia ...... B In your opinion, what are some serious health Cold/cough ...... C problems that can occur during the first 7 days Yellow skin/palm/feet/eye color (jaundice) ...... D after birth that could endanger the life of a Poor sucking or feeding ...... E newborn baby and for which treatment is Pus, bleeding, or discharge from around the required? umbilical cord ...... F Do not read out the answers. Skin lesions or blisters ...... G PROBE: Any others? Convulsions/spasms/rigidity ...... H Write down all the answers. 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 Others ______X (Specify) Don’t know/None mentioned ...... Y 315a What are the problems or symptoms that may Difficult or fast breathing ...... A arise in a newborn within 1 month after birth for Pneumonia ...... B which treatment is required? Cold/cough ...... C Yellow skin/palm/feet/eye color (jaundice) ...... D Do not read out the answers. Poor sucking or feeding ...... E Pus, bleeding, or discharge from around the ASK: Anything else? umbilical cord ...... F Skin lesions or blisters ...... G Write down all the answers. 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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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
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 1 July 2009 to 30 June 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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 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 Do not read out the answers. Paramedic ...... C FWV ...... D ASK: Anything else? Medical Assistant/SACMO ...... E ACCESS Counselor/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...... ACCESS Counselor/MaMoni Health Don’t know /Can’t remember ...... 97 Worker/CHW first visited you (in this pregnancy)? 406 How many months pregnant were you when the Months...... ACCESS Counselor/MaMoni Health Worker/ Don’t know /Can’t remember ...... 97 CHW last visited you (in this pregnancy)? 407 Did the ACCESS Counselor/MaMoni Health Yes ...... 1 Worker/Community Health Worker who visited No ...... 2 409 you provide any advice regarding care during Don’t know/Can’t remember ...... 7 409 pregnancy?
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 408 Can you recall what advice the ACCESS Check up during pregnancy ...... A Counselor/MaMoni Health Worker/Community TT vaccination ...... B Health Worker 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 ACCESS Counselor/MaMoni Health Yes ...... 1 Worker/ CHW counsel you about the importance No ...... 2 of antenatal care / check up by skilled provider? Don’t know ...... 7 410 Did the ACCESS Counselor/MaMoni Health Yes ...... 1 Worker/CHW counsel you where to go for No ...... 2 antenatal care? Don’t know ...... 7 410a Did the ACCESS Counselor/MaMoni Health Yes ...... 1 Worker/CHW counsel you how many times to go No ...... 2 419 for ANC? 410b ACCESS Counselor/MaMoni Health Times...... Worker/CHW counseled you to receive ANC for Don’t know ...... 97 how many times? 419 Did the ACCESS Counselor/MaMoni Health Yes ...... 1 Worker/CHW tell you how to take care of the No ...... 2 419c newborn immediately after birth? Don’t know ...... 7 419c 419a Can you recall the issues the ACCESS Clean/dry the baby immediately after birth ...... A Counselor/MaMoni Health Worker/Community Wrap the baby immediately after birth ...... B Health Worker told you regarding newborn care immediately after birth? Put the baby to breast before delivery of the Do not read out the answers. placenta...... C Ask: Anything else? Nothing to be applied to the umbilicus ...... D Write down all the answers. Not to remove the vernix or the white skin ...... E First bath should be given 72 hrs/3 days after delivery ...... F 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 ACCESS Counselor/MaMoni health worker/CHW give you while she visited you during your pregnancy? Before showing After showing Yes Yes No
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Family card (Preparation for safe delivery and complication) 1 2 3 Referral slip 1 2 3 Delivery notification card 1 2 3 Clean delivery kit 1 2 3
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 was principally selected to assist delivery and FWV ...... D record the name. Medical Assistant/SACMO ...... E Write down the name______ACCESS Counselor/MaMoni Health Worker/CHW ...... F HA ...... G Do not read out the answers. FWA ...... H Others: TTBA...... I Write down all the answers. 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 426 When you were pregnant with (Name) did you Yes ...... 1 or your family selects a person for newborn No ...... 2 428
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 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 was principally selected to assist delivery and MBBS doctor ...... A record the name. Nurse/midwife ...... B Name: ______Paramedic ...... C Do not read out the answers. FWV ...... D Write down all the answers. Medical Assistant/SACMO ...... E 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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Don’t know/Can’t remember ...... 7 500 428e From whom you received treatment for this Health professional: problem/complication? Do not suggest any answers. MBBS doctor ...... A Ask: Anything else? Nurse/midwife ...... B Write down all the answers. Paramedic ...... C FWV ...... D Medical Assistant/SACMO ...... E ACCESS Counselor/MaMoni Health Worker ...... 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 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
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) 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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 ______502 Who from outside (not a family member) assisted Health professional: in your delivery? MBBS doctor ...... 01 Nurse/midwife ...... 02 Record the name who was mainly responsible or Paramedic ...... 03 mostly involved in assisting the delivery. FWV ...... 04 Interviewer: Ask and record the name of the Medical assistant/SACMO ...... 05 person who assisted in delivery ACCESS Counselor/MaMoni Health 06 Name ------Worker/CHW ...... HA ...... 07 Circle only one from the list 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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 Plastic sheet 1 2 3 finishes, show the CDK items one by one and ask Blade 1 2 3 again whether she has received any of these. Record unprompted answers in the first column Thread 1 2 3 and the prompted answers in the second column. Soap 1 2 3 If she still does not mention the item then circle 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? d. Baby’s Hand or Feet Coming out First? ...... 1 2 Foul-Smelling Discharge? e. Baby is in abnormal position? ...... 1 2 High Fever? 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)? h. Rupture uterus/Cervical tear/Vaginal tear 1 2 Retained Placenta? ...... Rupture uterus/Cervical tear/Vaginal tear? i. Cord Prolapse ...... 1 2 Cord Prolapse? j. Cord around neck ...... 1 2 Cord around neck ? Convulsion? k. Convulsion ...... 1 2 Severe headache? l. Severe headache ...... 1 2 Greenish vaginal discharge? m. Greenish vaginal discharge ...... 1 2 Swelling of feet or face? n. Swelling of feet or face ...... 1 2 Any other problem? 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. MBBS doctor...... A Ask: Anyone else? Nurse/midwife...... B Write down all the answers. Paramedic ...... C FWV ...... D
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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
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 Bathed ...... 06 Circle only one answer. 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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
603 Who wiped (dried) the baby? Health professional: Name: ______MBBS doctor ...... 01 Circle only one code. Nurse/midwife ...... 02 Paramedic ...... 03 FWV ...... 04 Medical assistant/SACMO ...... 05 ACCESS Counselor/MaMoni Health Worker ...... 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 ...... 19 603 b Others ______96 (Specify) Don’t know/Can’t remember ...... 97 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 603a Was this person selected before for taking care of Yes ...... 1 (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 No answer in 427 and 603 or mentioned about (Interviewer: Are the person of 603 and the single person...... 3 person of 427 the same person?) 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 ACCESS Counselor/MaMoni Health Worker ...... 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)
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 No answer in 427 and 603 or mentioned about person of 425 the same person?) single person...... 3 606 What was used to cut the cord? Blade from the delivery bag ...... 01 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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 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 608b Who took initiative to resuscitate or to help the Health professional: baby cry? MBBS doctor ...... 01 Nurse/midwife ...... 02 Circle only one code. Paramedic ...... 03 FWV ...... 04 Medical assistant/SACMO ...... 05 ACCESS Counselor/MaMoni Health 06 Worker/CHW ...... 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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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
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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 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 d. Shuji/lei? 1 2 food what have you given to (NAME)? (Ask for e. Rice, bread, khichuri? 1 2 every item). 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 Ask: Anything else was used? Conducted delivery at kitchen ...... D Lighted some fire at delivery room...... E Circle all the answers. Rubbed the baby with hot oil ...... F 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 your breasts during the daytime and nighttime? Very often ...... 2 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
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
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 ACCESS Counselor/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 ACCESS Counselor/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?
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 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 born? Interviewer: Make sure that you make No ...... 2 702 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 ...... birth of (NAME) did any health worker visit Month ...... your baby? Record in days if less than 1 month, record in months if less than 1 year. If age is Year ...... less than 1 day, record ‘00’. 701i Which health worker/workers come to your house to visit 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 ACCESS Counselor/MaMoni Health Worker ...... 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 you? No ...... 2 702b 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 ACCESS Counselor/MaMoni Health Worker ...... 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 circled ...... 1 appropriately? Other code circled except F ...... 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? Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 703a You mentioned that ACCESS 1st time after _ days of delivery Counselor/MaMoni Health Worker/CHW with gray color bag visited you ……. times nd during the first seven days. Please specify the 2 time after _ days of delivery timing of those visits? ______3rd time after _ days of delivery When was 1st visit made after delivery by 4th time after _ days of delivery ACCESS Counselor/MaMoni Health Worker? ______5th time after _ days of delivery
When was 2nd visit made after delivery by 6th time after _ days of delivery ACCESS Counselor/MaMoni Health Worker? ______7th time after _ days of delivery rd When was 3 visit made after delivery by ACCESS Counselor/MaMoni Health Worker? ______When was 4th visit made after delivery by ACCESS Counselor/MaMoni Health Worker? ______When was 5th visit made after delivery by ACCESS Counselor/MaMoni Health Worker? ______When was 6th visit made after delivery by ACCESS Counselor/MaMoni Health Worker? ______When was 7th visit made after delivery by ACCESS Counselor/MaMoni Health Worker? 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. Examined the mother ...... C Ask: Anything else? Examined the newborn ...... D Interviewer: circle all responses. 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
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Now I will discuss about the health problems of your baby.
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 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) 707c Did the person who advised you to seek care Yes ...... 1 for your newborn give you a paper like this? No ...... 2 Interviewer: Show the ACCESS / MaMoni Don’t know/ Can’t say ...... 7 Referral Slip. 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 Do not suggest any answers. Paramedic...... C
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP Ask: Anything else? FWV ...... D Write down all the answers. Medical Assistant/SACMO ...... E ACCESS Counselor/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)
Midline survey report_MaMoni_Sylhet-Maternal & Newborn health 2010
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 No ...... 2 1001 towards improving you or your babies’ health? 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
Midline survey report_MaMoni_Sylhet_Maternal & Newborn health 2010
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 Do not PROBE, circle the appropriate answer. After eating ...... C 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 Do not PROBE, circle the appropriate answer. After eating ...... C 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
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Midline survey report_MaMoni_Sylhet_Maternal & Newborn health 2010
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) 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
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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) 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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