Determinants of the use of skilled birth

attendants at delivery by pregnant

women in Bangladesh

Author
S. M. Abul Bashar
Master Student
Department of Public Health and Clinical Medicine
Epidemiology and Global Health
Ume International School of Public Health
Ume University Sweden

2012

Supervisors:
Kjerstin Dahlblom
Hans Stenlund
 PROLOGUE
Before starting my Masters Program in Public Health, I worked as a Rehabilitation Officer in
a non-governmental organization. I worked both in urban and rural areas in Bangladesh
during the period of 2007 to 2009 in order to implement a rehabilitation program for
children with disabilities. While working in the actual setting where the children lived, I
observed several maternal deaths. There are health facilities and health personnel in the
community, though, an insufficient amount, yet mothers are not using these facilities and
health personnel adequately. Witnessing this situation, I asked myself the following
questions: Why are the mothers from different family backgrounds dying? Why do mothers
not give birth at a health facility? Why do not family members call trained health personnel
for delivery at home? These questions motivated me to search for the underlying factors
behind this situation. Now, as a public health student, I have the opportunity to look into
these factors. Therefore, the purpose of this thesis is to estimate the determining factors that
influence the use of skilled birth attendants at delivery in Bangladesh by using secondary
data accessed from the 2007 Bangladesh Demographic and Health Survey.

i
 ACKNOWLEDGEMENT

Foremost, I would like to thank following organizations for their effort to the dataset
available and allow me to use the data to conduct this study:
National Institute of Population Research and Training
Mitra and Associates
Measure Demographic and Health Survey
Macro International Inc.
U. S. Agency for International Development

I would like to thank many people who made this thesis possible. I would like to pass my
heartfelt gratitude and appreciation to my supervisors Kjerstin Dahlblom and Hans Stenlund
for their continuing and constructive assistance in all matters related to this thesis. I would
also like to thank all my teachers and administration workers especially for Sabina Bergsten
and Karin Johansson for their unconditional support.

I am indebted to my friends Negin Yekkalam, Laith Hussain, and Gilbonce Betson for helping
me throughout data analysis. I am deeply grateful to my friend Niha for emotional support,
camaraderie, entertainment, and caring she provided me.

Last but not least, I would like to thank my father and mother who have invested all their life
to support me. My parent, I thank you very much for your sweet words on the telephone
every weekend that gave me hope. To them I dedicated this thesis.

ii
 ABSTRACT
Background: Bangladesh has made a significant progress towards Millennium
Development Goal (MDG) 5, which specifies a 75% reduction in the maternal
mortality ratio (MMR) between 1990 and 2015. In 1990 the MMR was 570 per
100,000 live births and declined to 194 per 100,000 live births in 2010. Progress
on the indicator of MDG 5 for example, the use of antenatal care has been
remarkable. However, progress on the use skilled assistance at delivery is still far-
below any acceptable standard. Roughly 26% of the women use delivery assistance
from medically-trained personnel either at home or at a health facility. Many
factors are associated with this low use of skilled assistance at delivery.

Objective: The study aimed to estimate the magnitude of the use of skilled birth
attendants at delivery and the effects of predisposing and enabling factors on the
use of skilled assistance at delivery by pregnant women of Bangladesh

Methods: The study was a cross sectional analysis of the 2007 Bangladesh
Demographic and Health Survey, which is a nationally representative survey of
women in the 15-49 years age groups. Women who had at least one birth in the five
years preceding the survey were included in this study. To estimate the effects of
demographic and socio-economic factors on the use of skilled assistance at
delivery, logistic regression analyses were carried out.

Results: A total of 6,132 women fulfilled the study eligibility criteria and were
included in the analysis. Only 20.80% of births were attended by skilled birth
attendants either at home or at a health facility. Over 36% of urban women
delivered with skilled assistance compared to 12.42% of rural women. In logistic
regression analyses parental education, birth order, place of residence, husbands
occupation, and wealth index were found to be significantly associated with the use
of skilled assistance at delivery. Muslim women and women those who were from
male-headed household were less likely to use skilled assistance at delivery.
Womens age was not found to be significantly associated with the use of skilled
delivery assistance.

Conclusion: The study identified that the use of skilled attendants at delivery was
very low in Bangladesh. Parental education and birth order were strong predictors
for the use of skilled assistance at delivery. Rural women and women from Muslim
religion were at greater disadvantage in the use of skilled assistance at delivery. To
improve maternal health and reduce maternal mortality, special efforts and
attention to improve both formal and informal education of the girls and boys are
needed. Moreover, to explore cultural factors and traditional beliefs related with
the use of skilled assistance at delivery, qualitative study needs to be conducted.
Extra effort should be given to rural areas so that the rural women can easily access
to maternal health services.

Key Words: maternal health; skilled birth attendants; delivery practice;

Bangladesh

iii
 TABLE OF CONTENTS
PROLOGUE. i
ACKNOWLEDGEMENT ii
ABSTRACT.. iii
TABLE OF CONTENTS . iv
LIST OF ABBREVIATIONS.. V
LIST OF FIGURES AND TABLES.. Vi
1. INTRODUCTION. 1
1.1. Background Review.. 1
1.1.1. Global Overview of Maternal Health 1
1.1.2. International Initiatives on Maternal Health 2
1.1.3. Country Profile of Bangladesh.................................................................... 3
1.1.3.1. Geography and Demography............................................................. 3
1.1.3.2. Economy and Health Financing.......................................................... 4
1.1.3.3. Health Care Delivery System.............................................................. 4
1.1.3.4. Maternal Health Status.. 5
1.1.3.5. Delivery Care Services.. 6
1.2. Review of Literature. 7
1.2.1. Skilled Birth Attendants at Delivery 7
1.2.2. Delivery Practice in Developing Regions. 8
1.2.3. Delivery Practice of Pregnant Women in Bangladesh.. 8
1.2.4. Determinants of the Use of Skilled Birth Attendants. 9
1.3. Conceptual Framework. 11
1.4. Rationale of the Study... 12
1.5. Research Question 13
1.6. Aim of the study.. 13
1.6.1. Specific Objectives. 13
2. METHODS 14
2.1. Study Design............................................. 14
2.2. Data Source. 14
2.3. Sampling Method and Sample of 2007 BDHS 15
2.4. Study Participants.. 16
2.5. Variable Specification and Selection 16
2.5.1. Dependent Variable.. 16
2.5.2. Independent Variables 16
2.6. Data Collection. 18
2.7. Ethical Consideration. 18
2.8. Data Analysis. 18
3. RESULTS.... 19
3.1. Characteristics of the Women 19
3.2. Usage Patterns of Skilled Birth Attendants at Delivery 20
3.3. Logistic Regression Analyses 22
4. DISCUSSION... 26
4.1. Discussion of the Main Findings 26
4.2. Limitations of the Study. 30
5. CONCLUSION.. 32
6. REFERENCES 33

iv
 LIST OF ABBREVIATIONS

AIDS Acquired Immune Deficiency Syndrome

ANC Antenatal Care
BBS Bangladesh Bureau of Statistics
BDHS Bangladesh Demographic and Health Survey
BEOC Basic Emergency Obstetric Care
CEmOC Comprehensive Emergency Obstetric Care
CI Confidence Interval
CSBA Community Skilled Birth Attendant
DGFP Directorate General of Family Planning
DGHS Directorate General of Health Services
DHS Demographic and Health Survey
DSF Demand Side Financing
EOC Emergency Obstetric Care
FIGO International Federation of Gynecology and Obstetrics
GDP Gross Domestic Product
ICM International Confederation of Midwives
MDG Millennium Development Goal
MMR Maternal Mortality Ratio
MOHFW Ministry of Health & Family Welfare
NGO Non-Governmental Organization
NIPROT National Institute of Population Research and Training
OPD Out Patient Department
OR Odds Ratio
PSU Primary Sampling Unit
p-value Probability-Value
SBA Skilled Birth Attendant
TBA Traditional Birth Attendant
UNDP United Nations Development Program
WHO World Health Organization

v
 LIST OF FIGURES AND TABLES

Figure 1: Maternal mortality ratio by country....................................................................... 1

Figure 2: Map o Bangladesh.. 3
Figure 3: Causes of maternal death in Bangladesh. 6
Figure 4: Andersens behavioral model of use of health services 12
Table 1: Demographic characteristics of Bangladesh 3
Table 2: Different levels of public health care facilities in Bangladesh. 5
Table 3: Emergency obstetric care (EOC) services by type of facilities. 7
Table 4: Independent variables used in the study: definitions and categories 17
Table 5: Background characteristics of the women who had at least one birth in the five
years preceding the survey, Bangladesh 2007.. 19
Table 6: Percent distribution of women who had at least one birth in the five years
preceding the survey according to the use of SBAs by different background
characteristics, Bangladesh 2007. 21
Table 7: Logistic regression results with OR and 95% CI for the use of SBAs by the
pregnant women who had at least one birth in the five years preceding the survey,
Bangladesh 2007. 23

vi
 1. INTRODUCTION
1.1. Background Review
1.1.1. Global Overview of Maternal Health
Every day, pregnancy- and childbirth-related complications account for approximately 1,000
maternal deaths1 around the world [1]. In 2008, the World Health Organization (WHO)
estimates that 358,000 women of reproductive age die during and following pregnancy and
childbirth [2]. Nearly all (99%) of these deaths occur in developing regions. Developing
regions, like South Asia, alone account for more than one third of the global maternal deaths
[2]. The maternal mortality ratio (MMR) number of maternal deaths per 100,000 live
births is 280 maternal deaths per 100,000 live births in this region, which is in stark
contrast to developed regions where the figure is only 14 deaths per 100,000 live births [2].
Figure 1 below displays the MMR in varies countries in 2008. Explanations for these deaths
in developing regions are the inadequate access to modern health care services and the poor
use of these services [3].

Figure 1: Maternal mortality ratio by country (Adapted from WHO trends in maternal mortality: 1990
to 2008, 2010).

1
Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy,
irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its
management but not from accidental or incidental causes [4].

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Maternal death has a large impact on the baby the mother is carrying, the health and well-
being of the family, the community, and on the society in general. Each year, more than one
million children lose their mothers due to maternal mortality [5]. Evidence shows that
children up to 10 years of age whose mothers die, have a 3 to 10 times higher risk of dying
within two years than children who live with their mothers [5]. The WHO estimates that each
year US $15.5 billion is lost in potential productivity due to maternal and child death [6].
Maternal death is the most extreme consequence of poor maternal health. However, due to
inadequate care during pregnancy and delivery or the first critical hours after birth, more
than 30 million women in developing regions suffer from serious diseases and disabilities.
These diseases and disabilities include uterine prolapse, pelvic inflammatory disease, fistula,
incontinence, infertility, and pain during sexual intercourse [6]. The majority of these deaths
and complications could be avoided by access to basic maternity care and improved delivery
care, which is supported by adequate medical and surgical care [7].

1.1.2. International Initiatives on Maternal Health

Globally, several initiatives have been taken to reduce maternal deaths and improve maternal
health, in particular, the Nairobi Safe Motherhood Conference of 1987 [8]. The Nairobi
conference led to the establishment of Safe Motherhood Initiative. The specific activities of
this initiative include: provision of antenatal care (ANC)2, skilled assistance for normal
deliveries, appropriate referral for women with obstetric complications, postnatal care, family
planning and other reproductive health services [8-10]. Maternal health is further
emphasized in the International Conference on Population and Development in 1994 [8, 11]
and Fourth World Conference on Women in 1995 [12]. Finally, maternal health is reinforced
in the United Nations Millennium Summit of 2000, when it was included as one of the
Millennium Development Goal (MDG) [8]. The goal, which has the aim to improve maternal
health, includes two targets: reduce maternal mortality ratio by three quarters between 1990
and 2015 and achieve universal access to reproductive health by 2015. Proportion of births
attended by skilled birth attendants (SBAs) and coverage of ANC are the two main indictors
to measure these targets [8, 13]. The presence of a SBA at delivery, either at home or at a
health facility has been strongly emphasized throughout the international initiatives on
maternal health.

2
ANC care during pregnancy is the key entry point for a pregnant woman to receive a wide range of preventive
interventions and information which fosters their health, well-being and survival, and that of their infants [14].

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1.1.3. Country Profile of Bangladesh
1.1.3.1. Geography and Demography
The Peoples Republic of Bangladesh one of
the largest delta of the world emerged on
the world map as an independent and
sovereign country in 1971 following a nine-
month war of liberation. It is a low-lying
country with a total land area of 147,570 sq.
km, which lies in the north eastern part of
South Asia. On three sides, Bangladesh
borders with India [Figure 2]. In the
southeast, only a small strip is bordered by
Myanmar, and the Bay of Bengal lies to the
south. The country is covered with a network
of more than 230 rivers and canals with a
total length of 24,140 km and Bangladesh has
a coastline of about 580 km along the Bay of Figure 2: Map of Bangladesh
Bengal. The majority of the people are Muslim followed by Hindu, Buddhist, and Christian;
the figures are 89.35%, 9.64%, 0.5%, and 0.27%, respectively. Table 1 below represents a
summary of the basic demographic characteristics of Bangladesh [15, 16, 17].

Table 1: Demographic characteristics of Bangladesh

Characteristics Number
Population in thousand (male/female) (2011 census) 142,319 (71,255/71,064)
Population density (inhabitants per sq km) 964
Urban population (in %) 25.4
Rural population (in %) 74.6
Total fertility rate (birth per woman, 15-49 years) 2.40
Average household size (persons per household) 4.4
Mean age at first marriage male/female (years) 25.04/20.31
Life expectancy male/female (years) 65.61/67.96
Adult literacy rate (in %) 59.07
Source: Directorate General of Health Services [DGHS], 2010; Bangladesh Bureau of Statistics [BBS],
2011.

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1.1.3.2. Economy and Health Financing
Bangladesh is mainly an agricultural country. Agriculture, the single largest-producing
sector, contributes about 22% to the total Gross Domestic Product (GDP) and accommodates
approximately 48% of the countrys labor force [15]. According to the BBS, in 2008 the per
capita GDP was US $ 621 [15]. Until now, roughly one half of the total population had been
living under poverty, where around 36% of people lived with a per capita income of less than
US $ 1 a day [18]. Regarding health financing, a combination of several methods exists
including: households-out-of-pocket money, government revenue, and community financing
through non-governmental organizations (NGOs) and donors. In 2007-2008 fiscal years, the
government spending on health was 7% of the total countrys national budget, which
accounts for only 3.4% of the GDP. Out-of-pocket expenditure was the major source of health
financing. In 2007, approximately 64% of the total health expenditure came from
households out-of-pocket money. Households out-of-pocket contribution continues to be
two thirds of the total health expenditure, which was 57% of the total health expenditure in
1996-97, and rose to 64% in 2006-07. People often do not want to go to the doctor because
paying for such a visit greatly increases the household expenditure. Rather, individuals prefer
to go a seller of medicine in order to buy drugs without having any formal prescription.
Hence, people suffer from chronic poor health, which leads to morbidity and mortality [16,
19].

1.1.3.3. Health Care Delivery System

The Ministry of Health & Family Welfare (MOHFW) is responsible for developing policies,
planning, and decision-making for the total health care services in the country.
Implementation of these decisions and policies are then executed by various executing
authorities. The Directorate General of Health Services (DGHS) and the Directorate General
of Family Planning (DGFP) are the two largest branches of MOHFW. Health care services are
provided by a mix of public and private institutions, and NGOs. The public sector provides
both curative and preventive care, while the private sector mainly provides curative care.
Contrary, NGOs provide mainly preventive and basic care. Some of the governments services
are provided in collaboration with NGOs, which include immunization, nutrition, and
tuberculosis control program. The delivery of public sector services is performed through
different tires including national, divisional, district, upazila (sub-district), union, and the
ward and village levels. In rural areas, public facilities are the main source of modern care;
however, private hospital and clinics outnumber public facilities in the urban areas. Table 2
on the following page displays information of different levels of health care facilities in
Bangladesh [16, 18].

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Table 2: Different levels of public health care facilities in Bangladesh
Levels of Administrative Types of facilities Number
health care units
Primary Ward/Village Community Clinics 9722
Satellite Clinic per month (under DGFP) 30,000
Union Union Health and Family Welfare Centers 3806
Rural Health Centers (10-20 beds) 27
Union Sub-Center (OPD* only) 1362
Maternal and Child Welfare Center (under DGFP) 24
Upazila Upazila Health Complex 424
Other Hospitals 36
Maternal and Child Health-Family Planning clinic 407
(under DGFP)
Maternal and Child Welfare Center (under DGFP) 12
Secondary District District hospitals 59
Maternal and Child Health-Family Planning clinic 64
(under DGFP)
Maternal and Child Welfare Center (under DGFP) 61
Tertiary Division or Medical College Hospitals 18
District Specialized Hospitals and other Hospitals 40
Postgraduate Institutions 7
Source: DGHS, 2010 *OPD: Out Patient Department

1.1.3.4. Maternal Health Status

Due to inadequate access to modern health care services and poor use of services, the
situation of maternal health is worse in Bangladesh than other developing countries [3]. The
country faces what is considered to be a high number of maternal mortality and morbidity.
Estimates vary, but the official figure of maternal mortality is 194 maternal deaths per
100,000 live births [20], whereas the estimate of the United Nations Development Program
(UNDP) is 348 maternal deaths per 100,000 live births [21]. The major contributing factors
behind these high rates of maternal deaths are a very low use of assistance from skilled
personnel at delivery, poor facilities for delivery, and insufficient ANC services [20].
However, women die from a wide range of both direct and indirect causes. Indirect causes,
which are not the complications of pregnancy, complicate pregnancy or are aggravated by it.
Direct causes of death include hemorrhage, infections, eclampsia, obstructed labor, and

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unsafe abortion [20]. Among other causes, hemorrhage and eclampsia together comprise
more than half of the maternal deaths in the country (Figure 3).

Undetermined 1%

Hemorrhage
31%
Indirect Causes
35%

Eclampsia
20%

Figure 3: Causes of maternal death in Bangladesh

Source: Bangladesh maternal mortality and health care survey 2010 Summary of key findings and
implications.

1.1.3.5. Delivery Care Services

Achieving MDG5, Bangladesh with assistance from international agencies is continuing to
implement different strategies and services for delivery services. The country conducts
facility based Emergency Obstetric Care (EOC) program in all districts. The EOC service
provision is in two forms: Comprehensive Emergency Obstetric Care (CEmOC), and the Basic
Emergency Obstetric Care (BEOC). Table 3 on the following page demonstrates a summary of
EOC services by type of facilities in the country. A number of private clinics or hospital and
NGOs also provide similar services in different districts. Furthermore, special emphasis has
been given to increase the number of skilled health personnel as the shortage of skilled
personnel is thought to be a major barrier in improving delivery care. With 77,011 numbers of
existing doctors and nurses, the country has 23,472 and 5,179 numbers of mid-wives and
community skilled birth attendants (CSBAs), respectively [16].

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Table 3: Emergency obstetric care (EOC) services by type of facilities in Bangladesh
Types of EOC Types of facilities Number
Comprehensive Emergency Obstetric Care Medical College Hospital 18
(CEmOC)
District Hospital 22
Upazila Health Complex 269
24-hour CEmOC Maternal and Child Welfare Center 60
Basic Emergency Obstetric Care (BEOC) District Hospital 59
24- hour BEOC Upazila Health Complex 132
Maternal and Child Welfare Center 29

Source: Maternal, neonatal and child health program in Bangladesh review of good practices and
lessons learned, 2007 [22]; DGHS, 2010.

Additionally, the government conducts an innovative program, which is known as Demand

Side Financing (DSF). The aim of the program is to encourage pregnant women to seek ANC
service, delivery care, and postnatal care from skilled medical personnel. The pregnant
women receive a reimbursable maternal health voucher if she takes any other form of
pregnancy-related health care from a skilled medical personnel or health facilities in the
program area. The maternal health care package consists of three antenatal check-ups, safe
delivery, and a postnatal care within six weeks of delivery and services for obstetric
complications. Women receive a financial benefit for a normal delivery, a delivery with
complication, management of eclampsia, and a case that requires cesarean section.
Moreover, these women receive costs for travel to the health facility and to the district
hospital. Even after the baby is born in the health facility, the mother receives hygienic
toiletries and toys for newborns. In 2009, DSF covered 33 upazilas of Bangladesh; now the
program is continuing 53 upazilas. Beside the government facilities, there are NGOs and
private practitioners, including medical doctors and traditional healers, who also provide
maternal health care services across the country [16].

1.2. Review of the Literature

1.2.1. Skilled Birth Attendants at Delivery
In 2004, the WHO, International Confederation of Midwives (ICM) and the International
Federation of Gynecology and Obstetrics (FIGO) jointly define SBA as an accredited health
professional such as a midwife, doctor or nurse who has been educated and trained to
proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth
and the immediate postnatal period, and in the identification, management and referral of

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complications in women and newborns [23]. According to the definition of SBA, traditional
birth attendants (TBAs), either trained or not, are excluded from the category of SBAs. SBAs
can administer interventions to prevent and manage life-threatening complications or refer
the mother to the higher level of care if required. However, the definition of SBA is context
based. In Bangladesh doctor, nurse, midwife, CSBA, and Family Welfare Visitor (FWV) are
considered as SBA [24]. For this study the later definition of SBA is used.

The presence of SBAs during delivery is crucial. Research findings suggest that although all
women and babies need pregnancy care, care at childbirth is most important for the survival
of pregnant women and their babies [25]. Evidence also establishes a strong association
between having a SBA at delivery and reducing maternal mortality. For example, by
providing professional midwifery care at child birth, industrialized countries halved their
maternal mortality ratios in the early 20th century [6]. Similarly, in the 1950s and 1960s,
Malaysia, Sri Lanka, and Thailand halved their maternal mortality ratios within 10 years by
increasing the number of midwives [6]. International community agreed at the special
session of the United Nations General Assembly in 1999, that globally 80%, 85% and 90% of
all births should be assisted by SBA by 2005, 2010 and 2015, respectively [26]. The WHO
strongly advocates for skilled care at every birth to reduce the global burden of 358,000
maternal deaths, 3 million stillbirths and 3.7 million newborn deaths each year [2, 27].
Through extended coverage of SBAs at delivery, it is possible to reduce maternal mortality.

1.2.2. Delivery Practice in Developing Regions

Worldwide, around 60 million deliveries take place annually where the woman is cared for by
only a family member, an untrained TBA, or no one at all [28]. Although nearly all (99%)
births are assisted by SBAs in developed countries, the proportion is only 35.3% in the least
developed countries [26]. More than half of all births in South Asia still occur at home or in
other non-health facility settings [29]. Of the total, around 48% of deliveries are conducted
by SBAs in this region, while the remaining are conducted by an unskilled person [29].
However, the global target of using an SBA at delivery is 90% by the year 2015 [26]. In
developing regions, women often give birth at home because it is the cheapest option, but it is
also associated with the risk of infection and complication [30].

1.2.3. Delivery Practice of Pregnant Women in Bangladesh

Bangladesh Maternal Mortality and Health Care Survey 2010 reveal that almost 2.4 million
births take place at home annually, especially in rural areas. Of this, only 4.3% of women use

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an SBA to attend deliveries [20]. The survey also reveals that approximately 26% of women
in the country receive assistance from SBAs at delivery either at home or at a health facility
[20], however, the percentage is 32% according to the preliminary report of the Bangladesh
Demographic and Health Survey (BDHS) conducted in 2011 [24]. Despite using assistance
from SBAs, the vast majority of births in the country are delivered by TBAs. TBAs, who are
called dais, are usually family members, relatives, or neighbors with no or very little
knowledge of modern delivery practice. TBAs perform all the tasks related to child delivery
without having any formal training. They use unsterile razor blades to cut the umbilical cord
and uncleaned thread to tie the cord. Sometime they even use cow dung for dressing the
cord. These factors are thought to be the primary sources of childbirth complication, which in
turn leads to what is considered to be a high number of maternal mortality and morbidity in
the country [31]. The tragic consequence of poor maternal health is not only on maternal
mortality and morbidity but also on the babies who are born. The percentage of the babies
born to these women are likely to die within the first week of their life is around 75% [22].

1.2.4. Determinants of the Use of Skilled Birth Attendants

The use of health services is influenced by the characteristics of the health delivery system for
example, accessibility, quality, and cost of the services [3]. However, even where there is a
good supply of services, those services may not be fully used. Even under the same
circumstances of availability, some women are more likely to use services than others.
Therefore, a health delivery system is not the only factor that determines the level of use of
health care services. Other factors such as social characteristics and structure influence the
use of health care services [32]. Several studies emphasize factors like cultural beliefs, socio-
demographic characteristics, economic conditions, and physical and financial accessibility to
be important determinants of the use of maternal health care services [33, 34].

It is well-recognized that parental education, especially mothers education, plays an

important role in the use of skilled assistance at delivery. Association between womens
education and the use of maternal health care services is evident [32, 33, 35, 36, 37]. The
mothers education emerged as an independent factor in determining the choice of delivery
under skilled supervision in a study from Tanzania [38]. Like womens education, a study
from India points out the husbands education as a significant predictor of the use of an SBA
at delivery [35]. Educated families have better knowledge on current health practices, as they
are more accessible to resources than their less educated counterparts [31]. This, in turn, may
influence educated families to use proper medical care whenever they perceive it to be
necessary. A study of analysis of choice of delivery location reveals that parental education is

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a predisposing factor in determining the choice of facility for delivery with skilled attendants
[30].

Additionally, womens age is an important factor which may influence the use of maternal
health care services. The association between a womans age and the use of medical services
has been found to be inconsistent across studies. Because of greater exposure to and
knowledge of modern health care, younger women may make more use of modern health
care facilities than older women. Several studies indicate older women are less likely to use
skilled delivery assistance [30, 37, 38]. A womens age, however, may act as a proxy for the
womans accumulated knowledge of health care services. Moreover, women acquire
experience and skills with age. Therefore, older women may use more health care services
than their younger counterpart. A study in Bangladesh suggests a U-shaped relationship
between mothers age and use of skilled assistance [3].

Similarly, several studies indicate a negative association between higher birth order and the
use of maternal health care services [36, 39, 40]. A study from India affirms that women with
more than two children are less likely to deliver at health facilities [30]. A study from Nigeria
also indicates that women with three or more children are less likely to use SBAs at delivery
[36]. An analysis of the 1993 Turkish Demographic Health Survey shows that women having
their first childbirth are significantly more likely to use professional delivery assistance from
skilled personnel than women in the higher birth order [37]. One explanation for this may be
the perceived risk associated with first pregnancy which influences women to seek for skilled
assistance at delivery for the first birth more than higher birth order [3].

Place of residence is also a well-recognized factor that can affect a womans use of health care
service. Living in urban areas increases the probability of pregnant women using skilled
assistance at delivery [37]. A systematic review of inequalities in the use of maternal health
care in developing countries states that urban women are more likely to deliver with
assistance from skilled health personnel than rural women [41]. Similarly, a study in
Bangladesh suggests that the use of SBAs is higher among urban women compared to rural
women [42]. Likewise, a national survey in India highlights that urban women are less likely
to deliver at home compared to rural women [30]. Urban women tend to be more educated
than rural women, which broadens their knowledge about the benefits of modern health care
services [3, 41, 42]. Thus, the urban women may make use of more health care facilities
compared to their rural counterpart.

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Furthermore, studies find a positive association between economic status and the use of
skilled assistance at delivery [32, 36, 39]. A study from India indicates that low use of
maternal health care services is due to low level of household income [35]. A similar study in
Nigeria points out a significant association between household socio-economic status and the
use of skilled assistance at delivery. The study affirms that the use of skilled assistance at
delivery is more than four times higher among women from rich and very rich households
compared to the women from very poor households [36]. Likewise, evidence from Nepal
indicates that household economic status is an important factor associated with the use of
professional assistance at delivery [32]. However, some studies argue the association between
economic status and the use of skilled assistance at delivery [43, 44].

Additionally, the occupation of the husband also plays an important role in the use of
maternal health care services by the pregnant women. The occupation of the husband may
also serve as a proxy for family income and status. The husbands occupation appears as a
significant enabling factor in the use of skilled assistance at delivery [3]. In addition with the
above mentioned factors, religion and the gender of the household head influence the
pregnant women in using services to treat and prevent maternal morbidity and mortality. A
study from Bangladesh reveals that the use of skilled attendants at birth is higher among
women from Hindu religion compared to women from Muslim religion [42]. On the other
hand, studies in India claim that Muslim women are more likely to deliver with skilled
assistance compared to women from Hindu religion [30, 45]. Study from Nepal [32] and
Tanzania [38] show that women from female-headed households are more likely to use
skilled assistance at delivery than women from male-headed households [32, 38].

In summary, the above studies identify several factors that determine the use of SBAs at
delivery including: parental education, womens age, birth order, religion, gender of the head
of the household, place of residence, household economic status, and the husbands
occupation. It is also evident that the determinants are not consistent in different regions and
countries; they vary within and between regions and countries.

1.3. Conceptual Framework

The conceptual framework of the use of delivery care services used in this study was based on
Andersens Behavioral Model of Health Services Use [46]. This model has been widely used
to understand the factors that determine an individuals use of health care services [29]. The
model describes that the use of health care services are influenced by three sets of individual
characteristics: predisposing characteristics, enabling resources, and need (Figure 4).

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Predisposing factors are the combination of demographic characteristics, social structure,
and health beliefs. Demographic characteristics are the tendency of the individual to use
services which include: age, gender, family size, number of previous pregnancies and marital
status. Social structure such as education, occupation and religion or ethnicity measures the
coping ability of the individual with the problem and availability of the resources. Health
beliefs are the knowledge about health and health care system; for example, attitudes towards
disease and medical care [46]. Enabling factors are factors that make the individual able to
obtain health care services, such as income, health insurance, travel, waiting time, and
availability of the health care providers [46]. Need factors which are considered to be the
most immediate cause of health service use are the perception of ones own health status
and expectation of benefit from the treatment [46]. For this study, the selected independent
variables were in the categories of predisposing and enabling factors.

Figure 4: Andersens behavioral model of use of health services (adopted from Andersen RM, 1995).

1.4. Rationale of the Study

In Bangladesh there are services for delivery care which may be insufficient amount, but they
are not adequately used. Studies have been done to identify the determining factors of the use
of SBAs at delivery by the pregnant women in Bangladesh. However, few studies have been
done with country representative data on the use of SBAs. The 2007 BDHS a national
representative survey reported the frequency of the use of SBAs at delivery by the pregnant
women of Bangladesh based on different background characteristics. The survey report did
not cover some important factors such as sex of the household head, religion, and husbands
education and occupation. These factors play an important role in the use of SBAs at delivery.
It is needed to identify these factors in the use of SBAs at delivery. Additionally, the 2007
BDHS did not identify any association between the use of SBAs at delivery and background
characteristics. Therefore, the purpose of this study is to identify those factors that are not

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reported in the 2007 BDHS and to determine the factors hindering the use of SBAs at
delivery in Bangladesh by using country representative data.

1.5. Research Question

What are the major factors determining the use of SBAs at delivery by pregnant women of
Bangladesh?

1.6. Aim of the Study

The aim of this study was to estimate the factors related to the use of SBAs at delivery by
pregnant women of Bangladesh.

1.6.1. Specific Objectives

To examine the patterns of the use of SBAs at delivery by pregnant women of
Bangladesh by different background characteristics.
To investigate the determinants of the use of SBAs at delivery by pregnant women of
Bangladesh.

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 2. METHODS
2.1. Study Design
The study was a cross sectional analysis of the 2007 Bangladesh Demographic and Health
Survey (BDHS) dataset.

2.2. Data Source

Data for this study were collected from the 2007 BDHS, which is part of the global
Demographic and Health Surveys (DHS) program. Under the Ministry of Health and Family
Welfare (MOHFW) of Bangladesh, the 2007 BDHS was conducted by the authority of the
National Institute for Population Research and Training (NIPORT). The survey was
implemented by Mitra and Associates, a Bangladeshi research firm located in the capital city.
To conduct the survey, technical assistance was provided by Macro International Inc. as a
part of its international DHS program and the financial support was provided by the U.S.
Agency for International Development. The 2007 BDHS obtained detailed information on
basic national indicators including: fertility, childhood mortality, contraceptive knowledge
and use, maternal and child health, nutritional status of mothers and children, knowledge
and attitudes of AIDS and other sexually transmitted diseases, and domestic violence. To
obtain detailed information on the above mentioned areas, the 2007 BDHS used five
questionnaires: a Household Questionnaire, a Womens Questionnaire, a Mens
Questionnaire, a Community Questionnaire, and a Facility Questionnaire [47].

The Household Questionnaire was used to obtain household level information such as age,
sex, education etc., along with information on the households socioeconomic status. The
2007 BDHS did not include the question of household income. However, it collected
information on the source of water, type of toilet facilities, construction material used for the
floor and roof, and ownership of various durable goods such as radio, television, mobile
phone, refrigerator, table, chair, bicycle etc. The Womens Questionnaire collected
information from ever-married women aged 10-49 on the following topics:
Background characteristics such as age, residential history, education, religion, and
media exposure
Reproductive history
Knowledge and use of family planning methods
Antenatal, delivery, postnatal, and newborn care
Breastfeeding and infant feeding practices
Vaccinations and childhood illnesses

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 Marriage
Fertility preferences
Husbands background and respondents work
Awareness of AIDS and other sexually transmitted diseases
Knowledge of tuberculosis
Domestic violence
The Mens questionnaire collected information from ever-married men aged 15-54 on
background characteristics including respondents work, marriage, fertility preferences,
participation in reproductive health care, awareness of AIDS and other sexually transmitted
diseases, knowledge of tuberculosis, injuries, and tobacco consumption, and domestic
violence. The Community and Facility Questionnaires collected information on the existence
of development organizations in the community and the availability and accessibility of
health services and other facilities. These were administered in each selected cluster during
listing. The information obtained by these questionnaires was also used to verify information
gathered in the Womens and Mens Questionnaires on the type of facilities respondents
accessed and the health service personnel who saw [47].

To administer the Community and Facility Questionnaires and listing households, 42 field
staffs were trained and organized. The Household, Womens, and Mens Questionnaires were
pre-tested by 14 interviewers. Based on the suggestions of the interviewers, revisions were
made in the wording and translation of the questionnaires. Finally, 128 staffs were recruited
and trained to conduct the main survey. Fieldwork was conducted from March 24 to August
24, 2007. A team of quality controllers monitored the quality of the data. Data processing was
started shortly after fieldwork commenced using six microcomputers. Data processing began
on April 16 and ended on August 31, 2007 by ten data entry operators and two data entry
supervisors. Data were entered using CSPro, a program developed jointly by the U.S. Census
Bureau, Macro International, and Serpro S.A [47].

2.3. Sampling Method and Sample of 2007 BDHS

The 2007 BDHS used the sampling frame of the 2001 Population Census of Bangladesh,
which consists of a list of census enumeration areas with population and household
information. The 2007 BDHS was based on a two-stage stratified sample of households. The
proportions of the population of the country were not the same in urban and rural areas.
Thus, the country was divided into strata to achieve statistical precision. At the first stage of
sampling, 361 Primary Sampling Units (PSUs) were selected from the strata. Of the total
PSUs, 134 were from urban areas and 227 were from rural areas. At the second stage of

- 15 -
sampling, lists of households were used as the sampling frame for the selection of
households. On average, 30 households were selected from each PSU, using an equal
probability systematic sampling technique. Finally, 10,400 households were interviewed with
a representative sample of 3,771 ever-married men age 15-54 and 11,051 ever-married women
age 10-49. However, there were very few ever-married women age 10-15. These women have
been removed from the dataset. Therefore, the 2007 BDHS dataset constituted of a
representative sample of 10,996 ever-married women [47].

2.4. Study Participants

In the 2007 BDHS, 10,996 women age 15-49 were interviewed. For this study, the analysis
was limited to the women within the age group of 15-49 who had had at least one birth in the
five years prior to the survey. If the woman had more than one child in the five years
preceding the survey, information on the use of delivery assistance was collected for the last
birth. The total number of women who had had at least one birth in the five years before the
survey was 6,150. There were 18 cases in which information on assistance at delivery was
missing, and these cases were excluded from the analysis. At the end 6,132 cases were
included in the analysis.

2.5. Variable Specification and Selection

2.5.1. Dependent Variable
Assistance at delivery: In the 2007 BDHS, the respondents (ever-married women age 15-49)
were asked, with respect to the last birth occurring in the five years preceding the survey, who
assisted with the delivery. From this specific question, dichotomous variable was created for
this study. It was coded as 1 if the woman received assistance at delivery from SBAs
including: qualified Doctor, Nurse or Midwife, Family welfare visitor (FWV), and Community
skilled birth attendant (CSBA) either at home or at a health facility and 0 if otherwise.

2.5.2. Independent Variables

Based on the Andersens behavioral model of the use of health services, nine independent
variables were included in this study. Six variables were from predisposing factors and three
were from enabling factors. Definition and coding of the independent variables which
employed in this study are presented in the Table 4 on the following page.

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Table 4: Independent variables used in the study: definitions and categories
Variables Description
Predisposing factors:
Womens age In the survey, womens age was ranging from 15-49. In this study, women were
classified into three age groups. These were code as 0, 1, and 2 for the age
groups of 15-19, 20-34, and 35-49, respectively.

Womens This referred to the highest levels of education of the women. In the survey,
education women were classified into four levels of education including: no education,
primary, secondary, and higher education. In this study, women were categorized
into three categories and were coded as 0, 1, and 2 for the level of education of
no education, primary education, and more than primary education, respectively.
The number of women in the higher education group was too small to be treated
under separate category; thus, such women were included in secondary
category, and this category was than recoded as more than primary education.

Husbands Similar to the level of education of women.

education
Birth order This was the order in which a womans children were born ranging from 1-12
births. In this study, birth order was categorized into 4 categories including: 1
birth, 2-3 births, 4-5 births, and 6 or more births and were coded as 0, 1, 2, and 3,
respectively.

Religion This variable was derived from the type of religion that the women had at the
time of the survey. In the survey, women were classified into five different
religions namely Muslim, Hinduism, Buddhism, Christianity, and others. In this
study, women were classified into two categories as Muslim and Other religions
and were coded as 0 for Muslim and 1 for Other religions. The number of women
in the Buddhism, Christianity, and others religions were too small to be treated
under separate categories; thus, such women were included in the Hinduism
category, and this category was then recoded as Other religions.

Sex of This variable was created on the basis of the sex of the household head at the
household head time of the survey. In this study, sex of the head of the household was coded as 1
for female and 0 for male.
Enabling factors:
Husbands This was based on the question of the type of work that the respondents
occupation husband does primarily. In this study, husbands occupations were categorized
into two categories including: unskilled work and skilled work, and were coded as
0 and 1, respectively. Husbands who worked in agriculture, unskilled manual
work, and who never worked were classified as unskilled work and those who
were involved in business, services, and skilled manual work were classified as
skilled work.

Place of This variable was based on where the respondent was interviewed, either urban
residence or rural. This was not respondents own categorization, but was created based on
whether the cluster or sample point number was defined as urban or rural.
Urban areas were classified into large cities (capital cities and cities with over 1
million people), small cities (population over 50,000), and towns (other urban
areas) and all rural areas were assumed to be countryside. In this study, the
womens type of place of residence was coded as 1 for rural and 0 for urban.

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Table 4: Independent variables used in the study: definitions and categories (Continued)

Variables Description
Wealth index In the 2007 BDHS, wealth index was constructed from data on household
possession. This was based on the questions about whether a household had
items such as radios, televisions, and bicycles, and facilities such as type of floor,
piped water, toilets, and electricity. Each asset was assigned a weight, and each
household was then assigned a score for each asset, and the scores were
summed for the particular household. Individuals were then ranked according to
the total score. The higher the score, the higher the economic status of the
household. This variable was coded as 0, 1, 2, 3, and 4 for poorest, poorer,
middle, richer, and richest, respectively.

2.6. Data Collection

In the primary survey, data were collected using five questionnaires: a Household
Questionnaire, a Womens Questionnaire, a Mens Questionnaire, a Community
Questionnaire, and a Facility Questionnaire. For this study, only selected data collected using
the Household Questionnaire and the Womens Questionnaire were used. Data were directly
downloaded from the MEASURE DHS website after proper permission was obtained
(http://legacy.measuredhs.com/login.cfm) [48].

2.7. Ethical Consideration

To get access to the dataset of the 2007 BDHS, a written request was sent to the MEASURE
DHS and permission was granted to use the data for this study.

2.8. Data Analysis

The unit of analysis in this study was an ever-married woman, who had had at least one birth
in the five years preceding the survey. Data cleaning and analysis were carried out using
STATA SE, Version 10.1. Variables were re-coded to meet the desired classification.
Descriptive statistics (frequencies and percentages) were carried out to describe the data and
to estimate the patterns of the use of SBAs at delivery. The dependent variable being
dichotomous, logistic regression analysis was carried out by taking each independent variable
against the outcome variable to estimate the effect of the indicator variables on the outcome
variable. Odds ratio (OR) and 95% confidence interval (CI) were calculated. The significance
level of this study was p-value <0.05. Multivariate analysis was not used in this study because
some of the independent variables were highly correlated.

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 3. RESULTS
3.1. Characteristics of the Women
A total of 6,132 women fulfilled the study eligibility criteria and were included in the
analyses. Table 5 below represents the background characteristics of the women. Of the total
respondents, slightly more than 91% were from Muslim religion and over 90% were from
male-headed household. With the median age of 25, approximately 75% of women were in
the age group of 20-34. The majority (65.79%) of women lived in rural areas, while the
remaining 34.21% lived in urban areas. Among the respondents, with the median of 2
children, 42.68% had 2-3 children. Socioeconomic variables showed that 31.34% of women
were from primary level of education and 41.42% were from more than primary level of
education. The percentage of women who had no education was 27.23%. Regarding wealth
index, the percentages of women from different wealth categories were almost the same.
Among husbands, over 34% had no education, while more than 37% had more than primary
level of education and 28.47% had primary level of education. More than half (55.63%) of
husbands were involved in unskilled work, while around 43% worked in skilled work.

Table 5: Background characteristics of the women who had at least one birth in the five years
preceding the survey, Bangladesh 2007
Characteristics % Number
Demographic characteristics:
Womens age (years)
15-19 14.38 882
20-34 75.18 4610
35-49 10.44 640
Birth order
1 33.19 2035
2-3 42.68 2617
4-5 16.47 1010
6 7.66 470
Religion
Muslim 91.21 5593
Other religions 8.79 539
Place of residence
Urban 34.21 2098
Rural 65.79 4034
Sex of the household head
Male 90.83 5570
Female 9.17 562
Socio-economic characteristics:
Womens education
No education 27.23 1670
Primary 31.34 1922
More than primary 41.42 2540
Husbands education
No education 34.07 2089
Primary 28.47 1746
More than primary 37.46 2297

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Table 5: Background characteristics of the women who had at least one birth in the five years
preceding survey, Bangladesh 2007 (Continued)

Characteristics % Number
Husbands occupation
Unskilled work 55.63 3411
Skilled work 44.37 2721
Wealth index
Poorest 19.85 1217
Poorer 20.84 1278
Middle 18.79 1152
Richer 18.69 1146
Richest 21.84 1339
Total 100 6132

3.2. Usage Patterns of Skilled Birth Attendants at Delivery

Of the total 6,132 births, only 20.80% were attended by SBAs either at home or at a health
facility, while the remaining 79.20% were conducted by TBAs and family member or
relatives. Table 6 on the following page represents the distribution of women according to the
use of assistance at delivery by different predisposing and enabling factors.

Predisposing Factors
Table 6 shows that the type of assistance used at delivery did not differ notably among
women from different age groups. Differences are evident among women with different levels
of education. The percentage of women who received assistance from SBAs at delivery
increased from 4.79% among women with no education to 38.66% among women with more
than primary education. Likewise, slightly more than 11% of women with primary education
used assistance from SBAs at delivery (Table 6). A similar trend was seen between the
husbands level of education and the use of skilled delivery assistance. More than 39% of
women whose husbands had more than primary education received assistance from SBAs at
delivery compared to 6.41% of women whose husbands had no education. Similarly, 13.17%
of women whose husbands had primary education received skilled assistance at delivery
(Table 6). The percentage of women who received assistance from SBAs gradually decreased
with increasing number of births. Among women who had had one birth, the percentage of
those who received assistance at delivery from SBAs was 32.04%, while the percentage
declined substantially to 4.04% for those who had had six or more births. Around 19% of
women with 2-3 births used SBAs at delivery compared to 8.91% of women with 4-5 births
(Table 6). More than 26% of women from other religions received assistance from SBAs at
delivery compared to slightly over 20% among Muslim women (Table 6). Compared to male-
headed households, 4.34% more women from female-headed households used SBAs at
delivery (Table 6).

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Table 6: Percent distribution of women who had at least one birth in the five years preceding the
survey according to the use of SBAs by different background characteristics, Bangladesh 2007

Variables Skilled assistance at delivery Number

Used (%) Not used (%)
Predisposing factors:
Womens age (year)
15-19 171 (19.39) 711 (80.61) 882
20-34 993 (21.54) 3617 (78.46) 4610
35-49 111 (17.34) 539 (82.66) 640
Womens education
No education 80 (4.79) 1590 (95.21) 1670
Primary 213 (11.08) 1709 (88.92) 1922
More than primary 982 (38.66) 1558 (61.34) 2540
Birth order
1 652 (32.04) 1383 (67.96) 2035
2-3 514 (19.64) 2103 (80.36) 2617
4-5 90 (8.91) 920 (91.09) 1010
6 19 (4.04) 451 (95.96) 470
Religion
Muslim 1132 (20.24) 4461 (79.76) 5593
Other religions 143 (26.53) 396 (73.47) 539
Sex of household head
Male 1136 (20.39) 4434 (79.61) 5570
Female 139 (24.73) 423 (75.27) 562
Husbands education
No education 134 (6.41) 1955 (93.59) 2089
Primary 230 (13.17) 1516 (86.83) 1746
More than primary 911 (39.66) 1386 (60.34) 2297
Enabling factors:
Husbands occupation
Unskilled work 418 (12.25) 2993 (87.75) 3411
Skilled work 857 (31.50) 1864 (68.50) 2721
Place of residence
Urban 774 (36.89) 1324 (63.11) 2098
Rural 501 (12.42) 3533 (87.58) 4034
Wealth index
Poorest 65 (5.34) 1152 (94.66) 1217
Poorer 81 (6.34) 1197 (93.66) 1278
Middle 140 (12.15) 877 (87.85) 1152
Richer 296 (23.47) 882 (76.53) 1146
Richest 720 (53.77) 619 (46.23) 1339
Total 1275 (20.80) 4857 (79.20) 6132

Enabling Factors
Table 6 shows that more than 31% of women whose husbands worked in skilled work
received skilled assistance at delivery compared to 12.25% of women whose husbands were
involved in unskilled work. Nearly 37% of urban women delivered with professional
assistance compared to 12.42% of rural women (Table 6). The percentage of women who
received assistance from SBAs gradually increased as the household economic status
increased. The percentage of women who received assistance from medically trained

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personnel increased from 5.34% among women who were in poorest category to 53.77%
among women who were in richest category (Table 6).

3.3. Logistic Regression Analyses

The outcome variable being dichotomous, logistic regression analysis was carried out by
taking each independent variable against the outcome variable to estimate the effect of the
indicator variables on the outcome variable. Since the rural and urban women were different
in most of the characteristics, separate logistic regression analyses were carried out for urban
and rural women to get the precise results. Table 7 on the following page represents the
results derived from logistic regression analyses for use of assistance at delivery.

Predisposing factors
Womens age
Table 7 shows that the odds of using SBAs at delivery did not differ significantly among
women from 20-34 years age group (OR=1.14, CI: 0.95-1.37) and 35-40 years age group
(OR= 0.87 CI: 0.67-1.14) in the total sample (Table 7). The difference of odds ratio of using
SBAs at delivery between urban women from 35-49 years age group (OR= 0.99, CI: 0.68-
1.44) and rural women from the same age group (OR= 0.58, CI: 0.37-0.89) was 0.41 (Table
7).

Womens education
The results showed that the odds of delivering with assistance from SBAs significantly
increased as the level of education of the women increased. Women with primary education
(OR=2.48, CI: 1.90-3.23) had 2.48 times higher odds of delivering with assistance from SBAs
compared to women with no education (Table 7). Similarly, women with more than primary
education (OR=12.53, CI: 9.87-15.90) had 12.53 times higher odds of using SBAs at delivery
compared to women with no education (Table 7). When compared urban women with more
than primary education (OR= 17.81, CI: 12.29-25.82) to rural women from the same level of
education (OR= 8.12, CI: 5.91-11.16), the difference of odds ratio of using SBAs at delivery
was 9.69 (Table 7). The odds of delivering with SBAs were 2.01 for the rural women with
primary education (OR= 2.01, CI: 1.40-2.89), while the odds was 2.85 for the urban women
with the same level of education (OR= 2.85, CI: 1.90-4.27) (Table 7).

Birth order
The results showed a significant negative association between the use of SBAs at delivery and
higher birth order. Women with 2-3 births (OR=0.52, CI: 0.45-0.59) had 48% lower odds of

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using assistance from SBAs at delivery compared to the women with only one birth (Table 7).
Likewise, women with 4-5 births (OR=0.21, CI: 0.16-0.26) and 6 births (OR=0.09, CI: 0.06-
0.14) had 79% and 91%, respectively, lower odds of delivering with assistance from SBAs
compared to the women with one birth (Table 7). The differences of odds of using SBAs at
delivery among rural and urban women with different number of births were not noticeable
(Table 7).

Table 7: Logistic regression results with OR and 95% CI for the use of SBAs by the pregnant women
who had at least one birth in the five years preceding the survey, Bangladesh 2007
Variables Total Rural Urban
Odds Ratio (95% CI) Odds Ratio (95% CI) Odds Ratio (95% CI)
Predisposing factors:
Womens age (year)
15-19 1 1 1
20-34 1.14 (0.95-1.37) 1.08 (0.83-1.39) 0.98 (0.74-1.29)
35-49 0.87 (0.67-1.14) 0.58 (0.37-0.89)* 0.99 (0.68-1.44)
Womens education
No education 1 1 1
Primary 2.48 (1.90-3.23)** 2.01 (1.40-2.89)** 2.85 (1.90-4.27)**
More than primary 12.53 (9.87-15.90)** 8.12 (5.91-11.16)** 17.81 (12.29-25.82)**
Birth order
1 1 1 1
2-3 0.52 (0.45-0.59)** 0.41 (0.33-0.50)** 0.56 (0.47-0.96)**
4-5 0.21 (0.16-0.26)** 0.21 (0.15-0.29)** 0.22 (0.16-0.31)**
6 0.09 (0.06-0.14)** 0.11 (0.06-0.21)** 0.08 (0.04-0.18)**
Religion
Muslim 1 1 1
Other religions 1.42 (1.16-1.74)** 1.56 (1.17-2.07)** 1.60 (1.16-2.20)**
Sex of household head
Male 1 1 1
Female 1.28 (1.05-1.57)* 1.36 (1.01-1.82)* 1.38 (1.01-1.87)*
Husbands education
No education 1 1 1
Primary 2.21 (1.77-2.77)** 2.27 (1.67-3.09)** 1.98 (1.42-2.75)**
More than primary 9.59 (7.90-11.64)** 7.13 (5.42-9.36)** 9.98 (7.49-13.30)**
Enabling factors:
Husbands occupation
Unskilled work 1 1 1
Skilled work 3.29 (2.89-3.75)** 2.04 (1.69-2.46)** 3.56 (2.91-4.34)**
Place of residence
Urban 1 -- --
Rural 0.24 (0.21-0.28)**
Wealth index
Poorest 1 1 1
Poorer 1.20 (0.86-1.68) 1.16 (0.79-1.69) 1.18 (0.54-2.61)
Middle 2.45 (1.81-3.33)** 2.30 (1.63-3.24)** 2.42 (1.18-4.97)*
Richer 5.44 (4.09-7.23)** 4.98 (3.59-6.89)** 4.94 (2.51-9.72)**
Richest 20.61 (15.71-27.06)** 12.19 (8.63-17.21)** 18.86 (9.79-36.31)**
[*=p<0.05; **=p<0.01; CI=Confidence Interval]

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Religion
Women from other religions were significantly more likely to use skilled assistance at
delivery. These women (OR= 1.42, CI: 1.16-1.74) had 42% higher odds of delivering with
assistance from SBAs at delivery compared to the women from Muslim religion (Table 7).
The odds of using SBAs were almost the same among women from Muslim religion and other
religions when compared urban women to rural women (Table 7).

Sex of household head

Women whose household head was female (OR=1.28, CI: 1.05-1.57) had 28% higher odds of
using SBAs at delivery compared to the women whose household head was male (Table 7).
The odds of delivering with SBAs were almost the same among urban and rural women with
different sex of household head (Table 7).

Husbands education
Similar womens education, husbands education also had a significant influence on the use
of SBAs at delivery. Women whose husbands had primary education (OR=2.21, CI: 1.77-2.77)
and more than primary education (OR=9.59 CI: 7.90-11.64) had 2 times and 9.59 times,
respectively, higher odds of delivering with skilled assistance compared to the women whose
husbands had no education (Table 7). When compared urban women whose husbands had
more than primary education (OR= 9.98, CI: 7.49-13.30) to rural women with husbands from
the same level of education (OR= 7.13, CI: 5.42-9.36), the difference of odds ratio of using
SBAs at delivery was 2.85 (Table 7). Similarly, rural women whose husbands had primary
level of education (OR= 2.27, CI: 1.67-3.09) were more likely to receive SBAs at delivery
compared to their urban counterpart with husbands from the same level of education (OR=
1.98, CI: 1.42-2.75) (Table 7).

Enabling factors
Husbands occupation
Table 7 shows that, women whose husbands worked in skilled work were significantly more
likely to receive assistance from SBAs at delivery. The odds of using delivery assistance from
SBAs were 3.29 times higher among women whose husbands involved in skilled work (OR=
3.29, CI: 2.89-3.75) compared to the women whose husbands worked in unskilled work
(Table 7). When compared urban women whose husbands were involved in skilled work
(OR= 3.56, CI: 2.91-4.34) to rural women with husbands from the same occupational group
(OR= 2.04, CI: 1.69-2.46), the difference of odds ratio of using SBAs at delivery was 1.52
(Table 7).

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Place of residence
The logistic regression analysis of place of residence showed that the urban women were
more likely to receive assistance from SBAs at delivery compared to their rural counterpart.
Women from rural areas (OR=0.24, CI: 0.21-0.28) had 76% lower odds of using SBAs at
delivery compared to the urban women (Table 7).

Wealth index
Women who were classified as belonging to poorest and poorer categories were more likely to
receive assistance from unskilled attendants compared to their richest and richer
counterparts. Women from middle wealth group (OR=2.45, CI: 1.81-3.33) had 2.4 times
higher odds of using SBAs at delivery compared to the women from poorest wealth group
(Table 7).The odds of delivering with assistance from SBAs among women from richer
(OR=5.44, CI: 4.09-7.23) and richest wealth group (OR=20.61, CI: 15.71-27.06) were 5.4
times and 20.6 times, respectively, higher compared to the poorest women (Table 7).The
result for poorer group was not significant. The difference of odds ratio between urban
women from richest wealth group (OR= 18.86, CI: 9.79-36.31) and rural women from the
same wealth group (OR= 12.19 CI: 8.63-17.21) was 6.67 (Table 7). The differences among
urban and rural women from other wealth groups were almost the same.

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 4. DISCUSSION
4.1. Discussion of the Main Findings
This study was based on the 2007 BDHS data, which involved a nationally representative
sample. A total of 6,132 women were included in this study to examine the patterns of the use
of SBAs at delivery and to determine the factors that influence the use of skilled assistance at
delivery. Among rural women, the percentage of using SBAs at delivery was only 12.42%,
while the percentage was more than 36% for the urban women. Our results show that the
level of use of skilled assistance at delivery among women in Bangladesh is low. Indeed the
use of skilled assistance at delivery is lower in Bangladesh than in many other countries in
South East Asia. In our study we found that 20.80% of Bangladeshi mothers used SBAs at
delivery for their last birth, however, the 2011 BDHS-preliminary report reveals that the use
of SBAs at delivery in Bangladesh is 32% [24]. Still the percentage is low compared to other
countries in South East Asia. For example the comparative figures are 47% for India (2007
National Family Health Survey), 39% for Pakistan (2006-7 DHS), 73% for Indonesia (2007
DHS), and 95% for Maldives (2009 DHS) [49-52]. This low use of SBAs at delivery in
Bangladesh is for several reasons. First, unexpected user fee is one of the reasons. Pitchforth
et al observed that, although EOC is normally free of charge in Bangladesh, families face
considerable out-of-pocket expense. In their study no women reported to give money to any
doctors or nurses, but the women made payment to other staffs such as wardboys and ayas
(female workers responsible for cleaning). The payments were demanded for the staffs
scheduled job such as moving the patient between wards and taking them to the toilets [53].
Second, local culture and religious believes play an important role is using SBAs at delivery.
Parkhurst and Rahman observed that it is common for family members to visit some kind of
spiritualists before delivery. Family members collect spiritual remedy such as protective
amulet or items and oil or holy water for the laboring women [54]. In Bangladesh women
especially from Muslim religion do not speak to males who are unknown to them even with
doctors; instead, husbands or sons explain womens health condition to the doctor. Because
of greater comfort, women prefer female service provider. Most of the SBAs in Bangladesh
are males and from outside of the locality, while TBAs are usually females and are locally
available. Therefore, these women receive assistance at delivery from TBAs and relatives or
neighbors [31, 55]. Third, distance to health facility is also an important barrier in using SBAs
at delivery. Most of the health facilities are situated in the urban areas. Additionally, all
specialized hospitals and medical college hospitals are located only in the urban areas
whereas around 74% of the population lives in the rural areas. In contrast, TBAs are locally
available and are highly affordable [54, 55]. Finally, the poor quality of the available services
and inattentive or discourteous behavior of the providers are also a major concern to not use
skilled assistance at delivery [53, 54, 55].

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The analyses showed that among the predisposing factors, parental education appeared as a
strong predictor of the use of skilled assistance at delivery. Similarly, birth order was seen to
be strongly associated with the use of SBAs at delivery; however, the association was
negative. Womens age did not appear as a significant influencing factor in the use of SBAs at
delivery. We found that mothers other than those of Muslim were more likely to use SBAs at
delivery. The analyses also showed that female household heads significantly influenced the
use of SBAs at delivery. Among the enabling factors, husbands occupation and place of
residence found to be strong predictors of the use of SBAs at delivery.

In our study, we found a negative relationship between age and the use of SBAs at delivery,
however; the finding was not significant. This finding accepts some previous studies, which
indicate that older women are less likely to use skilled delivery assistance [37, 38]. This can
be explained by the fact that with age women gain more experience regarding childbirth,
which influences them to not use skilled assistance at delivery.

As have many other studies, our study showed a significant positive association between
education of the women and the use of skilled assistance at delivery for both urban and rural
women [3, 31, 36, 37, 38]. Education serves as proxy for information and knowledge of
available health care services [36]. Education also serves as proxy for womens higher socio-
economic status that improves the ability of educated women to afford the cost of health care
services [3]. It is also likely that education enhances level of autonomy and increases female
decision-making power that results in improved freedom to make decisions including
maternal health care services [37, 56]. Moreover, educated women are considered to have
better knowledge and information on modern health care services [36]. These factors,
therefore, enable women to seek for safer childbirth under the supervision of skilled
attendants. A Tanzanian study reported that educated women were more likely to make a
decision to use assistance from medical personnel at delivery compared to their uneducated
counterpart [38]. Womens education was found by Chakraborty et al in Bangladesh [3],
Navaneetham et al in India [45], and Celik et al in Turkey [37], to be a strong determinant of
the use of skilled assistance at delivery. Similar womens education, our study also found
husbands education as an important predictor of the use of SBAs at delivery. This finding
conforms with some previous studies [30, 31, 42]. It is likely that an educated family will
have a better understanding and knowledge of modern health care services. Education also
leads to better awareness of available services [31, 36]. These, in turn, sensitize the educated
family to make use of available services including maternal health services whenever they
perceive it to be necessary. Studies by both Thind et al in India [30] and Paul et al in

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Bangladesh [31] reported that husbands education is a strong influencing factor for using
professional assistance at delivery.

Whereas a previous study from rural Bangladesh find a U-shaped relationship between
higher birth order and the use of professional assistance at delivery [3], we found a
significant negative association between higher birth order and the use of SBAs at delivery for
both rural and urban women. Our finding agrees with several other studies that find negative
association between higher birth order and the use of skilled delivery assistance [30, 37, 45,
57]. This finding can be explained by a reason that fear of complication or lack of confidence
is of women who experience first birth and thus, are more likely to use SBAs at delivery than
women with higher birth order [3, 57]. Conversely, women with more children believe
themselves to be more experienced in childbirth, hence, are less likely to use skilled
assistance at delivery [57]. The low use of SBAs at delivery among women of higher number
of children can also be due to the resource constraints in the family as there are many
demands in the family [3]. Another reason that can be ascribed that women with lower birth
order were more educated then were women from higher birth order; in this study nearly half
of the women with more than primary education had a birth order less than two.

In this study, we found that women who are not Muslim are more likely to use skilled
assistance at delivery compared to their counterpart of Muslim women. Our finding conforms
with a study by Anwar et al indicating that Muslim women are less likely to use skilled
assistance at delivery compared to women from other religions [42]. A possible reason for
this finding may be the local tradition and culture that influence Muslim women not to use
SBAs at delivery. This is supported by Pauls observation cited in Paul et al [31], indicating
that the rural people in Bangladesh believe that pregnancy is a gift of God and childbirth is a
natural event. Therefore, they do not expect any complications and do not use skilled
assistance at delivery. Moreover, rural Muslim women do not usually talk to males unknown
to themselves. However, most of the deliveries at rural health centers are attended by
assistance from males [31, 42]. This presence of males, in turn, may act as an important
barrier to the use of SBAs at delivery by the Muslim women in Bangladesh. The other reason
may be the women from other religions were from families who have a higher level of
education. In this study around 3% more women from other religions than women from
Muslim religion had more than a primary education. Similarly, about 8% more women whose
husbands had more than a primary education were from other religions.

This study shows that women from female-headed households were more likely to use SBAs
at delivery than were women from male-headed households. Similar findings from a study in

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Nepal [32] and Tanzania [38] affirm the present studys result. This result can be due to
several reasons. For example, one reason is that being female, the household heads are more
aware of delivery complications. Another reason may be that the women can talk more easily
with the female head about their fear of complications and other problems. Therefore, the
female household head encouraged women and make the decision to use SBAs at delivery.
Usually the head of the household has the overall control over the household resources.
Therefore, the head irrespective of sex, can make a decision regarding the use of resources.
The female household heads use more resources to afford maternal health care services; this
is supported by research finding from India which indicates that a woman's control over
household resources has a significant positive effect on the use of antenatal care and
professional delivery assistance [58].

In this study, urban women were significantly associated with increased odds of delivering
with skilled assistance. This finding reflects the finding of several previous studies which
have reported a significantly higher use of skilled assistance at delivery by urban women
compared to rural women in Bangladesh [42] and elsewhere [30, 37, 41]. A reason for this
may be the availability of health facilities, because health facilities are much more convenient
in urban areas than rural areas in developing countries like Bangladesh. This close proximity
allows urban women greater access to information and knowledge regarding modern health
care facilities, which influences them to use these facilities. This is supported by Anwar et al
indicating that women who live more than five km from the health facility are significantly
less likely to receive skilled assistance at delivery [42]. Other reasons may be that the urban
women are from the families who have a higher level of education and have a higher level of
household economic status. In this study, nearly half (49.62%) of urban women had more
than primary education, while the percentage was 37.16% for the rural women. Similarly, the
percentage of urban women whose husbands had more than primary education was
approximately 49%, while it was 31.46% for the rural women. The majority (67.83%) of the
urban women were classified within richer and richest categories, while roughly 26% of rural
women were classified similarly. This finding is consistent with previous studies in Turkey
and Ethiopia among others [37, 57].

This studys finding regarding the positive association between economic status of the
household and the use of SBAs at delivery concurs with previous reports in Bangladesh [42]
and elsewhere [32, 35, 36]. The study in Bangladesh that aimed to assess the inequity in
maternal health care services, have reported that women with the highest asset quintile were
almost three times higher than the lowest quintile women to use skilled assistance at delivery
[42]. We found that the odds of using SBAs at delivery consistently increased as the

- 29 -
household economic status increased. A reason for this finding may be that the family
members from higher level of household economic status are more aware of existing modern
health care services and can afford those services easily. The costs of seeking skilled
assistance at delivery may act as an important barrier to women from poorer households.
Another reason may be that the women who were classified as belonging to the richer and
richest wealth index had a higher level of education. In this study, around 72% and more than
56% of women from richest and ricer wealth index, respectively, had more than a primary
education.

In this study, women whose husbands worked in skilled work such as business and services
were more likely to use SBAs at delivery compared to the women whose husbands were
involved in unskilled work. This finding consistent with a study by Chakraborty et al in
Bangladesh indicating husbands occupation as a significant predictor to use skilled
assistance at delivery [3]. Husbands occupation also serves as proxy for household economic
status. As it is discussed earlier, the more the household economic status the more likely to
use skilled assistance at delivery.

4.2. Limitations of the Study

There are several limitations in the interpretation of the results of this study. First, the
logistic regression results are not adjusted for other independent variables because of some
variables which were highly correlated. Therefore, the findings may be imprecise in
estimation. Second, this study was based on the analyses of the 2007 BDHS data set.
Recently, the 2011 BDHS preliminary report has been published. Thus, the findings of this
study are not up to date. As yet, the 2011 BDHS data set are not publicly available. Therefore,
the present study cannot include the analyses of the 2011 BDHS data set and the study
started before this recent survey. Third, because of the cross-sectional nature of the data, the
analysis can only provide evidence of statistical association between independent variables
and the use of SBAs at delivery and cannot show cause-effect relationship. Fourth, the 2007
BDHS did not collect information about many of the other recognized factors such as the
quality of services, cultural influences, the attitude of health care providers towards
clients, and psychosocial factors. Therefore, the study cannot provide additional
information about these factors, which are considered to be related to the use of maternal
health services. Finally, because data on distance to the health facilities were not collected, a
proxy measure of place of residence was taken for this study. Thus, it is not possible to
directly assess the effects of other factors on the accessibility to the health facilities.
Nevertheless, as the 2007 BDHS uses a well-established methodology that is used in

- 30 -
many countries and subject to good quality assurance procedures, the information
collected on the studied variables is valid and important.

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 5. CONCLUSION
This study has identified a number of important factors that influence the use of skilled
assistance at delivery by pregnant women of Bangladesh. The use of skilled attendants at
delivery was found to be very low and unequally distributed. The distribution of the use of
SBA varied among women with different demographic and socio-economic characteristics.
The logistic regression analysis indicated parental education as the most significant
predictive factors for the use of skilled assistance at delivery. Therefore, informal adult
education for women and men can be employed as an immediate intervention to provide
basic education and to increase awareness about basic maternity care. Besides, special efforts
and attention to improve formal education of the girls and boys are needed in a long run.
Higher birth order appeared as a strong predictor to not use of professional assistance at
delivery. Therefore, raising awareness about the use of SBAs among women and men through
mass media and local human resources (religious leader, political leader, school teacher,
village headman, and singer) may be an immediate intervention accompanied by improving
access to family planning as a long term strategy. Women from Muslim religion were less
likely to use SBAs at delivery. Further qualitative study needs to be conducted to explore the
insights of the women. However, as the religious leaders are considered influential persons
especially in the rural areas, meetings or seminars with them can be a way of short term
intervention to discuss the consequences of not using skilled assistance at delivery. Women
from rural areas, women whose husbands were involved in unskilled work, and women from
lower wealth index were at a greater disadvantage in using SBAs. Informal education and
vocational training for those groups of women may serve as an immediate strategy to
improve the use of SBAs at delivery. Informal education and vocational training will enable
the women to acquire skills and be engaged in income generating activities. These skills and
activities will empower the women and improve their access and the use of health care
services and SBAs at delivery in particular. Additionally, special attempts of delivery care
services should be prepared for those groups of women as a long term strategy. For example,
more services should be offered to the rural areas with mass awareness program to use those
services and a reimbursable maternal health voucher by the government facilities can be
introduced.

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 6. REFERENCES
1. World Health Organization. Maternal mortality: Factsheet; 2010. Available at:
http://www.who.int/mediacentre/factsheets/fs348/en/index.html (Accessed:
December 5, 2011).
2. World Health Organization. Trends in maternal mortality: 1990 to 2008: Estimates
developed by WHO, UNICEF, UNFPA and The World Bank. Geneva: World Health
Organization; 2010.
3. Chakraborty N, Islam MA, Chowdhury RI, Wasimul Bari W, Akhter HH.
Determinants of the use of maternal health services in rural Bangladesh. Health
Promotion International. 2003; 18 (4):327-337.
4. World Health Organization. International statistical classification of diseases and
related health problems, Tenth revision. Geneva: World Health Organization; 1992.
5. National Research Council. The Consequences of maternal morbidity and maternal
mortality: Report of a workshop. Committee on population. In: Reed HE, Koblinsky
MA, Mosley WH, editors. Commission on behavioral and social sciences and
education. Washington DC: National academy press; 2000. Available at:
http://www.nap.edu/openbook.php?record_id=9800&page=R1 (Accessed:
December 11, 2011).
6. World Health Organization. Maternal mortality in 2005: Estimates developed by
WHO, UNICEF, UNFPA and The World Bank. Geneva: World Health Organization;
2007.
7. Kwast BE. Reduction of maternal and perinatal mortality in rural and peri-urban
settings: what works? European Journal of Obstetrics & Gynecology and
Reproductive Biology. 1996; 69:47-53.
8. Starrs AM. Safe motherhood initiative: 20 years and counting. Lancet. 2006; 368
(9542):1130-1132.
9. Maine D, DrPH, Rosenfield A. The safe motherhood initiative: Why has it stalled?
American Journal of Public Health. 1999; 89 (4):480-481.
10. World Bank. Safe motherhood and maternal health. 2011. Available at:
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIO
NANDPOPULATION/EXTPRH/0,,contentMDK:20200213~menuPK:548457~pageP
K:148956~piPK:216618~theSitePK:376855,00.html (Accessed: December 7, 2011).
11. United Nations. Report of the international conference on population and
development program of action; 1994 September 5-13; Cairo. New York: United
Nations; 1995.
12. United Nations. Report of the fourth world conference on women; 1995 September 4
15; Beijing. New York: United Nations; 1996.

- 33 -
13. United Nations. The millennium development goals report 2011. New York: United
Nations; 2011.
14. United Nations Children's Fund. Progress for children: A report card on maternal
mortality. UNICEF; 2008.
15. Bangladesh Bureau of Statistics. Statistical year book of Bangladesh 2008 (28th
edition). Dhaka, Bangladesh: Bangladesh Bureau of Statistics; 2009.
16. Directorate General of Health Services. Health Bulletin 2010. Dhaka, Bangladesh:
Directorate General of Health Services; 2010.
17. Bangladesh Bureau of Statistics. Population & housing census 2011 preliminary
results. Dhaka, Bangladesh: Bangladesh Bureau of Statistics; 2011.
18. World Health Organization. Country health system profile: Bangladesh. 2007.
Available at: http://www.searo.who.int/en/Section313/Section1515_6038.htm
(Accessed: December 20, 2011).
19. Osman F A. Health policy, program and system in Bangladesh: achievements and
challenges. South Asian Survey. 2008; 15(2): 263-288.
20. Streatfield PK, Arifeen SE, Al-Sabir A, Jamil K. Bangladesh maternal mortality and
health care survey 2010: Summary of key findings and implications. Dhaka,
Bangladesh: National Institute of Population Research and Training; 2011.
21. United Nations Development Program: Bangladesh. MDGs and Bangladesh. 2010.
Available at: http://www.undp.org.bd/mdgs.php (Accessed: 25 December, 2011).
22. Nasreen HE, Ahmed SM, Begum HA, Afsana K. Maternal, neonatal and child health
program in Bangladesh-review of good practices and lessons learned. Dhaka,
Bangladesh: Research and evaluation division, Bangladesh Rural Advancement
Committee; 2007.
23. World Health Organization. Making pregnancy safer: the critical role of the skilled
attendant: a joint statement by WHO, ICM and FIGO. Geneva: World Health
Organization; 2004.
24. National Institute of Population Research and Training (NIPORT), Mitra and
Associates, and Macro International. Bangladesh Demographic and Health Survey
2011-Preliminary Report. Dhaka, Bangladesh and Calverton, Maryland, USA:
National Institute of Population Research and Training, Mitra and Associates, and
Macro International; 2012.
25. Wendy J, Graham WJ, Bell JS, Bullough CH. Can skilled attendance at delivery
reduce maternal mortality in developing countries? Safe motherhood strategies: A
review of the evidence. Antwerp, Belgium: ITG press; 2001.
26. World Health Organization. Proportion of births attended by a skilled health worker:
2008 updates. Geneva: World Health Organization; 2008.

- 34 -
27. World Health Organization. Neonatal and perinatal mortality: country, regional
and global estimates 2004. Geneva: World Health Organization; 2006. Available at:
http://www.who.int/maternal_child_adolescent/documents/9789241596145/en/ind
ex.html (Accessed: December 20, 2011).
28. Letamo G, Rakgoasi S D. Factors associated with the non-use of maternal health
services in Botswana. Journal of Health Population and Nutrition. 2003; 21:40-47.
29. United Nations Children's Fund. Monitoring the situation of children and women-
delivery in health facility. United Nations Children's Fund; 2012. Available at:
http://www.childinfo.org/delivery_care.html (Accessed: March 17, 2012).
30. Thind A, Mohani A, Banerjee K, Hagigi F. Where to deliver? Analysis of choice of
delivery location from a national survey in India. Bio Med Central Public Health.
2008; 8(29), doi: 10.1186/1471-2458-8-29.
31. Paul BK, Rumsey DJ. Utilization of health facilities and trained attendants for
childbirth in rural Bangladesh: an empirical study. Social Science and Medicine.
2002; 54: 1755-1765.
32. Matsumura M, Gubhaju B. Womens status, household structure and the Utilization
of maternal health services in Nepal. Asia-Pacific Population Journal. 2001; 16(1):
23-44.
33. Shaikh BT, Hatcher J. Health seeking behavior and health service utilization in
Pakistan: challenging the policy makers. Journal of Public Health. 2004; 27(1):4954
34. AbouZahr C. Global burden of maternal death and disability. British Medical Bulletin.
2003; 67:1-11.
35. Shariff A, Singh G. Determinants of maternal health care utilization in India: evidence
from a recent household survey. National Council of Applied Economic Research.
Working Paper Series. 2002; 85.
36. Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria-
looking beyond individual and household factors. Bio Med Central Pregnancy and
Childbirth. 2009; 9 (43), doi: 10.1186/1471-2393-9-43.
37. Celik Y, Hotchkiss DR. The socio-economic determinants of maternal health care
utilization in Turkey. Social Science & Medicine. 2000; 50(12):1797-1806.
38. Mrisho M, Schellenberg JA, Mushi AK, Obrist B, Mshinda H, Tanner M, Schellenberg
D. Factors affecting home delivery in rural Tanzania. Tropical Medicine and
International Health. 2007; 12 (7):862-872.
39. Raghupathy S. Education and the use of maternal health care in Thailand. Social
Science & Medicine. 1996; 43 (4): 459-471.
40. Ekale BA, Tunau KA. Place of delivery among who had antenatal care in a teaching
hospital. Acta Obstetricia et Gynecologia Scandinavica. 2007; 86 (5): 627-630.

- 35 -
41. Say L, Raine R. A systematic review of inequalities in the use of maternal health care
in developing countries: examining the scale of the problem and the importance of
context. Bulletin of the World Health Organization. 2007; 85 (10):812-819.
42. Anwar I, Sami M, Akhtar N, Chowdhury ME, Salma U, Rahmanc M, Koblinskya M.
Inequity in maternal health-care services: evidence from home-based skilled-birth-
attendant programs in Bangladesh. Bulletin of the World Health Organization. 2008;
86 (4):252-259.
43. Glei DA, Goldman N. Understanding ethinic variation in pregnancy related care in
rural Guatemala. Ethnicity and Health. 2000; 5 (1): 5-22.
44. Falkingham J, Inequality and changes in womens use of maternal health care
services in Tajikistan. Studies in Family Planning. 2003; 34 (1): 32-43.
45. Navaneetham K, Dharmalingam A. Utilization of maternal health care services in
Southern India. Social Science & Medicine. 2002; 55(10): 1849-1869.
46. Andersen RM: Revisiting the behavioral model and access to medical care: does it
matter? Journal of Health and Social Behavior. 1995; 36(1):1-10.
47. National Institute of Population Research and Training (NIPORT), Mitra and
Associates, and Macro International. Bangladesh Demographic and Health Survey
2007. Dhaka, Bangladesh and Calverton, Maryland, USA: National Institute of
Population Research and Training, Mitra and Associates, and Macro International;
2009.
48. MEASURE DHS. Demographic and health survey. Available at:
http://legacy.measuredhs.com/login.cfm. (Accessed: 20 May, 2011).
49. International Institute for Population Sciences (IIPS) and Macro International.
National Family Health Survey (NFHS-3), 200506: India: Volume I. Mumbai,
India: International Institute for Population Sciences; 2007
50. National Institute of Population Studies (NIPS) [Pakistan], and Macro International
Inc. Pakistan Demographic and Health Survey 2006-07. Islamabad, Pakistan:
National Institute of Population Studies and Macro International Inc; 2008.
51. Statistics Indonesia (Badan Pusat Statistik) and Macro International. Indonesia
Demographic and Health Survey 2007. Calverton, Maryland, USA: Badan Pusat
Statistik and Macro International; 2008.
52. Ministry of Health and Family (MOHF) [Maldives] and ICF Macro. Maldives
Demographic and Health Survey 2009. Calverton, Maryland: MOHF and ICF Macro;
2010.
53. Pitchforth E, Van Teijlingen E, Graham W, Dixon-Woods M, Chowdhury M. Getting
women to hospital is not enough: a qualitative study of access to emergency obstetric
care in Bangladesh. Quality and Safety Health Care. 2006; 15: 214219.

- 36 -
54. Parkhurst J O, Rahman S A. Non-professional health practitioners and referrals to
facilities: lessons from maternal care in Bangladesh. Health Policy and Planning.
2007; 22:149155.
55. Hossen Md. A, Westhues, A. Rural Women's Access to Health Care in Bangladesh:
Swimming Against the Tide? Social Work in Public Health. 2011; 26: 278293.
56. Bloom S S, Wypij D, Das Gupta M. Dimensions of womens autonomy and the
influence on maternal health care utilization in a north Indian city. Demography
2001; 38: 67-78.
57. Mekonnen Y, Mekonnen A. Factors influencing the use of maternal healthcare
services in Ethiopia. Journal of Health Population and Nutrition. 2003; 21:374-382.
58. Maitra P. Parental bargaining, health inputs and child mortality in India. Journal of
Health Economics. 2004; 23: 259-291.

- 37 -