International Journal of Public Health Research 2015; 3(6): 384-389 Published online December 8, 2015 (http://www.openscienceonline.com/journal/ijphr) ISSN: 2381-4829 (Print); ISSN: 2381-4837 (Online)
Perceptions, Practices and Challenges on Birth Planning in Rural Bangladesh Animesh Biswas1, 2, *, Abu Sayeed Md. Abdullah2 1 2
Department of Public Health Science, School of Health and Medical Sciences, Örebro University, Örebro, Sweden Centre for Injury Prevention and Research, Bangladesh (CIPRB), Dhaka
Email address
[email protected] (A. Biswas),
[email protected] (A. Biswas)
To cite this article Animesh Biswas, Abu Sayeed Md. Abdullah. Perceptions and Challenges on Birth Planning in Rural Bangladesh. International Journal of Public Health Research. Vol. 3, No. 6, 2015, pp. 384-389.
Abstract Background: Birth planning is essential to ensure safe delivery of mother. Inadequate birth planning during pregnancy increases risk of maternal and neonatal deaths including stillbirths. Bangladesh is facing challenge to address appropriate birth planning for pregnant mothers. Objective: The study explores the perception and practice of birth planning among the rural communities. Moreover, the study reveals the challenges in the community related to birth planning issues. Methods: A qualitative study has been conducted in a district of Bangladesh. Five focus group discussions (FGDs) and twenty in-depth interviews (IDIs) were conducted in the rural community. Results: The study found that mother’ perceptions are highly important, which are scarce in practice. Ignorance, traditional myth and perception of a male person in the family, influences of traditional birth attendants and villages doctors have been identified as the main barriers of an appropriate birth plan. Conclusions: The study concludes that community perception of birth planning is inadequate and the decision makers in the family are irresponsible to take appropriate planning for the mothers. Barriers in the society also influence, thus, to ensure safe delivery and to reduce the maternal and neonatal deaths in Bangladesh. Policy makers need to emphasise on the specific community needs on birth planning.
Keywords Birth Planning, Pregnancy and Childbirth, Maternal Death, Bangladesh
1. Introduction It has been estimated that 350000 mothers are dying every year due to pregnancy or delivery related causes around the world, most of deaths are occurring in developing countries [1, 2]. In Bangladesh, maternal mortality is progressively reducing from 320 to 194 per 100000 live births during the last decade [3]. The country has been putting tremendous effort to achieve millennium developmental goals (MDGs) in time [4]. The majority of deaths are occurring due to obstratical causes [5]. Pregnancy outcome influenced by quality antenatal care and social practices including awareness during pregnancy period [6, 7]. Birth planning is defined as an ideal way to communicate the preferences, so that the mother-to-be can fully focus on the process of birthing a baby [8]. Social culture and antenatal care seeking practices affect the pregnancy outcome [9, 10]. Moreover, awareness of mother during pregnancy period also play an
important role [11]. According to Bangladesh maternal mortality survey of 2010, 43% of pregnant women did not plan for place to deliver, and only 11% pregnant decided to deliver in a facility. Around 34% of pregnant did not decide about who would assist their delivery and only 17% decided to deliver with assistance of a trained provider [12-14]. Only 26% of pregnant women, who received ANC, knows the danger signs of pregnancy, where to deliver and where to go in emergency. 18% pregnant in the third trimester told about transport arrangements as a means of birth planning [12]. Perhaps, approximately 89.9% were prepared with selection of place for delivery and 79.9% are prepared with attendance at delivery, but are not prepared in terms of arrangement of transport, saving of money, identification of blood donor and arrangement of delivery kits [15]. In addition, significant number of mothers are delivering child at home by the untrained birth attendant or their relatives [16], which means that proper birth planning yet not in practiced. The perception, practices on birth planning in the rural
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community and its challenges need to be explored to understand the context for better planning to reduce maternal mortality in low-income country settings.
2. Methodology A qualitative study was conducted in Sirajganj district of Bangladesh during January to March 2014. Two sub-districts (upazilas) were selected purposively in where focus group discussions and in-depth interviews were conducted. For FGDs, we chose five groups. First group was with the pregnant mothers; second one with the recently delivered mothers (delivered a live baby in last three months), third group was selected of female guardians of pregnant or recently delivered mothers including mother in laws and mothers. Forth group was male guardian of pregnant or recently delivered mothers including husbands, fathers and father in laws were also included. In the last group was with the traditional birth attendants of that specific community. Each of group consist of 9 -11 participants. We have found six maternal deaths reported during October to December 2014 in two upazilas. For in-depth interviews, participants were chosen from those deceased families. Twenty IDIs were performed with the male and female guardians of the families to understand their views on birth planning. All IDIs were conducted following guidelines by face-to-face interview at the household level. Two trained research officers were assigned to collect the data from the field. Formal training was provided; guidelines were pre-tested before data collection. During FGDs, one research officer facilitated the discussion whereas, while other research officer took important notes. The objectives of the research were clearly demonstrated to respondents before the interviews. A written consent was taken from each of the respondents before the interviews or FGDs. A number of prompts were used to obtain the information. Audio voice recording was done prior to permission from the respondents. From the audio-recordings and hand notes of the interviewer’s, the research officers prepared IDIs and FGDs transcripts in native Bengali language. Later, translation of the transcripts was done. Randomly selected 10% transcripts were reviewed by the principal researcher to ensure quality of transcripts. Peer debriefing also performed to maintain reliability of the data. Initial open coded was done, then from those open code, selective coding was done. Themes were identified after read and re-read of the data [17, 18] and finally analysis was performed thematically.
3. Results 3.1. Perceptions The focus group discussions revealed a higher level of perceptions on birth planning among the mothers and their mother in laws who had delivered a live baby in the last three months. This group had planning on place of delivery and decided who will be accompany during the time of delivery.
On the other hand, male groups (included husbands, father and father in law) perceived that birth planning is an issue only confined to women; it’s not an issue of a male in the family. Whereas, the pregnant mother group felt importance of antenatal check-up, selection of place of delivery and person who will be delivered. We have performed in-depth interviews with deceased family members whose mothers died due to maternal complications. Majority of the female guardian understood birth planning in different ways such as ensuring safely movement of mother during working time, preparing baby’s cloths after birth, contact with traditional birth attendant (TBA) before delivery etc. While it was explored that around one fourth of the respondents did not have any idea on real birth planning. TBAs were not had clear ideas on birth planning. They perceived birth planning is to plan who will deliver. However, most of the participants felt that appropriate birth planning is extremely essential and they had a number of misperception, which caused maternal deaths. Mother of a deceased mother mentioned during IDI “My daughter was in good health so I didn’t worry about her delivery at home by TBA. I even never take my daughter to hospital for check-up as she looks healthy. But we couldn’t save her life, it was her fate assigned by the almighty god”. An eight months pregnant mother in FGD said “Most of our local villagers thought that the birth would occur normally without any preparation but we came to realize that birth planning is essential to take necessary action if any maternal complications arise.” One of the TBA mentioned in FGD “I am not aware of what’s birth planning is, but we suggest pregnant mothers to keep ready all materials required at time of delivery at home, I personally think if the mother eat more, the child will be more weight and it will be difficult to deliver normally ” Another mother of a deceased mother said “Villagers don’t understand the issues related to birth planning. When delivery pain started, the baby normally delivered at home by local TBA. If any problem occurs during home delivery, only on that case we think further”. “Preparation for delivery of pregnant mother is critical. We tried to deliver at home, my mother and relatives were delivering the baby, one of the leg come out at first. They were afraid and then decided to transfer my wife to near upazila health complex. It was too late, she died before arrived in the hospital. Now I realized that if we had proper birth planning, my wife could survive” –Husband of a deceased mother during interview mentioned. However, one of the mother who delivered a baby recently spoke
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“Our society still far behind. I had a great wish to deliver my baby by a nurse in the hospital. It was not possible because my mother and father in law believed that it can be easily performed by the local birth attendant”.
and my mother, but it is our fate that we cannot save her.” A recently delivered mother said in the FGD “It was my first child and my mother is a dai (TBA). So my delivery took place at my home, and it was more safe.”
3.2. Practices Majority of respondents in female guardian group of recently delivered mothers mentioned during FGD that they practiced where to deliver, special care for the mother during pregnancy, saved some money and planned for who will deliver. Most of the participants in IDIs from the deceased families described that they did not aware of exact date of delivery and were not prepare for any kind of birth planning. Moreover, they called the untrained birth attendant when the labour pain began. It was also identified that practice of birth planning means in mostly to them is expense money, which they felt difficult to organize. Whereas, the traditional birth attendants felt themselves confident to conduct the delivery. Furthermore, the community people contract TBA at first before delivery conduction. TBAs also conveyed social myths to the pregnant mother for easy come out of the baby. One of mother in law of a deceased mother mentioned during in-depth interview stated “How can I take birth planning, we cannot even bear the regular need of the family due to scarcity of money” Another mother in law of a delivered mother mentioned in FGD “From the beginning of pregnancy of my daughter in law, I give her egg every day and make sure of her health because she was ill health before marriage.” A recently delivered mother discussed in a FGD described “I have passed class eight before marriage and learn about birth planning from leaflet, papers and television. I took injection of tetanus and antenatal care during pregnancy, also saved some money in my trunk every month for delivery purpose.” Husband of a deceased mother, During IDI said “my sister in law came before delivery of my wife. I had saved one thousand taka to call traditional birth attendant near to my resident, when delivery pain arises.” It was also discussed on the key components of birth planning including place of delivery, place to go during complications, saving money, selecting person to go with, blood grouping and selecting of blood donors. Most of the participants in both FGDs and IDIs mentioned to practice delivery at home since they found home is the safest place for delivery than any other places. The respondents also mentioned that this caused minimum expenses required to deliver a baby. During IDI, a mother of a deceased mother told “previously my daughter delivered two babies normally at home; therefore, this time we also planned for home delivery. Other thing was that doctors at hospital always prefer for operation. Thus I decided to make delivery at home by TBA
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Table 1. List of Participants in the qualitative study. Qualitative instruments
Age range
FGD ( n=5)
18 - 50 years
IDI ( n=20)
25 - 60 years
Participants Pregnant mothers, recently delivered mothers, female guardians, male guardians and Traditional Birth Attendants Female guardians and male guardians of deceased mothers.
Table 2. Content of the focus-group discussion and In-depth interview. Area of discussion Perception on birth planning in the community
Practice of birth preparedness at Community
Barrier of the community to practices birth planning
Types of Prompts used Idea about birth planning? Where and from whom got ideas about birth planning? Why the responder didn’t get proper ideas on birth planning? What preparation during pregnancy? Where delivered? Who assist delivery? Where they go during complication? What is the blood group of mother & selection of blood donor? Whether the vehicle is ready to go at facility? Whether person is selected to go with mother? What are the social and family barrier at community in practicing birth planning
We did not find any respondents of IDIs practiced on where to go during any complications. They had in their mind that it was traditional birth attendant’s responsibility to manage. Whereas, some of the respondents in FGDs said that they had prepared planning on where to go during any complications. One of the Father in laws of a recently delivered mother described in FGD “We had a plan to go to the Upazila health complex, a kilometer away from our resident. However, by the grace of almighty, safe delivery took place at home by a local dai”. Another one mother of a deceased mother said, “We did not have any plan, it was bad luck. When the baby come out with hand prolapse, local birth attendant recommended us to bring my daughter to nearby private clinic” Prepared for a transport support to transfer mothers during complications were practiced by the participants in the FGDs in most of the cases. Whereas, in the deceased group, surprisingly, in most of the cases in IDI, respondents did not practice any selection of vehicle, rather they thought that it was easy to collect during complications. At the time of FGD, a mother in laws of recently delivered mother said, “I contracted a rickshaw puller beside my house in case of any emergency” During IDI father of a deceased mother, said, “We did not prepared for that, when bleeding started at around 4 am in the morning after the delivery conducted by a TBA. We were looking for a local transport. It took around two hours to get it, and my daughter died on the way to facility”.
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Issues related saving money for birth planning, FGD participants practiced in many of the cases, for example, they saved rice instead of money, in crisis they could sale those to get money back. Some of them have a plan to sale their domestic animals or lease their land if any complications arise. Whereas, during interviewing the deceased family, despite of planning properly, most of them spent money by borrowing from neighbours or relatives. A mother of a deceased mother spoke “We had no ability to save money separately for emergency. We borrowed money from relative during the complications.” A recently delivered mother said during FGD, “It was my second pregnancy. I reserved small amount rice every day for nine months, and my family knew this savings”. None of the participants in deceased family groups practiced on who will go with the mother or doing blood group or manage donor if any complications arise. However, only a few respondents had selected relatives or neighbors to go with mother in FGD participants. In addition, just delivered mothers group in FGD found that some of them knew their blood group but didn’t prepared any donor. 3.3. Challenges 45% male respondents in FGDs and majority of male respondents (85%) in IDIs had no ideas on birth planning. During discussions, male had a misperception on this issue and thought that it was an issue of women in the family. About 85% recently delivered mother and pregnant mothers in FGD mentioned that the main obstacles to prepare a birth planning is the female decision makers in the family including mother and mother in law. Whereas, most of the participants (80%) in the IDIs mentioned that they depended on traditional birth attendant. They believed that TBA would ensure their safe delivery, which did not happen at end. Whereas, TBAs are not much aware of birth planning. They still practice some traditional myth. Almost all participants expressed that knowledge of birth planning should be transmitted to the household head of the family. They recommended to aware the community through video show, health camp and courtyard meetings. They also suggested more involvement of government health workers in the community to motivate elder women in the family on birth planning. A recently delivered mother told in FGD “I wanted to deliver at facility, but my mother in law said to deliver at home, since in facility doctor will do operation.” One of the TBA in FGD described “I have conducted delivery for many years, no death occurred. I told to each mother to work hard before delivery. It helped me to easily deliver the baby”
4. Discussions The male and female guardian of a recently delivered mother have more ideas and practices more at community than the guardian of deceased mothers. The pregnant mothers and recently delivered mothers groups have good
knowledge on birth planning. However, they cannot practice properly due to family and social barrier at community. Male guardian has more ignorance on birth planning; for instance, they thought it should be managed by female members of a family. However, the mother and mother in law of deceased mothers have ideas on birth planning but cannot overcome the traditional practices at community. Whereas the guardian of a recently delivered mother adapted to practices birth planning, e.g., regular ante natal check-up, saving money, selecting places, skilled person for safe delivery. About 16.5% mothers prepared for birth and complications regarding place of delivery identification, means of transport, skilled attendant selection and saving money [19]. Some social conditions of mothers may adversely affect on the outcomes of pregnancy and socially excluded women are at higher risk of death during or after pregnancy [9]. About 17% mothers who died for maternal complication had social complex life with less likely to seek antenatal care during pregnancy [10]. The vulnerable mothers are late in recognizing their pregnancy to get early maternity care which could be overcome through providing flexible services according to the necessity [20]. Maternal stress in pregnancy has a detrimental effect on subsequent childhood development, which is two times higher in nonwhite ethnic group of women [21]. The more preparation during pregnancy, the more awareness of mother is found at delivery which is positively associated with the safe delivery and healthy baby [22]. Between 11000 and 12000 mother die during delivery. 85% of them died from obstetric cause every year in Bangladesh [5]. The financial barrier is one of the main factors for not to receive health care service from qualified provider rather took services from village doctors. Other factors include age at marriage and childbirth, educational level, work and economic status, telling about pregnancy complication and permission to go to hospital or health care are the significant determinant of receiving ANC. Moreover, the location of the services and residence and husband awareness also influences these barriers as well as there exist strong urban-rural differentials of receiving ANC [23, 24]. Understanding importance of knowledge and practices on ANC among pregnant mother and socio-demographic characteristics are very important to reduce maternal mortality [7]. The barrier to take maternal care at facility are inadequate human resources, logistics and supply of drugs, poor cleanliness, long waiting time with less consulting time, poor laboratory services and unnoticed cost for services [25]. Mother with one living child has higher percentage of ANC receive comparatively. For ensure ANC to rural mother information, communication and education are mandatory [26]. About half of mothers have life threatening complication during pregnancy, but refuse to deliver at facility due to over medical cost, and socio-economic disparities. Three-fourth of mothers have complication of convulsion or excessive bleeding failed to seek any treatment from qualified provider in both urban and rural
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Bangladesh [27]. If trained midwives posted at rural level with continuous supervision, the maternal survival can be improved in Bangladesh [28]. The maternal mortality ratio and perinatal mortality rate is declined if mother sought obstetric care with skill birth attendance at community level in Bangladesh [29]. Awareness among mothers through regular household visit with advocacy services and referral and recommend for nearby hospital services can reduce maternal complicacy. In addition, reducing the cost during child birth mid wives can play an important role at rural community in Bangladesh [11].
5. Conclusion Community perception of birth planning was found inadequate among the group who had a delivery of live births and the group who had maternal deaths in their family. There was scarcity of knowledge among male respondents in both group; therefore, in decision making to take appropriate birth planning was missing in majority cases. Mother and mother in law in a family also require to get better knowledge to improve their practice. It has been identified that the community are still dependent on traditional birth attendant to deliver in most of the cases. Focused intervention is required by the government at the local level to improve overall situation of birth planning which will subsequently reduce maternal and early neonatal deaths including stillbirths in Bangladesh.
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