BDHS 2001

Download as pdf or txt
Download as pdf or txt
You are on page 1of 237

Bangladesh Maternal

Health Services and


Maternal Mortality
Survey 2001

FINAL REPORT
Bangladesh 2001 Maternal Health Services and Maternal Mortality Survey
Bangladesh
Maternal Health Services and Maternal
Mortality Survey
2001

National Institute of Population Research and Training (NIPORT)


Dhaka, Bangladesh

ORC Macro
Calverton, Maryland, USA

Johns Hopkins University


Baltimore, Maryland, USA

ICDDR,B: Centre for Health and Population Research


Dhaka, Bangladesh

December 2003
Data collection and data processing agencies:

Associates for Community and Population Research (ACPR)


3/10 Block A, Lalmatia, Dhaka-1207

Mitra and Associates


2/17 Iqbal Road, Mohammadpur, Dhaka-1207

Special acknowledgement:

Dr. Kanta Jamil, Program Coordinator for Research, PHN Team, USAID, Dhaka for technical assistance
at all steps of survey implementation, data analysis and report generation

Mr. Han Raggers for data tabulation and analysis

Cover photo courtesy:

Dr. Syed Moshfiqur Rahman

The 2001 Bangladesh Maternal Health Services and Maternal Mortality Survey is part of the worldwide
MEASURE DHS+ project, which is funded by the U.S. Agency for International Development (USAID).
The opinions expressed herein are those of the authors and do not necessarily reflect the views of the
Government of Bangladesh or USAID.

Additional information about the Bangladesh Maternal Health Services and Maternal Mortality Survey
may be obtained from the National Institute of Population Research and Training (NIPORT), Azimpur,
Dhaka-1205, Bangladesh (Telephone: 862-5251; Fax: 861-3362). Information about the MEASURE
DHS+ program may be obtained from ORC Macro, Suite 300, 11785 Beltsville Drive, Calverton, MD
20705, U.S.A. (Telephone: 301-572-0200; Fax: 301-572-0999).

Suggested citation:

National Institute of Population Research and Training (NIPORT), ORC Macro, Johns Hopkins
University and ICDDR,B. 2003. Bangladesh Maternal Health Services and Maternal Mortality Survey
2001. Dhaka, Bangladesh and Calverton, Maryland (USA): NIPORT, ORC Macro, Johns Hopkins
University, and ICDDR,B.
CONTENTS
Page

Tables and Figures ........................................................................................................................... vii


Foreword.......................................................................................................................................... xi
Preface ........................................................................................................................................... xiii
Summary of Findings ....................................................................................................................... xv

CHAPTER 1 INTRODUCTION

1.1 Safe Motherhood and MCH-FP Programs in Bangladesh............................................1


1.2 History of MCH in Bangladesh...................................................................................1
1.3 NGO Sector ..............................................................................................................4
1.4 Plans for Emergency Obstetric Care (EOC) and Safe Motherhood ..............................4
1.5 Met Need for Emergency Obstetric Care ...................................................................5
1.6 Organization of the 2001 BMMS ...............................................................................6

1.6.1 Survey Objectives and Implementing Organizations ...................................6


1.6.2 Survey Design.............................................................................................6
1.6.3 Questionnaires ...........................................................................................7
1.6.4 Training and Fieldwork ...............................................................................8
1.6.5 Data Processing ..........................................................................................8
1.6.6 Response Rate ............................................................................................9

CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS

2.1 Household Population .............................................................................................11

2.1.1 Demographic Characteristics of Households .............................................11


2.1.2 Marital Status............................................................................................11
2.1.3 Household Composition...........................................................................12
2.1.4 Education .................................................................................................13

2.2 Housing Characteristics............................................................................................14

2.2.1 Household Possessions .............................................................................15

2.3 Characteristics of Survey Respondents .....................................................................17

2.3.1 Background Characteristics.......................................................................17


2.3.2 Educational Level of Survey Respondents ................................................17
2.3.3 Exposure to Mass Media ...........................................................................18

Contents | iii
CHAPTER 3 ADULT FEMALE MORTALITY: LEVELS AND CAUSES

3.1 Measures of Maternal Mortality ...............................................................................21

3.1.1 Measuring Maternal Mortality ...................................................................21


3.1.2 Maternal Mortality Measures in the BMMS ...............................................23

3.2 Maternal Mortality In Bangladesh: Levels And Causes ..............................................23

3.2.1 Estimates from Household Deaths ............................................................23


3.2.2 Estimates of Pregnancy-Related Mortality from Sibling Histories ................28
3.2.3 Distribution of Maternal Deaths by Timing Relative to Delivery ................29
3.2.4 Summary of Estimates of Pregnancy-Related and Maternal Mortality,
1986 to 2001 ...........................................................................................30

3.3 Overall Adult Mortality ............................................................................................31

3.3.1 Adult Mortality Estimates from Household Deaths ....................................31


3.3.2 Adult Mortality Estimates from Sibling Histories ........................................34

CHAPTER 4 MATERNITY CARE

4.1 Antenatal Care.........................................................................................................37

4.1.1 Source of Antenatal Care ..........................................................................38


4.1.2 Number and Initial Timing of Antenatal Care............................................39
4.1.3 Reasons for Seeking or Not Seeking Antenatal Care ..................................41
4.1.4 Information/Services Received during Antenatal Care ...............................42
4.1.5 Antenatal Care in Consecutive Pregnancies...............................................45

4.2 Birth Planning ..........................................................................................................46

4.2.1 Information Received on Delivery Advice During Pregnancy ....................46


4.2.2 Decision on Delivery Assistance for Current Pregnancy.............................47
4.2.3 Decisionmaker Regarding Delivery Assistance...........................................49

4.3 Delivery Care ..........................................................................................................50

4.3.1 Place of Delivery ......................................................................................50


4.3.2 Assistance During Delivery........................................................................50
4.3.3 Reasons for Delivering at a Health Facility ................................................53
4.3.4 Medical Procedures Performed during Delivery ........................................55

4.4 Postnatal Care .........................................................................................................57


4.5 Consistent Use of Antenatal, Delivery, and Postnatal Care .......................................62

iv | Contents
CHAPER 5 MATERNAL HEALTH PROBLEMS AND TREATMENT-SEEKING BEHAVIOR

5.1 Knowledge of Life-threatening Conditions ...............................................................65


5.2 Women’s Reporting of Maternal Complications .......................................................65
5.3 Treatment-seeking Decisions and Behavior for Reference Complication ..................69

5.3.1 Decisionmaker for Seeking Treatment ......................................................73


5.3.2 Type of Provider for Treatment.................................................................74
5.3.3 Place Where Treatment Sought ................................................................76
5.3.4 Number of Facilities Visited ......................................................................79
5.3.5 Reasons for Not Seeking Treatment ..........................................................80

5.4 Delays in Seeking Treatment for Reported Complications ........................................81

5.4.1 Delay in Recognizing Complication ..........................................................82


5.4.2 Delay in Seeking Treatment......................................................................84
5.4.3 Travel Time To Facility..............................................................................86
5.4.4 Waiting Time at Facility ............................................................................88

5.5 Delivery Expenditures.............................................................................................91


5.6 Source of Funds for Delivery/Treatment of Complications........................................92

CHAPTER 6 REPRODUCTIVE AND CHILD HEALTH

6.1 Fertility ....................................................................................................................93

6.1.1 Introduction .............................................................................................93


6.1.2 Current Fertility ........................................................................................93
6.1.3 Pregnancy Outcomes ...............................................................................95
6.1.4 Fertility Differentials..................................................................................95
6.1.5 Fertility Trends..........................................................................................96
6.1.6 Birth Intervals ...........................................................................................97
6.1.7 Age of Mothers at Their First Birth ............................................................98
6.1.8 Adolescent Fertility and Motherhood........................................................98

6.2 Fertility Regulation................................................................................................ 100


6.3 Childhood Mortality ............................................................................................. 103

6.3.1 Early Childhood Mortality Rates: Levels and Trends ............................... 103
6.3.2 Socioeconomic and Maternal Health Differentials in Childhood
Mortality................................................................................................ 104

6.4 Perinatal Mortality ................................................................................................ 106


6.5 High-risk Childbearing .......................................................................................... 108

Contents | v
CHAPTER 7 POLICY IMPLICATIONS

7.1 Introduction ......................................................................................................... 111

7.1.1 Maternal Mortality ................................................................................. 112


7.1.2 Antenatal Care....................................................................................... 114
7.1.3 Delivery Care ........................................................................................ 117
7.1.4 Postnatal Care ....................................................................................... 118
7.1.5 Awareness of Complications .................................................................. 119
7.1.6 Treatment for Complications ................................................................. 120
7.1.7 Delays in Seeking Treatment for Complications ..................................... 121

7.2 Conclusions and Recommendations ..................................................................... 123

REFERENCES .............................................................................................................................. 127

APPENDIX A TABLES ............................................................................................................... 131

APPENDIX B DATA QUALITY ................................................................................................. 133

APPENDIX C ASSESSMENT OF DATA QUALITY FOR CHILDHOOD MORTALITY ........ 139

APPENDIX D SAMPLE IMPLEMENTATION ........................................................................... 147

APPENDIX E SAMPLING ERRORS ......................................................................................... 149

APPENDIX F PERSONNEL INVOLVED IN BMMS 2001 .................................................. 155

APPENDIX G QUESTIONNAIRES.................................................................................... 157

vi | Contents
TABLES AND FIGURES

Page
CHAPTER 1 INTRODUCTION

Table 1.1 Percent distribution of health facilities by level of EOC services,


according to type of institution, Bangladesh 1999 ........................................ 5
Table 1.2 Results of the household and individual interviews ...................................... 9

CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS

Table 2.1 Marital status of the household population ................................................ 12


Table 2.2 Household composition............................................................................. 13
Table 2.3 Household characteristics .......................................................................... 14
Table 2.4 Household durable goods, land ownership, and household
wealth index.............................................................................................. 16
Table 2.5 Background characteristics of respondents ................................................. 17
Table 2.6 Level of education by background characteristics....................................... 18
Table 2.7 Exposure to mass media ............................................................................ 19

Figure 2.1 Percentage of males and females age 10-14 and age 15-19 with some
secondary education, 1996-2001 .............................................................. 13

CHAPTER 3 ADULT FEMALE MORTALITY: LEVELS AND CAUSES

Table 3.1 Pregnancy-related mortality rates and ratios............................................... 24


Table 3.2 Maternal mortality rates and ratios ............................................................. 25
Table 3.3 Differentials in maternal mortality .............................................................. 26
Table 3.4 Maternal mortality ratios by prior parity ..................................................... 27
Table 3.5 Maternal mortality rates by cause of death ................................................. 27
Table 3.6 Estimates of pregnancy-related mortality rates from the
BMMS sibling history ................................................................................. 28
Table 3.7 Sibling history pregnancy-related mortality by age and timing of death....... 29
Table 3.8 Age-specific mortality rates by sex.............................................................. 31
Table 3.9 Age-specific mortality rates by background characteristics .......................... 33
Table 3.10 Mortality rates by cause of death ............................................................... 34
Table 3.11 Mortality rates from sibling histories ........................................................... 35

Figure 3.1 BMMS estimates of pregnancy-related mortality and maternal mortality.


1998-2001 ................................................................................................ 30
Figure 3.2 Age-specific mortality rates by sex, BMMS 1998-2000 ............................... 32

Tables and Figures | vii


CHAPTER 4 MATERNITY CARE

Table 4.1 Antenatal care ........................................................................................... 38


Table 4.2 Summary of frequency and timing of antenatal care visits .......................... 39
Table 4.3 Number of antenatal care visits.................................................................. 40
Table 4.4 Stage of pregnancy at first antenatal care visit............................................. 41
Table 4.5 Reasons for seeking antenatal care............................................................. 42
Table 4.6 Information given for antenatal care........................................................... 43
Table 4.7 Procedures performed during pregnancy ................................................... 45
Table 4.8 Patterns of antenatal care from trained providers ....................................... 46
Table 4.9 Information given about delivery ............................................................... 47
Table 4.10 Intended assistance during delivery............................................................ 48
Table 4.11 Person making decision regarding assistance during delivery ...................... 49
Table 4.12 Place of delivery ........................................................................................ 51
Table 4.13 Assistance during delivery .......................................................................... 52
Table 4.14 Reasons for delivering in a health facility.................................................... 54
Table 4.15 Reasons for not delivering in a health facility.............................................. 55
Table 4.16 Procedures performed during delivery ....................................................... 56
Table 4.17 Postnatal care for mother........................................................................... 58
Table 4.18 Postnatal care for the baby......................................................................... 60
Table 4.19 Reasons mother did not receive postnatal care .......................................... 61
Table 4.20 Antenatal delivery and postnatal care......................................................... 62

Figure 4.1 Percentage of women who received antenatal care from a medically
trained provider for the last live birth in the three years preceding
the survey, Bangladesh 1996-1997, 1999-2000, and 2001........................ 37
Figure 4.2 Percentage of live births for which no antenatal care was sought, by
reason for not seeking antenatal care ......................................................... 42
Figure 4.3 Among live births for which antenatal care was received, percentage
for which specific procedures were performed at least once ...................... 44
Figure 4.4 Percentage of live births and stillbirths for which specific procedures
were performed during delivery................................................................. 57
Figure 4.5 Completeness of maternity care in Bangladesh .......................................... 63

CHAPTER 5 MATERNAL HEALTH PROBLEMS AND TREATMENT-


SEEKING BEHAVIOR

Table 5.1 Knowledge of life-threatening maternal conditions..................................... 66


Table 5.2 Women’s reporting of recent maternal complications ................................ 67
Table 5.3 Percentage of reported complications considered life threatening .............. 68
Table 5.4 Multiple complications .............................................................................. 69
Table 5.5 Sought treatment for recent reference complication................................... 70
Table 5.6 Person who decided that treatment should be sought ................................ 73
Table 5.7.1 Type of provider seen for life-threatening complications ............................ 74
Table 5.7.2 Type of provider seen for non-life-threatening complications ..................... 75
Table 5.8.1 Place of treatment for life-threatening complications.................................. 77
Table 5.8.2 Place of treatment for non-life-threatening complications .......................... 78
Table 5.9 Number of places women went for treatment of complications ................. 79
Table 5.10 Reasons for not seeking treatment for complications .................................. 80

viii | Tables and figures


Table 5.11.1 Delay in recognizing life-threatening complications.................................... 83
Table 5.11.2 Delay in recognizing non-life-threatening complications ............................ 84
Table 5.12.1 Delay between recognizing the life-threatening complication and
deciding to seek treatment......................................................................... 85
Table 5.12.2 Delay between recognizing the non-life-threatening complication
and deciding to seek treatment.................................................................. 86
Table 5.13.1 Travel time to facility for treatment of life-threatening complications.......... 87
Table 5.13.2 Travel time to facility for treatment of non-life-threatening
complications ............................................................................................ 88
Table 5.14 Waiting time at facility ............................................................................... 89
Table 5.15 Treatment costs for deliveries..................................................................... 91
Table 5.16 Source of funds for delivery costs............................................................... 92

Figure 5.1 Women’s reporting of recent maternal complications ................................ 67


Figure 5.2 Percentage of women seeking treatment by whether reference
complication was perceived as life threatening........................................... 71
Figure 5.3.1 Path diagram of treatment-seeking behavior for reference life-
threatening maternal complication............................................................. 72
Figure 5.3.2 Path diagram of treatment-seeking behavior for reference non-life-
threatening maternal complication............................................................. 72
Figure 5.4 Source of treatment for perceived life-threatening complications ............... 79
Figure 5.5 Reasons cited for not seeking treatment for reference complication ........... 81
Figure 5.6 Summary of responses of women who were asked about specific
delays in treatment for reference complication .......................................... 82
Figure 5.7 Summary of delays in treatment-seeking behavior for reference
life-threatening complications .................................................................... 90

CHAPTER 6 REPRODUCTIVE AND CHILD HEALTH

Table 6.1 Current fertility .......................................................................................... 94


Table 6.2 Pregnancy outcomes.................................................................................. 95
Table 6.3 Fertility by background characteristics........................................................ 96
Table 6.4 Trends in current fertility rates ................................................................... 97
Table 6.5 Trends in length of birth interval ................................................................ 98
Table 6.6 Adolescent fertility ..................................................................................... 99
Table 6.7 Current use of contraception by background characteristics ..................... 101
Table 6.8 Early childhood mortality rates................................................................. 104
Table 6.9 Infant and child mortality by background characteristics .......................... 106
Table 6.10 Perinatal mortality ................................................................................... 107
Table 6.11 High-risk fertility behavior........................................................................ 109

Figure 6.1 Age-specific fertility rates 1989-2001 ......................................................... 97


Figure 6.2 Trends in teenage pregnancy and motherhood among women
age 15-19, 1993-2001............................................................................. 100
Figure 6.3 Trends in contraceptive use among currently married women
under age 50 ........................................................................................... 102

Tables and Figures | ix


Figure 6.4 Trends in infant and childhood mortality, 1989-2000 .............................. 104

APPENDIX A TABLES

Table A.1 Household population by age, residence, and sex ................................... 131
Table A.2 Level of education by background characteristics..................................... 132

APPENDIX B DATA QUALITY

Figure B.1 Brass “growth balance” analysis of completeness of male death


reporting in the BMMS ............................................................................ 134
Figure B.2 Brass “growth balance” analysis of completeness of female death
reporting in the BMMS ............................................................................ 134
Figure B.3 Male age-specific mortality rates: BMMS and Matlab HDSS..................... 135
Figure B.4 Female age-specific mortality rates: BMMS and Matlab HDSS ................. 135
Figure B.5 Male age-specific mortality rates: BMMS sibling histories and
Matlab HDSS........................................................................................... 137
Figure B.6 Female age-specific mortality rates: BMMS sibling histories and
Matlab HDSS........................................................................................... 138

APPENDIX C ASSESSMENT OF DATA QUALITY FOR


CHILDHOOD MORTALITY

Table C.1 Household age distribution...................................................................... 141


Table C.2 Age distribution of eligible and interviewed women................................. 142
Table C.3 Completeness of reporting ...................................................................... 142
Table C.4 Births by calendar years .......................................................................... 143
Table C.5 Reporting of age at death in days ............................................................. 144
Table C.6 Reporting of age at death in months ........................................................ 145

APPENDIX D SAMPLE IMPLEMENTATION

Table D.1 Sample implementation........................................................................... 147

APPENDIX E SAMPLING ERRORS

Table E.1 List of selected variables for sampling errors ............................................. 149
Table E.2 Sampling errors for selected variables, National sample............................ 149
Table E.3 Sampling errors for selected variables, Urban sample ............................... 150
Table E.4 Sampling errors for selected variables, Rural sample................................. 150
Table E.5 Sampling errors for selected variables, Barisol sample .............................. 151
Table E.6 Sampling errors for selected variables, Chittagong sample ........................ 151
Table E.7 Sampling errors for selected variables, Dhaka sample............................... 152
Table E.8 Sampling errors for selected variables, Khulna sample .............................. 152
Table E.9 Sampling errors for selected variables, Rajshahi sample............................ 153
Table E.10 Sampling errors for selected variables, Sylhet sample ............................... 153

x | Tables and figures


FOREWORD

The 2001 Bangladesh Maternal Health Services and Maternal Mortality Survey (BMMS) is the
first nationally representative sample survey designed to provide information on the level of maternal
mortality, causes of maternal and nonmaternal deaths, and perception, experience, and utilization of ma-
ternal health care in Bangladesh.

The 2001 BMMS provides a comprehensive look at levels of and differentials in maternal health
parameters for policymakers and program managers. The survey estimates the maternal mortality ratio
(MMR) in Bangladesh during the period 1998-2001 as in the range of 320 to 400 per 100,000 live births.
The direct estimates show a 20 percent decline over a decade, from 514 in 1986-1991 to 400 in 1998-
2001. In Bangladesh, two-thirds of maternal deaths occur after delivery, only one in ten occurs during
delivery, and the remaining one in five occurs before delivery. The major causes of maternal deaths are
retained placenta, postpartum/puerperal sepsis, and postpartum hemorrhage.

The information presented in this report will be instrumental in identifying strategic directions for
the national Health and Family Planning Program in Bangladesh. Information from the survey will pro-
vide crucial indicators for evaluating policies and programs and for designing future program strategies.
The survey will hopefully contribute to an increased global commitment to improving the lives of moth-
ers and children worldwide.

The need for further detailed analysis of the BMMS data remains. It is hoped that researchers,
academicians, and program personnel will carry out such analysis to provide in-depth information that
will benefit the future direction and effective implementation of maternal health programs.

The contributors of this report deserve special thanks. I express my thanks to the National Insti-
tute of Population Research and Training (NIPORT) and ORC Macro for their sincere efforts in conduct-
ing the 2001 BMMS. I thank The Johns Hopkins University (USA) and the ICDDR,B for providing tech-
nical support. Special thanks also goes to Associates for Community and Population Research ACPR) and
Mitra and Associates for their sincere efforts in conducting the field survey. The U.S. Agency for Interna-
tional Development (USAID) deserves thanks for their financial support to accomplish the important sur-
vey.

A.F.M. Sarwar Kamal


Secretary
Ministry of Health and Family Welfare
Government of the People’s
Republic of Bangladesh

Foreword | xi
PREFACE

The Bangladesh Maternal Health Services and Maternal Mortality Survey (BMMS) carried out in
2001 is a nationally representative survey that was implemented for the first time in Bangladesh through a
collaborative effort of the National Institute of Population Research and Training (NIPORT) and ORC
Macro (USA). The Johns Hopkins University (USA) and the ICDDR,B provided technical assistance.
Associates for Community and Population Research (ACPR) and Mitra and Associates, two Bangladeshi
private research firms, collected the survey data. The financial support for the survey was provided by the
United States Agency for International Development (USAID)/Dhaka. The BMMS 2001 provides up-
dated estimates of levels of maternal mortality, causes of maternal deaths, and utilization of maternal
health services in Bangladesh.

The information concerning maternal health services and maternal mortality at the national level
will be instrumental in identifying new directions for the national health and family planning program in
Bangladesh. The survey report will hopefully contribute to an increased commitment to improving the
lives of mothers and children.

The members of the Technical Review Committee (TRC) included persons with professional ex-
pertise from government, nongovernmental, and international organizations, as well as researchers and
professionals working for the maternal health program, who contributed valuable comments during major
phases of the survey. In addition, a Technical Task Force (TTF) was formed with representatives from
NIPORT, the Directorate of Family Planning, USAID, ICDDR,B, UNICEF, and ORC Macro for design-
ing and implementing the survey. I would like to extend my deepest gratitude and appreciation to the
members of the TRC and the TTF for their valuable contributions during different phases of the survey.

The preliminary results of the 2001 BMMS with its major findings were released in a dissemina-
tion seminar held in March 2002. The final report supplements the preliminary report released earlier. I
hope the survey results will be useful for monitoring and implementation of the national maternal health
program.

The contributors of the various chapters of this report deserve special thanks. I express also my
heartfelt thanks to the professionals of the research unit of NIPORT, ORC Macro, The Johns Hopkins
University, ICDDR,B, ACPR, Mitra and Associates, and USAID/Dhaka for their sincere efforts in the
successful completion of the survey.

Lokman Hakim
Director General
National Institute of Population
Research and Training

Preface | xiii
SUMMARY OF FINDINGS

The 2001 Bangladesh Maternal Health 460). A survival history for each respondent’s sisters
Services and Maternal Mortality Survey combined with questions about timing of death rela-
(BMMS) is a nationally representative survey tive to pregnancy estimate the pregnancy-related
that was implemented by Associates for Com- mortality ratio (PRMR) as 400 (95% CI 337-462)
munity and Population Research (ACPR) and for the same time period, and indicates a gradual de-
Mitra and Associates under the authority of the cline in the PRMR over the recent past from 514 for
National Institute of Population Research and the period 10-14 years before the survey. It is thus
Training (NIPORT) from January through June notable that the various methods give rather similar
2001. The Johns Hopkins University (JHU) in estimates. The survey does not find large differences
the U.S. and the International Center for Diar- in maternal mortality or pregnancy-related mortality
rheal Disease Research, Bangladesh (ICDDR,B) by region or socioeconomic status, but does find
provided assistance in questionnaire design and very large differences in risk by age of mother.
data analysis. ORC Macro of Calverton, Mary-
land provided technical assistance in all phases A by-product of the methods used to estimate
of the project as part of its international MEAS- maternal mortality is estimates of overall adult mor-
URE DHS+ program, while financial assistance tality, both male and female. Data quality checks
was provided by the U.S. Agency for Interna- show these data to be satisfactory. Overall adult
tional Development (USAID)/Bangladesh. mortality in Bangladesh is estimated to be very simi-
lar to that found by the ICDDR,B Demographic and
The BMMS is intended to serve as a Health Surveillance System in Matlab Thana. The
source of maternal health and maternal death proportion of persons expected to die between age
data for policymakers and the research commu- 15 and 60 is 18 percent for males and 15 percent for
nity. In general, the objectives of the BMMS females. Data from household deaths and sibling
were to (i) collect data at the national level that histories are once again notably consistent. The sib-
will facilitate an assessment of the level of ma- ling histories suggest a marked improvement in fe-
ternal mortality in Bangladesh; (ii) identify spe- male adult survivorship during the 15 years preced-
cific causes of maternal and nonmaternal deaths ing the survey, but a much smaller improvement
among adult women; (iii) collect data on among males.
women’s perceptions of and experience with an-
tenatal, maternity, and emergency obstetrical MATERNAL HEALTH PROBLEMS AND TREATMENT-
care; and (iv) measure indicators of utilization of SEEKING BEHAVIOR
maternal health services in Bangladesh.
Knowledge of life-threatening maternal
MATERNAL AND OTHER CAUSES OF ADULT complications: Knowledge of life-threatening com-
MORTALITY plications among Bangladeshi women is low, with
fewer than half able to name most major complica-
tions. Knowledge of such conditions ranges from a
On the basis of deaths among women of high of 56 percent for tetanus, to 49 percent for pro-
reproductive age reported by households as oc- longed or obstructed labor, to only 18 percent for
curring in the three years before the survey com- vaginal bleeding. Knowledge levels for life- threat-
bined with a verbal autopsy to identify those ening conditions are low among all major demo-
deaths that are maternal, the maternal mortality graphic and socioeconomic subgroups.
ratio (MMR) for the approximate period 1998-
2000 is estimated as 322 per 100,000 live births Prevalence of maternal complications:
(95 percent confidence interval (CI) 253-391). Among live births and stillbirths that took place dur-
Questions about timing of these deaths relative ing the three years preceding the survey, 61 percent
to pregnancy estimate the pregnancy-related had at least one associated complication during
mortality ratio (PRMR) as 382 (95% CI 305- pregnancy, delivery, or after delivery. The most
Summary of Findings | xv
commonly reported complication was one or recognizing it within six hours of onset. Delays in
more symptoms of preeclampsia (41 percent), the decision to seek treatment were also not lengthy,
followed by malpresentation or prolonged/ob- with 46 percent deciding to seek treatment immedi-
structed labor (22 percent). The importance of ately after recognizing the complication, and 64 per-
specific complications varied by stage of preg- cent seeking treatment within six hours. Among the
nancy, with one or more symptoms of pre- subgroup of women who sought treatment outside
eclampsia (39 percent) the most commonly re- the home, 73 percent reported that they were re-
ported complication during pregnancy, malpre- quired to travel less than 60 minutes to the clinic or
sentation or prolonged/obstructed labor the most provider. Waiting time to be seen for treatment was
commonly reported complication during deliv- similarly brief, with 85 percent reporting that they
ery (22 percent), and excessive vaginal bleeding were seen by a staff member within one hour of
the most commonly reported complication after reaching the facility.
delivery (10 percent). Among reported compli-
cations, almost one-half (46 percent) were per- REPRODUCTIVE AND CHILD HEALTH
ceived as potentially life threatening, with this
proportion ranging from 75 percent for retained Fertility: Like the 1993-1994, 1996-1997, and
placenta to 55 percent for excessive vaginal 1999-2000 Bangladesh Demographic and Health
bleeding to 31 percent for symptoms of pre- Surveys (BDHS), the BMMS results show that
eclampsia. Bangladesh continues to experience a fairly rapid
decline in fertility. However, the pace of fertility de-
Treatment-seeking behavior: Among the cline has slowed in the most recent period compared
most recent reference complication, treatment with the exceptionally rapid decline during the late
was sought for 62 percent of those complications 1980s and early 1990s. The total fertility rate
which were perceived as life threatening, com- dropped slightly from 3.4 for the period 1991-1993
pared to 42 percent of those perceived as non- to 3.3 in 1994-1996, remained constant during 1997-
life threatening. Considerable variation is evi- 1999, and then edged lower again to 3.2 for the pe-
dent in the propensity to seek treatment by the riod 1998-2000. At current fertility levels, a Bangla-
nature of the complication: among perceived deshi woman will have an average of 3.2 children
life-threatening cases, treatment was sought for during her reproductive years. The total fertility rate
77 percent of convulsions cases, 57 percent of is higher in rural areas (3.4 children per woman)
cases of malpresentation or prolonged/obstruct- than in urban areas (2.7 children per woman). Fertil-
ed labor, and 39 percent of cases of retained pla- ity is lowest in Khulna (2.6) and Rajshahi (2.9) divi-
centa. Treatment seeking for perceived life- sions, and highest in Sylhet (4.3) and Chittagong
threatening complications was associated with (3.7) divisions. Dhaka and Barisal divisions have in-
urban residence and higher socioeconomic termediate levels of fertility, with total fertility rates
status. Among women with perceived life- of about 3.2 children per woman. Women with no
threatening complications who did seek treat- formal education and women in poorer households
ment, only one in three women (32 percent) have more children than their counterparts. With a
sought care from a facility or nonfacility-based TFR of 4.2, women in the poorest households are
qualified provider. In the remaining two-thirds likely to bear about two children more than women
of cases, either the woman failed to seek care in the wealthiest households (2.4).
(38 percent), or she sought care from an unquali-
fied provider (29 percent). Among women who In Bangladesh, 90 percent of pregnancies re-
failed to seek treatment for perceived life- sult in a live birth, and 5 percent in a miscarriage or
threatening complications, the most commonly abortion. Stillbirths and menstrual regulations (MRs)
cited reason was cost (44 percent), followed by comprise another 5 percent of pregnancy outcomes.
perception that treatment was not necessary (39 Miscarriages and abortions are higher among
percent). younger women and older women.

Delays in obtaining treatment: Among The data show that birth intervals are gener-
women with a perceived potentially life-threat- ally long in Bangladesh. Among nonfirst births,
ening condition, recognition of the complication nearly one in six children (16 percent) is born after a
was generally timely, with 26 percent recogniz- “too short” interval (less than 24 months). More than
ing the problem immediately, and 55 percent
xvi | Summary of Findings
half (57 percent) of nonfirst births occur three or 2001 BMMS (for the period 1999-2000). This repre-
more years after the previous birth, and 27 per- sents a 36 percent decline, or nearly 5 percent per
cent of such births take place 24 to 35 months year during the 1990s. The internal data from the
after the previous birth. The overall median birth BMMS show that under-five mortality decreased by
interval length is 38.8 months, the same as that one-third from the period 1986-1990 to 1996-2000.
found in the 1999-2000 BDHS survey. Child- The variable most strongly associated with variation
bearing begins early in Bangladesh, with the in under-five mortality is the length of the interval
large majority of women becoming mothers be- between births. As the birth interval gets shorter, the
fore they reach the age of 20. The median age at risk that a child will die increases sharply. For ex-
first birth is 19 years women age 20-24. ample, the neonatal mortality rate is twice as high
for children born less than 24 months after a previ-
Almost 30 percent of adolescent women in ous sibling as for children born 24 months or more
Bangladesh are already mothers with at least one after a previous sibling (72 and 35 percent, respec-
child and 5 percent are currently pregnant, for a tively). Differences are even larger for child mortal-
total of 34 percent who have started childbear- ity (between age 1 and 4). Sylhet division has ex-
ing. The proportion who have begun childbear- tremely high mortality rates: Neonatal, postneonatal,
ing increases rapidly with age. In rural areas, 35 infant, and under-five mortality in Sylhet is about 40
percent of the adolescents have already begun percent higher than the national average. Rajshahi
childbearing, compared with 27 percent in urban and Dhaka divisions also have relatively high under-
areas. There are also variations by division. five mortality rates of about 100 per 1,000 live
births.
Fertility Regulation: The 2001 BMMS
indicates that 50 percent of currently married The perinatal mortality rate in Bangladesh is
women in Bangladesh are using a method of estimated to be 59 perinatal deaths per 1,000 quali-
family planning. Modern methods are more fying pregnancies. First pregnancies have a risk of
widely used (44 percent of married women) than 88 deaths per 1,000, and pregnancies with interpreg-
traditional methods (6 percent). The increase in nancy intervals of less than 15 months have a risk of
use of family planning from 8 percent of married 79 deaths per 1,000, compared with a risk of just 46
women in the 1975 Bangladesh Fertility Survey per 1,000 for pregnancies with interpregnancy inter-
to 54 percent in the 1999-2000 BDHS survey vals of 39 months or more. Perinatal mortality is
has declined to 50 percent in the 2001 BMMS. higher in rural areas (60 deaths per 1,000 pregnan-
The decline in overall use is due to a decline in cies) than in urban areas (52 per 1,000). Perinatal
the use of traditional methods (from 10 to 6 per- mortality is the highest in Sylhet Division (74 deaths
cent). Use of modern methods has remained un- per 1,000 pregnancies) and the lowest in Barisal and
changed since 1999-2000. Chittagong divisions (48 per 1,000).

Contraceptive use varies moderately by MATERNITY CARE


urban-rural residence but greatly by division.
Contraceptive use is highest in Khulna division Antenatal Care: The data indicate that less
(62 percent), followed by Rajshahi (56 percent) than half of mothers in Bangladesh receive antenatal
and Dhaka divisions (52 percent), and lowest in care from a trained or untrained provider. For births
Sylhet division (28 percent). Contraceptive that occurred in the three years before the survey,
prevalence ranges from 43 percent among only 48 percent of mothers received any antenatal
women living in the poorest households to 58 care during pregnancy. The primary source of ante-
percent among women living in the wealthiest natal care is doctors (24 percent), followed by
households. nurses, midwives, and female paramedical workers
(15 percent). Among those who receive care, the
Childhood Mortality: Evidence of a de- median number of antenatal visits per live birth was
cline in childhood mortality comes from com- less than two; women had three or more antenatal
paring the BMMS data with the data from visits for only one in five births. Antenatal care is
BDHS surveys. The estimate for under-five mor- more common among younger women and low-
tality calculated from the 1993-1994 BDHS data parity women. The percentage of births for which
(for the period 1989-1993) is 133 deaths per mothers had one or more antenatal care checkups
1,000, compared with 85 per 1,000 from the
Summary of Findings | xvii
was also significantly higher in urban areas than cent). For women who deliver at a health facility,
in rural areas (64 and 44 percent, respectively), more than half said that the reason they did so was to
with differences due largely to the percentage ensure a safe delivery. Three-fourths of births in
seeking care from a qualified doctor. The high- Bangladesh are assisted by a traditional birth atten-
est and lowest levels of antenatal care are found dant, and only 12 percent of births are assisted by a
in Khulna division (57 percent) and Barisal divi- trained medical professional. Low-parity women,
sion (33 percent), respectively. The use of ante- urban women, and women with more education or
natal care is strongly associated with level of who live in wealthier households are associated with
education and household economic status. greater likelihood that the delivery is assisted by a
Among women who sought antenatal care, three trained medical professional. Caesarean section is
in four sought care for a general checkup rather reported in fewer than 3 percent of deliveries.
than for a specific problem. For all live births in
which at least one antenatal visit took place, an Postnatal Care: Less than one in five women
abdominal examination or measurement of with recent deliveries reported having a postnatal
blood pressure was common but not universal checkup for themselves, with most reporting being
(75 percent). For two-thirds of live births, meas- seen by a qualified doctor (9 percent) or an unquali-
urement of maternal weight and/or height was fied doctor (5 percent). The proportions of women
reported. Blood or urine tests were less com- seeking postnatal care for their babies was also low
monly reported (30 and 37 percent, respec- (24 percent). Women whose pregnancy resulted in a
tively). stillbirth, or who had their first birth, and those who
live in urban areas, have more education, or live in
Delivery Care: Delivery at home remains wealthier households were all more likely to have
almost universal in Bangladesh. Use of health had a postnatal checkup. The primary reason for not
facilities for delivery is more common in urban having a postnatal checkup was the perceived ab-
areas (22 percent of births), among mothers with sence of need (56 percent). Concern about cost
some secondary education (23 percent), and (22 percent) was the second most commonly cited
among women in wealthier households (30 per- reason for not having a postnatal checkup.

xviii | Summary of Findings


INTRODUCTION 1
Peter Kim Streatfield, Tulshi D. Saha, and Alfredo Aliaga

1.1 SAFE MOTHERHOOD AND MCH-FP PROGRAMS IN BANGLADESH

The past three decades have seen impressive achievements from certain maternal and child health
and family programs (MCH-FPs), such as a dramatic increase in the use of family planning to over half of
all couples and a consequent halving of fertility levels. During the same period, however, indicators of
safe motherhood suggest that there was little progress in the crucial area of reproductive health. Two out
of three pregnant women have not had even a single antenatal care visit, and nine out of ten births still
occur at home, usually attended only by an untrained birth attendant or unskilled relative or neighbor.

Thus, it is significant that at the beginning of a new century the government has released the long-
awaited Bangladesh National Strategy for Maternal Health (Ministry of Health and Family Welfare,
2001). This strategy is explicitly focused on emergency obstetric care (EOC) for reducing maternal mor-
tality, based on the following:

• All pregnant women are at risk of developing life-threatening complications;

• Most complications can neither be predicted accurately nor prevented;

• Once a woman develops complications, she needs prompt access to emergency obstetric care
services if death or disability is to be prevented.

The strategy also sets out several other priorities under the headings of 1) providing essential ob-
stetric care and basic maternity care services for early detection and appropriate referral of complications,
2) promoting women’s access to resources, and 3) improving quality of services. Five aims of the strategy
are articulated with clear indicators to be achieved over the ten-year strategy duration. Some progress has
already been made during the final years of the national Health and Population Sector Programme (HPSP)
1998-2003.

The strategy has adopted the “Three Delays” framework of factors that affect safe motherhood
service utilization and outcomes. The three phases of delay relate to birth complications requiring facility-
based intervention and include: 1) deciding to seek care—usually the family of the pregnant woman, 2)
reaching the medical facility, and 3) receiving adequate treatment or management at the facility.

The Three Delays approach marks a change from earlier approaches, and a review of the history
of MCH and safe motherhood programs in Bangladesh can be seen in terms of the evolving focus on the
different levels of the process, from the service provider at the household and community level, to the
provision of facilities offering higher level care.

1.2 HISTORY OF MCH IN BANGLADESH

Bangladesh has a long history of MCH activities going back to 1946, but the first MCH unit was
established in the Directorate of Health in 1952-1953. At that time, the Maternal and Child Health Train-
ing Institute in Azimpur started training lady health visitors, and ten maternal and child welfare centers

Introduction | 1
(MCWCs) started functioning, mainly at district level, some at the thana level.1 Between 1961 and 1971,
152 rural health centers (RHCs) were established, each with six MCH beds.

In the mid-1970s, it was realized that improving child survival would encourage wider adoption
of family planning, so in 1975 MCH services were integrated with the health service, and a combined ap-
proach was adopted in the first official population policy document in 1976. This approach promoted the
construction of facilities at the union and thana levels, utilization of traditional birth attendants (TBAs) for
integrated MCH-FP activities, training of family welfare assistants (FWAs) for MCH work, and an accel-
erated training program for family welfare visitors (FWVs).2 Since 1975, the previous RHCs were con-
verted to thana health complexes (THCs), and many new ones were built. These are the centers of MCH
activity at thana level, supported by the MCWCs and district hospitals offering MCH services and referral
at district level.

At the union level, FWCs provided basic MCH care, and the FWVs provided technical support to
the TBAs and FWAs for community-based MCH services. At the ward and village levels, the 23,500
FWAs, 50,000 TBAs, and 30,000 satellite clinics (started in 1988) constituted the core MCH services for
the rural population.

Under this initial approach of providing low- or intermediate-level MCH-FP facilities with train-
ing for field-level staff rather than for specialized institution-based EOC staff, the primary focus was on
the promotion of antenatal care, TBA training, risk identification, tetanus toxoid immunization, iron and
folic acid supplementation, clean delivery practices, and family planning. But there were relatively few
actions to provide emergency obstetric care for women who develop complications during pregnancy and
delivery.

This emphasis on provision of mid-level facilities was an advance on the earlier approach, which
focused on household deliveries. In the 1970s, TBAs handled most deliveries, so the government took the
initiative at that time to train these TBAs, who had generally not received any previous training in hy-
giene or proper delivery practices. The TBA training project trained women across the entire country,
with the goal of providing one trained TBA for each of the 68,000 villages.

An evaluation found that many negative and harmful practices continued despite the training, al-
though these practices were less common among trained TBAs than among untrained TBAs (Akhter et
al., 1995). After some time it also became apparent that there was no decline in maternal mortality. One
reason was that although more than 42,000 TBAs were trained, only about 6 percent of births were deliv-
ered by them. This evaluation highlighted numerous issues that persist today including problems of in-
adequate supervision and support and insufficient practical experience. Finally, the referral system was
not sufficiently well developed to ensure that complicated cases, if identified by the TBAs, would receive
adequate treatment as required (Chowdhury et al., 2002).

It was at this time that global policy shifted away from the “risk approach,” in which women with
certain characteristics3 were defined as being at risk of a complicated pregnancy. (This approach was use-
ful at the clinical or individual level but not at the public health or group level.) The late 1980s saw the
promotion of the Three Delays model (described above). While recognizing that the three delays were
critical in hindering use of EOC facilities, the approach in Bangladesh was that first the facilities them-
selves must be made available.

1
The administrative levels (with numbers) are, from highest to lowest, division (6), district (64), thana or upazila
(name can change with different governments) (460 or 490), union (more than 4,000), and ward (13,500).
2
Across the country there are now 12 FWV training institutes.
3
Very young or old, high parity, short birth interval, short stature, poor pregnancy history, etc.

2 | Introduction
There was an immediate response to the new initiative, with many ongoing programs adopting an
EOC approach. The main avenue for developing the national initiative was the Pilot Project for the De-
velopment of Maternal and Neonatal Health Care supported by the World Health Organization (WHO).
The project targeted the thana level (31 thanas in four districts), the most difficult level for implementing
change. This effort emphasized training of health and community-level workers for community mobiliza-
tion in addition to physicians such as anesthetists and obstetricians as in other projects. Initially, most of
the trained physicians were transferred within six months, although restrictions were later enforced.

At the same time, the UNFPA supported the Strengthening of Maternal and Child Welfare Cen-
tres (MCWCs) project, and the European Union supported the Thana Functional Improvement Pilot Pro-
ject (TFIPP). The UNFPA project used a phased MCWC upgrading approach, starting in July 1995, with
11 MCWCs then 17 more in 1998, 18 more in 1999, and the remaining 14 in 2000. These formerly un-
derutilized facilities, staffed predominantly by females, showed a dramatic increase in most EOC indica-
tors—antenatal care (ANC), delivery care, C-sections, postnatal care (PNC), treatment of complications,
and clinical contraception. There has been some overlap of services in upgraded MCWCs at the district
level with services at nearby district hospitals.

The TFIPP project, like the WHO pilot project, targeted the thana level, but was limited to 55
thanas (out of 460 nationwide) with a range of intensive and comprehensive interventions. The interven-
tions were generously financed and proved quite effective, but the project came to an end in the late
1990s, and many of the most innovative aspects were never scaled up to the national level.

Meanwhile, on behalf of the Ministry of Health and Family Welfare (MOHFW), representatives
of the Obstetrics and Gynaecology Society of Bangladesh met with UNICEF in 1993 to develop a pilot
project called Strengthening of EOC Services in 11 Districts of Bangladesh, which commenced in 1994
with a series of advocacy workshops organized at the national and district levels. The objectives of this
project included establishing 1) comprehensive EOC facilities at district hospitals, 2) basic EOC facilities
at THCs, and 3) obstetric first aid facilities at health and family welfare centers (HFWCs) and MCWCs.
Links would be established between district hospitals and tertiary referral facilities for monitoring and
improving EOC, as well as between the different levels of facilities. Another objective was to formulate a
proposal for a national plan of action for reducing maternal mortality through provision of EOC services.

As with many of the other approaches tried, this one concentrated primarily on the provision of
high-level EOC facilities (i.e., the third delay). The final review of the project highlighted a number of
obstacles to implementing such EOC activities in Bangladesh. These included issues of inappropriate se-
lection and frequent transfers of trained doctors (i.e., trained in obstetrics or anesthesiology), lack of
qualified trainers, reluctance of trained female doctors to work in remote areas, shortages of drugs and
equipment, and transport to facilities (the second delay). Many of these obstacles still hinder the function-
ing of high-level EOC facilities around the country.

The conclusion was that “there has been essentially no change in the performance (increased cov-
erage or utilization of services) of key strategies to address maternal health during the Fourth Population
and Health Program (FPHP) 1992-1998: 95 percent of deliveries still occur at home, 10 percent are at-
tended by medical/nursing personnel and 8 percent are attended by trained traditional birth attendants
(i.e., dais); 27 percent of pregnant women receive antenatal care from qualified medical/nursing person-
nel. Similarly, just over 25 percent of women seek care for maternal morbidity” (Allison et al., 1999).

Although efforts to coordinate health and family planning activities during the FPHP proved dif-
ficult, the experience gained was valuable for the design of future programs such as the Health and Popu-
lation Sector Program (HPSP) 1998-2003 “in terms of level of EOC training needed and the need to de-
velop both a community behavior change communication (BCC) and a service delivery system respon-

Introduction | 3
siveness.” This explicitly highlighted the first and second delays rather than just the third delay in obtain-
ing EOC (Allison et al., 1999).

1.3 NGO SECTOR

While the government has tended to emphasize the provision of EOC facilities during the last two
decades, the nongovernmental organization (NGO) sector has focused its efforts on provision of house-
hold-level services and referrals. Although NGO catchment areas are not always clearly delineated, they
have field workers who perform domiciliary visits, provide preventive services, and refer clients for ap-
propriate care to their clinics. The clinics can usually provide limited pregnancy care along with other
services. Most of the NGOs charge modest fees for services.

Most of the NGOs have supported a network of trained traditional birth attendants (TTBAs) who
were trained, supervised, and paid by them (Quaiyum et al., 1999). In some cases, these TTBAs received
incentives based on their performance in bringing pregnant women to facilities that provide ANC, for re-
ferring women with obstetric complications, and for accompanying patients to the referral hospital.

Few NGOs have facilities for delivery and first-aid EOC, so their staff are expected to refer
women to government facilities, but this does not happen often. Systems using referral slips (from NGOs
to government EOC facilities) for patients were not common and did not function well. Providing picto-
rial cards showing the signs of high-risk pregnancy did appear to have a positive impact on clients’ refer-
ral to higher-level facilities, particularly when efforts had been made to raise community awareness of the
danger signs of complicated pregnancies.

In selected cases, the NGO approach had a substantial impact on improving maternal health care:
in the FPHP-funded NGOs (Bangladesh Population and Health Consortium) at least 60 percent of women
receive two antenatal care visits compared with 25 percent nationally, and 55 percent receive postnatal
care compared with 16 percent in the government program. NGO experience was gained in innovative
Bangladesh Population and Health Consortium NGOs that emphasized birth preparedness, accompanied
referral, and the shift to a case management approach. Other NGOs also have well-integrated systems
with good linkage between the community and EOC-level facilities. The role of the private sector in ma-
ternal health care needs further review to assess how partnerships with this group can be strengthened
(Allison et al., 1999).

1.4 PLANS FOR EMERGENCY OBSTETRIC CARE (EOC) AND SAFE MOTHERHOOD

In line with global goals for the provision of safe motherhood, the Bangladesh government has a
plan for comprehensive EOC to be available at all 13 medical college hospitals and all 59 district hospi-
tals, as well as at 64 MCWCs and 120 upazila health complexes (UHCs). Basic EOC services should be
available at all union health and family welfare centers (UHFWCs).

Translating these goals into numbers means that the target by the end of the HPSP 1998-2003 was
that for every 500,000 people there will be four facilities offering basic EOC and one facility offering
comprehensive EOC, which implies around 1,000 basic EOC facilities and 250 comprehensive EOC fa-
cilities nationwide.

In 1994 the actual number of facilities per 500,000 population offering EOC was 0.41 for basic
EOC (10 percent of target) and 0.14 for comprehensive EOC (14 percent of target). By 1999, these ratios
had increased to 0.60 for basic EOC (15 percent of target) and to 0.27 for comprehensive EOC (27 per-
cent of target). A survey conducted in 1999 by Associates for Community and Population Research
(ACPR) for UNICEF reviewed the status of a number of these EOC facilities (see Table 1.1).

4 | Introduction
Table 1.1 Percent distribution of health facilities by level of EOC services, according to type
of institution, Bangladesh 1999

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Medical Upazila
college District health
Service level hospital hospital complex MCWC Private Total
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Comprehensive EOC 100 .0 81.4 18.3 27.4 41.7 40.9
Basic EOC 0.0 6.8 25.8 19.4 5.7 10.2
No EOC 0.0 11.9 55.8 53.2 52.5 48.9

Total 100.0 100.0 100.0 100.0 100.0 100.0

Number of facilities 13 59 120 62 472 726


––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Source: Figures for the medical college hospitals, some upazila health complexes, the
maternal and child welfare centers, and private facilities are based on the 1999 survey by
Associates for Community and Population Research.

The government of Bangladesh (GOB) comprehensive EOC facilities are mainly at division and
district levels, while basic EOC services are at district and lower levels (UHC and MCWC). The private
clinics offering comprehensive EOC tend to be concentrated in the four big cities: Dhaka, Chittagong,
Rajshahi, and Khulna.

1.5 MET NEED FOR EMERGENCY OBSTETRIC CARE

While the provision of EOC facilities gives a picture of the essential inputs for safe motherhood,
it does not give any indication of the outputs, particularly the utilization of facilities. A measure used in-
creasingly is “met need” for EOC services. Met need for EOC is calculated from the number of compli-
cated deliveries taking place in EOC facilities compared with the estimated number requiring such ser-
vices, based on the global assumption that 15 percent of all deliveries are complicated and 5 percent are
potentially life threatening (i.e., one-third of the complicated cases). The second national facility survey
indicated an impressive rise in met need for EOC from 5 percent in 1994 to 27 percent in 1999.4

The Unit of Management Information System (UMIS) of the Ministry of Health and Family Wel-
fare currently has a system implemented in all 13 medical college hospitals, 59 district hospitals, 56
MCWCs, 2 national specialized hospitals, and 120 upazila health complexes. The reporting is not yet
fully functional, but a first report is available from 218 of the 250 facilities for the year 2002. These data
will be useful for monitoring progress in institutional deliveries (particularly complicated cases), but at
this time the proportion of births taking place in the reporting institutions is still quite low (3 percent na-
tionwide). Caesarean sections account for 19 percent of deliveries and 10 percent of births are by other,
non-normal means (UMIS, 2003: 5). Met need for complicated cases is 13 percent, which is considerably
lower than the 27 percent observed in the second national facility survey. The UMIS does not include any
private sector institutions, but this cannot fully explain the difference.

It seems clear that the focus must be on all three of the potential delays to women delivering
safely in a suitably equipped clinic or hospital. Greater understanding is needed about the cultural and
social obstacles to women and their families recognizing that childbirth is potentially risky and that deci-
sions and actions must be taken immediately when complications arise. Such responsive decision-making

4
The latter figure was calculated from the 72,505 complicated deliveries in government facilities plus 27,275 in
private facilities, amounting to about one-quarter of the estimated 376,498 complicated births from 2.5 million esti-
mated total births nationwide. The 2.5 million is almost certainly an underestimate, so met need may be overesti-
mated.

Introduction | 5
may be facilitated by well-trained field-level health staff, but they cannot be expected to resolve the prob-
lems without referral to appropriate facilities.

The recent efforts to upgrade facilities nationwide to provide obstetric first aid, and basic and
comprehensive EOC are admirable, but the monitoring data suggest that they remain substantially under-
utilized, partly because of functional problems, and partly because the referral system is not working
properly. More fundamentally, a key reason for the underutilization of EOC services may be that commu-
nities do not yet accept that safe delivery can be assured only in a properly equipped and staffed institu-
tional environment. The potential exists now in Bangladesh to make rapid progress in minimizing mater-
nal morbidity and mortality, provided the present momentum is maintained and accelerated.

1.6 ORGANIZATION OF THE 2001 BMMS

1.6.1 Survey Objectives and Implementing Organizations

The Bangladesh Maternal Health Services and Maternal Mortality Survey (BMMS) is intended to
serve as a source of maternal health and maternal death data for policymakers and the research commu-
nity. In general, the objectives of the BMMS are to:

• Collect data at the national level, which will facilitate an assessment of the level of maternal
mortality in Bangladesh;

• Identify specific causes of maternal and nonmaternal deaths to adult women;

• Collect data on women’s perception of and experience with antenatal, maternity, and emer-
gency obstetrical care;

• Measure indicators of utilization of maternal health services in Bangladesh.

The 2001 BMMS was conducted under the authority of the National Institute of Population Re-
search and Training (NIPORT) of the Ministry of Health and Family Welfare. The survey was imple-
mented by Associates for Community and Population Research (ACPR) and Mitra and Associates, two
Bangladeshi research firms located in Dhaka. These two field organizations had primary responsibility for
implementing the following tasks for the 2001 BMMS: translating and pretesting the questionnaires, hir-
ing and training the field staff, implementing and supervising the data collection, and entering and proc-
essing the data. Each organization was responsible for the fieldwork in three divisions. The Johns Hop-
kins University (JHU) in the United States and the International Centre for Diarrhoeal Disease Research,
Bangladesh (ICDDR,B) provided assistance in questionnaire design and data analysis. ORC Macro of
Calverton, Maryland provided technical assistance in all phases of the project as part of its international
MEASURE DHS+ program, while financial assistance was provided by the U.S. Agency for International
Development (USAID)/Bangladesh.

1.6.2 Survey Design

Administratively, Bangladesh is divided into six divisions. Each division is divided into districts
(zilas), and then thanas or upazilas. Each urban area in a thana or upazila is divided into wards, and each
ward is divided into mohallas; each rural area in a thana or upazila is divided into union parishadas, and
each union is divided into mouzas.

Smaller subdivisions called enumeration areas (EAs) were created for the 1991 census based on
the number of dwellings units. However, experience with the 1999-2000 Bangladesh Demographic and
Health Survey (BDHS) showed that EA maps and sketch maps were not easily accessible. For this reason,

6 | Introduction
EAs were not considered suitable as primary sampling units for the 2001 BMMS survey. Also, it was not
feasible to obtain a computer file of the census information with the codes for the different subdivisions
and their corresponding basic household or population information. However, the complete basic census
information is available in published reports, from the division level down to the mouza level, but not at
the EA level. Consequently, it was decided to make use of the published census reports and to use wards
and unions as the primary sampling units. The second stage of sampling for urban areas involved select-
ing two mohallas in each ward, while for rural areas, two mouzas were selected in each selected union
(with a few exceptions of one mouza or one mohalla per union or per ward, respectively). The third stage
involved selecting households. In summary, in each division, the list of wards constituted the initial sam-
ple frame for urban areas and the list of unions was the sample frame for rural areas. A total of 808 pri-
mary sampling units were selected: 134 urban and 674 rural.

The field organizations (ACPR and Mitra and Associates) conducted a household listing opera-
tion in all of the sample points from November 2000 to April 2001. To obtain an accurate estimate of the
maternal mortality rate at the national level (as well as to achieve other objectives of the survey), a strati-
fied national sample of 104,323 households was systematically selected from a total of 1,616 clusters.

All ever-married women age 13-49 were eligible to be interviewed. It was expected that the sam-
ple would yield interviews with more than 100,000 ever-married women.

1.6.3 Questionnaires

Three questionnaires were used for the BMMS: a Household Questionnaire, a Women’s Ques-
tionnaire (for ever-married women age 13-49), and a Verbal Autopsy Questionnaire (for deaths of women
age 13-49).

The Household Questionnaire consisted of a schedule for listing all household members. For each
listed person, the survey collected basic information such as age, sex, marital status, and education. In-
formation was also collected on household characteristics such as type of housing, source of water, and
availability of electricity. The Household Questionnaire asked about any deaths of household members in
the three years preceding the survey. The information on age, sex, and marital status of household mem-
bers was used to identify eligible respondents for the Women’s Questionnaire. The information about fe-
male adult deaths identified deaths for which the Verbal Autopsy Questionnaire was used.

The Women’s Questionnaire was administered to all ever-married women age 13-49 who were
listed in the Household Questionnaire. These women were asked questions on the following topics:

• Background characteristics (age, education, religion, etc.),

• Reproductive history,

• Use of family planning methods,

• Information about siblings (to calculate the maternal mortality rate),

• Knowledge of maternal health problems,

• Antenatal, delivery, and postnatal care,

• Experience with and treatment of maternal health problems during pregnancy, delivery, and
after delivery,

Introduction | 7
• Treatment-seeking behavior.

The Verbal Autopsy Questionnaire was used to collect information on causes of death for all fe-
male adult (age 13-49) deaths in the household in the three years preceding the survey. The questionnaire
was both structured (precoded questions) and nonstructured (open-ended questions) in nature, and was
answered by the most knowledgeable member of the household.

During the design of the questionnaires, input was sought from various organizations that were
expecting to use the data. ORC Macro designed the questionnaires with assistance from JHU, ICDDR,B,
and USAID. After preparation of the questionnaires in English, they were translated into Bengali. Then
back-translations were done by people other than the initial translators, to verify the accuracy of the trans-
lations.

1.6.4 Training and Fieldwork

The BMMS questionnaires were pretested in November 2000. Pretest teams from both ACPR and
Mitra and Associates were trained jointly at NIPORT. After training, the teams conducted interviews at
various locations in the field under the observation of staff from the two field organizations and members
of the technical task force. Before the pretest, the verbal autopsy methodology was validated in a field
trial in Matlab, Bangladesh, during October-November 2000. ACPR was responsible for recruiting a field
trial team and conducting fieldwork, with assistance from ICDDR,B, to pretest the methodology in a
sample of households with a disproportionate number of maternal deaths as reported by the Demographic
Surveillance System. Based on observations in the field and suggestions made by the pretest and field
trial teams, the technical task force revised the wording of the questionnaires and adjusted the transla-
tions.

In December 2000, candidates for field staff positions for the main survey were recruited. Re-
cruitment criteria included educational attainment, maturity, experience with other surveys, and a firm
commitment to spend one month in training and at least five months in the field. Training for the main
survey was conducted at two different sites by each field organization from December 3 to January 7,
2001. Initially, training consisted of lectures on how to complete the questionnaires, with mock interviews
between participants to gain practice in asking questions. Toward the end of the training course, the par-
ticipants spent several days carrying out practice interviews in places close to Dhaka. Trainees whose per-
formance was considered superior were selected as supervisors and field editors.

Fieldwork for the BMMS was carried out by 50 interviewing teams (23 teams from ACPR and 27
teams from Mitra and Associates) in five phases. Each team consisted of a male supervisor, a female field
editor, and four female interviewers. During fieldwork, emphasis was placed on the quality of data.
ACPR and Mitra and Associates also fielded quality control teams to check on the fieldwork. Feedback
was given to teams after each phase to improve on the quality of data collection. In addition, staff from
USAID, NIPORT, and ORC Macro monitored the fieldwork by visiting teams in the field. Fieldwork
started on January 9, 2001 and was completed in the second week of June 2001.

1.6.5 Data Processing

All questionnaires for the BMMS were returned to Dhaka for data processing at ACPR and Mitra
and Associates. Data entry personnel were trained in Dhaka in February 2001 by ORC Macro data proc-
essing personnel. The processing operation consisted of office editing, coding of open-ended questions,
data entry, and resolving inconsistencies found by the computer edit programs. The data were processed
on microcomputers working in double shifts. The ISSA (Integrated System for Survey Analysis) program
developed by MEASURE DHS+ was used during all stages of data entry and processing. Data processing
commenced in mid-February 2001 and was completed by the end of August 2001.

8 | Introduction
1.6.6 Response Rate

Table 1.2 shows response rates for the survey. A total of 104,323 households were selected for
the sample, of which 99,202 were successfully interviewed. The shortfall is primarily due to dwellings
being vacant or the inhabitants being gone for an extended period at the time of the survey. Of the
100,379 households occupied, 99 percent were successfully interviewed. In these households, 106,789
women were identified as eligible for the individual interview (i.e., ever-married women age 13-49), and
interviews were completed for 103,796, or 97 percent. The principal reason for nonresponse among eligi-
ble women was the failure to find them at home, despite repeated visits to the household. The refusal rate
was low.

Table 1.2 Results of the household and individual interviews

Number of households, number of interviews, and response rates, according to residence,


Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Residence
–––––––––––––––––––––––––––––––––––
Metro-
All politan/ Other
Result urban town urban Rural Total
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Household interviews
Households selected 17,294 9,169 8,125 87,029 104,323
Households occupied 16,536 8,699 7,837 83,843 100,379
Households interviewed 16,306 8,541 7,765 82,896 99,202

Household response rate 98.6 98.2 99.1 98.9 98.8

Individual interviews
Number of eligible women 17,943 9,502 8,441 88,846 106,789
Number of women interviewed 17,330 9,094 8,236 86,466 103,796

Eligible woman response rate 96.6 95.7 97.6 97.3 97.2

Introduction | 9
CHARACTERISTICS OF HOUSEHOLDS
AND RESPONDENTS 2
Tulshi D. Saha

This chapter provides information on some of the socioeconomic characteristics of the household1
population and the individual survey respondents, such as age, sex, and educational level. It also exam-
ines the conditions of the households in which the survey population lives, including availability of elec-
tricity, sanitation facilities, housing materials, and possession of household durable goods. The back-
ground characteristics of women age 13-49 are discussed in the last part of the chapter. Information col-
lected on the characteristics of the households and respondents is important in understanding and inter-
preting the findings of the survey and also provides indicators of the representativeness of the survey.

Whenever possible, the Bangladesh Maternal Health Services and Maternal Mortality Survey
(BMMS) data are compared with the data from the 1999-2000 and 1996-1997 Bangladesh Demographic
and Health Surveys (BDHS). The BMMS collected information from all usual residents of the selected
households (the de jure population) and persons who stayed in the selected households the night before
the interview (the de facto population). Since the difference between these two populations is very small,
all tables in this report refer to the de facto population unless otherwise specified.

2.1 HOUSEHOLD POPULATION

The BMMS Household Questionnaire was used to collect data on the demographic and social
characteristics of all usual residents of the sampled households and visitors who spent the night before the
interview in the household.

2.1.1 Demographic Characteristics of Households

Age and sex are important demographic variables and are the primary basis of demographic clas-
sification in vital statistics, censuses, and surveys. They are also important variables in the study of mor-
tality, fertility, and nuptiality. The effect of variations in sex composition from one population group to
another should be taken into account in comparative studies of mortality. In general, a cross-classification
with sex is useful for the effective analysis of all forms of data obtained in surveys.

The BMMS households constitute a population of 502,385 persons (Table A.1 in Appendix A).
The population is almost equally divided between females (50 percent) and males (50 percent). Because
of relatively high levels of fertility in the past, as well as the effects of mortality, there are more persons in
the younger age groups than in the older age groups for both sexes.

2.1.2 Marital Status

The BMMS includes information on the marital status of all household members age 10 and
above. Table 2.1 shows the marital status distribution of the de facto household population age 13 and
above. Among females age 15-49, 77 percent are currently married and 17 percent have never been mar-
ried. The proportion never married is higher for males (40 percent) than for females (17 percent). The
proportion formerly married (widowed, divorced, separated, or deserted) is small—6 percent for females
and less than 1 percent for males.

1
A household was defined as a person or group of people who live and eat together.

Characteristics of Households and Respondents | 11


Table 2.1 Marital status of the household population

Percent distribution of the de facto household population by current marital status according to sex and age group, Bangladesh
2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Male Female
––––––––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––
Currently Formerly Never Currently Formerly Never
Age married married married Missing Total Number married married married Missing Total Number
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
13-14 1.3 0.2 97.8 0.8 100.0 11,945 11.2 0.3 87.7 0.8 100.0 13,269
15-19 4.0 0.2 95.3 0.5 100.0 25,643 46.5 1.2 52.1 0.2 100.0 31,639
20-24 25.4 0.4 73.9 0.3 100.0 17,765 80.4 2.8 16.8 0.0 100.0 24,157
25-29 64.0 0.6 35.3 0.1 100.0 17,025 92.0 3.9 4.1 0.0 100.0 19,346
30-34 87.4 0.6 12.0 0.1 100.0 16,066 92.6 6.2 1.2 0.0 100.0 17,326
35-39 96.6 0.6 2.8 0.1 100.0 16,089 90.8 8.7 0.4 0.0 100.0 14,280
40-44 98.4 0.7 0.8 0.0 100.0 13,259 86.9 12.8 0.3 0.0 100.0 11,507
45-49 98.9 0.7 0.4 0.0 100.0 10,758 81.8 18.0 0.2 0.0 100.0 8,502
50-54 98.4 1.2 0.3 0.0 100.0 8,040 70.9 28.7 0.2 0.2 100.0 6,689
55+ 93.5 6.2 0.2 0.1 100.0 24,920 40.1 59.3 0.3 0.4 100.0 21,717

15-49 59.8 0.5 39.6 0.2 100.0 116,604 77.2 5.6 17.1 0.1 100.0 126,757

Also of interest is the proportion of persons who marry young. At age 15-19, the proportions ever
married are 4 percent for males and 48 percent for females. By age 25-29, 96 percent of females in Bang-
ladesh have been married. For males in this age group, 65 percent have been married. The singulate mean
age at marriage (SMAM) calculated from age-specific proportions single in the BMMS is 26 for males
and 19 for females.2 According to the SMAM measure, men in Bangladesh tend to marry women who are
almost seven years younger than they are.

2.1.3 Household Composition

Table 2.2 shows the distribution of the households in the survey by the sex of the head of the
household and by the number of de jure household members in urban and rural areas. These characteris-
tics are important because they are often associated with differences in household socioeconomic levels.
For example, female-headed households are frequently poorer than households headed by males. In addi-
tion, the size and composition of the household affects the allocation of financial and other resources
among household members, which in turn influences the overall well-being of these individuals. House-
hold size is also associated with crowding in the dwelling, which can lead to unfavorable health condi-
tions.

A small minority of households in Bangladesh are headed by women (10 percent), with 90 per-
cent headed by males. The average household size observed in the survey is 5.1 people, with no variation
between rural and urban areas.

2
For 15-49 years of age

12 | Characteristics of Households and Respondents


Table 2.2 Household composition

Percent distribution of households by sex of head of household and mean household


size, according to residence, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Residence
–––––––––––––––––––––––––––––––––––
Metro-
All politan/ Other
Household headship/size urban town urban Rural Total
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Sex of head of household
Male 89.4 89.6 89.0 90.3 90.1
Female 10.6 10.4 11.0 9.7 9.9

Total 100.0 100.0 100.0 100.0 100.0

Number of households 18,541 10,205 8,336 80,661 99,202

Mean size of household 5.1 5.1 5.2 5.1 5.1


––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Table is based on de jure members (i.e., usual residents).

2.1.4 Education

The educational attainment of household members is an important determinant of their opportuni-


ties and behavior. Studies have consistently shown that educational attainment has strong effects on re-
productive behavior, contraceptive use, fertility, infant and child mortality, morbidity, and issues related
to family health and hygiene. Table A.2 in Appendix A provides data on educational attainment of the
household population listed in the BMMS.

Education has become more widespread over time in Bangladesh. This is apparent from the dif-
ferences in levels of educational attainment by age group. A steadily decreasing percentage of both males
and females have never attended school in each younger age group. Data from previous BDHSs (1996-
1997 and 1999-2000) show that proportions who attended secondary school have increased for women
age 10-14 and 15-19, although not recently for men (Figure 2.1).

Figure 2.1 Percentage of Males and Females Age 10-14 and Age
15-19 with Some Secondary Education, 1996-2001

56 55
53 52
49 49

34
32
27 26
21
19

10-14 15-19 10-14 15-19


Male Female

1996-1997 BDHS 1999-2000 BDHS 2001 BMMS

BMMS 2001

Characteristics of Households and Respondents | 13


2.2 Housing Characteristics

The physical characteristics of households are important in assessing the general socioeconomic
condition of the population. In the BMMS, respondents to the Household Questionnaire were asked about
access to electricity, type of toilet facility, and main materials of the roof, wall, and floor. Information on
the characteristics of the sampled households is presented in Table 2.3.

Table 2.3 Household characteristics

Percent distribution of households by housing characteristics, according to residence,


Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Residence
–––––––––––––––––––––––––––––––––––
Metro-
All politan/ Other
Characteristic urban town urban Rural Total
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Electricity
Yes 64.6 82.0 43.3 23.7 31.4
No 35.4 18.0 56.7 76.2 68.6

Total 100.0 100.0 100.0 100.0 100.0

Sanitation facility
Septic tank, modern toilet 26.1 38.7 10.6 4.7 8.7
Water sealed/slab latrine 20.8 21.7 19.7 14.6 15.7
Traditional pit latrine 22.5 16.0 30.5 25.6 25.0
Open latrine 17.6 17.3 18.0 24.8 23.4
Hanging latrine 2.6 1.4 3.9 3.7 3.5
No facility 10.4 4.8 17.2 26.6 23.6

Total 100.0 100.0 100.0 100.0 100.0

Roof material
Katcha (bamboo/thatch) 8.7 6.0 12.0 17.1 15.6
Tin 68.6 59.3 80.1 77.5 75.9
Tile 1.7 1.5 1.9 2.7 2.5
Cement/concrete 19.6 31.5 5.1 2.0 5.3
Other 1.3 1.7 0.8 0.6 0.7

Total 100.0 100.0 100.0 100.0 100.0

Wall material
Katcha (jute/bamboo/mud) 37.8 27.9 49.9 63.4 58.6
Wood 2.1 1.2 3.2 2.3 2.3
Brick/Cement 38.8 57.4 16.1 9.0 14.6
Tin 20.8 12.9 30.5 24.7 24.0
Other 0.4 0.6 0.3 0.5 0.5

Total 100.0 100.0 100.0 100.0 100.0

Floor material
Earth/bamboo (katcha) 60.2 40.8 84.0 93.3 87.1
Wood 0.3 0.4 0.2 0.4 0.4
Cement/concrete 39.4 58.8 15.7 6.3 12.5
Other 0.0 0.0 0.0 0.0 0.0

Total 100.0 100.0 100.0 100.0 100.0

14 | Characteristics of Households and Respondents


About one-third (31 percent) of households in Bangladesh have electricity, but this varies widely
by residence. Three-quarters of Bangladeshi households have some type of toilet facility; only 49 percent
have hygienic toilets (septic tank/modern toilets, water-sealed/slab latrines, and pit toilets). Lack of sani-
tation facilities is more common in rural areas than in urban areas. Twenty-seven percent of rural house-
holds have no toilet facility at all, compared with only 10 percent of urban households.

Tin is the most common roofing material in Bangladesh, accounting for 76 percent of households.
In urban areas, 20 percent of households live in dwellings with cement or concrete roofs, while in rural
areas, bamboo or thatch (17 percent) is the most common roofing material after tin.

About six in ten households in Bangladesh live in structures with walls made of natural materials
such as jute, bamboo, or mud. Fifteen percent live in houses with brick or cement walls, and 24 percent
live in houses with tin walls. Urban households live in more solid dwellings than rural households. Al-
most 40 percent of urban households live in structures with brick or cement walls, compared with only 9
percent of rural households.

Eighty-seven percent of households have floors made of earth; only 13 percent have cement
floors. Rural houses are more likely than urban houses to have earth floors. Likewise, urban houses are
more likely than rural houses to have cement floors. About 60 percent of households in towns (39 percent
for total urban) have cement floors, while more than 90 percent of rural households have floors made of
earth.

2.2.1 Household Possessions

Information on the possession of various durable goods was collected at the household level.
Table 2.4 shows that possession of household durable goods is not common in Bangladesh. Overall, 86
percent of households own a cot or bed, 61 percent own a table or chair, 58 percent own a watch or clock,
34 percent own an almirah (wardrobe), and 19 percent own a bench. For more valuable items, 30 percent
of households own a radio, 21 percent own a bicycle, 17 percent own a television, and 5 percent own a
sewing machine; only 2 percent of households have a telephone. About one in ten households owns
none of the items listed in the questionnaire. In general, households in rural Bangladesh are less likely to
have consumer items like a radio, television, or telephone.

The BMMS collected data on household ownership of land. Almost 90 percent of Bangladeshi
households own a homestead, while half own land other than a homestead; 8 percent of households do not
own any land. Ownership of a homestead or land is less common in urban areas than in rural areas.

The wealth index was constructed from data on ownership of household assets, as well as dwell-
ing characteristics such as type of drinking water available, sanitation facilities, roofing, and flooring.
Each asset was assigned a weight (factor score) generated through principle components analysis, and the
resulting asset scores were standardized to a normal distribution with a mean of zero and a standard de-
viation of one (Gwatkin et al., 2000). Each household was then assigned a score for each asset, and the
scores were summed by household; individuals were ranked according to the total score of the household
in which they resided. The sample was then divided into population quintiles ranked from lowest (poor-
est) to highest (wealthiest). According to Table 2.4, 45 percent of urban households are in the highest
quintile, compared with only 12 percent of rural households. As expected, most of the wealthiest house-
holds are located in metropolitan/town areas.

Characteristics of Households and Respondents | 15


Table 2.4 Household durable goods, land ownership, and household wealth

Percentage of households possessing various durable consumer goods, ownership of


land, and household wealth, according to residence, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Residence
–––––––––––––––––––––––––––––––––––
Metro-
Ownership and All politan/ Other
wealth index urban town urban Rural Total
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Durable goods
Almirah (wardrobe) 54.7 64.8 42.3 29.7 34.3
Table/chair 68.9 71.4 65.8 59.6 61.3
Bench 16.0 12.4 20.5 19.4 18.7
Watch/clock 72.5 79.7 63.7 54.0 57.5
Cot/bed 91.5 94.3 88.0 84.5 85.8
Radio 39.1 43.4 33.9 28.1 30.1
Television 41.2 54.1 25.4 11.7 17.2
Bicycle 17.4 17.1 17.7 21.5 20.7
Motorcycle 3.2 3.8 2.4 1.0 1.4
Sewing machine 11.4 15.6 6.2 3.2 4.7
Telephone 6.7 10.5 2.0 0.5 1.6
None of the above 5.3 3.5 7.6 10.2 9.3

Land ownership
Owns a homestead 81.2 75.0 88.8 91.6 89.7
Owns other land 42.1 39.6 45.3 52.7 50.7
None of the above 14.1 18.2 9.0 7.0 8.3

Wealth quintile
Lowest 11.8 6.1 18.8 25.5 23.0
Second 13.2 8.9 18.4 23.3 21.4
Middle 14.0 10.3 18.5 21.0 19.7
Fourth 15.6 12.3 19.5 18.7 18.1
Highest 45.4 62.2 24.8 11.5 17.8

Number of households 18,541 10,205 8,336 80,661 99,202

2.3 CHARACTERISTICS OF SURVEY RESPONDENTS

2.3.1 Background Characteristics

The distribution of ever-married women age 13-49 by background characteristics including age,
marital status, place of residence, division, educational level, and participation in women’s organizations
is shown in Table 2.5.

The age distribution of ever-married women is similar to that found in the BDHS (1993-1994,
1996-1997, and 1999-2000) surveys; half of ever-married women are age 13-29. About 20 percent of re-
spondents live in urban areas (11 percent in metropolitan city/town and 9 percent in the other urban ar-
eas), while about 80 percent live in rural areas. About one-third of respondents live in Dhaka division, and
about one-fourth live in Rajshahi division. Eighteen percent of respondents live in Chittagong division, 12
percent in Khulna division, 7 percent in Barisal division, and only 6 percent in Sylhet division.

About half (47 percent) of ever-married women have never been to school. Twenty-eight percent
of respondents have attended primary school and one-quarter have some secondary school. More than
one-quarter of respondents have an affiliation with a women’s organization. Ninety-three percent of ever-
married women are currently married.

16 | Characteristics of Households and Respondents


Table 2.5 Background characteristics of respondents

Percent distribution of ever-married women by background charac-


teristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of women
Background Weighted –––––––––––––––––––––
characteristic percent Weighted Unweighted
–––––––––––––––––––––––––––––––––––––––––––––––––––––––
Age
13-19 14.5 15,097 15,051
20-24 18.7 19,417 19,396
25-29 17.2 17,840 17,860
30-34 16.1 16,736 16,706
35-39 13.3 13,809 13,816
40-44 10.7 11,083 11,129
45-49 7.9 8,190 8,241

Residence
All urban 19.2 19,896 17,330
Metropolitan/town 10.7 11,083 9,094
Other urban 8.5 8,813 8,236
Rural 80.8 83,900 86,466

Division
Barisal 6.6 6,839 10,202
Chittagong 17.6 18,275 18,633
Dhaka 34.5 35,848 27,577
Khulna 11.9 12,307 17,079
Rajshahi 23.6 24,495 19,296
Sylhet 5.8 6,032 11,009

Education
No education 46.5 48,243 47,860
Primary incomplete 17.9 18,630 18,999
Primary complete 10.4 10,764 11,236
Secondary+ 25.2 26,159 25,701

Marital status
Currently married 93.4 96,945 96,805
Separated 0.9 937 947
Deserted 0.7 759 785
Divorced 1.2 1,280 1,330
Widowed 3.7 3,875 3,929

Membership in any
women’s organization
No 73.8 76,564 76,957
Yes 26.2 27,232 26,839

Total 100.0 103,796 103,796

2.3.2 Educational Level of Survey Respondents

Table 2.6 shows the educational level of ever-married women by background characteristics.
Among ever-married women, education is inversely related to age, that is, older women are less educated
than younger women. For instance, 26 percent of ever-married women age 13-19 years have never at-
tended school, compared with 63 percent of those age 45-49.

Characteristics of Households and Respondents | 17


Urban residents have more education than rural residents. For example, 49 percent of rural
women have had no education, compared with 36 percent of urban women. In contrast, while about four
in ten urban women (39 percent) have attended secondary school, only 22 percent of rural women have
done so.

Women in Barisal, Chittagong, and Khulna divisions are better educated than women in the other
divisions. In these divisions, the proportion of women with no education does not exceed 43 percent. Re-
spondents in these divisions are also more likely than other respondents to complete primary school
and/or to attend secondary school.

Table 2.6 Level of education by background characteristics

Percent distribution of ever-married women by highest level of education attended, according to background
characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Level of education
–––––––––––––––––––––––––––––––––––––––––––––––
Background No Primary Primary Secondary
characteristic education incomplete complete or higher Total Number
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Age
13-19 25.5 20.2 14.0 40.3 100.0 15,097
20-24 36.3 18.3 10.6 34.8 100.0 19,417
25-29 47.2 17.5 9.6 25.7 100.0 17,840
30-34 53.0 17.6 9.2 20.2 100.0 16,736
35-39 56.5 17.4 9.3 16.8 100.0 13,809
40-44 60.9 16.0 9.0 14.1 100.0 11,083
45-49 63.1 16.4 9.4 11.1 100.0 8,190

Residence
Urban 35.9 15.4 9.5 39.2 100.0 19,896
Metropolitan/town 31.0 13.7 9.5 45.9 100.0 11,083
Other urban 42.1 17.6 9.5 30.8 100.0 8,813
Rural 49.0 18.6 10.6 21.9 100.0 83,900

Division
Barisal 30.5 25.2 17.8 26.5 100.0 6,839
Chittagong 43.2 14.6 11.5 30.6 100.0 18,275
Dhaka 47.1 18.2 9.5 25.3 100.0 35,848
Khulna 40.2 22.3 9.4 28.2 100.0 12,307
Rajshahi 52.7 16.8 8.8 21.7 100.0 24,495
Sylhet 58.7 14.3 12.1 14.9 100.0 6,032

Wealth quintile
Lowest 76.3 15.5 4.8 3.4 100.0 21,186
Second 60.6 21.4 8.6 9.3 100.0 20,982
Middle 46.8 21.7 12.4 19.1 100.0 20,491
Fourth 30.8 19.2 14.7 35.4 100.0 20,257
Highest 17.0 12.0 11.6 59.4 100.0 20,880

Total 46.5 17.9 10.4 25.2 100.0 103,796

2.3.3 Exposure to Mass Media

The BMMS collected information on the exposure of respondents to the broadcast media. Re-
spondents were asked whether they listen to a radio or watch television at least once a week. This infor-
mation is important because it provides an indication of women’s exposure to mass media; mass media
are used to disseminate family planning, health, and other information. Table 2.7 shows that more than
one-third of women watch television or listen to the radio at least once a week. Half of women are ex-
posed to at least one of these media sources once a week.

18 | Characteristics of Households and Respondents


Media exposure varies with the age of respondent. Younger women are somewhat more likely
than older women to listen to the radio or watch television. Exposure to these media is higher among ur-
ban and more educated women. For example, the proportion of women who watch television at least once
a week ranges from 21 percent among those with no education to 61 percent among those with some sec-
ondary school. Differentials by division are not large, except that women in Sylhet and Barisal divisions
have less exposure to mass media than women in other divisions. Women in wealthier households are
more likely to be exposed to mass media than women in poorer households.

Table 2.7 Exposure to mass media

Percentage of women who usually watch television at least once a week and
listen to the radio at least once a week, by background characteristics, Bangladesh
2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Exposure to mass media
–––––––––––––––––––––––––––––––––––
Watches Exposed
television Listens to the to either
Background at least radio at least TV or radio
characteristic once a week once a week once a week Number
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Age
13-19 39.7 44.0 58.7 15,097
20-24 41.6 39.6 57.2 19,417
25-29 37.0 34.0 51.4 17,840
30-34 34.7 31.1 48.1 16,736
35-39 31.3 29.9 45.1 13,809
40-44 28.1 28.3 41.8 11,083
45-49 26.7 27.0 40.4 8,190

Residence
Urban 62.9 39.5 70.9 19,896
Metropolitan/town 75.6 39.3 80.7 11,083
Other urban 46.9 39.6 58.6 8,813
Rural 28.8 33.4 45.5 83,900

Division
Barisal 21.7 34.2 41.9 6,839
Chittagong 36.1 38.7 52.2 18,275
Dhaka 42.2 35.6 55.8 35,848
Khulna 38.8 37.8 55.0 12,307
Rajshahi 29.8 29.9 44.2 24,495
Sylhet 23.2 28.2 38.1 6,032

Education
No education 21.3 23.5 34.6 48,243
Primary incomplete 32.3 34.8 49.4 18,630
Primary complete 40.3 42.1 58.9 10,764
Secondary+ 61.3 51.7 76.6 26,159

Wealth quintile
Lowest 14.0 16.2 24.1 21,186
Second 19.8 24.6 34.7 20,982
Middle 25.6 35.4 46.4 20,491
Fourth 40.1 46.2 62.4 20,257
Highest 77.5 50.9 85.1 20,880

Total 35.3 34.5 50.4 103,796

Characteristics of Households and Respondents | 19


ADULT FEMALE MORTALITY:
LEVELS AND CAUSES 3
Kenneth Hill, Shams-El-Arifeen, Hafizur Rahman Chowdhury, and Saifur Rahman

Two of the principal objectives of the BMMS were to measure maternal mortality and to test al-
ternative strategies for such measurement. This chapter presents BMMS findings relevant to these objec-
tives. Maternal mortality was expected to be high, given Bangladesh’s relatively low levels of female
literacy and proportions of deliveries assisted by trained professionals. Identifying factors associated with
high risk provides a basis for targeting interventions. The methods used in the BMMS to collect data on
maternal mortality also provide information about overall adult mortality, and this chapter reviews the
information on adult mortality in general and on maternal mortality in particular.

3.1 MEASURES OF MATERNAL MORTALITY

The “Tenth Revision of the International Classification of Diseases” defines a maternal death as
any “death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the
duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its
management but not from accidental or incidental causes” (World Health Organization, 1992). A preg-
nancy-related death is defined as any death of a woman while pregnant or within 42 days of termination
of pregnancy, irrespective of the cause.

Maternal mortality can be measured using a number of different indicators. The most commonly
used indicator is the maternal mortality ratio (MMR), which is calculated as the ratio of maternal deaths
in a period to live births during the period, expressed per 100,000 live births. This indicator relates ma-
ternal deaths to a measure of risky events, namely births; ideally, the indicator should relate maternal
deaths to the number of pregnancies, since pregnancies are the risky events, but good counts of pregnan-
cies are rarely available. In this chapter, the pregnancy-related mortality ratio (PRMR) is also used. The
PRMR which is calculated in the same way as the MMR, but it includes not just maternal deaths, but all
pregnancy-related deaths in the numerator.

Maternal mortality is sometimes expressed relative to the number of women of reproductive age.
The maternal mortality rate (MMRate) is typically calculated as the ratio of the annual number of mater-
nal deaths to the midyear number of women age 15-44, expressed per 1,000. The MMRate thus does not
express the risk of death per risky event, but rather per person potentially exposed to the risk. A change
in fertility will not per se affect the MMR, but it will directly affect the MMRate.

Two other measures of maternal mortality are sometimes cited: the lifetime risk of dying of ma-
ternal causes, which takes into account not only the risk per event but also the number of risky events a
woman may expect during her reproductive life; and the proportion maternal of deaths of women of re-
productive age, which expresses the risk of a maternal death relative to the risk of death from all causes
during age 15-49.

Each of these measures expresses reproductive mortality in a different and potentially revealing
way. Most of the results in this chapter will be PRMRs because of the way the data were collected, but
MMR and MMRate results are also presented.

Adult Female Mortality: Levels and Causes | 21


3.1.1 Measuring Maternal Mortality

Despite their major societal impacts, maternal deaths are relatively infrequent events. They are
also difficult events to record. Even in countries with complete recording of births and deaths, maternal
deaths are generally underreported because of incorrect classification of cause. (Bouvier-Colle et al.,
1991; Atrash et al., 1995). In countries lacking complete vital registration systems, the problems are even
greater: Not only may maternal deaths be misclassified, they may simply be omitted. Various strategies
have been developed for trying to estimate maternal mortality in settings where death registration is seri-
ously incomplete. The most widely used method is the “sisterhood” approach. Respondents to a sample
survey are asked about the survival or otherwise of their sisters, and for sisters who have died, a further
set of questions is added to identify those deaths that occurred while the woman was pregnant, during de-
livery, or in a defined postpartum period. There are two versions of the sisterhood method: an indirect
method, collecting only information on numbers of sisters alive or dead (Graham et al., 1989), and a di-
rect method, collecting detailed information about each individual sister (Rutenberg and Sullivan, 1991).
A second strategy uses a population census or large household survey to collect information about deaths
by age and sex in each household in a defined reference period and asks additional questions for deaths of
women of reproductive age to determine whether they died while they were pregnant or during some de-
fined postpartum period (Stanton et al., 2001).

The fact that maternal deaths are relatively infrequent has important implications for measure-
ment. Sample surveys need large samples to obtain reasonably precise estimates. The sisterhood method
can enhance sample size in a high fertility population because each respondent will report on multiple
sisters. However, once fertility drops below about four children per woman, this advantage erodes and
may be a major disadvantage in a population with an average of two children per mother. Both the direct
sisterhood approach and the deaths in the household approach can attempt to improve precision by in-
creasing the length of the reference period for which estimates are calculated. For the direct sisterhood
approach, the length of the reference period for which an estimate is calculated can be determined during
the tabulation stage. Experience from the Demographic and Health Surveys (DHS) project has shown that
samples of about 10,000 households will provide direct sisterhood estimates of maternal mortality for a
reference period covering the seven years before the survey with 95 percent confidence intervals (95%
CI) on the order of ±25 percent. For the household deaths approach, the basic data on deaths are collected
for a specified reference period; estimates can be calculated for shorter but not longer periods during the
tabulation stage. Accurate recall of household deaths also becomes a concern as the reference period for
which information on deaths is collected increases.

Both the sisterhood and the household deaths approaches to measuring maternal mortality gener-
ally define a “maternal” death in terms of time of death relative to pregnancy. Both methods thus meas-
ure pregnancy-related mortality rather than maternal mortality. Although these deaths will include some
deaths that are unrelated to the pregnancy (and thus should not be considered maternal deaths), it has been
argued that the time of death questions tend to omit some maternal deaths in early pregnancy, simply be-
cause the pregnancy was not known to the respondent, and that the overreporting of maternal deaths re-
sulting from the inclusion of incidental deaths tends to cancel out the exclusion of maternal deaths for
which the pregnancy was not declared (Hill et al., 2001).

A measure of maternal mortality can be obtained by combining the household death approach
with a verbal autopsy, which attempts to identify the true cause of each death by asking about the symp-
toms that accompanied the final illness. Methods for conducting a verbal autopsy vary, but a common
approach is to interview a close relative or other knowledgeable household member. The interview starts
with an open-ended question asking the respondent to describe in his or her own words the circumstances
surrounding the death, and then it continues with questions about the presence or absence of specific
symptoms. Evaluations of verbal autopsies indicate that their results, particularly for many chronic dis-

22 | Adult Female Mortality: Levels and Causes


eases of adulthood, are neither highly specific nor highly sensitive [e.g., for maternal mortality (Sloan et
al., 2001)]; results therefore need to be treated with caution. It is also possible that a verbal autopsy may
misclassify some maternal deaths because the autopsy respondent did not know the deceased woman was
pregnant.

3.1.2 Maternal Mortality Measures in the BMMS

The BMMS used both the sisterhood and the household deaths approaches to measuring maternal
mortality and also used both a time of death and a verbal autopsy approach to identify pregnancy-related
or maternal deaths among deaths of women of reproductive age. The Household Questionnaire included
a section concerning deaths of usual residents of the household since April 1997. If any death was re-
ported, further details regarding the name, sex, age at death, and month and year of death were collected.
In addition, if the deceased person was a woman age 13-49 at the time of death, three questions were
asked as to whether the woman died while she was pregnant, giving birth, or within 42 days of the end of
the pregnancy, and a verbal autopsy was conducted with the household to try to ascertain whether the
death was maternal. Cause of death was determined from the verbal autopsy by physician review; two
physicians independently reviewed each case, but if they could not agree, the case was reviewed by a
third physician.

The Women’s Questionnaire, administered to all ever-married female household members age
13-49, included a complete sibling history—the name, sex, survival status, and age (if living) or age at
death and years since death (if dead)—for every live birth the respondent’s mother had, excluding the re-
spondent herself. Further, for any sisters who died at age 12 or older, the time of death relative to preg-
nancy, childbirth, and the first two months after the end of the pregnancy was also ascertained.

In addition to providing information about maternal mortality, both sets of questions provide in-
formation about overall mortality, at all ages in the case of household deaths of usual residents and for
age 15-49 in the case of data from the sibling history. The verbal autopsy also provides information on
nonmaternal causes of death for women of reproductive age. Overall and nonmaternal mortality are ex-
amined in Section 3.3.

3.2 MATERNAL MORTALITY IN BANGLADESH: LEVELS AND CAUSES

The BMMS included three ways of measuring the mortality risks associated with pregnancy: es-
timates of pregnancy-related mortality obtained from both household deaths and sister deaths combined
with time of death information and estimates of maternal mortality obtained from household deaths com-
bined with the verbal autopsy.

3.2.1 Estimates from Household Deaths

Pregnancy-related mortality estimates based on time of death information and maternal mortality
estimates based on the verbal autopsy are presented below. The BMMS recorded household deaths for
the period from April 1997 to the time of the survey, but the results presented here are based on deaths in
the 36 months before interview date, excluding the month of interview. Since BMMS fieldwork was
conducted during the first six months of 2001, and half of the households covered had been interviewed
by the end of March, the mortality estimates given here refer approximately to the period from early 1998
to early 2001. For a discussion of data quality of household deaths, see Appendix B.

Adult Female Mortality: Levels and Causes | 23


Pregnancy-Related Mortality

Table 3.1 shows pregnancy-related deaths in the period 1998-2001 by the age of the deceased
woman and by the time of death relative to the pregnancy. Deaths are weighted, hence the decimal por-
tions. Table 3.1 also shows exposure time: the number of woman-years of exposure to risk in each age
group.1 Mortality rates are calculated by dividing the number of events (deaths) in a particular category
by the exposure time in that category. A rate can then be expressed relative to births by dividing by the
fertility rate specific for the category. The overall PRMR is 382 per 100,000 live births. Assuming that
there were 3.8 million births in Bangladesh in 2001, there would have been about 14,500 pregnancy-
related deaths in that year. The PRMR increases monotonically with age from the age group 15-19 to 45-
49. Risks are very high for the oldest women, but the difference in risk even between women age 15-19
and those age 35-39 is substantial: the risk per birth for women age 35-39 is over 3.5 times that for
women age 15-19.

Table 3.1 Pregnancy-related mortality rates and ratios

Pregnancy-related mortality rates and ratios for the three years preceding the survey by age, Bangladesh
2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Age-specific
fertility rate and
Mortality age-specific
–––––––––––––––––––––––––––––––––––––––––––––––––– pregnancy-
Exposure Deaths: Total Pregnancy- related
time –––––––––––––––––––––– pregnancy- related mortality ratio
(woman During During Post- related mortality ––––––––––––––
Maternal age years) pregnancy delivery partum deaths rate1 ASFR2 PRMR3
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
15-19 90,099 12.981 2.100 11.543 26.624 0.296 0.134 221
20-24 67,390 10.854 3.444 17.253 31.550 0.468 0.185 253
25-29 57,606 10.651 5.013 16.499 32.164 0.558 0.149 374
30-34 48,931 10.654 4.488 15.580 30.722 0.628 0.097 650
35-39 40,111 7.187 2.700 7.456 17.343 0.432 0.053 814
40-44 31,989 2.411 0.000 6.251 8.662 0.271 0.020 1,363
45-49 21,881 7.306 0.000 0.937 8.242 0.377 0.006 6,166

Total 358,007 62.044 17.745 75.519 155.308 0.434 3.222 -


GFR - - - - - - 0.113 -
PRMR - - - - - - - 382
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Information from the Household Questionnaire considers de jure female household population in
exposure, gets maternal deaths from listing with usual members who died in the three years before the
survey, and assumes same fertility rates as de facto interviewed women.
1
Deaths per 1,000
2
Births per woman
3
Deaths per 100,000

Maternal Mortality

The verbal autopsies administered for all households where the death of a woman age 13-49 was
reported provide a basis for identifying maternal, as opposed to pregnancy-related, deaths. Table 3.2
shows the numbers of deaths judged to be maternal on the basis of the verbal autopsy, by the same time of
death relative to pregnancy categories as used in Table 3.1. The total (weighted) number of maternal
deaths is 131, about 15 percent lower than the number of pregnancy-related deaths in Table 3.1. The es-
timated MMR is 322 per 100,000 live births, compared with the PRMR of 382 in Table 3.1. Assuming

1
Exposure to risk is the length of time lived in a particular category by all women surveyed—thus, a woman who
was 21 at the beginning of 1998 and survived to age 24 at the end of 2000 contributed three years of exposure time
to age group 20-24.

24 | Adult Female Mortality: Levels and Causes


again that there were 3.8 million births in Bangladesh in 2001, there would have been about 12,200 ma-
ternal deaths in that year. The age pattern of maternal risk is very similar to pregnancy-related risk, rising
very steeply with age, such that the risk per birth for women over 35 is almost ten times the risk per birth
for women age 15-24.

Table 3.2 Maternal mortality rates and ratios

Maternal mortality rates and ratios for the three years preceding the survey by age, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Age-specific
Mortality fertility rate and
–––––––––––––––––––––––––––––––––––––––––––––––––– age-specific
Exposure Deaths: maternal
time –––––––––––––––––––––– Total Maternal mortality ratio
(woman During During Post- maternal mortality ––––––––––––––
Maternal age years) pregnancy delivery partum deaths rate1 ASFR2 MMR3
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
15-19 90,099 3.173 3.822 13.506 20.501 0.228 0.134 169.883
20-24 67,389 8.467 1.246 19.845 29.559 0.439 0.185 236.585
25-29 57,605 5.256 1.838 23.726 30.820 0.535 0.149 358.383
30-34 48,931 5.814 4.194 14.392 24.399 0.499 0.097 516.151
35-39 40,110 1.947 1.584 6.960 10.490 0.262 0.053 492.483
40-44 31,989 2.411 1.105 8.852 12.367 0.387 0.020 1,945.921
45-49 21,880 1.838 0.709 0.709 3.256 0.149 0.006 2,435.431

Total 358,007 28.906 14.498 87.989 131.392 0.367 3.222 -


GFR - - - - - - 0.113 -
MMR - - - - - - - 322.156
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Information from the Household Questionnaire and the verbal autopsy considers de jure female
household population in exposure, gets maternal deaths from the Verbal Autopsy Questionnaire, and
assumes same fertility rates as de facto interviewed women.
1
Deaths per 1,000
2
Births per woman
3
Deaths per 100,000

Maternal Mortality Ratios by Background Characteristics

Table 3.3 shows exposure time, maternal deaths, and MMRs based on household deaths with ver-
bal autopsy by selected background characteristics: residence, division, and socioeconomic status of the
household. These estimates were interpreted on the basis of limited exposure time and small numbers of
events; thus, they have large potential sampling errors (the 95 percent confidence intervals around each
estimate are shown in Table 3.3). Risks are below average in the major metropolitan areas, but they are
above average in the smaller urban areas. By division, Sylhet and Barisal have the highest risks, whereas
Dhaka and Rajshahi have the lowest. There is a general tendency for risks to be lower in households that
are better-off economically and higher in poorer households, although the highest risk is found in the
middle quintile.

Adult Female Mortality: Levels and Causes | 25


Table 3.3 Differentials in maternal mortality

Differentials in maternal mortality by residence, division, and socioeconomic status, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Exposure 95% confidence
time Maternal General Maternal interval
(woman Maternal mortality fertility mortality ––––––––––––––––
Characteristic years) deaths rate rate ratio Lower Upper
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Residence
Metropolitan 41,570 9.7 0.233 0.087 262 62 463
Other urban 30,937 11.6 0.374 0.106 344 111 576
Rural 285,498 110.2 0.386 0.117 326 251 401

Division
Barisal 23,562 10.4 0.443 0.115 387 176 597
Chittagong 66,717 27.7 0.416 0.127 325 186 463
Dhaka 123,201 45.6 0.370 0.112 320 203 437
Khulna 40,745 13.3 0.327 0.094 351 149 552
Rajshahi 80,856 19.0 0.235 0.104 223 96 351
Sylhet 22,922 15.2 0.665 0.139 471 259 682

Wealth quintile
Lowest 68,835 34.4 0.499 0.146 343 222 466
Second 68,531 26.9 0.392 0.128 302 177 428
Middle 69,092 36.4 0.527 0.112 473 308 637
Fourth 72,409 19.7 0.272 0.100 268 144 393
Highest 79,143 14.0 0.177 0.084 208 93 324

Total 358,007 131.4 0.367 0.113 322 253 391


––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Data are weighted; hence, the number of deaths is not a round number.

The verbal autopsy used to follow up all deaths of women of reproductive age included a question
on the number of previous live births the deceased woman had. It is thus possible to classify maternal
deaths, as identified by the verbal autopsy, by the woman’s parity prior to the final pregnancy and esti-
mate parity-specific maternal mortality risks. Table 3.4 shows the maternal deaths by parity, as well as
the parity-specific births in the three years before the survey and the resulting MMRs by parity. The
MMRs in this instance are calculated in a different way from those elsewhere in this report. Elsewhere,
MMRates are calculated from maternal deaths and exposure time, and converted into MMRs using the
general fertility rate (GFR). For the calculations by parity, the MMR was calculated directly from mater-
nal deaths at a given parity divided by the births of that parity, estimated after adjusting observed births
for those not reported by women who died. Although small numbers of deaths at higher parities result in
a rather erratic pattern, it is clear that the safest births of all are second births, and second to fifth births
are all of fairly low risk. First births are associated with more than twice the risk of second and third
births, and births of parity six and over also average twice the risk of the least risky births.

26 | Adult Female Mortality: Levels and Causes


Table 3.4 Maternal mortality ratios by prior parity

Maternal mortality ratios for the three years preceding the survey by prior parity,
Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
General Estimated Maternal
fertility total live Maternal mortality
Prior parity Births rate births deaths ratio
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
0 10,662 0.0330 10,691 54.6 511
1 9,872 0.0306 9,900 19.0 192
2 6,870 0.0213 6,889 16.0 232
3 4,422 0.0137 4,434 12.2 275
4 2,913 0.0090 2,921 8.1 276
5+ 4,517 0.0139 4529 21.5 475

Total 39,256 0.1215 39,364 131.4 334


––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Data are weighted; hence, the number of deaths is not a round number.
Prior parity is the woman’s parity prior to the final pregnancy.

Maternal Deaths by Cause of Death

A verbal autopsy is a fairly blunt instrument for identifying cause of death, especially when it is
administered as much as three years after the death. Interpreting the information recorded is still some-
thing of an art form. It is not surprising, therefore, that of 189 deaths identified as maternal, the cause of
death could not be specified for 31 (16 percent). Table 3.5 shows the cause-specific maternal mortality
rates by age group. Ante- and postpartum hemorrhage and eclampsia were the most common causes of
maternal death, followed by obstructed or prolonged labor, and deaths related to induced abortion. The
BMMS finds a smaller proportion of maternal deaths associated with induced abortion than observed by
ICDDR, B in Matlab, though closer inspection of the BMMS verbal autopsy information reveals no evi-
dent problems with the data.

Table 3.5 Maternal mortality rates by cause of death

Maternal mortality rates (per 1,000) in the three years preceding the survey by cause of death and age,
Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Exposure Hemorrhage
time (ante-
(woman- and post- Other Not
Age group years) partum) Eclampsia direct Indirect classified Total
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
15-19 90,099 0.014 0.126 0.030 0.032 0.024 0.228
20-24 67,390 0.073 0.135 0.066 0.077 0.087 0.439
25-29 57,606 0.187 0.056 0.089 0.076 0.102 0.535
30-34 48,931 0.197 0.096 0.107 0.046 0.052 0.499
35-39 40,111 0.127 0.079 0.016 0.000 0.039 0.262
40-44 31,989 0.168 0.000 0.098 0.092 0.029 0.387
45-49 21,881 0.032 0.000 0.032 0.000 0.084 0.149

Total 358,007 0.105 0.088 0.061a 0.055b 0.058 0.367


––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
a
Major components of the other direct category and their rates were obstructed/prolonged labor (0.019),
puerperal sepsis (0.013), abortion-related deaths (0.018), and other direct (0.011).
b
Major components of the indirect category were anemia (0.014), cardiovascular conditions (0.002), res-
piratory conditions (0.013), and other indirect (0.026).

Adult Female Mortality: Levels and Causes | 27


3.2.2 Estimates of Pregnancy-Related Mortality from Sibling Histories

Data from the sibling histories can be analyzed in one of two ways: direct estimation, based on
reported pregnancy-related deaths and exposure time, and indirect estimation, using the proportion of sis-
ters dead of pregnancy-related causes by age of respondent as a basis for estimating the lifetime risk of
dying from maternal causes. The latter method makes strong assumptions about unchanging fertility and
produces an estimate of risk for a time point that is approximately 12 years before the survey. In the
Bangladesh case, the fertility assumption clearly does not hold, and the value of producing an estimate for
around 1990 is questionable. Therefore, only direct estimates are presented in this report.

For each death of a woman of reproductive age identified in the sibling history, additional infor-
mation was collected about the timing of the death relative to pregnancy. Pregnancy-related deaths can
therefore be identified and PRMRates and PRMRs can be calculated. The average PRMRate for women
age 15-49 can then be divided by the GFR for the same period to estimate the PRMR. One advantage of
the sibling history over the household deaths is that the data can be used to look at trends, since informa-
tion is available about deaths for a lengthy period in the past. Table 3.6 shows pregnancy-related sister
deaths, sister exposure time, and rates by age group of sister for three five-year periods—1986-1991,
1991-1996, and 1996-2001—as well as for the most recent three-year period—1998-2001. The PRMR
declines from 514 per 100,000 live births in the period 1986-1990 to 449 for the period 1996-2000, and to
400 for the three-year period 1998-2000.

Table 3.6 Estimates of pregnancy-related mortality rates from the BMMS sibling history

Estimates of pregnancy-related mortality from the BMMS sibling history, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
1986-1990 1991-1996 1996-2001 1998-2001
––––––––––––––––––––––– –––––––––––––––––––––– ––––––––––––––––––––––– –––––––––––––––––––––––
Preg- Preg- Preg- Preg-
Preg- nancy- Preg- nancy Preg- nancy- Preg- nancy-
nancy- related nancy- related- nancy- related nancy- related
related Sister mortality related Sister mortality related Sister mortaltiy related Sister mortality
Age group deaths exposure rate deaths exposure rate deaths exposure rate deaths exposure rate
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
15-19 153 201,360 0.00076 112 205,084 0.00055 100 187,243 0.00054 48 109,058 0.00044
20-24 140 170,280 0.00082 165 198,992 0.00083 116 202,957 0.00057 61 120,526 0.00050
25-29 133 132,239 0.00100 123 168,298 0.00073 132 196,810 0.00067 64 120,740 0.00053
30-34 86 82,003 0.00105 104 130,366 0.00080 89 166,278 0.00054 52 103,286 0.00050
35-39 40 43,998 0.00092 67 80,727 0.00083 76 128,732 0.00059 40 82,961 0.00048
40-44 24 18,078 0.00130 43 43,011 0.00100 28 79,192 0.00035 16 52,688 0.00030
45-49 7 5,973 0.00119 9 17,596 0.00050 10 42,076 0.00023 7 28,497 0.00024

Total 584 653,932 0.00089 623 844,074 0.00074 552 1,003,288 0.00055 287 617,758 0.00046
GFR 184 151 119 113
PRMR 5141 4852 4493 4004
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
GFR = General fertility rate
PRMR = Pregnancy-related mortality rate
CI = Confidence interval
1
95% CI 453 to 574
2
95% CI 438 to 532
3
95% CI 400 to 498
4
95% CI 337 to 462

28 | Adult Female Mortality: Levels and Causes


The nature of the information concerning time of death relative to pregnancy for the sibling
deaths makes it possible to calculate the proportion of such deaths that occurred during pregnancy, during
delivery, and in the postpartum period, as was done with household deaths. Table 3.7 shows this break-
down for the period 1998-2001. Also shown are PRMRs by age group for the same time period. The
distribution of deaths by time relative to pregnancy is different from the distribution for household deaths
and very different from the distribution of household deaths identified as maternal by the verbal autopsy.
The age pattern of pregnancy-related mortality risk, however, is remarkably similar to that estimated from
the household deaths, rising steeply with age of woman.

Table 3.7 Sibling history pregnancy-related mortality by age and timing of death

Sibling history pregnancy-related mortality by age and timing of death, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Exposure Deaths during: Total Pregnancy- Age- Pregnancy-
time ––––––––––––––––––––––––––– pregnancy- related specific related
Age (woman Post- related mortality rate fertility mortality
group years) Pregnancy Delivery partum deaths (per 1,000) rate1 ratio
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
15-19 109,058 27.1 7.9 12.7 47.7 0.437 0.134 326
20-24 120,526 31.4 15.7 13.5 60.7 0.503 0.185 272
25-29 120,740 24.1 13.6 26.5 64.3 0.532 0.149 357
30-34 103,286 22.3 11.0 18.7 52.0 0.503 0.097 519
35-39 82,961 19.0 7.8 13.1 39.9 0.481 0.053 908
40-44 52,688 11.9 1.5 2.2 15.5 0.295 0.020 1,475
45-49 28,497 3.0 2.6 1.2 6.7 0.236 0.006 3,933

Total 617,758 138.7 60.1 88.0 286.7 0.464 0.113 400


–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Data are weighted; hence, the number of deaths is not a round number.
1
Births per woman age 15-49

3.2.3 Distribution of Maternal Deaths by Timing Relative to Delivery

As mentioned, the timing of maternal deaths relative to delivery varies by source of data. Less
than 25 percent of the maternal deaths identified by the Verbal Autopsy Questionnaire occurred during
pregnancy, and two-thirds occurred after delivery (Table 3.2). However, when this pattern is compared
with pregnancy-related deaths from the Household Questionnaire and from the sibling history, some in-
teresting patterns emerge. Of the pregnancy-related deaths recorded by the time-of-death questions on the
Household Questionnaire, 40 percent occurred during pregnancy and 49 percent occurred postpartum
(Table 3.1). The difference is more pronounced for sibling deaths: 48 percent occurred during pregnancy
and 31 percent occurred postpartum (Table 3.7).

For deaths reported in the Household Questionnaire, it is possible to compare the classification of
deaths as pregnancy-related using time of death with the classification as maternal from the verbal au-
topsy. Overall, about 18 percent of the pregnancy-related deaths were not classified as maternal by the
verbal autopsy, but this figure was 26 percent for pregnancy-related deaths that were reported as occur-
ring during pregnancy (the nonmaternal causes of pregnancy-related deaths included infections, malig-
nancies, and violent deaths, including suicides). The difference probably reflects the hierarchical way in
which the questions about timing of death relative to pregnancy were asked in both the Household Ques-
tionnaire and the sibling history, starting with pregnancy, then delivery, and finally after delivery. Sup-
port for this conclusion comes from the fact that 20 percent and 13 percent, respectively, of pregnancy-
related deaths reportedly occurring during pregnancy were defined by the verbal autopsy as maternal
deaths during delivery or after delivery. This shift is one reason why the number of maternal deaths is
higher than the number of pregnancy-related deaths in the postpartum period; the other reason is that five
deaths occurring more than 42 days after delivery, the cutoff for pregnancy-related deaths, were classified
as maternal deaths by the verbal autopsy.

Adult Female Mortality: Levels and Causes | 29


The magnitude of the difference between the number of pregnancy-related deaths on the one hand
and the number of maternal deaths on the other serves to inform the debate in the literature concerning the
interpretation of sisterhood-based estimates of the PRMR as estimates of the MMR. Stecklov (1995) es-
timated that 31 percent of the pregnancy-related sister deaths reported by the 1988 Bolivia DHS survey
were nonmaternal, and argued that pregnancy-related sister deaths were overestimating the MMR.
Shahidullah (1995) collected sibling reports of maternal and nonmaternal deaths in the Demographic Sur-
veillance System in Matlab, Bangladesh, and found that 19 percent of true maternal deaths were not re-
ported by siblings as pregnancy related. It has been argued (Stanton et al., 2000) on the basis of these two
studies that the two errors—including incidental deaths among maternal deaths by interpreting the PRMR
as the MMR on the one hand, and the failure to report as pregnancy-related deaths those deaths that actu-
ally were pregnancy-related deaths—may approximately cancel out. The BMMS results, however, sug-
gest that deaths reported as pregnancy-related, both in the Household Questionnaire and in the sibling
history, substantially overestimate the number of maternal deaths. Of course, it has to be recognized that
the BMMS verbal autopsy may also have missed some maternal deaths during pregnancy as a result of
the failure to report the fact that the deceased woman was pregnant; such an error may for instance ac-
count for the relatively low proportion of maternal deaths reported as due to induced abortion.

3.2.4 Summary of Estimates of Pregnancy-Related and Maternal Mortality, 1986 to 2001

Figure 3.1 shows estimates of pregnancy-related and maternal mortality by time period, together
with the 95 percent confidence intervals (95% CI) around the estimates. The sibling estimates show a
steady but nonsignificant downward trend over time, from 514 per 100,000 live births (95% CI 453-574)
in the late 1980s to 485 per 100,000 live births (95% CI 438-532) in the early 1990s, to 449 per 100,000
live births (95% CI 400-498) in the late 1990s, and to 400 per 100,000 live births (95% CI 337-462) in
the three years before the survey. This last value is slightly (though not significantly) higher than the cor-
responding PRMR estimate derived from household deaths over the same period, 382 (95% CI 305-460).
The MMR estimate based on verbal autopsies and household deaths for the three years before the survey,
322 (95% CI 253-391), is about 15 percent lower than the PRMR based on the same deaths.

Figure 3.1 BMMS Estimates of Pregnancy-Related Mortality


and Maternal Mortality, 1988 -2001

30 | Adult Female Mortality: Levels and Causes


3.3 OVERALL ADULT MORTALITY

3.3.1 Adult Mortality Estimates from Household Deaths

The mortality estimates given here are based on deaths recorded in the 36 months prior to inter-
view and refer approximately to the period early 1998 to early 2001.

Mortality Levels and Patterns

Table 3.8 shows the deaths, exposure time, and mortality rates from the BMMS for the three
years before the survey. The rates are graphed (on a log scale) in Figure 3.2. The rates show the expected
J-shaped pattern with age of high risk in early childhood, dropping to a minimum at age 10-14, and then
rising steadily into old age. Male mortality is generally slightly higher than female mortality, although the
differences are least pronounced between age 5 and 40. Table 3.8 shows two summary measures of adult
mortality: the probability of dying between age 15 and 50 (35q15) and the probability of dying between age
15 and 60 (45q15). Females have a slight advantage on the first measure and a somewhat larger advantage
on the second. For both sexes, however, the mortality risks are surprisingly low, corresponding approxi-
mately to mortality risks in England and Wales around 1960 for males and around 1950 for females.

Table 3.8 Age-specific mortality rates by sex

Age-specific mortality rates by sex, Bangladesh 2001


––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Male Female
––––––––––––––––––––––––––– –––––––––––––––––––––––––––
Mortality Mortality
Age group Deaths Exposure rates Deaths Exposure rates
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
<1 1,407 19,076 0.07374 1,109 18,434 0.06019
1-4 415 78,826 0.00526 407 76,366 0.00533
5-9 138 103,210 0.00134 146 99,441 0.00147
10-14 87 96,935 0.00089 97 101,442 0.00096
15-19 101 74,174 0.00137 103 90,099 0.00115
20-24 67 56,349 0.00120 83 67,390 0.00123
25-29 93 56,631 0.00164 95 57,606 0.00165
30-34 95 51,289 0.00185 106 48,931 0.00217
35-39 105 48,876 0.00214 94 40,111 0.00233
40-44 143 36,373 0.00394 89 31,989 0.00277
45-49 157 29,669 0.00529 114 21,881 0.00521
50-54 238 19,272 0.01236 117 25,541 0.00459
55-59 180 19,938 0.00901 233 22,162 0.01052
60-64 475 14,485 0.03278 467 13,198 0.03541
65-69 379 15,666 0.02419 354 10,600 0.03337
70-74 781 9,132 0.08551 574 5,227 0.10975
75-79 350 7,884 0.04442 232 5,739 0.04050
80+ 1,357 5,657 0.23984 1,212 4,797 0.25270

Total 6,567 743,441 0.00883 5,633 740,954 0.00760

Probability of dying
q
35 15 - - 0.08348 - - 0.07931
q
45 15 - - 0.17645 - - 0.14635
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Rates are based on data from the Household Questionnaire.

Adult Female Mortality: Levels and Causes | 31


Figure 3.2 Age-Specific Mortality Rates by Sex, BMMS 1998-2000

Table 3.9 shows mortality rates by age, sex, residence, and household wealth quintile. The two
summary measures of adult mortality are also shown. For both summary indicators, urban males have
higher mortality risks than their rural counterparts, whereas rural females have higher risks between age
15 and 50 but somewhat lower risks between age 15 and 60. The rural female excess mortality is particu-
larly pronounced in the age groups of highest fertility and may be related to higher reproductive risks in
rural areas. Mortality risks tend to be highest in the poorest households and lowest in the wealthiest
households. The patterns are not entirely uniform, however—perhaps because of fairly small numbers of
deaths. For example, for both males and females, the 35q15 for the second quintile is lower than that for
the middle quintile, and for males, the 45q15 for the highest quintile is higher than that for the middle or
fourth quintiles.

32 | Adult Female Mortality: Levels and Causes


Table 3.9 Age-specific mortality rates by background characteristics

Age-specific mortality rates by residence and household wealth quintile, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Residence Wealth quintile
–––––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––––
Age group Urban Rural Lowest Second Middle Fourth Highest Total
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
MALE
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
<1 0.07309 0.07384 0.08882 0.08706 0.07521 0.06260 0.04351 0.07374
1-4 0.00407 0.00550 0.00725 0.00601 0.00440 0.00446 0.00292 0.00526
5-9 0.00103 0.00140 0.00206 0.00173 0.00079 0.00102 0.00072 0.00134
10-14 0.00085 0.00090 0.00128 0.00113 0.00084 0.00078 0.00045 0.00089
15-19 0.00132 0.00138 0.00162 0.00163 0.00137 0.00125 0.00113 0.00137
20-24 0.00127 0.00118 0.00186 0.00142 0.00124 0.00069 0.00108 0.00120
25-29 0.00208 0.00153 0.00154 0.00172 0.00156 0.00148 0.00189 0.00164
30-34 0.00188 0.00184 0.00259 0.00113 0.00159 0.00214 0.00178 0.00185
35-39 0.00203 0.00218 0.00321 0.00169 0.00245 0.00152 0.00177 0.00214
40-44 0.00373 0.00399 0.00609 0.00357 0.00364 0.00343 0.00297 0.00394
45-49 0.00611 0.00509 0.00708 0.00388 0.00588 0.00492 0.00478 0.00529
50-54 0.01392 0.01197 0.02028 0.01693 0.00848 0.00682 0.01168 0.01236
55-59 0.01136 0.00854 0.01031 0.00904 0.00649 0.00768 0.01218 0.00901
60-64 0.03953 0.03142 0.04818 0.03651 0.02926 0.02324 0.03079 0.03278
65-69 0.03593 0.02213 0.02908 0.02312 0.02143 0.02332 0.02466 0.02419
70-74 0.13104 0.07781 0.09993 0.09132 0.08307 0.06771 0.09016 0.08551
75-79 0.06424 0.04093 0.04172 0.04012 0.04271 0.04281 0.05421 0.04442
80+ 0.28888 0.23109 0.24079 0.23793 0.26016 0.20909 0.25708 0.23984
Total 0.00901 0.00879 0.01095 0.00943 0.00818 0.00770 0.00796 0.00883
Probability of dying
q
35 15 0.08799 0.08234 0.11311 0.07246 0.08486 0.07426 0.07412 0.08348
q
45 15 0.19645 0.17189 0.23917 0.18559 0.15092 0.13907 0.17837 0.17645
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
FEMALE
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
<1 0.05077 0.06220 0.08190 0.06712 0.05825 0.04422 0.03717 0.06019
1-4 0.00354 0.00570 0.00797 0.00612 0.00494 0.00361 0.00230 0.00533
5-9 0.00100 0.00156 0.00199 0.00197 0.00179 0.00085 0.00030 0.00147
10-14 0.00089 0.00097 0.00113 0.00100 0.00124 0.00078 0.00066 0.00096
15-19 0.00073 0.00125 0.00114 0.00151 0.00193 0.00079 0.00055 0.00115
20-24 0.00069 0.00138 0.00164 0.00109 0.00200 0.00090 0.00070 0.00123
25-29 0.00123 0.00176 0.00215 0.00167 0.00173 0.00200 0.00074 0.00165
30-34 0.00181 0.00227 0.00292 0.00269 0.00246 0.00149 0.00126 0.00217
35-39 0.00215 0.00238 0.00215 0.00267 0.00336 0.00172 0.00178 0.00233
40-44 0.00271 0.00279 0.00438 0.00291 0.00210 0.00304 0.00164 0.00277
45-49 0.00484 0.00530 0.00802 0.00445 0.00628 0.00437 0.00348 0.00521
50-54 0.00583 0.00436 0.00359 0.00518 0.00435 0.00387 0.00611 0.00459
55-59 0.01343 0.00998 0.01092 0.01162 0.00945 0.01086 0.00975 0.01052
60-64 0.04120 0.03422 0.04139 0.04237 0.03659 0.02967 0.02886 0.03541
65-69 0.03472 0.03311 0.02400 0.03452 0.03528 0.03678 0.03597 0.03337
70-74 0.11759 0.10799 0.12497 0.13608 0.11023 0.09725 0.08921 0.10975
75-79 0.05479 0.03757 0.03860 0.03852 0.03365 0.03798 0.05167 0.04050
80+ 0.26929 0.24926 0.26335 0.24444 0.24793 0.23072 0.27842 0.25270
Total 0.00695 0.00775 0.00886 0.00799 0.00766 0.00688 0.00661 0.00760
Probability of dying
q
35 15 0.06835 0.08205 0.10603 0.08149 0.09457 0.06902 0.04951 0.07931
q
45 15 0.15399 0.14561 0.16862 0.15556 0.15497 0.13520 0.12206 0.14635
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Rates are based on data from the Household Questionnaire.

Adult Female Mortality: Levels and Causes | 33


Causes of Nonmaternal Deaths

The Verbal Autopsy Questionnaire was used to collect information about signs and symptoms
surrounding every female death between age 13 and 49 (inclusive) and reported by the household. The
primary purpose of the verbal autopsy was to identify maternal deaths, but the results also permit the as-
signation of nonmaternal causes. Table 3.10 shows mortality rates by cause of death among women 15-
49 in the three years preceding the survey. The cause categories are infectious diseases; malignancies;
diseases of the circulatory system; suicide; other violent deaths; miscellaneous causes; and deaths for
which it was impossible to assign a cause on the basis of the verbal autopsy, or for which the reviewing
physicians could not agree).

Table 3.10 Mortality rates by cause of death

Mortality rates (per 1,000 years of exposure) among women age 15-49 in the three years preceding the survey, by cause of death,
Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Other Miscel-
Age Infectious Circulatory violent laneous Not
group Maternal disease Malignancy disease Suicide causes causes classified Total
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
15-19 0.228 0.140 0.102 0.000 0.232 0.058 0.153 0.122 1.035
20-24 0.439 0.153 0.107 0.055 0.212 0.066 0.153 0.039 1.225
25-29 0.535 0.245 0.035 0.105 0.227 0.063 0.133 0.197 1.541
30-34 0.499 0.396 0.213 0.268 0.074 0.030 0.274 0.199 1.953
35-39 0.262 0.200 0.433 0.502 0.167 0.112 0.236 0.413 2.326
40-44 0.387 0.268 0.590 0.691 0.083 0.090 0.545 0.380 3.035
45-49 0.149 0.411 1.178 1.321 0.059 0.294 0.607 0.544 4.563

Total 0.367 0.229 0.254 0.263 0.175 0.080 0.239 0.211 1.816

It was not possible to assign a cause to 82 deaths (12 percent of the total). However, for mortality
across all ages, the largest single cause of death was maternal death (20 percent), followed by diseases of
the circulatory system (14 percent), malignancies (14 percent), and infectious diseases (13 percent).
Death rates from circulatory diseases and malignancies both rise sharply with age, whereas death rates
from infections rise moderately with age. Suicide rates, on the other hand, are highest under the age of
30. External causes— injuries, drowning and a few homicides—show no clear age pattern of risk. Both
miscellaneous and unclassified death rates rise moderately with age.

3.3.2 Adult Mortality Estimates from Sibling Histories

All eligible women (ever-married women age 13-50) were asked for a complete sibling history,
as described above. The information from the sibling history permits the calculation of age-specific mor-
tality rates by sex for age groups up to 45-49: sibling deaths at a given age and a given number of years
before the survey provide the numerators for the rates, and the person-years lived by both surviving sib-
lings and prior to death by those who died provide the denominators. Table 3.11 shows mortality rates by
age and sex estimated from the BMMS sibling histories for three five-year periods, 1986-1991,
1991-1996, 1996-2001, and for the three years preceding the survey, 1998-2001.

34 | Adult Female Mortality: Levels and Causes


Table 3.11 Mortality rates from sibling histories

Direct estimates of mortality rates from sibling listings for specific periods preceding the survey, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Male Female
––––––––––––––––––––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––––
Age group 1986-1991 1991-1996 1996-2001 1998-2001 1986-1991 1991-1996 1996-2001 1998-2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
0-4 0.02790 0.02052 0.01412 0.01235 0.02965 0.02379 0.01875 0.01401
5-9 0.00401 0.00350 0.00178 0.00124 0.00521 0.00374 0.00276 0.00223
10-14 0.00181 0.00144 0.00094 0.00072 0.00241 0.00145 0.00113 0.00092
15-19 0.00132 0.00092 0.00104 0.00083 0.00211 0.00196 0.00165 0.00164
20-24 0.00153 0.00130 0.00121 0.00102 0.00252 0.00226 0.00166 0.00135
25-29 0.00170 0.00136 0.00154 0.00140 0.00259 0.00221 0.00188 0.00154
30-34 0.00256 0.00212 0.00168 0.00131 0.00357 0.00276 0.00200 0.00180
35-39 0.00322 0.00222 0.00227 0.00204 0.00357 0.00326 0.00243 0.00198
40-44 0.00676 0.00492 0.00361 0.00299 0.00662 0.00498 0.00348 0.00300
45-49 0.00571 0.00732 0.00595 0.00555 0.00714 0.00590 0.00449 0.00375

Probability of dying
35q15 0.10783 0.09593 0.08289 0.07291 0.13125 0.11019 0.08422 0.07254

Mortality Levels and Trends

An important potential advantage of the sibling history over the household deaths approach to
measuring adult mortality is that the sibling history provides information about recent trends, assuming
that recall or other data errors do not change over time. Table 3.11 shows trends in the summary measure
35q15 over the 15 years before the survey. For the three-year period preceding the survey, the sibling esti-
mates of 35q15 are similar to, if somewhat lower than, the estimates based on household deaths for both
males and females shown in Table 3.9: a 7.3 percent risk of dying between age 15 and 50 for both males
and females, as opposed to 8.3 percent for males and 7.9 percent for females from the household deaths.
The sibling data show declining adult mortality for both sexes, but more rapid declines for females (45
percent over 10 years) than males (33 percent over 10 years). For the period 10-14 years before the sur-
vey, females have more than a 20 percent excess risk of dying between the age 15 and 50 relative to
males, but this male advantage declines sharply to approximate equality in the period 0 to 4 years before
the survey. These declines compare with a reduction of 35 percent in the under-five mortality rate for
both sexes over the same period, shown in Table 6.8 (chapter 6). It appears therefore that adult mortality
has been declining at much the same pace as child mortality during the 1990s on average, but faster for
females than for males. The nature of the sibling mortality data precludes the calculation of differentials
because the persons at risk (siblings) do not necessarily share the geographic or socioeconomic character-
istics of the respondent.

Adult Female Mortality: Levels and Causes | 35


MATERNITY CARE 4
Michael Koenig, Tulshi D. Saha, and Ahmed Al-Sabir

This chapter presents findings from the Bangladesh Maternal Health Services and Maternal Mor-
tality Survey (BMMS) on aspects of birth planning and antenatal, delivery, and postdelivery care deci-
sionmaking and behavior among Bangladeshi women. The results in the following section are based on
data obtained from mothers on all stillbirths and live births that occurred in the three years preceding the
survey.

4.1 ANTENATAL CARE

Proper care during pregnancy and childbirth is important to the health of both the mother and
child. Antenatal care is recognized as a major component of comprehensive maternal health care. Antena-
tal care facilitates the detection and treatment of problems during pregnancy such as infections, hyperten-
sive disease, and maternal anemia, and provides an important and timely opportunity to provide health
information to women and their families (Carroli et al., 2001a, 2001b). In addition, early and regular con-
tact by women with the formal health care system can contribute to timely and effective use of services
during delivery or obstetric complications. It is during an antenatal care visit that screening for complica-
tions and advice on a range of issues (including place of delivery and referral of mothers with complica-
tions) occur.

In the 1999-2000 Bangladesh Demographic and Health Survey (BDHS) and 1996-1997 BDHS,
questions on antenatal care were asked for live births in the five years preceding the survey. In the
BMMS, data were collected for all birth outcomes (live and stillbirths) in the three years preceding the
survey. In addition, sample size and sample designs differed slightly between the two BDHS surveys and
the BMMS. A comparison of estimates of antenatal care across the three surveys is shown in Figure 4.1.
The figure shows that antenatal care has been increasing steadily over time, from 30 percent of births in
the 1996-1997 BDHS survey to 35 percent in the 1999-2000 BDHS and to 41 percent in the 2001 BMMS.

Figure 4.1 Percentage of Women Who Received Antenatal Care


from a Medically Trained Provider for the Last Live Birth
in the Three Years Preceding the Survey,
Bangladesh 1996-1997, 1999-2000, and 2001
41

35

30

1996-1997 BDHS 1999-2000 BDHS 2001 BMMS

Maternity Care | 37
4.1.1 Source of Antenatal Care

In the BMMS, women who had a live birth or a stillbirth in the three years preceding the survey
were asked a number of questions about antenatal care. Interviewers recorded the source of antenatal care,
the person who provided that care, advice or information received on birth planning, and elements of an-
tenatal care received. Table 4.1 shows the percent distribution of source of antenatal care received during
pregnancy for all births in the three years before the survey, according to background characteristics. Al-
though interviewers were instructed to record all the providers a woman consulted for care, only the most
qualified provider is considered in this analysis.

Table 4.1 Antenatal care

Percent distribution of live births and stillbirths in the three years preceding the survey by source of antenatal care (ANC) during pregnancy, ac-
cording to background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Medically trained Nonmedically trained
–––––––––––––––––––– –––––––––––––––––––––––––
Nurse/ Un-
midwife/ Trained trained
Quali- para- birth birth Unquali-
Background Received fied medic MA/ HA/ attend- attend- fied
characteristic any ANC doctor FWV SACMO FWA ant ant provider Other No one Missing Total Number
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth outcome
Live birth 47.6 24.4 15.4 0.3 4.5 0.2 0.1 2.1 0.6 52.4 0.1 100.0 39,525
Stillbirth 47.9 25.1 15.8 0.4 3.7 0.2 0.0 2.4 0.3 51.3 0.9 100.0 1,133

Mother's age at birth


<20 49.8 23.6 17.5 0.4 5.2 0.2 0.1 2.2 0.6 50.2 0.1 100.0 13,016
20-34 47.8 25.7 14.8 0.3 4.2 0.2 0.1 2.0 0.5 52.2 0.1 100.0 24,899
35+ 35.0 15.7 11.6 0.2 4.0 0.1 0.0 2.7 0.6 64.9 0.2 100.0 2,743

Birth order
1 58.3 32.8 17.7 0.4 4.5 0.2 0.0 2.0 0.5 41.7 0.1 100.0 11,663
2-3 48.7 24.5 16.4 0.4 4.5 0.2 0.1 2.0 0.6 51.3 0.1 100.0 16,405
4-5 38.0 16.9 13.0 0.3 4.7 0.2 0.1 2.1 0.6 62.0 0.1 100.0 7,102
6+ 30.4 13.2 9.4 0.2 4.5 0.1 0.1 2.3 0.5 69.6 0.1 100.0 4,355

Residence
Urban 64.2 42.2 16.5 0.2 3.5 0.1 0.1 1.3 0.3 35.8 0.1 100.0 6,989
Metropolitan/town 73.3 55.0 14.7 0.2 2.2 0.1 0.1 0.7 0.3 26.7 0.0 100.0 3,681
Other urban 54.2 28.0 18.5 0.3 4.9 0.1 0.0 1.9 0.3 45.8 0.2 100.0 3,308
Rural 44.1 20.7 15.2 0.4 4.7 0.2 0.1 2.3 0.6 55.8 0.1 100.0 33,669

Division
Barisal 32.8 19.3 10.4 0.1 1.7 0.1 0.0 0.9 0.2 67.2 0.0 100.0 2,672
Chittagong 42.1 25.6 13.7 0.1 1.3 0.3 0.2 0.9 0.0 57.9 0.0 100.0 8,440
Dhaka 52.0 26.4 13.8 0.4 7.1 0.1 0.1 2.8 1.1 47.9 0.2 100.0 13,978
Khulna 57.4 28.5 18.9 0.6 6.0 0.1 0.0 2.8 0.5 42.6 0.1 100.0 3,919
Rajshahi 44.1 18.2 21.7 0.2 2.6 0.1 0.0 1.2 0.0 55.9 0.0 100.0 8,559
Sylhet 52.5 27.9 10.0 0.7 7.2 0.1 0.1 4.9 1.3 47.4 0.3 100.0 3,088

Mother’s education
No education 34.2 12.0 13.5 0.3 5.2 0.1 0.0 2.4 0.6 65.8 0.1 100.0 18,158
Primary incomplete 44.6 18.7 16.9 0.5 5.0 0.2 0.2 2.5 0.7 55.3 0.1 100.0 7,544
Primary complete 49.9 25.6 16.7 0.4 4.6 0.3 0.1 1.7 0.3 50.1 0.0 100.0 4,332
Secondary+ 71.7 49.1 17.1 0.3 2.9 0.2 0.0 1.5 0.5 28.3 0.1 100.0 10,624

Wealth quintile
Lowest 31.3 9.0 12.9 0.3 5.6 0.1 0.1 2.7 0.6 68.6 0.1 100.0 10,201
Second 37.9 13.8 15.2 0.3 5.1 0.2 0.1 2.4 0.7 62.1 0.1 100.0 8,911
Middle 45.5 19.9 17.3 0.3 4.9 0.2 0.1 2.2 0.5 54.5 0.1 100.0 7,721
Fourth 56.4 30.8 18.4 0.4 3.8 0.3 0.0 1.9 0.7 43.6 0.1 100.0 7,166
Highest 78.5 60.3 14.1 0.4 2.4 0.1 0.0 0.8 0.4 21.5 0.2 100.0 6,658

Total 47.6 24.4 15.4 0.3 4.5 0.2 0.1 2.1 0.6 52.4 0.1 100.0 40,657
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
FWV = Family welfare visitor, MA = Medical assistant, SACMO = Sub-assistant community medical officer, HA = Health assistant, FWA = Family wel-
fare assistant.

38 | Maternity Care
The data indicate that fewer than half of mothers in Bangladesh receive antenatal care from a
trained or untrained provider. For births that occurred in the three years before the survey, only 48 percent
of mothers received any antenatal care during pregnancy. The primary source of antenatal care is doctors
(24 percent), followed by nurses, midwives, and family welfare visitors (FWVs) (15 percent). Fewer than
1 percent of pregnant mothers receive antenatal care from trained or untrained traditional birth attendants
(dais). Table 4.1 shows that there are substantial differences in levels of antenatal care among subgroups
in Bangladesh. Antenatal care is more common among younger women and women of lower birth order.
The percentage of births for which the mother had one or more antenatal care checkups was significantly
higher in urban than rural areas (64 and 44 percent, respectively), with differences largely due to the per-
centage seeking care from qualified doctors. The highest and lowest levels of antenatal care are found in
Khulna division (57 percent) and Barisal division (33 percent), respectively. The use of antenatal care is
strongly associated with level of education and household economic status. Mothers with some secondary
education are twice as likely as mothers with no education to receive antenatal care, and mothers from the
wealthiest households are more than twice as likely to obtain antenatal care as mothers from the poorest
households.

4.1.2 Number and Initial Timing of Antenatal Care

The number of antenatal care visits and the timing of the Table 4.2 Summary of frequency and
first checkup are both considered important in detecting and timing of antenatal care visits
preventing an adverse pregnancy outcome (Carolli et al., 2001a).
Care is most effective if the visits are started early during Percent distribution of live births and still-
pregnancy and continued at regular intervals throughout the births in the three years preceding the
pregnancy. The World Health Organization and the Government survey by number of antenatal care visits
and by the stage of pregnancy at the time
of Bangladesh recommend a minimum of three antenatal care of the first visit, Bangladesh 2001
visits, with one visit taking place in each pregnancy trimester. –––––––––––––––––––––––––––––––––––
Number and timing
Table 4.2 shows the frequency and timing of the initial of ANC visits Total
–––––––––––––––––––––––––––––––––––
antenatal visit for live births and stillbirths that occurred in the Number of visits
three years preceding the survey. For a majority of these birth 0 52.4
outcomes (52 percent), no antenatal care was sought. The me- 1 14.3
dian number of antenatal visits sought per live birth was 1.8 vis- 2 12.3
3 9.3
its. Only one in five births was characterized by three or more 4+ 11.6
antenatal visits. Table 4.3 shows that the median number of Don’t know/missing 0.2
antenatal visits is highest among women with first births, women
in urban or metropolitan areas, women who have completed Total 100.0
secondary school or more, and women in households in the Median number of visits 1.8
highest wealth quintile, with substantial percentages of each
reporting four or more antenatal care visits. Table 4.4 shows that Number of months pregnant
at the time of the first visit
the timing of the initial antenatal care visit for many Bangladeshi No antenatal care 52.4
women is quite late, a median of 5.4 months into the pregnancy. <4 months 14.6
Among births to women who sought antenatal care, less than one 4-6 months 21.1
in three sought initial antenatal care during the first trimester (31 7+ months 11.7
Don’t know/missing 0.2
percent) and one in four (24 percent) delayed seeking care until
the third trimester. Table 4.4 shows that early initiation of ante- Total 100.0
natal care is more common among women who resided in urban
areas, have completed secondary school or more, and are from Median number of months
pregnant at first visit 5.4
households in the highest wealth quintile.
Total 40,657

Maternity Care | 39
Table 4.3 Number of antenatal care visits

Percent distribution of live births and stillbirths in the three years preceding the survey by number of antenatal
care visits, according to background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of antenatal care visits
–––––––––––––––––––––––––––––––––––––––––––––––
Don’t Median Number
Background know/ number of
characteristic 0 1 2 3 4+ missing Total of visits births
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth outcome
Live birth 52.4 14.3 12.3 9.3 11.6 0.1 100.0 1.8 39,525
Stillbirth 51.3 14.8 14.0 8.4 10.4 1.2 100.0 1.6 1,133

Mother's age at birth


< 20 50.2 15.5 13.7 9.8 10.7 0.2 100.0 1.7 13,016
20-34 52.2 13.8 12.0 9.2 12.7 0.1 100.0 1.8 24,899
35+ 64.9 13.0 8.9 7.4 5.5 0.3 100.0 1.5 2,743

Birth order
1 41.7 15.0 14.6 11.2 17.4 0.1 100.0 2.0 11,663
2-3 51.3 14.4 12.6 9.5 12.0 0.1 100.0 1.8 16,405
4-5 62.0 13.8 10.0 7.6 6.6 0.1 100.0 1.5 7,102
6+ 69.6 12.5 8.2 6.4 3.2 0.2 100.0 1.3 4,355

Residence
Urban 35.8 13.0 13.1 12.1 26.0 0.1 100.0 2.5 6,989
Metropolitan/town 26.7 11.0 12.9 13.1 36.1 0.1 100.0 3.0 3,681
Other urban 45.8 15.3 13.3 10.9 14.6 0.1 100.0 1.9 3,308
Rural 55.8 14.5 12.2 8.7 8.6 0.2 100.0 1.6 33,669

Division
Barisal 67.2 11.7 8.1 5.9 7.0 0.1 100.0 1.6 2,672
Chittagong 57.9 12.3 11.1 8.2 10.5 0.0 100.0 1.8 8,440
Dhaka 47.9 15.8 13.5 9.3 13.4 0.2 100.0 1.8 13,978
Khulna 42.6 15.8 15.4 11.3 14.6 0.3 100.0 1.8 3,919
Rajshahi 55.9 13.0 10.7 10.1 10.2 0.0 100.0 1.8 8,559
Sylhet 47.4 16.6 14.7 10.5 10.4 0.4 100.0 1.6 3,088

Mother’s education
No education 65.8 13.4 9.8 6.8 4.2 0.1 100.0 1.4 18,158
Primary incomplete 55.3 15.5 13.1 8.7 7.2 0.2 100.0 1.5 7,544
Primary complete 50.1 15.6 13.8 9.9 10.5 0.2 100.0 1.7 4,332
Secondary+ 28.3 14.5 15.5 13.7 27.9 0.1 100.0 2.4 10,624

Wealth quintile
Lowest 68.6 12.7 8.9 6.3 3.3 0.2 100.0 1.3 10,201
Second 62.1 14.9 11.2 7.0 4.7 0.1 100.0 1.4 8,911
Middle 54.5 15.4 13.4 9.5 7.0 0.1 100.0 1.5 7,721
Fourth 43.6 16.6 15.5 11.3 12.8 0.1 100.0 1.7 7,166
Highest 21.5 12.0 14.3 14.5 37.4 0.2 100.0 2.9 6,658

Total 52.4 14.3 12.3 9.3 11.6 0.2 100.0 1.8 40,657

40 | Maternity Care
Table 4.4 Stage of pregnancy at first antenatal care visit

Percent distribution of live births and stillbirths in the three years preceding the survey for which antenatal care was received, by
stage of pregnancy at the time of the first visit, according to background characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number
Stage of pregnancy at first antenatal care visit of births
––––––––––––––––––––––––––––––––––––––––––––––– Number for which
Don’t of months antenatal
Background know/ pregnant care was
characteristic <4 months 4-6 months 7+ months missing Total at first visit sought
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth outcome
Live birth 31.0 44.3 24.4 0.3 100.0 5.4 18,804
Stillbirth 23.2 49.3 27.2 0.3 100.0 5.6 543

Mother's age at birth


<20 27.1 47.4 25.2 0.2 100.0 5.5 6,483
20-34 32.8 43.1 23.8 0.3 100.0 5.3 11,903
35+ 29.7 41.0 28.8 0.5 100.0 5.5 960

Birth order
1 33.6 44.2 22.0 0.2 100.0 5.3 6,796
2-3 30.5 45.3 23.9 0.4 100.0 5.4 7,984
4-5 28.2 42.7 28.7 0.4 100.0 5.5 2,698
6+ 26.3 41.8 31.3 0.6 100.0 5.6 1,326

Residence
Urban 40.1 41.6 18.0 0.3 100.0 5.0 4,488
Metropolitan/town 46.4 39.9 13.6 0.2 100.0 4.3 2,697
Other urban 30.6 44.3 24.7 0.4 100.0 5.4 1,791
Rural 28.0 45.3 26.4 0.3 100.0 5.5 14,859

Division
Barisal 34.5 43.8 21.1 0.6 100.0 5.2 877
Chittagong 30.0 44.0 25.8 0.2 100.0 5.4 3,551
Dhaka 33.4 43.6 22.7 0.3 100.0 5.3 7,274
Khulna 27.9 45.8 26.0 0.3 100.0 5.5 2,250
Rajshahi 24.4 47.3 27.9 0.3 100.0 5.6 3,772
Sylhet 37.3 40.7 21.4 0.7 100.0 5.1 1,622

Mother’s education
No education 24.3 45.9 29.3 0.5 100.0 5.6 6,207
Primary incomplete 25.2 45.6 28.6 0.5 100.0 5.6 3,366
Primary complete 28.3 46.8 24.8 0.2 100.0 5.5 2,161
Secondary+ 39.2 42.0 18.6 0.2 100.0 5.0 7,612

Wealth quintile
Lowest 23.4 46.9 29.1 0.7 100.0 5.7 3,195
Second 23.6 45.5 30.8 0.1 100.0 5.7 3,373
Middle 24.7 46.3 28.7 0.3 100.0 5.6 3,513
Fourth 29.2 45.9 24.4 0.4 100.0 5.4 4,042
Highest 45.2 39.8 14.8 0.2 100.0 4.5 5,224

Total 30.8 44.4 24.5 0.3 100.0 5.4 19,347

4.1.3 Reasons for Seeking or Not Seeking Antenatal Care

Table 4.5 shows that among women who sought antenatal care, three in four sought care for a
general checkup rather than for a specific problem. Among the 24 percent of women who did seek antena-
tal care for a specific reason, 9 percent cited lower abdominal pain as the primary problem for which care
was sought, with smaller percentages citing excessive vomiting (4 percent), headache (4 percent), edema
(3 percent), or vaginal bleeding (1 percent). Ten percent of women cited other problems, which included
weakness, loss of appetite, or limited fetal movement.

Maternity Care | 41
Table 4.5 Reasons for seeking antenatal care

Percent distribution of live births in the three years


preceding the survey for which antenatal care (ANC)
was received, by reason for seeking care, and per-
centage citing specific problems, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––
Number
Reason for of
ANC visit Percentage births
–––––––––––––––––––––––––––––––––––––––––––––
General checkup 76.0 14,287
Specific problem 24.0 4,517

Total 100.0 18,804

Specific problem
Headache 3.6 686
Edema/preeclampsia 2.6 495
Lower abdominal pain 8.6 1,623
Excessive vomiting 3.9 742
Vaginal bleeding 1.1 200
Other 10.2 1,913
–––––––––––––––––––––––––––––––––––––––––––––
Note: Multiple problems were allowed.

Among the majority of women who did not seek antenatal care, the most frequently cited reason
was lack of need (62 percent), followed by monetary constraints (21 percent), familial or religious con-
straints (14 percent), perception that antenatal care is not “customary” (13 percent), transportation con-
straints (10 percent), and service-related constraints (8 percent) (Figure 4.2).

Figure 4.2 Percentage of Live Births for Which no Antenatal Care


was Sought, by Reason for not Seeking Antenatal Care,
Bangladesh 2001

Lack of need 62

Monetary 21

Family/religious/other 14

Not customary 13

Transportation 10

Service related 8

BMMS 2001

4.1.4 Information/Services Received during Antenatal Care

Of particular interest is the range and content of services provided to women during their antena-
tal care visit(s). The BMMS collected data on information and services provided during antenatal care for
all birth outcomes during the three years preceding the survey. Table 4.6 shows the specific types of in-
formation provided during any of the antenatal visits by background characteristics, among women who

42 | Maternity Care
reported making at least one antenatal visit. While 84 percent of women received advice about diet, only
54 percent recall being told where to go if complications occurred, and fewer than half (45 percent) were
informed about the danger signs of pregnancy. Women who resided in urban areas, more educated
women, and women who live in wealthier households were more likely than others to report having re-
ceived information on both the danger signs of pregnancy and where to go if complications occur. The
association of these characteristics with having received advice on diet, however, was weaker.

Table 4.6 Information given for antenatal care

Percent distribution of live births and stillbirths in the three years preceding the
survey for which mothers received information on antenatal care, by background
characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of
Where to births for
Danger go if com- which ante-
Background Advice signs of plications natal care
characteristic on diet pregnancy occur was sought
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth outcome
Live birth 84.0 45.5 54.3 18,804
Stillbirth 78.0 42.6 49.8 543

Mother's age at birth


<20 83.1 43.3 51.8 6,483
20-34 84.6 46.9 55.8 11,903
35+ 78.2 41.8 50.6 960

Birth order
1 85.9 46.5 56.0 6,796
2-3 84.5 47.0 56.2 7,984
4-5 81.2 42.1 50.0 2,698
6+ 76.1 38.0 43.4 1,326

Residence
Urban 87.8 48.7 60.6 4,488
Metropolitan/town 89.9 51.7 65.0 2,697
Other urban 84.7 44.3 53.9 1,791
Rural 82.6 44.4 52.2 14,859

Division
Barisal 86.8 51.6 57.0 877
Chittagong 86.5 51.1 60.5 3,551
Dhaka 82.0 42.2 50.5 7,274
Khulna 84.4 44.1 56.5 2,250
Rajshahi 86.8 50.3 58.6 3,772
Sylhet 76.5 34.6 41.8 1,622

Mother’s education
No education 78.2 38.9 44.6 6,207
Primary incomplete 82.7 44.4 51.5 3,366
Primary complete 85.2 45.4 54.8 2,161
Secondary+ 88.4 51.2 63.0 7,612

Wealth quintile
Lowest 75.5 37.7 41.6 3,195
Second 80.6 40.8 48.5 3,373
Middle 83.4 45.1 52.1 3,513
Fourth 85.9 46.3 56.3 4,042
Highest 89.5 52.7 65.3 5,224

Total 83.8 45.4 54.2 19,347

Maternity Care | 43
The specific procedures that women reported receiving during their antenatal checkups are shown
in Figure 4.3 (for live births only) and Table 4.7 (live births and stillbirths). It should be emphasized that
respondents are likely to report those procedures that could be directly observed (e.g., physical proce-
dures, discussions); other procedures (e.g., separate laboratory tests) are likely to have been under-
reported. Among all live births where at least one antenatal visit took place, an abdominal examination or
measurement of blood pressure was common but by no means universal (75 percent). For two-thirds of
live births, measurement of maternal weight and/or height was reported. Blood or urine tests were less
commonly reported (30 and 37 percent, respectively). For 17 percent of births, the mothers reported hav-
ing an ultrasound taken during an antenatal care visit, and for 12 percent of births the mothers reported
receiving an internal pelvic examination. Table 4.7 shows that women of lower parity, urban women, and
women who are more educated or live in wealthier households were more likely than others to report hav-
ing these antenatal procedures, most likely because of their greater propensity to seek antenatal care from
a doctor. Particularly striking are the proportions of women in urban areas (29 percent), more highly edu-
cated women (31 percent), and women in wealthier households (40 percent) who report having undergone
an ultrasound procedure. In urban areas, this number is almost 50 percent among more educated women
and women in wealthier households (results not shown).

Figure 4.3 Among Live Births for Which Antenatal Care Was
Received, Percentage for Which Specific Procedures Were
Performed at Least Once, Bangladesh 2001

74 75

65

37
30

17
12

Blood Abdominal Weight/ Urine Blood Ultra- Pelvic


pressure exami- height test test sound exami-
nation nation

BMMS 2001

44 | Maternity Care
Table 4.7 Procedures performed during pregnancy

Among all live births and stillbirths in the three years preceding the survey for which antenatal care was received, percentage for
which mothers received specific procedures during pregnancy, by background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Procedures performed during antenatal visit Number of
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– births for
Weight Blood Blood Internal which ante-
Background or height pressure test Urine Abdomen pelvic Ultra- natal care
characteristic measured taken done tested examined exam sound was sought
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth outcome
Live birth 65.3 73.8 30.1 37.2 74.7 12.3 16.5 18,804
Stillbirth 62.0 73.5 30.9 39.1 73.3 13.9 21.9 543

Mother's age at birth


<20 66.7 72.0 27.2 34.2 75.4 10.7 12.6 6,483
20-34 65.3 75.0 32.3 39.7 75.1 13.5 19.1 11,903
35+ 53.7 71.3 22.3 28.3 65.2 9.3 13.7 960

Birth order
1 71.2 77.0 36.3 43.2 80.3 14.4 20.4 6,796
2-3 65.9 74.0 29.2 37.3 74.6 12.5 16.4 7,984
4-5 57.0 69.1 22.2 28.4 68.8 9.3 11.0 2,698
6+ 48.3 66.3 18.9 24.2 58.9 6.8 8.3 1,326

Residence
Urban 75.2 82.6 43.2 49.5 82.9 19.4 28.6 4,488
Metropolitan/town 82.5 88.0 52.6 57.8 88.2 23.9 36.4 2,697
Other urban 64.1 74.4 29.0 36.9 75.1 12.7 17.0 1,791
Rural 62.2 71.2 26.1 33.6 72.2 10.2 13.0 14,859

Division
Barisal 69.7 77.9 30.1 37.0 76.6 13.5 14.9 877
Chittagong 67.6 79.4 38.8 44.6 82.7 17.7 17.8 3,551
Dhaka 60.3 69.6 29.6 35.2 70.3 11.0 20.0 7,274
Khulna 69.3 74.3 25.5 35.0 75.6 10.5 16.1 2,250
Rajshahi 77.5 78.3 27.6 38.1 80.3 12.4 11.7 3,772
Sylhet 44.7 67.5 25.2 32.4 61.4 8.6 12.0 1,622

Mother’s education
No education 56.2 63.8 16.0 22.3 63.3 6.4 5.2 6,207
Primary incomplete 62.2 69.5 21.0 29.1 70.5 8.9 8.8 3,366
Primary complete 63.4 73.7 27.1 33.8 75.6 9.7 13.0 2,161
Secondary+ 74.3 84.0 46.4 54.2 85.6 19.6 30.5 7,612

Wealth quintile
Lowest 54.1 60.9 15.1 21.2 59.7 6.0 2.6 3,195
Second 58.7 66.1 16.4 23.5 67.0 6.4 5.0 3,373
Middle 62.5 71.0 20.9 28.6 72.8 8.8 8.3 3,513
Fourth 65.0 74.7 30.0 38.0 76.9 11.3 15.1 4,042
Highest 78.2 88.0 54.3 61.3 88.4 23.3 39.5 5,224

Total 65.2 73.8 30.1 37.3 74.7 12.4 16.6 19,347

4.1.5 Antenatal Care in Consecutive Pregnancies

Among women who had a live birth or stillbirth during the three years preceding the BMMS, 8
percent (3,330 women) had more than one birth event during this period. For these women, it is possible
to examine the consistency of individual women in seeking antenatal care for their two most recent preg-
nancies (Table 4.8). The results indicate that more than half (52 percent) did not receive any antenatal
care for either pregnancy; an additional 21 percent received care for one but not both pregnancies. Only
27 percent of women reported having one or more antenatal visits for both recent pregnancies. The likeli-
hood of consistent antenatal care is highest for women in urban areas, more educated women, and women
in wealthier households.

Maternity Care | 45
Table 4.8 Patterns of antenatal care from trained providers

Percent distribution of women with more than one live or stillbirth in the three years preceding the survey, by
their consistency of receipt of antenatal care (ANC) from a medically trained person for the last two birth out-
comes, according to background characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
ANC ANC No ANC Number
Background ANC for for first for last for either of
characteristic both births birth only birth only birth Missing Total women
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Residence
Urban 39.9 7.9 13.0 39.1 0.1 100.0 485
Metropolitan/town 48.4 4.6 14.9 32.1 0.0 100.0 210
Other urban 33.4 10.4 11.5 44.4 0.2 100.0 275
Rural 24.8 7.8 13.5 53.7 0.1 100.0 2,845

Division
Barisal 13.8 6.1 13.0 67.0 0.0 100.0 172
Chittagong 25.1 4.8 14.1 56.0 0.0 100.0 761
Dhaka 28.1 8.0 13.4 50.3 0.2 100.0 1,161
Khulna 35.1 9.1 16.1 39.8 0.0 100.0 240
Rajshahi 25.2 10.4 13.1 51.3 0.0 100.0 598
Sylhet 31.3 9.0 11.5 47.6 0.6 100.0 398

Mother’s education
No education 17.7 7.5 13.3 61.4 0.2 100.0 1,701
Primary incomplete 25.5 8.2 14.3 52.0 0.0 100.0 586
Primary complete 32.1 8.1 14.5 45.1 0.1 100.0 362
Secondary+ 48.9 8.2 12.6 30.1 0.2 100.0 681

Wealth quintile
Lowest 16.3 7.2 11.2 65.1 0.2 100.0 999
Second 19.5 8.3 15.5 56.8 0.0 100.0 785
Middle 26.7 8.5 12.8 51.8 0.2 100.0 628
Fourth 36.2 8.0 17.1 38.7 0.1 100.0 529
Highest 57.8 7.0 11.1 23.7 0.3 100.0 390

Total 27.0 7.8 13.5 51.6 0.1 100.0 3,330

4.2 BIRTH PLANNING

4.2.1 Information Received on Delivery Advice During Pregnancy

The BMMS collected detailed information on types of information about delivery care provided
to women during antenatal care. For all live births and stillbirths during the three years preceding the sur-
vey for which the mother received antenatal care, women were asked whether they or their family mem-
bers had been informed about a range of issues related to safe delivery. The results presented in Table 4.9
underscore the low level of information that pregnant Bangladeshi women and their families receive on
aspects of delivery; on no subject did a majority of respondents report having received information or ad-
vice. The proportion having received advice or information during pregnancy ranged from 45 percent,
concerning the location of a hospital to go to if delivery complications occurred, to 31 percent, regarding
the importance of the delivery assistant washing their hands or using gloves, to only 15 percent, concern-
ing the importance of making transport arrangements. Although differences were not pronounced, women
who were more educated and from wealthier families were more likely to report having received informa-
tion regarding aspects of safe delivery. It is interesting that while urban women were more likely to have
received information about place of delivery or complications and delivery personnel, rural women were
equally well (or poorly) informed in terms of appropriate aseptic delivery procedures.

46 | Maternity Care
Table 4.9 Information given about delivery

Among the live births and stillbirths in the three years preceding the survey for which mothers received antenatal care, percentage for which
mother received information on delivery, by background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Hospital Arrange- Arrange- Using
Where Person for ment of ment Compli- Washing clean Births
baby who can compli- trans- Arrange- of safe cation hands/ Using thread Use with
can be assist in cation por- ment of delivery during using sterilized to of anti- antenatal
characteristic delivered delivery handling tation money kit pregnancy gloves blade tie cord septic care
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth outcome
Live birth 34.2 27.4 45.2 14.5 20.1 15.9 25.6 30.6 41.5 41.1 39.7 18,804
Stillbirth 27.9 23.0 43.1 14.4 17.3 11.7 21.1 25.0 32.5 32.7 31.6 543

Mother's age at birth


<20 31.0 25.0 41.7 13.5 20.1 15.9 23.6 30.3 42.5 41.9 40.9 6,483
20-34 36.2 28.8 47.3 15.3 20.4 16.0 26.8 30.9 41.0 40.7 39.4 11,903
35+ 28.5 23.8 40.8 11.7 15.6 11.2 21.6 26.5 36.0 35.1 32.0 960

Birth order
1 35.5 28.5 46.7 16.0 22.1 16.9 26.8 31.0 42.7 42.2 41.6 6,796
2-3 36.3 28.4 46.8 14.9 20.8 16.9 26.9 32.1 42.1 41.9 40.5 7,984
4-5 29.9 25.2 41.0 11.7 16.5 12.9 21.8 28.5 39.4 38.6 36.5 2,698
6+ 24.5 19.8 36.2 10.0 13.2 10.7 19.2 24.2 35.9 35.1 31.8 1,326

Residence
Urban 43.1 33.8 52.0 15.7 22.5 16.4 27.9 30.1 39.6 39.1 39.1 4,488
Metropolitan/town 48.8 37.3 56.2 16.7 24.7 15.1 30.5 29.6 36.7 36.1 36.9 2,697
Other urban 34.6 28.6 45.8 14.2 19.2 18.4 24.0 30.8 43.9 43.8 42.4 1,791
Rural 31.3 25.3 43.0 14.1 19.3 15.6 24.8 30.6 41.8 41.3 39.6 14,859

Division
Barisal 39.5 33.1 48.5 15.3 19.7 20.1 29.9 39.1 48.1 48.0 46.7 877
Chittagong 40.3 34.3 51.2 18.4 24.8 19.3 30.6 33.6 45.9 45.9 44.6 3,551
Dhaka 31.7 23.4 41.2 12.6 19.2 13.2 22.5 27.5 36.5 35.7 34.5 7,274
Khulna 33.4 25.8 46.0 13.3 17.9 11.5 23.7 28.1 38.3 38.5 37.5 2,250
Rajshahi 36.4 31.3 49.7 17.3 21.7 21.8 29.2 35.7 49.2 49.0 47.3 3,772
Sylhet 23.3 18.4 35.3 9.4 12.5 9.0 18.9 23.7 34.2 33.1 31.4 1,622

Mother’s education
No education 24.4 20.1 35.6 10.0 15.0 11.2 18.0 25.5 36.7 36.2 33.2 6,207
Primary incomplete 29.9 23.9 41.3 11.8 17.9 14.5 23.7 28.6 40.7 40.7 39.0 3,366
Primary complete 32.2 26.0 46.4 14.1 20.9 16.1 24.8 31.6 42.7 42.3 41.4 2,161
Secondary+ 44.3 35.0 54.1 19.5 24.9 19.9 32.6 35.1 44.8 44.3 44.4 7,612

Wealth quintile
Lowest 21.1 17.5 32.1 10.3 14.7 11.4 18.3 25.2 36.6 36.0 32.8 3,195
Second 25.8 21.4 37.5 11.0 16.8 13.0 20.1 27.5 40.2 40.1 36.9 3,373
Middle 29.1 24.0 42.7 13.0 20.0 15.3 23.5 31.2 43.0 42.8 41.8 3,513
Fourth 35.7 28.8 47.4 14.9 21.4 18.0 26.9 32.6 44.4 44.1 42.9 4,042
Highest 49.4 38.0 57.7 20.0 24.4 18.9 33.6 33.5 41.2 40.4 41.1 5,224

Total 34.1 27.3 45.1 14.5 20.0 15.8 25.5 30.5 41.3 40.8 39.5 19,347

4.2.2 Decision on Delivery Assistance for Current Pregnancy

Women who were currently pregnant at the time of the survey were asked whether they had dis-
cussed or decided who would assist them during delivery. Table 4.10 shows that among currently preg-
nant women, almost two-thirds had neither discussed nor made a decision concerning assistance at deliv-
ery. Among those who had made a decision, the most frequently cited providers were untrained (22 per-
cent) and trained (5 percent) traditional birth attendants. Only 4 percent mentioned a doctor as the in-
tended assistant. The likelihood of having decided on delivery assistance was greater the more advanced
the pregnancy was. Nonetheless, more than half of pregnant women in their third trimester had still not
decided on delivery assistance. Women with no previous live births were less likely to have decided on
the type of assistance during delivery. Not surprisingly, the intention to seek medically trained delivery
assistance is higher for urban women, more educated women, and women in wealthier households.

Maternity Care | 47
Table 4.10 Intended assistance during delivery

Percent distribution of currently pregnant women by whether a decision regarding assistance during delivery had been made, and by type
of intended assistant, according to background characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Intended assistant during delivery No decision
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– regarding
Don’t assistance Number
Background Nurse/ Trained Untrained Relative/ know/ during of
characteristic Doctor midwife TBA TBA other missing delivery Total women
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Duration of pregnancy
<4 months 4.4 0.8 3.2 13.7 1.8 0.0 76.1 100.0 2,217
4-6 months 4.7 1.6 4.6 19.6 2.8 0.1 66.6 100.0 2,861
>6 months 4.2 2.2 6.7 31.0 4.5 0.1 51.3 100.0 2,534

Age
<20 3.3 1.2 6.0 21.1 3.6 0.1 64.6 100.0 2,790
20-34 5.3 1.8 4.4 21.9 2.8 0.1 63.8 100.0 4,417
35+ 1.6 1.5 3.0 23.3 2.9 0.0 67.7 100.0 406

Number of live births


before current pregnancy
0 5.3 1.4 3.4 14.0 2.5 0.1 73.3 100.0 2,642
1 7.0 2.1 5.8 21.6 2.9 0.1 60.5 100.0 1,894
2-3 2.9 1.7 5.9 26.1 3.8 0.1 59.5 100.0 1,975
4-5 0.4 1.0 5.1 32.2 3.7 0.0 57.6 100.0 728
6+ 0.9 1.1 5.1 31.4 3.4 0.0 58.1 100.0 374

Residence
Urban 14.0 3.4 4.2 18.6 1.9 0.2 57.7 100.0 1,371
Metropolitan/town 21.7 3.9 3.6 16.9 1.7 0.2 52.1 100.0 730
Other urban 5.3 2.7 4.8 20.5 2.2 0.2 64.2 100.0 641
Rural 2.3 1.2 5.0 22.3 3.3 0.1 65.7 100.0 6,242

Division
Barisal 2.1 1.4 3.4 20.4 2.6 0.0 70.2 100.0 462
Chittagong 3.9 2.0 5.0 21.5 1.8 0.0 65.8 100.0 1,601
Dhaka 6.0 1.7 5.4 23.7 3.3 0.2 59.8 100.0 2,623
Khulna 6.2 1.8 5.3 20.6 4.4 0.3 61.4 100.0 741
Rajshahi 2.9 1.1 4.5 16.6 3.5 0.0 71.4 100.0 1,624
Sylhet 2.2 1.1 3.9 29.7 3.5 0.2 59.4 100.0 562

Education
No education 0.6 0.6 4.8 25.9 3.5 0.0 64.6 100.0 2,833
Primary incomplete 1.0 0.8 4.2 25.2 3.7 0.1 65.0 100.0 1,331
Primary complete 2.1 1.0 5.8 23.3 3.7 0.1 64.0 100.0 892
Secondary+ 11.2 3.3 5.1 14.5 2.1 0.1 63.7 100.0 2,557

Wealth quintile
Lowest 0.4 0.4 4.5 23.1 3.4 0.0 68.1 100.0 1,726
Second 0.7 0.6 4.5 22.1 3.8 0.0 68.2 100.0 1,570
Middle 1.2 1.3 5.8 23.7 3.4 0.0 64.6 100.0 1,452
Fourth 3.1 1.9 5.3 22.0 2.5 0.1 65.1 100.0 1,520
Highest 18.7 4.2 4.3 16.8 2.2 0.3 53.4 100.0 1,345

Total 4.4 1.6 4.9 21.7 3.1 0.1 64.3 100.0 7,613

48 | Maternity Care
4.2.3 DECISIONMAKER REGARDING DELIVERY ASSISTANCE

Among currently pregnant women who had discussed or decided on delivery assistance, the pri-
mary decisionmaker on this issue was the respondent (51 percent) (Table 4.11). The second most fre-
quently cited main decisionmaker was the husband (24 percent), followed by in-laws (13 percent), and
then the woman’s own parents (9 percent). The importance of in-laws and parents in delivery assistance
decisions is particularly striking for women having their first birth; thereafter, the importance of the
woman herself sharply increases, with a corresponding decrease in importance of the husband and other
family members. The greater level of primary decisionmaking by the husband and the lower level by the
wife among more educated women and women in wealthier households is evident in Table 4.11.

Table 4.11 Person making decision regarding assistance during delivery

Percent distribution of currently pregnant women who have decided on assistance during delivery by person who mainly made the deci-
sion, according to background characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Person who mainly made decision on assistance during delivery
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Other family Don’t Number
Background members/ know/ of
characteristic Respondent Husband In-laws Parents relatives Others missing Total women
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Age
<20 48.7 23.0 13.6 11.1 2.3 0.6 0.8 100.0 953
20-34 52.9 25.4 12.0 7.1 2.0 0.3 0.3 100.0 1,553
35+ 48.0 21.0 18.8 8.0 3.5 0.0 0.7 100.0 126

Number of live births


before current pregnancy
0 26.0 29.5 17.1 22.0 4.3 0.3 0.8 100.0 668
1 50.2 26.3 14.3 7.0 1.5 0.5 0.1 100.0 727
2-3 61.3 20.6 12.6 2.9 1.4 0.6 0.6 100.0 784
4-5 70.1 20.1 5.8 1.9 1.6 0.0 0.4 100.0 299
6+ 75.6 19.5 2.5 0.0 1.5 0.0 0.8 100.0 155

Residence
Urban 48.4 30.3 10.3 6.5 3.2 0.5 0.8 100.0 558
Metropolitan/town 46.5 31.1 9.9 6.4 4.3 0.8 0.9 100.0 338
Other urban 51.3 29.1 11.0 6.5 1.6 0.0 0.6 100.0 220
Rural 51.9 22.7 13.5 9.2 1.9 0.4 0.5 100.0 2,075

Division
Barisal 51.1 23.3 15.7 8.1 1.7 0.0 0.0 100.0 134
Chittagong 49.5 24.6 17.1 5.7 2.9 0.2 0.0 100.0 529
Dhaka 52.3 23.3 11.4 9.1 2.5 0.4 1.0 100.0 1,023
Khulna 47.6 26.5 8.3 13.6 2.7 0.5 0.9 100.0 275
Rajshahi 52.8 26.0 10.4 9.7 0.6 0.6 0.0 100.0 448
Sylhet 50.8 22.3 18.3 5.1 2.2 0.7 0.5 100.0 224

Education
No education 60.1 19.0 13.7 4.7 1.6 0.1 0.7 100.0 981
Primary incomplete 55.1 22.8 11.1 9.0 1.2 0.1 0.7 100.0 450
Primary complete 48.3 19.3 15.1 13.8 2.9 0.3 0.2 100.0 308
Secondary+ 40.2 32.5 12.1 10.9 3.1 0.9 0.3 100.0 893

Wealth quintile
Lowest 58.8 20.0 13.5 5.8 1.1 0.1 0.7 100.0 539
Second 57.2 21.0 10.7 9.5 0.7 0.0 0.9 100.0 480
Middle 49.4 23.0 15.4 9.3 2.1 0.7 0.2 100.0 500
Fourth 47.6 22.8 14.7 11.6 2.2 0.6 0.4 100.0 509
Highest 43.9 33.0 10.5 7.2 4.5 0.5 0.4 100.0 604

Total 51.1 24.3 12.9 8.6 2.2 0.4 0.5 100.0 2,633

Maternity Care | 49
4.3 DELIVERY CARE

An important component of efforts to reduce the health risks for mothers and children is to in-
crease the proportion of babies who are delivered by skilled providers with adequate medical supervision
(Graham et al., 2001). Proper medical attention and hygienic conditions during delivery can reduce the
risk of infection and increase the timeliness of effective intervention in the event of obstetric emergencies,
both of which can lead to serious illness or death to the mother or the newborn.

4.3.1 Place of Delivery

Table 4.12 presents data on the place of delivery for all live births and stillbirths that occurred
during the three years preceding the survey. Delivery at home remains almost universal among Bangla-
deshi women (91 percent). Six percent of deliveries occur in a public sector clinical facility (hospital,
upazila health complex, maternal and child welfare center, or upazila health and family welfare center),
and 3 percent occur in a private hospital or clinic. Twenty-two percent of urban (32 percent of metropoli-
tan/town) deliveries, compared with only 7 percent of rural deliveries, took place in a facility. Delivery in
a facility was more common for first births (15 percent), for women who reported health problems during
pregnancy or delivery (12 percent), for more educated women (23 percent), and for women in wealthier
households (30 percent). There is an association between the frequency of antenatal care visits and place
of delivery: women who have three or more antenatal checkups are much more likely to deliver in a pub-
lic or private sector institutional setting (27 percent).

4.3.2 Assistance During Delivery

Increasing the proportion of births delivered by skilled health personnel constitutes one of the
main indicators of maternal health in the Millennium Development Goals (UNFPA, 2003). Table 4.13
shows the types of persons providing assistance during delivery, according to background characteristics,
for all live births and stillbirths in the three years preceding the survey. When more than one type of at-
tendant was reported to have assisted at delivery, only the most qualified person is shown. Three-fourths
of births in Bangladesh are assisted by traditional birth attendants (i.e., dais), with 12 percent reporting
assistance from a trained birth attendant and 63 percent reporting assistance from an untrained birth atten-
dant. It is important to emphasize that the designation of trained versus untrained is based wholly on re-
ports from respondents and thus may not be accurate. An additional 11 percent of deliveries were assisted
by friends or relatives. Only 12 percent of births were assisted by medically trained persons, either doc-
tors (7 percent), or nurses, midwives, or family welfare visitors (5 percent). A comparison with the 1999-
2000 BDHS shows comparable results in terms of the type of assistance during delivery. Lower order
births, urban residence, and higher education or socioeconomic status are all associated with a greater
likelihood of the delivery being assisted by a trained medical professional (doctors, nurses, midwives, or
family welfare visitors). More frequent antenatal visits also show a strong association with delivery assis-
tance from a trained medical professional.

50 | Maternity Care
Table 4.12 Place of delivery

Percent distribution of live births and stillbirths in the three years preceding the survey by place of delivery, according to background char-
acteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Place of delivery
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Government
Not hospital/
delivered upazila health NGO
Background in health complex/ Private health facilities
characteristic facility MCWC UHFWC hospital/clinic and others Total Number
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth outcome
Live birth 91.2 5.4 0.1 2.7 0.6 100.0 39,525
Stillbirth 76.4 15.5 0.3 5.5 1.5 100.0 1,133

Mother's age at birth


<20 91.5 5.6 0.2 2.0 0.6 100.0 13,016
20-34 90.1 5.9 0.1 3.3 0.6 100.0 24,899
35+ 94.1 4.0 0.1 1.4 0.4 100.0 2,743

Birth order
1 85.0 9.1 0.2 4.7 0.9 100.0 11,663
2-3 91.9 4.8 0.1 2.6 0.6 100.0 16,405
4-5 96.2 2.7 0.1 0.8 0.3 100.0 7,102
6+ 97.3 2.0 0.1 0.5 0.2 100.0 4,355

Problems during
pregnancy or delivery
No 94.9 3.1 0.1 1.4 0.4 100.0 17,797
Yes 87.6 7.6 0.2 3.8 0.8 100.0 22,860

Residence
Urban 78.4 12.0 0.1 8.4 1.1 100.0 6,989
Metropolitan/town 68.4 17.0 0.0 13.3 1.3 100.0 3,681
Other urban 89.5 6.4 0.2 3.0 0.9 100.0 3,308
Rural 93.4 4.3 0.1 1.6 0.5 100.0 33,669

Division
Barisal 94.9 3.7 0.1 1.1 0.2 100.0 2,672
Chittagong 92.0 5.5 0.1 1.9 0.5 100.0 8,440
Dhaka 89.3 5.9 0.1 3.9 0.7 100.0 13,978
Khulna 87.4 6.7 0.3 4.6 1.0 100.0 3,919
Rajshahi 91.3 6.2 0.1 1.7 0.7 100.0 8,559
Sylhet 93.9 3.9 0.0 1.8 0.2 100.0 3,088

Mother’s education
No education 96.6 2.5 0.1 0.5 0.3 100.0 18,158
Primary incomplete 94.4 3.9 0.1 1.1 0.4 100.0 7,544
Primary complete 92.7 5.4 0.1 1.3 0.5 100.0 4,332
Secondary+ 77.5 12.4 0.3 8.4 1.4 100.0 10,624

Wealth quintile
Lowest 97.5 1.9 0.0 0.3 0.3 100.0 10,201
Second 96.0 2.9 0.1 0.6 0.3 100.0 8,911
Middle 94.4 4.0 0.2 0.9 0.4 100.0 7,721
Fourth 90.8 6.5 0.2 1.9 0.5 100.0 7,166
Highest 69.6 16.0 0.1 12.4 1.8 100.0 6,658

Antenatal care visits


None 97.6 1.8 0.0 0.4 0.2 100.0 21,295
1-2 91.8 5.8 0.2 1.8 0.4 100.0 10,811
3+ 72.7 15.1 0.3 9.9 2.0 100.0 8,489

Total 90.8 5.7 0.1 2.7 0.6 100.0 40,657


––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Total includes 63 births for which antenatal care visits are missing.
MCWC = Maternal and child welfare center, UHFWC = Union health and family welfare center, NGO= Nongovernment organization

Maternity Care | 51
Table 4.13 Assistance during delivery

Percent distribution of births in the three years preceding the survey by type of assistance during delivery, according to back-
ground characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Medically trained Nonmedically trained
––––––––––––––––––––––––––– –––––––––––––––––––––––––
Un-
Trained trained
Nurse birth birth Relatives
Background midwife/ MA/ HA/ attend- attend- and
characteristic Doctor FWV SACMO FWA ant ant friends Other No one Total Number
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth outcome
Live birth 6.5 5.1 0.0 0.2 11.9 63.7 11.1 0.3 1.3 100.0 39,525
Still birth 16.5 8.2 0.1 0.5 9.3 49.3 11.5 1.3 3.3 100.0 1,133

Mother's age at birth


<20 5.8 5.4 0.1 0.2 12.8 64.0 10.9 0.3 0.6 100.0 13,016
20-34 7.6 5.2 0.0 0.2 11.6 62.4 11.2 0.3 1.5 100.0 24,899
35+ 4.1 3.5 0.0 0.1 9.4 68.1 10.9 0.6 3.3 100.0 2,743

Birth order
1 11.4 7.7 0.1 0.3 13.2 58.4 8.4 0.3 0.3 100.0 11,663
2-3 5.8 5.0 0.1 0.2 12.4 63.4 11.8 0.2 1.2 100.0 16,405
4-5 2.7 2.8 0.0 0.1 11.1 68.0 12.9 0.4 2.0 100.0 7,102
6+ 1.9 2.1 0.0 0.0 8.2 71.6 12.6 0.3 3.1 100.0 4,355

Problems during
pregnancy or delivery
No 3.4 3.6 0.0 0.2 10.9 66.6 13.1 0.2 1.9 100.0 17,797
Yes 9.4 6.3 0.0 0.2 12.6 60.6 9.5 0.3 0.9 100.0 22,860

Residence
Urban 16.9 10.1 0.0 0.3 11.8 53.3 6.6 0.1 0.9 100.0 6,989
Metropolitan/town 25.5 11.7 0.0 0.3 9.8 46.0 5.9 0.1 0.7 100.0 3,681
Other urban 7.3 8.3 0.0 0.2 14.0 61.5 7.4 0.1 1.1 100.0 3,308
Rural 4.7 4.1 0.0 0.2 11.9 65.3 12.0 0.3 1.4 100.0 33,669

Division
Barisal 4.0 4.3 0.1 0.3 10.5 69.6 9.9 0.0 1.2 100.0 2,672
Chittagong 6.4 5.2 0.0 0.1 12.0 68.6 6.7 0.0 0.9 100.0 8,440
Dhaka 8.3 4.8 0.0 0.2 13.1 62.4 9.7 0.4 1.1 100.0 13,978
Khulna 8.7 7.7 0.1 0.4 12.8 58.6 10.0 0.7 1.0 100.0 3,919
Rajshahi 5.0 5.5 0.1 0.2 11.2 56.4 19.2 0.1 2.4 100.0 8,559
Sylhet 5.5 3.3 0.0 0.2 7.8 72.2 9.6 0.5 0.9 100.0 3,088

Mother’s education
No education 2.0 2.4 0.0 0.1 10.0 70.1 13.0 0.4 1.9 100.0 18,158
Primary incomplete 3.7 3.9 0.0 0.3 11.9 66.4 12.5 0.2 1.2 100.0 7,544
Primary complete 5.1 5.3 0.0 0.1 13.0 64.4 10.9 0.2 1.0 100.0 4,332
Secondary+ 17.7 10.8 0.1 0.3 14.7 48.9 6.9 0.2 0.4 100.0 10,624

Wealth quintile
Lowest 1.3 2.2 0.0 0.1 9.5 70.0 14.3 0.4 2.2 100.0 10,201
Second 2.3 3.1 0.0 0.2 10.4 68.3 13.4 0.3 1.9 100.0 8,911
Middle 3.6 4.1 0.0 0.1 12.7 66.8 11.2 0.3 1.1 100.0 7,721
Fourth 6.7 6.0 0.0 0.3 14.6 62.6 9.0 0.1 0.6 100.0 7,166
Highest 24.8 12.6 0.1 0.4 13.5 42.9 5.2 0.2 0.4 100.0 6,658

Antenatal care visits


None 1.4 2.0 0.0 0.1 9.0 71.7 13.7 0.3 1.8 100.0 21,295
1-2 5.6 6.1 0.0 0.3 14.2 62.7 9.8 0.3 0.9 100.0 10,811
3+ 21.6 11.9 0.1 0.3 15.9 42.9 6.4 0.1 0.8 100.0 8,489

Total 6.8 5.2 0.0 0.2 11.9 63.3 11.1 0.3 1.3 100.0 40,657
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: “Other” includes 17 unweighted cases with missing information on assistance during delivery. Total includes 63 births for
which antenatal care visits are missing.
FWV = Family welfare visitor, MA = Medical assistant, SACMO = Sub-assistant community medical officer, HA = Health assistant,
FWA = Family welfare assistant, TBA= Traditional birth attendant.

52 | Maternity Care
4.3.3 Reasons for Delivering at a Health Facility

The reasons cited by respondents for both delivering and not delivering in a health facility are
shown in Tables 4.14 and 4.15, respectively. For recent births in a health facility, the reason most com-
monly cited for using the facility was to ensure a safe delivery (51 percent). Health or delivery-related
problems were the second most commonly cited reason for delivering in a facility (38 percent). Other less
frequently cited reasons included the availability of a doctor/modern facility (9 percent), having been ad-
vised to do so by a doctor or health worker (7 percent), the baby being overdue (7 percent), and the pre-
ceding birth having been a caesarean delivery (5 percent). Concern for safe delivery, as the reason for de-
livering in a facility, is more commonly cited by low parity women, urban women, more educated
women, and women in wealthier households. Women with more antenatal visits are more likely to cite
concern for safe delivery and are correspondingly less likely to cite health or delivery problems as reasons
for delivering in a facility, suggesting that such visits may have been motivated largely for preventive
care, rather than in response to pregnancy-related problems.

Table 4.15 summarizes the reasons women cited for not delivering in a health facility. Among the
high proportion of women who delivered at home, the most frequently cited reason for not delivering in a
facility was the perceived absence of need (“not necessary”), cited by 68 percent of such women; 9 per-
cent said that the practice of facility-based delivery was “not customary.” Cost was mentioned by 18 per-
cent of women as a reason for not going to a health facility for delivery. Service-related factors were also
important, with 10 percent mentioning poor quality service, 6 percent mentioning access or transport
problems, and smaller numbers of women citing fear of service (4 percent) or not wanting to be attended
by a male doctor (1 percent). As would be expected, less-educated women and women in poorer house-
holds were more likely to cite cost as a reason for not going to a health facility for delivery. Women with
more antenatal visits are less likely to cite cost or access as factors and are somewhat more likely to cite
poor quality and fear of service as reasons for delivering outside of a facility, although these differences
are small.

Maternity Care | 53
Table 4.14 Reasons for delivering in a health facility

Percentage of live births and stillbirths in a health facility during the three years preceding the survey for which the mother cited specific
reasons for delivering in a health facility, according to background characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Reason for delivering in a hospital/health center
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Availability Delivery/ Doctor/ Number
Previous of doctor health- health of births
Background child was and modern related Baby worker For safe a health
characteristic caesarean facility problem overdue advised delivery Other Missing facility
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth outcome
Live birth 4.9 9.3 36.2 7.6 6.9 53.5 5.4 0.6 3,465
Stillbirth 0.0 1.6 63.7 5.6 7.5 22.5 9.4 4.0 267

Mother's age at birth


<20 0.9 6.0 47.6 7.4 5.9 43.7 5.9 0.8 1,104
20-34 6.2 10.3 33.5 7.4 7.4 55.6 5.3 0.8 2,467
35+ 4.4 4.9 45.3 7.3 7.7 37.4 8.4 1.6 162

Birth order
1 NA 9.5 39.6 8.3 6.5 52.4 5.0 0.7 1,746
2-3 11.7 9.4 29.3 6.8 6.8 57.6 5.5 0.3 1,331
4-5 3.0 8.7 41.7 7.3 9.4 47.7 7.2 1.4 271
6+ 4.1 6.7 53.3 5.8 8.6 37.8 4.2 0.0 118

Problems during
pregnancy or delivery
No 6.4 16.0 11.2 6.5 5.4 70.1 3.2 2.0 899
Yes 3.9 6.5 46.8 7.7 7.5 45.3 6.4 0.4 2,833

Residence
Urban 5.4 11.4 28.2 8.2 7.8 60.0 5.5 0.5 1,512
Metropolitan/town 5.9 12.9 26.3 7.9 7.0 62.0 4.2 0.5 1,163
Other urban 3.8 6.4 34.7 9.3 10.2 53.3 9.7 0.7 349
Rural 4.0 7.0 45.0 6.8 6.4 45.3 5.8 1.0 2,221

Division
Barisal 2.4 10.9 39.9 8.8 6.8 51.2 1.9 0.0 136
Chittagong 4.2 15.0 37.0 6.5 8.5 52.2 0.8 0.0 675
Dhaka 5.0 6.3 35.9 7.6 6.9 53.4 8.6 1.5 1,496
Khulna 4.0 6.5 37.0 8.8 5.4 54.1 9.6 0.9 493
Rajshahi 3.7 9.9 43.3 6.1 6.2 47.3 1.4 0.0 746
Sylhet 8.4 6.1 42.7 9.6 8.7 39.0 9.0 2.3 187

Mother’s education
No education 2.4 5.2 53.7 4.8 5.7 36.9 8.5 2.4 610
Primary incomplete 2.0 4.9 46.1 7.8 7.4 42.5 7.6 0.9 420
Primary complete 3.5 5.5 45.0 6.9 4.5 45.3 5.4 0.8 316
Secondary+ 5.6 10.8 31.9 8.1 7.5 57.3 4.6 0.4 2,387

Wealth quintile
Lowest 2.3 5.0 56.0 5.7 4.2 32.5 6.4 2.8 259
Second 1.1 4.7 55.2 4.3 7.7 34.9 6.5 2.3 357
Middle 1.6 4.6 48.9 7.5 7.6 43.5 6.7 0.5 432
Fourth 3.1 6.2 45.2 7.5 6.5 47.5 6.9 0.3 657
Highest 6.5 11.7 28.4 8.1 7.2 59.4 4.8 0.6 2,027

Antenatal care visits


None 2.0 4.1 58.3 4.3 3.2 32.1 8.8 0.5 506
1-2 3.1 4.7 45.2 7.1 5.2 48.1 5.5 0.5 887
3+ 5.7 11.5 31.4 8.2 8.5 57.0 5.0 0.3 2,316

Total 4.5 8.8 38.2 7.4 7.0 51.3 5.6 0.8 3,733
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Total includes 63 births for which antenatal care visits are missing.

54 | Maternity Care
Table 4.15 Reasons for not delivering in a health facility

Percentage of live births and stillbirths at home in the three years preceding the survey for which the mother reported specific reasons for
not delivering in a health facility, according to background characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Reason for not delivering in a health facility
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Did
Poor Fear not want
Background Not Not Access/ quality of service
characteristic necessary customary Cost transport service service from male Other Number
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth outcome
Live birth 68.6 9.3 17.7 5.8 9.6 3.4 1.3 7.6 36,059
Stillbirth 41.5 11.5 23.3 11.8 10.1 4.7 1.7 23.0 866
Mother's age at birth
<20 69.9 7.5 14.0 5.8 9.4 3.6 1.3 9.2 11,913
20-34 67.7 9.6 19.2 6.0 9.9 3.4 1.2 7.4 22,432
35+ 61.3 15.3 23.5 6.8 8.6 3.3 2.1 6.8 2,580
Birth order
1 70.3 6.4 12.5 5.8 10.4 4.1 1.2 9.4 9,917
2-3 70.6 8.4 16.7 5.5 9.6 3.2 1.2 7.4 15,074
4-5 65.2 11.6 22.9 6.2 8.9 3.5 1.5 6.4 6,831
6+ 63.0 15.1 25.2 6.6 9.0 2.7 1.7 6.1 4,237
Residence
Urban 69.5 7.7 15.0 4.1 11.7 6.1 1.7 8.6 5,477
Metropolitan/town 67.2 5.0 15.4 4.5 11.1 7.7 1.5 9.2 2,518
Other urban 71.5 9.9 14.8 3.6 12.3 4.8 1.9 8.2 2,959
Rural 67.7 9.6 18.3 6.3 9.3 3.0 1.3 7.8 31,448
Division
Barisal 63.0 7.7 16.4 6.7 7.2 3.4 2.0 7.3 2,536
Chittagong 59.4 10.8 19.6 5.8 9.4 2.9 1.5 6.6 7,765
Dhaka 72.9 9.0 19.5 6.6 11.4 4.8 1.4 8.6 12,482
Khulna 74.7 7.3 17.8 7.4 9.5 3.7 1.2 11.1 3,426
Rajshahi 65.5 9.8 12.2 4.4 9.4 2.0 1.0 7.6 7,813
Sylhet 72.3 8.9 22.9 5.8 5.8 2.9 1.3 6.4 2,901
Mother’s education
No education 64.0 11.8 23.8 6.6 9.3 3.2 1.2 6.9 17,548
Primary incomplete 68.4 8.3 18.6 6.2 9.7 3.0 1.6 8.5 7,124
Primary complete 70.6 7.9 13.4 5.2 10.3 3.3 1.3 8.4 4,017
Secondary+ 74.8 5.6 6.7 4.9 10.0 4.5 1.4 9.4 8,237
Wealth quintile
Lowest 61.0 11.6 28.6 7.9 9.3 2.9 1.0 6.4 9,942
Second 66.3 10.2 21.8 6.0 9.0 2.7 1.4 8.3 8,554
Middle 69.9 8.8 14.9 5.5 9.7 3.4 1.5 8.5 7,289
Fourth 73.2 8.4 8.5 4.6 10.2 3.5 1.5 8.6 6,509
Highest 75.6 5.0 5.1 4.6 10.6 6.3 1.4 8.8 4,631
Antenatal care visits
None 65.6 11.5 20.2 6.7 8.6 2.8 1.3 7.9 20,789
1-2 71.5 7.2 16.8 5.5 10.7 3.7 1.5 7.3 9,924
3+ 70.1 5.4 11.8 4.4 11.6 5.3 1.2 9.1 6,173
Total 68.0 9.3 17.9 6.0 9.6 3.5 1.3 8.0 36,925
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Total includes 63 births for which antenatal care visits are missing.

4.3.4 Medical Procedures Performed during Delivery

Table 4.16 and Figure 4.4 show the medical procedures performed at the time of delivery, as re-
ported by women respondents. Caesarean section was reported to have occurred in fewer than 3 percent
of deliveries. Forceps delivery occurred in fewer than 2 percent of such deliveries, and fewer than 1 per-
cent of deliveries involved blood transfusions. These levels are substantially below levels of intervention

Maternity Care | 55
suggested by previous studies of rates of operative instrumental intervention and/or postpartum hemor-
rhage (Abou Zahr, 1998). By far the most common procedure was the provision of intravenous fluids,
reported to have occurred in 15 percent of recent deliveries. The 1999-2000 BDHS also found that 2 per-
cent of recent deliveries were delivered by caesarean section.

Table 4.16 Procedures performed during delivery


Percentage of live births and stillbirths in the three years preceding the survey for which specific proce-
dures were performed during delivery, according to background characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Procedures performed at time of delivery
–––––––––––––––––––––––––––––––––––––––––––––––––––––
Abdominal
operation/ Received Number
Background Forceps caesarean Blood intravenous of
characteristic delivery section transfusion fluid births
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth outcome
Live birth 1.7 2.6 0.7 14.6 39,525
Stillbirth 5.2 5.0 4.6 32.1 1,133
Mother's age at birth
<20 1.9 1.9 0.7 16.4 13,016
20-34 1.8 3.2 0.9 14.9 24,899
35+ 0.9 1.6 1.0 10.7 2,743
Birth order
1 3.4 4.7 1.1 24.4 11,663
2-3 1.2 2.4 0.7 12.4 16,405
4-5 0.8 0.8 0.4 8.3 7,102
6+ 0.5 0.6 0.3 7.0 4,355
Residence
Urban 3.5 7.5 1.5 27.3 6,989
Metropolitan/town 4.6 11.5 2.2 37.5 3,681
Other urban 2.3 3.0 0.8 16.0 3,308
Rural 1.5 1.7 0.7 12.5 33,669
Division
Barisal 1.0 1.7 0.7 9.9 2,672
Chittagong 1.9 2.3 0.8 15.8 8,440
Dhaka 2.0 3.4 0.9 16.1 13,978
Khulna 2.4 3.6 1.1 19.8 3,919
Rajshahi 1.2 1.9 0.8 13.6 8,559
Sylhet 1.9 1.9 0.8 11.4 3,088
Mother’s education
No education 0.7 0.6 0.5 7.8 18,158
Primary incomplete 1.0 1.2 0.7 11.1 7,544
Primary complete 1.4 1.8 0.6 14.1 4,332
Secondary+ 4.5 7.5 1.6 30.7 10,624
Wealth quintile
Lowest 0.5 0.4 0.4 6.2 10,201
Second 0.7 0.8 0.5 9.0 8,911
Middle 1.2 1.0 0.7 11.8 7,721
Fourth 2.3 2.1 0.9 17.3 7,166
Highest 5.5 11.1 2.1 38.1 6,658
Antenatal care visits
None 0.5 0.5 0.3 7.1 21,295
1-2 1.6 1.8 0.8 15.8 10,811
3+ 5.2 9.3 2.2 34.2 8,489
Place of delivery
At home 0.4 0.1 0.2 8.6 36,925
Government hospital/
THC/MCWC 16.2 22.2 7.9 78.9 2,301
UHFWC 6.4 0.0 2.5 67.7 51
Private hospital/clinic 17.4 46.7 8.3 88.4 1,113
NGO and others 9.7 11.9 2.8 52.0 246
Total 1.8 2.7 0.8 15.1 40,657
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Total includes 63 births for which antenatal care visits and 21 births for which place of delivery are
missing.

56 | Maternity Care
Figure 4.4 Percentage of Live Births and Stillbirths
for Which Specific Procedures Were Performed during
Delivery, Bangladesh 2001

15

3
2
1

Intervenous Caesarean Forceps Blood


fluids section delivery transfusion
delivery

BMMS 2001

Table 4.16 shows that a strong urban-rural differential exists with respect to the frequency of cae-
sarean section (8 and 2 percent, respectively), differences that are even more pronounced when only
women residing in metropolitan areas or towns are considered. Low parity, higher education, and living in
wealthier households were all associated with an increased likelihood of having a forceps delivery, cae-
sarean section, or intravenous fluid during the delivery. A similar association is evident with respect to a
greater number of antenatal visits. As would be expected, the place of delivery was an important factor in
whether these medical procedures took place: while all such procedures were unlikely for the large num-
ber of deliveries that occurred at home, a striking 22 and 47 percent of deliveries that took place in gov-
ernment and private clinics, respectively, involved caesarean section; significantly higher rates of forceps
delivery and blood transfusion were also evident for deliveries in these settings. A plausible explanation
for this finding may be that the delivery caseloads in such facilities are heavily composed of more com-
plicated deliveries, requiring these medical procedures. The provision of intravenous fluids during deliv-
ery appears to be an almost universal practice in government and private sector facilities.

4.4 POSTNATAL CARE

A number of problems that women and children experience surrounding childbirth occur during
the postpartum period. Thus, postnatal checkups and care are recognized as an integral component of
comprehensive maternity and delivery care. In the BMMS, for each live birth or stillbirth in the three
years preceding the survey, respondents were asked whether they went for a checkup for either them-
selves or their baby during the two months following delivery and, if so, the types of providers seen and
facility visited. Those who did not go for a checkup were asked the reasons for not doing so.

Table 4.17 shows that only 17 percent of women with recent deliveries reported having a postna-
tal checkup for themselves, with 9 percent reporting having been seen by a qualified doctor and 5 percent
reporting having been seen by an unqualified doctor. Women whose pregnancy resulted in a stillbirth or a
first birth, urban women, more educated women, and women in wealthier households were more likely to
have had a postnatal checkup. Problems during pregnancy and, particularly, problems after delivery were
both strongly linked to women having sought postnatal care. Significant differences appear to exist across

Maternity Care | 57
Table 4.17 Postnatal care for mother

Percent distribution of live births and stillbirths in the three years preceding the survey by type of postnatal care received for the
mother, according to background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Medically trained Nonmedically trained
–––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––
Nurse/
Received Quali- midwife/ Unquali-
Background postnatal fied paramedic/ MA/ HA/ fied
characteristic care doctor FWV SACMO FWA doctor Other No one Missing Total Number
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth outcome
Live birth 16.1 8.7 1.4 0.1 0.4 5.1 0.3 83.9 0.1 100.0 39,525
Stillbirth 32.1 20.3 1.8 0.2 0.5 8.4 0.8 67.0 1.0 100.0 1,133

Mother's age at birth


<20 15.7 8.1 1.4 0.1 0.4 5.2 0.4 84.3 0.1 100.0 13,016
20-34 17.1 9.8 1.4 0.1 0.4 5.0 0.3 82.9 0.1 100.0 24,899
35+ 16.1 7.1 1.2 0.1 0.5 6.5 0.6 83.8 0.1 100.0 2,743

Birth order
1 19.9 12.7 1.7 0.1 0.4 4.5 0.4 80.1 0.1 100.0 11,663
2-3 15.3 8.1 1.2 0.1 0.4 4.9 0.4 84.7 0.1 100.0 16,405
4-5 13.0 5.6 1.4 0.1 0.3 5.5 0.2 86.9 0.1 100.0 7,102
6+ 14.0 5.5 1.0 0.1 0.5 6.4 0.4 86.0 0.1 100.0 4,355

Problems during
pregnancy or delivery
No 9.1 4.6 1.0 0.1 0.3 2.9 0.2 90.8 0.1 100.0 17,797
Yes 22.4 12.5 1.7 0.1 0.5 6.9 0.5 77.6 0.1 100.0 22,860

Problems after delivery


No 13.0 7.5 1.3 0.1 0.3 3.4 0.3 86.9 0.1 100.0 31,217
Yes 28.2 14.1 1.6 0.2 0.7 10.9 0.7 71.7 0.1 100.0 9,440

Residence
Urban 23.9 18.0 1.9 0.0 0.4 3.2 0.4 76.0 0.1 100.0 6,989
Metropolitan/town 29.4 24.3 1.8 0.0 0.2 2.6 0.3 70.6 0.1 100.0 3,681
Other urban 17.8 10.9 2.0 0.1 0.6 3.7 0.5 82.0 0.2 100.0 3,308
Rural 15.0 7.2 1.3 0.1 0.4 5.6 0.4 84.9 0.1 100.0 33,669

Division
Barisal 7.0 3.9 1.5 0.0 0.6 1.0 0.1 93.0 0.0 100.0 2,672
Chittagong 9.3 6.3 1.1 0.0 0.3 1.4 0.1 90.7 0.0 100.0 8,440
Dhaka 22.9 12.5 1.4 0.1 0.5 7.7 0.5 77.0 0.2 100.0 13,978
Khulna 28.1 13.5 1.3 0.1 0.6 11.5 1.0 71.9 0.1 100.0 3,919
Rajshahi 6.4 3.5 1.5 0.0 0.4 1.0 0.0 93.6 0.0 100.0 8,559
Sylhet 29.3 15.5 1.5 0.5 0.4 10.6 0.7 70.5 0.3 100.0 3,088

Mother’s education
No education 11.7 4.3 1.0 0.1 0.4 5.5 0.3 88.2 0.1 100.0 18,158
Primary incomplete 14.6 6.1 1.2 0.1 0.5 6.2 0.4 85.4 0.1 100.0 7,544
Primary complete 16.2 8.8 1.2 0.1 0.5 5.4 0.2 83.8 0.1 100.0 4,332
Secondary+ 26.4 19.3 2.3 0.2 0.4 3.7 0.4 73.6 0.1 100.0 10,624

Wealth quintile
Lowest 10.9 3.3 0.9 0.1 0.4 5.8 0.4 89.1 0.1 100.0 10,201
Second 12.3 4.6 0.9 0.1 0.5 5.8 0.4 87.6 0.1 100.0 8,911
Middle 14.0 6.5 1.2 0.1 0.5 5.3 0.4 85.9 0.1 100.0 7,721
Fourth 17.7 9.8 1.9 0.1 0.5 4.9 0.2 82.3 0.1 100.0 7,166
Highest 32.6 26.0 2.2 0.2 0.4 3.4 0.5 67.3 0.2 100.0 6,658

Antenatal care visits


None 9.1 3.2 0.5 0.0 0.2 4.9 0.2 90.9 0.0 100.0 21,295
1-2 17.7 8.4 1.6 0.2 0.5 6.6 0.4 82.3 0.1 100.0 10,811
3+ 33.7 24.4 3.4 0.2 0.8 4.1 0.7 66.3 0.2 100.0 8,489

Total 16.5 9.1 1.4 0.1 0.4 5.1 0.4 83.4 0.1 100.0 40,657
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
FWV = Family welfare visitor, MA = Medical assistant, SACMO = Sub-assistant community medical officer, HA = Health assistant, FWA =
Family welfare assistant, TBA= Traditional birth attendant

58 | Maternity Care
geographical divisions in the propensity to have a postnatal checkup, with only 6 to 9 percent of women
in Barisal, Chittagong, and Rajshahi divisions reporting a postnatal visit, compared with 22 to 29 percent
of women in Dhaka, Khulna, and Sylhet divisions. Not surprisingly, more frequent antenatal visits are
associated with a greater likelihood of having a postnatal checkup.

Table 4.18 indicates that the proportions of women seeking postnatal care for their baby were also
very low (24 percent). Qualified doctors were the most frequently reported providers of postnatal baby
care (12 percent), followed by unqualified doctors (6 percent). Differences in seeking postnatal care for
the baby closely mirrored those found for postnatal care for the mother, with low parity women, urban
women, more educated women, and women in wealthier households being much more likely to receive a
postnatal checkup. The strong link between frequent prenatal care and a postnatal checkup is also again
evident. The percentage of women who brought their babies for a postnatal checkup ranged from a low of
9 percent in Rajshahi division to a high of 42 percent in Khulna division.

Table 4.19 shows the main reasons cited for not seeking a postnatal checkup for the mother,
among women who did not obtain a postnatal checkup for themselves. The primary reason for not having
a postnatal checkup was the perceived absence of need (56 percent). Concern about cost was the second
most commonly cited reason (22 percent). Other service-related factors (access, transportation, poor ser-
vice quality, reluctance to be seen by a male provider) were cited by much smaller percentages of respon-
dents. Cost was much more likely to be cited as a factor in not seeking care among older women, women
of higher parity, women with lower education, and women in poorer households. Higher percentages of
more educated or wealthier respondents cited the absence of need as a primary reason for not seeking
postnatal care.

Maternity Care | 59
Table 4.18 Postnatal care for the baby

Percent distribution of live births in the three years preceding the survey by type of postnatal care received for the baby, according to
background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Medically trained Non-medically trained
–––––––––––––––––––––– –––––––––––––––––––––––––––––––––––––
Nurse/
Received Quali- midwife/ Unquali-
Background postnatal fied paramedic/ MA/ HA/ fied
characteristic care doctor FWV SACMO FWA doctor Other No one Missing Total Number
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Mother's age at birth
<20 24.5 11.7 3.0 0.2 1.5 6.3 1.7 75.1 0.6 100.0 12,562
20-34 24.5 12.8 2.8 0.1 1.9 5.2 1.5 75.2 0.4 100.0 24,312
35+ 19.4 7.7 2.4 0.1 1.8 5.8 1.5 80.1 0.5 100.0 2,650

Birth order
1 29.8 17.5 3.2 0.2 1.5 5.5 1.7 69.9 0.5 100.0 11,663
2-3 24.0 11.8 2.8 0.2 1.9 5.5 1.7 75.7 0.5 100.0 16,405
4-5 19.4 7.9 2.4 0.1 1.8 5.8 1.3 80.2 0.4 100.0 7,102
6+ 17.6 5.9 2.4 0.1 2.0 5.7 1.3 81.9 0.7 100.0 4,355

Problems during
pregnancy or delivery
No 16.6 7.9 2.5 0.1 1.6 3.6 0.9 83.1 0.4 100.0 17,559
Yes 30.2 15.5 3.1 0.2 1.9 7.1 2.2 69.4 0.5 100.0 21,966

Problems after delivery


No 22.3 11.5 2.9 0.1 1.7 4.7 1.4 77.3 0.5 100.0 30,456
Yes 30.3 14.4 2.6 0.2 2.0 8.6 2.4 69.4 0.6 100.0 9,069

Residence
Urban 35.6 25.0 3.7 0.1 1.5 3.5 1.7 64.1 0.4 100.0 6,826
Metropolitan/town 43.5 33.1 4.4 0.0 1.6 2.6 1.5 56.2 0.5 100.0 3,599
Other urban 26.8 15.9 2.9 0.1 1.4 4.4 1.9 73.0 0.3 100.0 3,227
Rural 21.8 9.4 2.7 0.2 1.8 6.0 1.6 77.8 0.5 100.0 32,699

Division
Barisal 11.1 4.8 2.6 0.0 2.0 1.1 0.6 88.4 0.6 100.0 2,615
Chittagong 13.0 8.3 2.3 0.0 0.6 1.5 0.3 86.6 0.4 100.0 8,247
Dhaka 35.0 17.7 3.2 0.2 2.6 8.7 2.4 64.6 0.6 100.0 13,531
Khulna 42.0 18.8 3.1 0.2 2.8 12.7 4.1 57.5 0.7 100.0 3,792
Rajshahi 9.4 4.4 3.0 0.1 0.9 0.9 0.1 90.4 0.3 100.0 8,359
Sylhet 35.8 17.0 2.1 0.5 2.3 10.2 3.5 63.6 0.7 100.0 2,980

Mother’s education
No education 17.9 6.3 2.4 0.1 1.7 6.0 1.4 81.6 0.5 100.0 17,668
Primary incomplete 22.6 8.8 2.6 0.3 2.2 7.0 1.7 77.1 0.5 100.0 7,296
Primary complete 23.3 11.0 2.9 0.1 1.6 5.6 1.9 76.5 0.4 100.0 4,220
Secondary+ 36.3 25.0 3.8 0.2 1.7 3.7 1.7 63.4 0.4 100.0 10,340

Wealth quintile
Lowest 17.1 5.1 1.9 0.1 1.6 6.8 1.6 82.5 0.4 100.0 9,893
Second 18.5 6.3 2.3 0.2 1.7 6.3 1.6 80.9 0.6 100.0 8,670
Middle 21.4 8.4 3.0 0.2 2.3 5.9 1.6 78.1 0.6 100.0 7,504
Fourth 24.7 12.8 3.5 0.1 1.8 4.7 1.6 75.1 0.5 100.0 6,948
Highest 45.0 34.1 4.2 0.2 1.5 3.3 1.6 54.9 0.3 100.0 6,509

Antenatal care visits


None 14.4 5.1 1.3 0.1 1.2 5.4 1.3 85.1 0.5 100.0 20,714
1-2 26.5 11.4 3.6 0.1 2.4 6.8 1.9 73.2 0.4 100.0 10,486
3+ 45.6 30.6 5.8 0.2 2.5 4.3 1.9 54.2 0.4 100.0 8,276

Total 24.2 12.1 2.8 0.2 1.8 5.6 1.6 75.5 0.5 100.0 39,525
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Total includes 49 births for which antenatal care visits are missing.
FWV = Family welfare visitor, MA = Medical assistant, SACMO = Sub-assistant community medical officer, HA = Health assistant, FWA =
Family welfare assistant, TBA= Traditional birth attendant

60 | Maternity Care
Table 4.19 Reasons mother did not receive postnatal care

Among live births in the three years preceding the survey for which the mother did not receive postnatal care, percentage for which the
mother cited specific reasons for not receiving postnatal care, according to background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Reasons mother did not receive postnatal care
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Did
not want
service Family No Unaware
Background Not Not Access/ from did not time of
characteristic necessary customary Cost transport Quality male allow to go need Other Number
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Mother's age at birth
<20 58.6 5.5 17.5 5.2 1.4 0.2 5.8 0.3 20.0 0.3 10,663
20-34 55.5 7.2 23.6 5.2 1.7 0.3 4.3 0.3 17.7 0.3 20,248
35+ 46.4 10.3 31.5 5.4 2.2 0.6 3.7 0.3 19.1 0.3 2,239

Birth order
1 60.5 5.2 14.6 4.9 1.4 0.2 5.6 0.3 20.2 0.3 9,341
2-3 57.4 6.4 21.0 5.1 1.5 0.2 4.7 0.3 18.2 0.3 13,892
4-5 50.7 8.1 30.1 5.5 2.1 0.5 4.0 0.3 17.4 0.4 6,172
6+ 47.4 10.3 32.8 6.0 1.9 0.5 3.9 0.3 17.5 0.3 3,744

Problems during
pregnancy or delivery
No 59.9 7.0 16.5 4.6 1.4 0.3 4.0 0.2 20.1 0.2 15,971
Yes 52.1 6.7 27.5 5.7 1.9 0.3 5.4 0.4 17.1 0.4 17,179

Problems after delivery


No 58.6 6.8 19.5 4.7 1.5 0.3 4.3 0.3 18.8 0.3 26,567
Yes 44.8 7.0 33.3 7.0 2.4 0.4 6.4 0.4 17.5 0.5 6,582

Residence
Urban 64.4 5.9 17.4 3.2 1.7 0.3 3.6 0.3 16.9 0.3 5,202
Metropolitan/town 66.4 4.4 16.1 3.1 1.1 0.3 3.1 0.4 15.9 0.4 2,546
Other urban 62.6 7.3 18.7 3.2 2.3 0.2 4.1 0.2 18.0 0.3 2,656
Rural 54.3 7.0 23.1 5.6 1.6 0.3 4.9 0.3 18.8 0.3 27,948

Division
Barisal 44.1 6.5 20.7 6.4 1.2 0.5 4.7 0.2 25.0 0.0 2,434
Chittagong 45.8 8.6 20.8 6.3 1.2 0.5 4.2 0.2 26.0 0.1 7,501
Dhaka 67.5 5.4 26.9 4.8 2.3 0.2 5.1 0.4 9.2 0.6 10,495
Khulna 69.8 5.2 24.2 4.3 1.9 0.2 5.7 0.3 10.2 0.8 2,758
Rajshahi 46.9 8.4 13.8 5.0 1.3 0.2 4.6 0.3 28.8 0.0 7,834
Sylhet 62.4 4.4 34.3 4.0 1.3 0.3 3.9 0.3 3.7 0.6 2,128

Mother’s education
No education 49.0 7.9 30.2 5.5 1.7 0.3 4.3 0.2 19.9 0.2 15,669
Primary incomplete 54.2 6.4 22.6 5.8 1.7 0.3 5.4 0.3 19.4 0.6 6,262
Primary complete 59.4 6.4 17.4 5.0 1.7 0.5 5.1 0.2 17.2 0.2 3,563
Secondary+ 69.8 5.3 7.9 4.2 1.4 0.3 4.9 0.4 15.7 0.4 7,656

Wealth quintile
Lowest 43.7 7.5 36.3 6.3 1.7 0.2 3.8 0.3 20.6 0.3 8,862
Second 51.1 6.8 27.6 5.4 1.8 0.3 5.3 0.3 19.7 0.3 7,624
Middle 57.1 7.5 18.1 5.0 1.6 0.4 5.6 0.2 19.5 0.3 6,494
Fourth 64.0 6.7 11.2 5.0 1.7 0.3 5.4 0.4 16.9 0.4 5,755
Highest 76.3 4.8 5.0 3.2 1.4 0.4 3.4 0.4 13.2 0.4 4,415

Antenatal care visits


None 50.6 8.2 25.9 6.1 1.5 0.4 5.8 0.2 19.3 0.3 18,903
1-2 60.9 5.5 20.2 4.3 2.0 0.2 3.9 0.3 16.9 0.3 8,685
3+ 66.1 4.2 12.7 3.4 1.5 0.1 2.3 0.6 18.5 0.3 5,533

Total 55.9 6.8 22.2 5.2 1.6 0.3 4.7 0.3 18.5 0.3 33,150
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Total includes 29 births for which antenatal care visits are missing.

Maternity Care | 61
4.5 CONSISTENT USE OF ANTENATAL CARE, DELIVERY CARE, AND POSTNATAL CARE

Table 4.20 and Figure 4.5 show eight combinations of antenatal care, delivery care, and postnatal
care for live births and stillbirths in the three years preceding the survey, by background characteristics.
The column headings separate maternity care received from a doctor, nurse, or midwife into eight catego-
ries: (i) antenatal care only; (ii) delivery care only; (iii) postnatal care only; (iv) antenatal and delivery
care; (v) antenatal and postnatal care; (vi) delivery care and postnatal care; (vii) all three types of mater-
nity care, and (viii) neither antenatal care nor delivery care nor postnatal care from a trained provider.
Postnatal care refers to care for the mother.

Table 4.20 Antenatal delivery and postnatal care

Percent distribution of live births and stillbirths in the three years preceding the survey by whether mother received antenatal care
(ANC), delivery care (DC), and postnatal care (PNC) from medically trained persons, according to background characteristics,
Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Both Neither
Both ANC Both All ANC, ANC, Number
Background ANC DC PNC ANC and DC and DC, and DC, of
characteristic only only only and DC PNC PNC PNC nor PNC Missing Total births
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Mother's age at birth
<20 33.6 1.8 1.5 5.2 4.0 0.6 3.9 49.3 0.2 100.0 13,016
20-34 29.8 1.3 1.8 5.7 3.9 0.4 5.5 51.2 0.2 100.0 24,899
35+ 23.0 1.5 2.4 2.8 3.1 0.9 2.5 63.4 0.4 100.0 2,743

Number of pregnancies
in last three years
1 31.1 1.5 1.7 5.7 3.9 0.5 5.2 50.2 0.2 100.0 33,965
2 27.7 1.5 2.0 3.5 3.8 0.7 2.6 57.8 0.4 100.0 6,595
3 22.0 6.9 3.2 4.9 4.7 0.0 6.4 51.9 0.0 100.0 98

Birth order
1 34.2 2.0 1.3 8.3 4.4 0.8 8.4 40.4 0.3 100.0 11,663
2-3 32.3 1.2 1.6 5.4 3.9 0.3 4.2 51.1 0.1 100.0 16,405
4-5 27.3 1.1 2.0 2.4 3.3 0.2 1.9 61.6 0.2 100.0 7,102
6+ 21.8 1.1 2.8 1.6 2.9 0.4 1.0 68.2 0.3 100.0 4,355

Residence
Urban 32.3 1.8 1.4 11.8 5.3 0.7 12.9 33.6 0.3 100.0 6,989
Rural 30.2 1.4 1.9 4.0 3.6 0.5 3.1 55.2 0.2 100.0 33,669

Division
Barisal 22.2 1.5 1.6 5.2 2.3 0.2 1.8 65.1 0.0 100.0 2,672
Chittagong 28.1 1.6 1.1 6.2 2.7 0.3 3.7 56.4 0.0 100.0 8,440
Dhaka 31.8 1.1 2.5 4.6 4.5 0.7 6.7 47.6 0.5 100.0 13,978
Khulna 34.9 1.8 2.2 6.7 5.0 1.0 7.3 40.9 0.2 100.0 3,919
Rajshahi 31.9 1.9 0.5 6.3 2.3 0.3 2.3 54.6 0.0 100.0 8,559
Sylhet 29.9 1.1 3.8 2.3 8.5 0.4 5.1 48.4 0.5 100.0 3,088

Mother’s education
No education 25.7 1.3 2.0 1.8 2.3 0.5 1.0 65.1 0.3 100.0 18,158
Primary incomplete 31.7 1.8 1.8 3.8 3.9 0.6 1.6 54.7 0.2 100.0 7,544
Primary complete 34.7 1.9 2.2 4.8 4.5 0.5 3.4 48.0 0.1 100.0 4,332
Secondary+ 36.3 1.5 1.2 12.7 6.2 0.6 14.1 27.2 0.3 100.0 10,624

Wealth quintile
Lowest 23.8 1.2 1.6 1.5 2.0 0.5 0.5 68.7 0.2 100.0 10,201
Second 28.1 1.7 1.9 2.5 2.8 0.4 1.0 61.4 0.2 100.0 8,911
Middle 32.8 1.3 2.0 3.8 3.6 0.6 2.1 53.6 0.2 100.0 7,721
Fourth 37.7 1.8 2.1 6.0 5.0 0.6 4.6 42.0 0.2 100.0 7,166
Highest 34.0 1.5 1.3 16.1 7.2 0.6 19.6 19.4 0.3 100.0 6,658

Number of months pregnant


at the time of the first visit
No antenatal care 0.0 2.6 3.1 0.0 0.0 0.9 0.0 93.3 0.1 100.0 21,295
<4 months 52.6 0.2 0.5 12.7 9.8 0.1 17.8 6.0 0.3 100.0 5,954
4-6 months 68.0 0.2 0.3 11.0 7.9 0.1 7.8 4.5 0.3 100.0 8,594
7+ months 72.0 0.2 0.4 9.7 6.6 0.1 4.6 6.2 0.2 100.0 4,737

Total 30.6 1.5 1.8 5.3 3.9 0.5 4.8 51.4 0.2 100.0 40,657
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Medically trained persons include doctor, nurse, paramedic, family welfare visitor, sub-assistant community medical officer, health assis-
tant, and family welfare assistant. Pregnancy status was not known for 77 births.

62 | Maternity Care
Background characteristics show essentially the same differences seen separately for the three
indicators; that is, births to less educated women, rural women, and women in poorer households are less
likely to receive maternity care than urban women, more educated women, and women in wealthier
households.

Figure 4.5 Completeness of Maternity Care in Bangladesh

ANC and DC
5.3%

Antenatal care Delivery care


(ANC) only (DC) only
30.6% 1.5%

DC and PNC
0.5%
ANC and PNC Postnatal care
3.9% (PNC) only
1.8% ANC, DC, and PNC
4.8%

Note: Percentage of births for which mothers received neither antenatal, delivery,
nor postnatal care: 51.4 percent

Maternity Care | 63
MATERNAL HEALTH PROBLEMS
AND TREATMENT-SEEKING BEHAVIOR 5
Michael Koenig, Tulshi D. Saha, Peter Kim Streatfield, and Yasmin Ali Haque

An innovative feature of the Bangladesh Maternal Health Services and Maternal Mortality Survey
(BMMS) is the collection of information on women’s reports of complications during pregnancy, during
delivery, and after delivery and related treatment-seeking behavior. In this chapter, BMMS findings on
maternal complications are explored in detail. The focus is on women’s knowledge of potentially life-
threatening complications, the frequency of self-reported complications, and treatment-seeking behavior
in relation to the most recently occurring complication.

5.1 KNOWLEDGE OF LIFE-THREATENING CONDITIONS

Awareness of life-threatening conditions during pregnancy, during delivery, or after delivery is


low among Bangladeshi women (Table 5.1). While 56 percent of women cited tetanus and 49 percent
cited prolonged or obstructed labor as potentially life threatening, smaller numbers of women identified
retained placenta (38 percent), convulsions (26 percent), abnormal fetal presentation (24 percent), or ex-
cessive vaginal bleeding (18 percent) as potentially life-threatening conditions. Knowledge of life-
threatening conditions is particularly low among the youngest group of women (<20 years) and, overall,
differentials in knowledge according to background characteristics are small, with low levels of knowl-
edge for almost all subgroups.

5.2 WOMEN’S REPORTING OF MATERNAL COMPLICATIONS

In this section, results are presented on self-reported maternal health complications among all
women who had either one or two live births or stillbirths during the three-year period preceding the sur-
vey. The limitations of self-reported reproductive morbidity (generally) and maternal morbidity (specifi-
cally) are widely recognized, with poor correspondence between women’s self-reports and clinically di-
agnosed conditions (Jejeebhoy et al., 2003; Fortney and Smith, 1999). However, obtaining information on
women’s self-reports of morbidity is critical for understanding how women perceive such conditions,
their perceived severity, and treatment-seeking decisions and behavior in response to such complications
(Cleland and Harlow, 2003).

Table 5.2 shows the frequency of individual maternal complications during pregnancy, during de-
livery, or after delivery, as reported by women with a live birth or stillbirth outcome during the three
years preceding the BMMS survey. It is striking that 61 percent of women reported at least one complica-
tion during or following their pregnancy; only 39 percent of pregnancies were free of one or more per-
ceived complications. The most commonly reported complication overall was headache/blurry vi-
sion/high blood pressure (27 percent), followed by prolonged or obstructed labor (16 percent), edema/pre-
eclampsia (14 percent), and excessive bleeding (13 percent). Less commonly reported complications in-
cluded convulsions/eclampsia (5 percent), retained placenta (5 percent), and high fever with foul-smelling
discharge (4 percent).

Maternal Health Problems and Treatment-seeking Behavior | 65


Table 5.1 Knowledge of life-threatening maternal conditions

Percentage of women who mention specific life-threatening maternal conditions, by type of condition and background characteristics, Bangladesh
2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Problems during pregnancy, during delivery, and after delivery
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Foul-
smelling Pro-
discharge longed
Severe Edema/ Con- Extensive with Abnormal labor/ Don’t Number
Background head- pre- vulsions/ vaginal high presenta- obstructed Retained know/ of
characteristic ache eclampsia eclampsia bleeding fever Tetanus tion labor placenta Other missing women
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Age
<20 5.2 5.4 17.1 11.6 0.8 43.3 18.3 38.7 28.8 15.9 20.8 15,097
20-24 7.2 7.0 24.1 16.9 0.9 52.5 24.2 46.2 36.6 20.6 10.4 19,417
25-29 8.4 7.6 27.7 19.1 0.9 58.5 25.3 49.1 39.3 22.4 7.4 17,840
30-34 8.7 8.3 28.7 20.4 1.0 61.1 26.4 51.7 41.2 24.2 5.9 16,736
35-39 8.6 7.9 28.8 20.0 1.0 60.6 26.1 53.1 41.5 22.4 6.3 13,809
40-44 8.3 7.5 28.8 19.7 1.0 58.9 26.8 54.9 41.1 23.0 6.6 11,083
45-49 7.3 7.5 28.7 18.8 0.9 58.4 27.2 57.0 41.9 21.8 6.9 8,190

Children ever born


None 4.7 4.8 15.8 10.5 0.7 41.1 14.5 27.8 22.0 15.3 29.5 11,905
1 7.5 7.4 24.1 17.4 1.0 50.3 23.9 46.2 36.2 21.3 10.7 18,210
2-3 8.2 8.0 27.8 19.9 1.0 59.2 25.9 50.5 41.1 23.2 6.7 36,445
4-5 8.1 7.4 27.8 18.9 0.9 60.4 26.3 53.9 41.5 22.2 6.0 21,515
6+ 7.8 6.8 27.6 17.1 0.9 56.9 26.9 57.0 39.9 20.0 7.1 15,722

Residence
Urban 9.7 8.5 27.6 20.6 1.0 55.8 24.9 44.8 33.5 28.3 9.5 19,896
Metropolitan/ town 10.3 8.8 29.8 21.9 0.8 54.3 24.7 38.0 29.6 31.5 9.9 11,083
Other urban 9.0 8.1 24.9 19.0 1.2 57.8 25.0 53.4 38.4 24.3 9.1 8,813
Rural 7.1 6.9 25.3 17.1 0.9 55.4 24.4 49.8 39.0 19.6 10.0 83,900

Division
Barisal 7.2 7.0 23.6 19.7 0.7 61.4 23.0 40.3 41.0 12.7 12.0 6,839
Chittagong 8.4 8.1 16.3 17.6 0.9 50.2 32.7 42.8 30.3 13.1 15.0 18,275
Dhaka 5.8 7.1 27.1 17.1 0.8 59.4 22.9 54.5 34.0 30.3 7.8 35,848
Khulna 5.9 6.5 28.5 19.3 1.2 59.3 21.7 51.1 40.9 31.9 6.5 12,307
Rajshahi 7.7 6.6 25.7 19.6 1.0 55.0 22.8 44.3 50.3 11.2 10.3 24,495
Sylhet 18.8 8.8 42.9 9.2 0.9 35.9 22.9 57.2 25.1 20.9 10.8 6,032

Education
No education 6.8 5.7 25.4 14.4 0.8 53.3 23.7 51.4 39.1 18.0 10.6 48,243
Primary incomplete 6.7 6.6 25.2 17.3 0.9 57.2 24.5 52.3 40.8 21.5 8.9 18,630
Primary complete 7.1 7.8 24.9 17.9 1.0 57.4 23.8 48.8 37.7 21.8 10.1 10,764
Secondary+ 9.8 10.1 27.1 24.1 1.3 57.4 26.1 41.8 33.9 26.9 9.2 26,159

Wealth quintile
Lowest 7.1 5.4 26.1 12.8 0.7 51.0 22.0 49.6 37.6 17.1 12.1 21,186
Second 6.6 6.1 25.0 15.0 0.8 55.4 23.2 50.7 39.9 18.5 10.3 20,982
Middle 6.6 6.4 23.9 17.0 0.9 57.1 24.1 50.2 40.2 19.5 9.8 20,491
Fourth 7.1 7.9 23.7 19.2 1.1 58.2 25.7 49.7 39.5 21.2 9.4 20,257
Highest 10.5 10.3 29.8 25.0 1.2 55.8 27.4 44.0 32.7 30.1 7.9 20,880

Total 7.6 7.2 25.7 17.8 0.9 55.5 24.5 48.8 38.0 21.2 9.9 103,796

Table 5.2 also shows that complications were most commonly reported during pregnancy (46
percent), followed by during delivery (35 percent), then after delivery (24 percent).1 Figure 5.1 shows the
frequency of reported complications, grouped into seven major categories,2 across pregnancy stages. The
importance of specific complications varies over specific segments of pregnancy/delivery. For example,
during pregnancy the most commonly reported cluster of complications was one or more symptoms of
preeclampsia (headache/blurry vision/high blood pressure), reported for 39 percent of all pregnancies.

1
It is possible that the same complication persisted over multiple segments of pregnancy or delivery. In such cases,
the complication would be included in the prevalence of all periods in which it occurred.
2
“One or more symptoms of preeclampsia” includes headache, blurry vision, high blood pressure, edema, and pre-
eclampsia; “malpresentation and prolonged/obstructed labor” includes hands/feet came first, prolonged labor, and
obstructed labor; “other” includes tetanus, torn uterus, vomiting, diarrhea, gastric problems, dysentery, general
weakness, premature leakage of membrane, and other miscellaneous complications.

66 | Maternal Health Problems and Treatment-seeking Behavior


Table 5.2 Women’s reporting of recent maternal complications

Percentage of live births and stillbirths in the last three years for which women had com-
plications during pregnancy, during delivery, or after delivery, by type of complication,
Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Complications
–––––––––––––––––––––––––––––––––––––
During During After Any
Type of complication pregnancy delivery delivery stage
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
No complications 54.2 65.4 76.2 39.4

One or more complications 45.8 34.6 23.8 60.6


Headache/blurry vision/
high blood pressure 25.2 4.7 5.2 27.2
Edema/preeclampsia 13.4 6.2 2.5 13.5
Excessive bleeding 1.6 4.6 10.2 13.3
High fever with foul-smelling discharge 2.6 0.7 2.0 4.4
Convulsions/eclampsia 1.4 1.7 3.1 5.4
Hands/feet came first na 2.4 na 2.4
Prolonged labor na 16.3 na 16.3
Tetanus 0.1 0.1 0.2 0.3
Retained placenta na 2.2 2.8 4.7
Torn uterus na 0.4 na 0.4
Obstructed labor na 3.1 na 3.1
Abdominal pain 3.1 0.0 0.0 3.1
Vomiting 1.6 0.0 0.0 1.6
Diarrhea/gastric problems/ dysentery 0.4 0.0 0.0 0.4
General weakness 1.1 0.0 0.0 1.1
Premature leakage of membrane 0.3 0.0 na 0.3
Other 4.1 2.5 4.1 7.6
Missing 0.2 0.3 0.6 0.0

Number 40,657 40,657 40,657 40,657


–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
na = Not applicable

Figure 5.1 Women’s Reporting of Recent


Maternal Complications

50

39
40

30
Percent

22
20

10 11 10
10 8
5 4
2 3 2 2 3 2 3 3
1 1
0
During pregnancy During delivery After delivery
One or more symptoms Excessive bleeding High fever Convulsions
of preeclampsia with discharge
Malpresentation and Retained placenta Other
prolonged/obstructed labor

BMMS 2001

Maternal Health Problems and Treatment-seeking Behavior | 67


Other complications were less frequently reported. During delivery, complications related to fetal malpre-
sentation and prolonged or obstructed labor were most commonly reported (22 percent), followed by one
or more symptoms of preeclampsia (11 percent). During the postdelivery period, excessive bleeding was
the most commonly reported complication (10 percent), followed by one or more symptoms of pre-
eclampsia (8 percent).

Table 5.3 shows, for all individual complications reported (N=48,434), the proportion perceived
by women to be life threatening. Overall, 46 percent of reported complications were perceived as life
threatening. Considerable variation in the perception of life-threatening complications is evident across
grouped categories of complications: The categories of complications that women were most likely to
have perceived as life threatening were retained placenta and malpresentation/prolonged or obstructed
labor (75 and 70 percent, respectively). A majority of women who reported having experienced either
convulsions (57 percent) or excessive bleeding (55 percent) also viewed these complications as life
threatening. A much lower percentage of women viewed the complication of one or more symptoms of
preeclampsia—the most commonly reported complication group—as life threatening (31 percent); the
percentage perceiving high fever with discharge to be potentially life threatening was also very low (29
percent).

Table 5.3 Percentage of reported complications considered life threatening

Among live births and stillbirths in the last three years with complications dur-
ing pregnancy, at delivery or after delivery, percentage perceived by the
mother to be life threatening, by type of complication, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Percentage of
complications
considered Number of
Grouped complications life threatening complications
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
One or more symptoms of preeclampsia 30.9 20,393
Excessive bleeding 55.2 5,419
High fever with discharge 29.2 1,777
Convulsions 57.3 2,200
Malpresentation and prolonged/
obstructed labor 70.3 10,130
Retained placenta 75.1 1,905
Other 39.4 6,611

Total 45.9 48,434


–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Totals include births with type of complication missing.

Table 5.4 shows the distribution of perceived life-threatening complications among women re-
porting one or more complications during the most recent pregnancy outcome in the three years preceding
the survey. For the 11,188 women reporting only one complication, 56 percent considered it to be life
threatening. Among women reporting two complications, 18 percent viewed neither complication as life
threatening, 15 percent viewed both complications as life threatening, and the majority (67 percent) re-
ported one of the two complications as life threatening. A similar mix of perceived life threatening and
nonlife threatening complications was evident for the substantial number of women (N=6,400) who re-
ported three or more complications during the most recent pregnancy, with the highest proportion report-
ing one of the three or more complications to be life threatening.

68 | Maternal Health Problems and Treatment-seeking Behavior


Table 5.4 Multiple complications

Percent distribution of live births and stillbirths with complications by number of complications considered life threatening, according to
total number of complications, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of complications considered life threatening
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
None One Two Three or more
Number of ––––––––––––––– ––––––––––––––– ––––––––––––––– –––––––––––––––
complications Total Number Total Number Total Number Total Number Total Number
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
One complication 44.3 4,960 55.7 6,228 - - - - 100.0 11,188
Two complications 18.2 1,279 67.3 4,734 14.5 1,017 - - 100.0 7,030
Three or more complications 8.4 536 55.8 3,568 23.2 1,483 12.7 813 100.0 6,400

5.3 TREATMENT-SEEKING DECISIONS AND BEHAVIOR FOR REFERENCE COMPLICATION

A central objective of the BMMS was to obtain a better understanding of women’s treatment-
seeking behavior in response to life-threatening complications. Women were therefore asked a series of
questions concerning treatment-seeking behavior in relation to the most recent life-threatening complica-
tion. When women reported more than one life threatening complication, only the last reported life-
threatening complication was considered (N=18,117). For those women who reported the occurrence of
complications, but none as life threatening (N=6,501), treatment-seeking behavior in relation to the last
reported (non-life-threatening) complication was explored. Given this selection process, it is important to
emphasize that in the following presented data on treatment-seeking behavior, cases with perceived life-
threatening complications are significantly overrepresented and are thus not representative of treatment-
seeking behavior among the population as a whole. For this reason, the results for life-threatening and
non-life-threatening complications are shown separately.

Table 5.5 and Figure 5.2 show the percentage of births with complications for which the mother
sought care, according to whether the complication was life threatening and other background characteris-
tics. As expected, the proportion of women seeking care was substantially higher for perceived life-
threatening than non-life-threatening complications (62 versus 42 percent). For perceived life-threatening
conditions, care was most likely to be sought for convulsions (77 percent) and high fever with discharge
(74 percent), and least likely to be sought for retained placenta (39 percent). Care seeking was also very
high among the “other” group of complications, which included tetanus, torn uterus, vomiting, diarrhea,
gastric problems, dysentery, general weakness, premature leakage of membrane, and other miscellaneous
conditions. The likelihood of seeking care for life threatening complications was also higher among urban
residents and women from more educated or wealthier households. Similar differentials persisted among
the subgroup of women with non-life-threatening complications.

Maternal Health Problems and Treatment-seeking Behavior | 69


Table 5.5 Sought treatment for recent reference complication

Percentage of live births and stillbirths in the last three years with life-threatening and non-life-threatening
complications during pregnancy, at delivery, or after delivery for which treatment was sought, by type of
complication and background characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Life-threatening Non-life-threatening
complications complications
––––––––––––––––––––––––– –––––––––––––––––––––––
Sought Sought
treatment for treatment for
Background reference reference
characteristic complication Number complication Number
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Grouped complications
One or more symptoms of
preeclampsia 55.6 4,621 34.0 3,636
Excessive bleeding 65.1 2,653 38.3 595
High fever with discharge 74.5 387 54.9 129
Convulsions 76.6 961 59.3 91
Malpresentation and prolonged/
obstructed labor 57.1 5,711 42.4 708
Retained placenta 38.6 1,250 20.0 129
Other 84.3 2,533 69.6 1,109

Residence
Urban 68.9 3,181 52.7 1,185
Metropolitan/town 74.3 1,670 57.3 688
Other urban 63.0 1,511 46.2 496
Rural 60.3 14,936 40.0 5,316

Division
Barisal 55.6 1,044 38.5 281
Chittagong 67.0 3,138 48.4 1,047
Dhaka 60.0 7,314 40.6 2,778
Khulna 65.3 2,078 41.6 845
Rajshahi 61.1 2,837 38.8 1,035
Sylhet 61.2 1,706 49.2 515

Mother’s education
No education 53.9 7,758 33.0 2,848
Primary incomplete 58.6 3,514 39.1 1,205
Primary complete 64.8 1,916 45.0 633
Secondary+ 75.4 4,929 58.0 1,814

Wealth quintile
Lowest 51.4 4,512 30.3 1,566
Second 56.1 3,907 35.8 1,386
Middle 61.4 3,435 39.4 1,196
Fourth 68.3 3,133 48.6 1,151
Highest 78.2 3,130 62.2 1,201

Total 61.8 18,117 42.3 6,501

70 | Maternal Health Problems and Treatment-seeking Behavior


Figure 5.2 Percentage of Women Seeking Treatment by Whether
Reference Complication Was Perceived as Life Threatening

70
62
60 58

50
42
40 38
Percent

30

20

10

0
Life threatening (N=18,117) Non-life threatening (N=6,501)
Sought treatment Did not seek treatment

BMMS 2001

Figures 5.3.1 and 5.3.2 show the path diagrams of treatment-seeking behavior for the most recent
life-threatening and non-life-threatening complication among the 24,618 stillbirths or live births in which
one or more complications were reported. For the 18,117 women with one or more life-threatening com-
plications (Figure 5.3.1), some form of treatment was sought in 11,203 cases (62 percent); in the other
6,914 cases (38 percent), no treatment was sought. Among those women seeking treatment, 30 percent
sought treatment outside the home, and 32 percent sought home-based treatment. The 30 percent of cases
who sought treatment outside the home could be further stratified as follows: 19 percent reported visiting
a facility (public or private), 5 percent reported visiting a qualified provider (e.g., office of private doctor)
but not at a facility, and the remaining 5 percent visited an unqualified provider outside of a formal facil-
ity. Among the 32 percent of cases who obtained home-based treatment, 8 percent visited or were visited
by a qualified provider, while 24 percent were seen by an unqualified provider. Thus, only one in three
women (32 percent) who reported at least one life-threatening complication could be considered to have
sought care at a facility or from a qualified provider (either at home or at the provider’s office/home); in
two-thirds of cases with complications, either the respondent failed to seek care (38 percent) or sought
care from an unqualified provider (29 percent). For cases with perceived non-life-threatening complica-
tions (Figure 5.3.2), a significantly higher percentage (58 percent) failed to seek any treatment; only 22
percent of such cases sought care from a facility or a qualified provider.

Maternal Health Problems and Treatment-seeking Behavior | 71


Figure 5.3.1 Path Diagram of Treatment-Seeking Behavior for Reference Life-
Threatening Maternal Complication, Bangladesh 2001

Reference life-threatening complication


(N=18,117)

Sought treatment Did not seek treatment


(N=11,203) (61.8%) (N=6,914) (38.2%)

Sought treatment outside home Sought home-based treatment


(N=5,358) (29.6%) (N=6,835) (32.2%)a

Facility-based provider Non-facility-based Non-facility-based Qualified provider Unqualified provider


(N=3,457) (19.1%) qualified provider unqualified provider (N=1,425) (7.9%) (N=4,410) (24.3%)
(N=979) (5.4%) (N=923) (5.1%)

a
Ten missing cases on place of treatment

Figure 5.3.2 Path Diagram of Treatment-Seeking Behavior for Reference Non-Life-


Threatening Maternal Complication, Bangladesh 2001
Reference non-life-threatening complication
(N=6,501)

Sought treatment Did not seek treatment


(N=2,749) (42.3%) (N=3,752) (57.7%)

Sought treatment outside home Sought home-based treatment


(N=1,553) (23.9%) (N=1,189) (18.3%)a

Facility-based provider Non-facility-based Non-facility-based Qualified provider Unqualified provider


(N=778) (12.0%) qualified provider unqualified provider (N=227) (3.5%) (N=962) (14.8%)
(N=416) (6.4%) (N=317) (4.9%)
a
Six missing cases on place of treatment

72 | Maternal Health Problems and Treatment-seeking Behavior


5.3.1 Decisionmaker for Seeking Treatment

Table 5.6 shows the distribution of births with complications, by the person(s) who made the de-
cision to seek treatment for complications (with multiple responses permitted), separately for perceived
life-threatening and non-life-threatening complications. For life-threatening complications, the husband
was mentioned in approximately two-thirds of cases with complications as a primary decisionmaker con-
cerning seeking treatment. Other prominent decisionmakers include the respondent’s parents (31 percent),
other family members (22 percent), and the parents-in-law (17 percent). The respondent cited herself as a
main decision-maker in 28 percent of the cases. The significance of the wife’s parents as decision-makers
among very young (<20 years) or first order births (48 percent) may reflect in part the common practice
of the wife returning to her natal home to deliver her first child. The decline in significance of the hus-
band’s and wife’s parents in treatment decisions with increasing age or parity, and the corresponding in-
creased decisionmaking by the respondent or her husband in such decisions, is also evident from Table
5.6.

Among non-life-threatening complications, the husband is again mentioned in two-thirds of all


cases. The parents and other family members are mentioned less frequently, and the respondent herself is
mentioned more frequently, compared with decisionmakers in life-threatening complications. Similar as-
sociations are evident with respect to maternal age and birth order.

Table 5.6 Person who decided that treatment should be sought

Among live births and stillbirths in the last three years for which women had complications during pregnancy, at delivery, or
after delivery and for which treatment was sought, percentage for which specific people made the decision that treatment
should be sought, by background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Person who decided that treatment should be sought
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Other
Background Parents- family
characteristic Respondent Husband in-law Parents members Other Number1
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
LIFE-THREATENING COMPLICATIONS
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Mother's age at birth
< 20 18.4 53.1 23.2 46.7 24.4 5.4 3,527
20-34 31.0 68.1 15.6 25.7 20.8 5.0 6,870
35+ 37.5 76.7 6.7 8.6 20.2 5.8 806

Birth order
1 20.5 52.5 22.1 48.3 26.8 5.9 3,655
2-3 29.2 66.0 17.1 27.9 20.3 4.6 3,953
4-5 33.9 72.9 12.4 16.2 17.7 4.7 1,850
6+ 36.4 80.2 9.8 9.0 15.7 5.6 1,182

Total 27.5 64.0 17.3 31.1 21.9 5.2 11,203


–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
NON-LIFE-THREATENING COMPLICATIONS
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Mother's age at birth
< 20 25.0 53.9 20.1 35.9 14.5 2.3 901
20-34 39.2 70.1 12.8 17.1 11.2 3.3 1,710
35+ 42.8 69.1 7.0 3.2 13.9 4.6 138

Birth order
1 25.6 54.7 19.9 37.0 18.0 3.4 888
2-3 38.7 67.7 14.5 19.7 11.0 2.3 1,158
4-5 40.0 71.0 9.6 8.9 7.2 4.4 402
6+ 42.8 77.2 5.7 3.4 7.1 3.0 240

Total 34.7 64.8 14.9 22.6 12.4 3.0 2,749


–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
1
Percentages may not sum to 100 percent because of multiple responses

Maternal Health Problems and Treatment-seeking Behavior | 73


5.3.2 Type of Provider for Treatment

Table 5.7.1 shows the type of provider initially sought for treatment of complications, among
those with perceived life threatening complications. In 38 percent of cases, women did not seek treatment
for their complication(s). Among those respondents who sought care, 28 percent sought treatment from a

Table 5.7.1 Type of provider seen for life-threatening complications

Percentage of live births and stillbirths in the last three years with life-threatening complications for which women sought assistance from
providers for the last occurring complication, by type of provider and background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Provider seen for last occurring complication
Did not ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
seek Nurse/ Unquali-
assistance midwife/ Trained fied
Background from Qualified paramedic/ MA/ HA/ birth Untrained private
characteristic provider doctor FWV SACMO FWA attendant attendant doctor Other Number
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Grouped complications
One or more symptoms of
preeclampsia 44.4 26.7 4.1 0.5 0.9 0.1 0.1 21.8 4.4 4,621
Excessive bleeding 34.9 25.9 4.9 0.3 0.8 0.1 0.1 33.9 4.0 2,653
High fever with discharge 25.5 32.5 3.9 1.0 0.3 0.0 0.3 35.0 7.8 387
Convulsions 23.4 33.6 6.9 0.6 0.6 0.4 0.2 37.3 4.0 961
Malpresentation and
prolonged/obstructed labor 42.9 23.8 11.3 0.4 0.5 1.0 2.0 21.2 5.2 5,711
Retained placenta 61.4 13.2 5.4 0.2 0.3 1.1 5.9 13.0 3.1 1,250
Other 15.7 43.0 9.3 0.4 1.1 0.2 0.2 31.7 7.0 2,533

Mother's age at birth


< 20 38.7 26.2 8.0 0.4 0.8 0.5 1.2 25.6 4.9 5,753
20-34 37.7 28.7 7.2 0.4 0.6 0.4 1.2 24.8 4.8 11,034
35+ 39.4 23.0 6.7 0.7 1.0 0.4 0.9 28.0 5.7 1,330

Birth order
1 33.4 32.8 10.6 0.4 0.7 0.7 1.0 23.8 4.8 5,492
2-3 40.5 26.4 6.5 0.5 0.7 0.4 1.2 24.1 5.1 6,641
4-5 41.1 22.6 5.6 0.3 0.8 0.4 1.1 27.1 5.2 3,144
6+ 42.6 19.9 3.8 0.5 0.7 0.2 1.3 29.7 4.9 2,059

Residence
Urban 31.1 42.8 11.4 0.2 1.0 0.4 1.1 15.6 4.3 3,181
Metropolitan/town 25.7 52.2 12.4 0.1 0.6 0.5 1.4 12.9 3.2 1,670
Other urban 37.0 32.5 10.4 0.2 1.4 0.3 0.9 18.7 5.5 1,511
Rural 39.7 24.2 6.6 0.5 0.7 0.5 1.1 27.3 5.0 14,936

Division
Barisal 44.4 24.8 7.0 0.4 0.7 0.4 0.4 22.4 3.5 1,044
Chittagong 33.0 30.1 7.8 0.3 0.7 0.7 1.8 27.3 3.3 3,138
Dhaka 40.0 26.8 7.3 0.4 0.7 0.3 1.3 23.3 6.4 7,314
Khulna 34.7 28.5 8.0 0.4 1.1 0.4 0.5 30.1 5.1 2,078
Rajshahi 38.9 25.9 9.0 0.3 0.8 0.7 1.1 26.2 3.0 2,837
Sylhet 38.8 29.0 4.6 1.1 0.4 0.4 0.7 24.6 5.0 1,706

Mother’s education
No education 46.1 17.4 4.9 0.4 0.7 0.4 1.2 27.8 5.2 7,758
Primary incomplete 41.4 23.6 6.6 0.5 0.6 0.3 1.4 25.5 5.5 3,514
Primary complete 35.2 29.8 7.2 0.6 0.8 0.6 0.6 26.2 4.4 1,916
Secondary+ 24.6 45.3 12.1 0.4 0.8 0.6 1.0 20.8 4.2 4,929

Wealth quintile
Lowest 48.6 15.1 4.3 0.4 0.7 0.4 1.3 27.3 6.0 4,512
Second 43.9 19.0 5.6 0.4 0.7 0.5 1.0 28.5 4.8 3,907
Middle 38.6 24.8 6.5 0.5 0.9 0.4 1.4 27.6 5.2 3,435
Fourth 31.7 33.0 9.4 0.4 0.8 0.6 0.9 24.9 4.6 3,133
Highest 21.8 53.5 13.4 0.5 0.6 0.4 1.1 16.3 3.4 3,130

Total 38.2 27.5 7.4 0.4 0.7 0.5 1.1 25.3 4.9 18,117
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Percentages may not sum to 100 percent because of multiple responses. Table excludes 8 cases with missing information on all
complications.

74 | Maternal Health Problems and Treatment-seeking Behavior


Table 5.7.2 Type of provider seen for non-life-threatening complications

Percentage of live births and stillbirths in the last three years with non-life-threatening complications for which women sought assistance from
providers by the last occurring complication, by type of provider and background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Provider seen for last occurring complication
Did not ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
seek Nurse/ Unquali-
assistance midwife/ Trained fied
Background from Qualified paramedic/ MA/ HA/ birth Untrained private
characteristic provider doctor FWV SACMO FWA attendant attendant doctor Other Number
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Grouped complications
One or more symptoms
of pre-eclampsia 66.0 15.9 2.3 0.2 0.5 0.1 0.0 13.4 2.6 3,636
Excessive bleeding 61.7 14.8 2.1 0.1 0.3 0.0 0.5 19.7 1.4 595
High fever with discharge 45.1 19.5 2.2 0.0 1.0 0.0 0.0 29.2 5.0 129
Convulsions 40.7 28.0 8.0 0.0 0.0 0.0 0.0 22.7 4.8 91
Malpresentation and
prolonged/obstructed labor 57.6 16.8 7.4 0.0 0.6 1.0 2.8 14.5 4.5 708
Retained placenta 80.0 8.1 2.0 0.0 0.0 1.0 1.0 6.4 2.6 129
Other 30.4 31.8 6.0 0.3 0.5 0.1 0.0 27.7 7.0 1,109

Mother's age at birth


< 20 59.8 16.1 4.3 0.1 0.5 0.3 0.4 17.0 3.5 2,241
20-34 55.9 21.2 3.3 0.2 0.5 0.1 0.4 17.0 3.5 3,874
35+ 64.2 13.7 4.1 0.1 0.7 0.2 0.3 15.2 3.7 386

Birth order
1 54.8 22.5 5.2 0.1 0.7 0.1 0.3 15.1 3.9 1,964
2-3 57.6 19.6 3.1 0.2 0.4 0.1 0.5 17.1 3.2 2,730
4-5 61.6 14.5 2.5 0.3 0.2 0.3 0.4 18.3 3.4 1,046
6+ 60.8 11.5 2.6 0.0 0.8 0.2 0.5 20.5 4.5 613

Residence
Urban 47.3 35.5 5.6 0.2 0.5 0.1 0.2 10.5 3.4 1,185
Metropolitan/town 42.7 44.3 6.7 0.0 0.3 0.0 0.2 7.3 2.7 688
Other urban 53.8 23.3 4.0 0.5 0.7 0.1 0.2 15.0 4.5 496
Rural 60.0 15.4 3.2 0.2 0.5 0.2 0.4 18.3 3.5 5,316

Division
Barisal 61.5 19.4 3.1 0.2 0.7 0.0 0.0 15.3 1.9 281
Chittagong 51.6 23.3 3.2 0.1 0.5 0.2 0.7 19.6 2.7 1,047
Dhaka 59.4 18.5 3.8 0.1 0.5 0.2 0.4 15.2 4.0 2,778
Khulna 58.4 16.9 4.5 0.1 0.6 0.2 0.2 17.6 4.7 845
Rajshahi 61.2 15.3 3.5 0.2 0.2 0.0 0.5 18.1 1.7 1,035
Sylhet 50.8 23.7 3.0 0.7 0.5 0.3 0.3 18.0 5.4 515

Mother’s education
No education 67.0 10.4 2.0 0.1 0.5 0.2 0.4 17.4 2.9 2,848
Primary incomplete 60.9 12.7 3.3 0.2 0.5 0.0 0.6 18.8 4.7 1,205
Primary complete 55.0 18.4 2.8 0.2 0.0 0.2 0.6 20.8 4.7 633
Secondary+ 42.0 37.1 6.9 0.2 0.6 0.2 0.1 13.5 3.3 1,814

Wealth quintile
Lowest 69.7 7.2 2.0 0.2 0.5 0.1 0.4 18.2 3.0 1,566
Second 64.2 10.8 1.9 0.3 0.4 0.2 0.6 19.6 3.3 1,386
Third 60.6 15.2 2.7 0.1 0.3 0.3 0.3 17.8 4.0 1,196
Fourth 51.4 21.9 5.7 0.0 0.5 0.1 0.5 17.6 4.9 1,151
Highest 37.8 45.0 6.8 0.4 0.7 0.2 0.1 10.6 2.5 1,201

Total 57.7 19.0 3.7 0.2 0.5 0.2 0.4 16.9 3.5 6,501
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Percentages may not sum to 100 percent because of multiple responses. Table excludes 8 cases with missing information on all com-
plications.

Maternal Health Problems and Treatment-seeking Behavior | 75


qualified doctor, another 9 percent sought treatment from other health professionals, 25 percent sought
care from unqualified private doctors, and less than 1 percent sought care from traditional birth atten-
dants. In terms of types of life-threatening complications, cases in the “other” category of complications
were more likely to seek treatment from a qualified doctor (43 percent), followed by respondents who
experienced convulsions (34 percent) and high fever with discharge (33 percent); women with retained
placenta were least likely to seek care from a qualified doctor (13 percent). The likelihood of seeking
treatment for perceived life-threatening complications from a qualified doctor was notably higher for
lower order births, respondents residing in urban areas, and respondents from more educated or wealthier
families. The likelihood of seeking treatment from an unqualified doctor was higher among women in
rural areas.

Among those respondents with non-life-threatening complications, only 19 percent sought treat-
ment from a qualified doctor (Table 5.7.2). The lower visitation rates for these complications were seen
for all categories of providers, reflecting the greater tendency of this group to not seek any treatment (58
percent).

5.3.3 Place Where Treatment Sought

Table 5.8.1 and Figure 5.4 show the place where treatment was sought for respondents for whom
the reference complication was perceived as life threatening and where some form of treatment was
sought. A total of 55 percent of respondents with life threatening complications reported obtaining treat-
ment at home from qualified (14 percent) and unqualified (42 percent) providers. Among respondents
who sought treatment outside their home, the most commonly mentioned site was a government hospital
facility (hospital, thana health complex, or maternal and child welfare center) (21 percent). Private sector
sources—either private health facilities or the offices of qualified private doctors—were the source of
treatment for 18 percent of all cases with complications. Another 8 percent reported visiting the office or
pharmacy of an unqualified private doctor. Treatment at a government or private health facility was sub-
stantially more common among younger women, women with first births, urban women, women with
greater education, and women in wealthier households. In particular, the use of private health facilities for
treatment is more common among women with the highest education levels or wealth categories (24 per-
cent of women in the highest wealth quintile versus only 2 percent of women in the lowest quintile).

Respondents for whom the reference complication was perceived as non-life-threatening were
somewhat less likely to have sought treatment from a public sector facility and more likely to have sought
treatment from the office of either a qualified or unqualified private doctor (Table 5.8.2).

76 | Maternal Health Problems and Treatment-seeking Behavior


Table 5.8.1 Place of treatment for life-threatening complications

Percentage of live births and stillbirths in the last three years with life-threatening complications during pregnancy, during delivery,
or after delivery for which women sought treatment, by place where treatment was received and background characteristics, Bang-
ladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Place where respondent received assistance
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Government NGO
Home hospital/ and Private doctor’s office
––––––––––––––––– thana NGO private ––––––––––––––––––
Un- health FWC/ static and hospital Un-
Background Qualified qualified complex/ satellite satellite and Qualified qualified
characteristic provider provider MCWC clinic clinic clinic doctor doctor Number
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Grouped complications
One or more symptoms of
pre-eclampsia 8.6 30.5 20.0 4.5 1.2 7.0 18.0 15.7 2,570
Excessive bleeding 19.3 51.4 13.2 1.1 0.6 6.0 7.0 7.1 1,727
High fever with discharge 14.4 39.1 17.8 2.0 0.5 4.9 11.1 16.4 288
Convulsions 17.8 50.5 21.6 0.9 0.0 7.5 4.4 3.4 737
Malpresentation and
prolonged/obstructed labor 17.0 48.1 23.8 0.9 0.4 11.1 1.6 1.6 3,263
Retained placenta 19.2 56.8 20.8 0.4 0.3 4.9 1.9 0.9 483
Other 11.0 32.6 22.1 3.1 1.2 10.9 16.1 10.4 2,135

Mother's age at birth


< 20 14.9 44.1 22.2 2.1 0.7 7.2 7.9 6.6 3,527
20-34 14.0 40.5 20.2 2.2 0.8 9.7 10.3 8.1 6,870
35+ 15.1 44.8 16.8 2.6 0.7 6.4 8.3 10.9 806

Birth order
1 15.2 39.0 25.5 1.9 0.7 11.6 7.7 4.7 3,655
2-3 14.0 41.6 18.6 2.5 0.8 9.0 10.4 8.5 3,953
4-5 14.0 44.9 15.5 2.4 1.0 5.1 10.5 11.1 1,850
6+ 13.0 50.1 13.8 1.9 0.3 3.9 10.2 11.6 1,182

Residence
Urban 17.0 25.0 27.6 1.9 1.1 17.5 11.5 5.0 2,193
Metropolitan/town 16.4 20.6 29.3 1.6 1.4 23.7 11.4 3.0 1,241
Other urban 17.7 30.7 25.5 2.4 0.8 9.6 11.6 7.5 952
Rural 13.7 46.1 18.8 2.3 0.7 6.5 8.9 8.5 9,010

Division
Barisal 18.5 39.7 20.4 2.7 0.8 3.8 11.0 7.6 581
Chittagong 17.8 42.6 20.2 1.8 0.6 7.0 9.4 6.6 2,102
Dhaka 12.6 41.4 20.3 2.0 0.6 10.4 9.4 8.5 4,386
Khulna 11.9 44.5 20.9 2.4 0.7 12.9 7.2 7.6 1,357
Rajshahi 14.5 44.3 23.8 2.9 1.5 6.8 6.9 5.4 1,733
Sylhet 15.7 36.7 16.7 2.0 0.4 5.1 15.3 11.7 1,044

Mother’s education
No education 12.3 50.8 15.5 2.6 0.6 3.0 7.9 11.6 4,184
Primary incomplete 14.9 45.8 18.9 2.1 1.2 5.1 9.9 8.1 2,061
Primary complete 14.3 41.3 23.2 2.1 0.7 6.5 10.9 7.3 1,241
Secondary+ 16.3 30.0 26.2 1.7 0.7 17.8 10.3 3.7 3,717

Wealth quintile
Lowest 10.9 52.6 14.9 2.3 0.7 2.2 7.5 13.2 2,317
Second 13.2 49.9 16.5 2.4 0.9 3.5 8.4 9.9 2,190
Middle 15.9 45.8 19.1 2.2 0.6 4.6 9.3 8.8 2,108
Fourth 15.9 39.4 24.4 2.7 0.6 7.3 9.8 5.1 2,141
Highest 16.0 23.5 27.5 1.6 1.0 24.1 11.8 2.4 2,447

Total 14.4 41.9 20.6 2.2 0.8 8.7 9.4 7.8 11,203
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Percentages may not sum to 100 percent because of multiple responses. Table excludes 8 cases with missing information on
all complications.

Maternal Health Problems and Treatment-seeking Behavior | 77


Table 5.8.2 Place of treatment for non-life-threatening complications

Percentage of live births and stillbirths in the last three years with non-life-threatening complications during pregnancy, during de-
livery, or after delivery, for which women sought treatment, by place where treatment was received and background characteristics,
Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Place where respondent received assistance
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Government NGO
Home hospital/ and Private doctor’s office
––––––––––––––––– thana NGO private ––––––––––––––––––
Un- health FWC/ static and hospital Un-
Background Qualified qualified complex/ satellite satellite and Qualified qualified
characteristic provider provider MCWC clinic clinic clinic doctor doctor Number
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Grouped complications
One or more symptoms
of preeclampsia 7.1 30.9 16.0 3.6 1.4 9.4 18.1 14.8 1,238
Excessive bleeding 13.1 49.9 11.1 0.5 1.9 5.8 9.4 8.9 228
High fever with discharge 7.1 38.6 16.7 1.7 0.0 3.1 17.4 22.2 71
Convulsions 22.4 44.5 28.6 2.3 2.2 5.1 0.0 5.5 54
Malpresentation and
prolonged/obstructed labor 13.0 50.1 20.8 0.7 0.0 14.3 0.4 0.8 300
Retained placenta 15.2 54.6 18.7 0.0 0.0 11.4 5.0 0.0 26
Other 8.5 35.2 15.8 4.2 0.4 11.4 16.1 11.2 772
Missing 16.1 23.0 34.0 4.2 1.0 13.9 14.7 9.3 60

Mother's age at birth


< 20 8.7 36.8 16.1 3.4 1.4 6.8 14.0 13.2 901
20-34 9.0 35.9 17.1 2.8 0.9 12.1 14.6 10.5 1,710
35+ 14.4 37.4 16.0 4.4 0.0 6.1 12.2 12.2 138

Birth order
1 8.7 31.0 18.8 3.0 1.6 13.6 15.0 9.7 888
2-3 9.6 36.0 17.1 3.0 0.7 9.7 14.5 12.3 1,158
4-5 8.3 45.1 12.8 3.5 0.7 5.8 14.8 11.3 402
6+ 9.3 46.5 10.1 3.8 0.8 4.1 10.5 15.6 240

Residence
Urban 10.0 19.0 23.4 1.7 1.0 22.4 16.7 6.5 624
Metropolitan/town 9.8 13.8 23.3 1.8 1.3 30.7 17.3 3.5 395
Other urban 10.3 27.8 23.4 1.4 0.6 8.1 15.7 11.5 229
Rural 8.9 41.4 14.8 3.5 1.0 6.4 13.6 13.0 2,125

Division
Barisal 7.9 29.8 23.9 5.5 0.6 7.3 13.5 13.1 108
Chittagong 10.0 33.7 17.6 3.0 1.2 7.3 17.8 12.3 506
Dhaka 8.8 35.8 15.7 2.3 1.0 12.9 14.1 10.7 1,127
Khulna 8.5 40.0 18.5 3.7 0.4 12.7 8.1 11.2 352
Rajshahi 8.4 41.1 16.3 4.1 1.2 7.1 11.9 11.5 402
Sylhet 12.2 33.7 14.6 3.2 0.9 5.1 20.9 13.5 253

Mother’s education
No education 8.6 47.3 10.3 3.8 0.7 3.8 11.9 14.3 941
Primary incomplete 8.0 42.2 12.2 4.1 1.1 6.6 11.8 16.2 471
Primary complete 10.7 39.9 16.9 2.2 1.1 5.7 11.6 13.9 285
Secondary+ 9.8 22.8 24.5 2.2 1.2 18.4 18.3 6.3 1,052

Wealth index
Lowest 8.2 50.3 10.5 3.4 0.6 2.1 8.5 18.3 475
Second 6.2 49.3 13.8 3.1 1.2 3.2 11.2 13.5 496
Middle 9.3 39.2 13.8 2.7 0.7 4.8 14.5 14.6 472
Fourth 12.8 36.7 19.5 3.6 0.5 7.3 13.9 8.7 560
Highest 9.0 16.6 22.5 2.8 1.7 25.0 20.2 6.1 747

Total 9.2 36.3 16.7 3.1 1.0 10.1 14.3 11.5 2,749
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Percentages may not sum to 100 percent because of multiple responses. Table excludes 8 cases with missing information on
all complications.

78 | Maternal Health Problems and Treatment-seeking Behavior


Figure 5.4 Source of Treatment for Perceived
Life-Threatening Complications

50

42
40

30
Percent

21
20
14
10 9
10 8

2
0
Qualified Unqualified Goverment FWC/ Private Qualified Unqualified
provider provider hospital/ satellite health doctor doctor
Thana health clinic facility/
Home Private doctor’s office
complex/MCWC NGO

BMMS 2001

5.3.4 Number of Facilities Visited

Table 5.9 shows the number of facilities visited by women who attended a facility for treatment
of complications, both life-threatening and non-life-threatening complications. For both groups, the vast
majority (92 and 86 percent of those with life-threatening and non-life-threatening complications, respec-
tively) sought treatment from only one place. Respondents with a perceived life-threatening complication
were somewhat more likely than those with a non-life-threatening complication to have visited two or
more places (14 versus 8 percent, respectively). Little variation in the propensity to seek treatment from
multiple facilities was evident for other background characteristics (not shown).

Table 5.9 Number of places women went for treatment of complications

Among live births and stillbirths in the last three years for which the last complication occurred during
pregnancy, during delivery, or after delivery and for which treatment was sought, percent distribution
by number of places where treatment was sought, according to whether complication was perceived
to be life-threatening or not, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of places women went for treatment
––––––––––––––––––––––––––––––––––––––
One Two More than
Complication place only places two places Missing Total Number
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Life threatening 86.1 11.6 2.3 0.1 100.0 5,090
Non-life threatening1 91.9 7.3 0.8 0.0 100.0 1,439
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
1
Includes missing

Maternal Health Problems and Treatment-seeking Behavior | 79


5.3.5 Reasons for Not Seeking Treatment

Table 5.10 and Figure 5.5 show the most commonly cited reasons for not seeking treatment for
the most recent complication, for both perceived life-threatening and non-life-threatening complications.
Among life-threatening reference complications, the most commonly cited reason for not seeking care
was cost, mentioned by 44 percent of respondents. The second prominent reason why treatment was not
sought was a perception that treatment was not necessary or the condition was not serious, cited by 39
percent of those not seeking care. Prohibition by family members (12 percent), transport and access is-
sues (12 percent), and concerns over quality (6 percent) were all less frequently cited reasons for not seek-
ing treatment. Cost barriers were most likely to be cited by respondents with the complications of high
fever with discharge (60 percent) and excessive bleeding (56 percent); they were least likely to be cited
among respondents reporting a retained placenta (30 percent) and malpresentation and prolonged/
obstructed labor (39 percent). Issues of access/transport were most commonly cited for cases of retained
placenta (20 percent).

Among respondents with non-life-threatening reference complications, the primary reason for not
seeking treatment was a perception that treatment was not necessary or the condition was not serious (64
percent); cost considerations were also mentioned (28 percent), although less frequently than among re-
spondents with a perceived life-threatening complication. All other reasons cited were of relatively minor
importance.

Table 5.10 Reasons for not seeking treatment for complications

Percentage of live births and stillbirths in the last three years for which the last complication occurred during pregnancy, during delivery, or after delivery
and for which treatment was not sought, by type of complication and reason for not seeking treatment, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Reasons for not seeking treatment
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Not Cost too Poor
necessary, much, Family quality,
Type of not lack of Access did not better care Not Number
complications serious money problems1 allow at home Other customary Missing of births
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
LIFE-THREATENING COMPLICATION
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
One or more symptoms
of preeclampsia 40.5 47.8 7.1 13.7 4.2 3.7 6.6 0.1 2,051
Excessive bleeding 39.8 56.3 8.4 15.6 3.2 3.5 4.6 0.1 926
High fever with discharge 28.6 59.5 9.3 16.6 3.8 7.9 1.3 0.0 99
Convulsions 34.5 51.6 13.8 8.9 4.8 8.4 1.4 0.6 228
Malpresentation and
prolonged/obstructed labor 38.1 38.7 15.2 10.0 7.8 15.1 6.9 0.1 2,464
Retained placenta 41.2 30.3 19.9 5.5 9.7 17.4 4.0 0.2 767
Other 35.9 52.3 10.8 14.5 5.5 8.6 4.7 0.0 379

Total 39.0 44.3 12.1 11.6 6.0 9.7 5.8 0.1 6,914
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
NON-LIFE-THREATENING COMPLICATION
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
One or more symptoms
of preeclampsia 66.2 27.3 5.5 7.5 3.4 2.4 8.1 0.3 2,398
Excessive bleeding 56.3 40.2 6.6 8.5 2.1 2.5 9.1 0.4 367
High fever with discharge 51.7 51.2 4.6 9.6 3.5 2.8 4.7 2.2 58
Convulsions 56.8 28.6 13.6 4.9 14.3 10.5 3.5 0.0 37
Malpresentation and
prolonged/obstructed labor 61.2 23.3 8.5 5.8 8.4 8.7 8.4 0.6 413
Retained placenta 65.2 20.2 7.3 7.4 6.8 10.3 4.5 0.0 103
Other 62.6 28.5 6.6 9.7 5.2 6.0 9.0 1.2 332

Total 63.6 28.5 6.2 7.5 4.2 3.9 8.0 0.4 3,769
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
1
Access problems include “too far,” “transport problem,” “no one to accompany,” “don’t know how to go,” and “don’t know where to go.”

80 | Maternal Health Problems and Treatment-seeking Behavior


Figure 5.5 Reasons Cited for Not Seeking Treatment for
Reference Complication

70
64

60

50
44
39
40
Percent

29
30

20
12 12
10 8
6 6
4

0
Not necessary/ Cost-related Access Quality Family
Not serious reason opposition
Life threatening Non-life threatening

BMMS 2001

5.4 DELAYS IN SEEKING TREATMENT FOR REPORTED COMPLICATIONS

Figure 5.6 provides a summary of responses from women who were asked questions in the
BMMS regarding four specific delays in treatment-seeking behavior related to the reference complication:
the delay in recognizing the complication, the delay in seeking treatment, travel time to the treatment fa-
cility, and waiting time at the facility. All respondents who had birth outcomes that involved one or more
complications (N=24,618) were asked about the delay in initially recognizing the complication. Those
respondents who sought treatment for complications (N=13,952) were asked additional questions con-
cerning the delay in seeking treatment.3 Finally, the subset of respondents who had birth outcomes with
complications who sought treatment outside the home (N= 6,529) were asked additional questions con-
cerning travel time to the facility/provider and waiting time at the facility/provider. Results are shown for
reference complications that were perceived as life threatening and non-life threatening.

3
The delay in seeking treatment was actually composed from two questions: the time between the onset of the com-
plication and recognition that treatment was needed, and the time between when the decision to seek treatment was
made and treatment was actually sought. Separate analysis (not shown) indicates that a very high proportion of
women (90 percent) actually sought care soon after making the decision to do so. These two responses have been
combined in this chapter.

Maternal Health Problems and Treatment-seeking Behavior | 81


Figure 5.6 Summary of Responses of Women Who Were Asked About Specific
Delays in Treatment for Reference Complication

Delay in Delay in
recognizing seeking Travel time Waiting time
complication treatment to facility at facility

All birth outcomes


with complications
(N=24,618 X
All birth outcomes
with reference com-
plications who sought
treatment
(N=13,952
X X
All birth outcomes
with complications
who sought treat-
ment outside home
X X X X
(N=6,529)

5.4.1 Delay in Recognizing Complication

Tables 5.11.1 and 5.11.2 show the delays in recognizing reported complication by selected back-
ground characteristics. Twenty-six percent of respondents with perceived life-threatening conditions rec-
ognized the problem immediately, and 55 percent recognized the problem within 6 hours of onset (Table
5.11.1). There is wide variation across categories in the timely recognition of complications. While 90
percent of respondents report recognizing the complication of retained placenta within six hours, this fig-
ure declined to 66 percent for malpresentation and prolonged/obstructed labor, 59 percent for excessive
bleeding, and 34 percent for symptoms of preeclampsia. Timely recognition of perceived life-threatening
complications was slightly higher among the most highly educated women and women in wealthier
households, although differentials were generally small. Not surprisingly, women with complications that
were perceived as non-life threatening were less likely to recognize such complications early: 40 percent
recognized them within six hours of onset (Table 5.11.2).

82 | Maternal Health Problems and Treatment-seeking Behavior


Table 5.11.1 Delay in recognizing life-threatening complications

Among live births and stillbirths in the last three years with last occurring life-threatening complication during pregnancy, during delivery, or
after delivery, percent distribution by timing of recognition of the complication, according to type of complication and background charac-
teristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Delay in recognizing life-threatening complication
Type of –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
complication/ No delay/ Don’t
Background Imme- <6 6-23 1-2 3-6 3+ know/ Median
characteristic diate hours hours days days days missing Total Number hours
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Grouped complications
One or more symptoms
of preeclampsia 22.5 11.0 1.0 10.7 14.6 35.8 4.4 100.0 4,621 72.4
Excessive bleeding 28.0 31.0 2.9 14.0 9.7 9.8 4.6 100.0 2,653 2.1
High fever with discharge 19.5 22.6 2.8 18.7 12.2 20.8 3.3 100.0 387 24.4
Convulsions 34.5 31.2 2.0 3.0 2.9 2.3 24.1 100.0 961 a
Malpresentation and
prolonged/obstructed labor 23.7 42.0 14.5 11.4 2.1 1.0 5.2 100.0 5,711 2.6
Retained placenta 38.1 51.7 1.1 1.6 0.2 0.3 7.0 100.0 1,250 a
Other 28.5 18.0 2.6 13.6 10.6 23.4 3.2 100.0 2,533 12.1

Mother's age at birth


<20 23.6 31.5 6.8 11.8 7.7 12.1 6.5 100.0 5,753 3.0
20-34 27.3 28.0 5.5 10.5 7.7 15.7 5.3 100.0 11,034 2.7
35+ 28.1 24.4 4.7 10.4 7.9 18.6 6.0 100.0 1,330 3.1

Birth order
1 23.2 32.0 7.8 12.1 7.4 11.1 6.4 100.0 5,492 3.2
2-3 27.3 28.1 5.1 10.5 7.6 16.3 5.1 100.0 6,641 2.7
4-5 26.7 26.0 5.0 10.4 8.6 17.9 5.4 100.0 3,144 3.0
6+ 27.5 26.6 4.3 10.5 8.0 17.4 5.7 100.0 2,059 2.7

Residence
Urban 26.6 28.7 6.5 11.0 7.5 14.5 5.3 100.0 3,181 2.6
Metropolitan/town 26.5 29.4 6.6 10.4 7.0 13.7 6.3 100.0 1,670 2.4
Other urban 26.7 28.0 6.4 11.6 8.0 15.2 4.1 100.0 1,511 2.9
Rural 26.1 28.9 5.7 10.9 7.8 14.8 5.8 100.0 14,936 2.9

Mother’s education
No education 25.3 27.5 5.0 11.1 8.3 16.0 6.8 100.0 7,758 3.0
Primary incomplete 25.4 28.0 5.6 11.2 7.9 16.1 5.7 100.0 3,514 3.0
Primary complete 24.9 30.3 6.6 11.5 7.8 14.6 4.4 100.0 1,916 2.9
Secondary+ 28.5 30.9 7.1 10.3 6.7 11.9 4.6 100.0 4,929 2.4

Wealth quintile
Lowest 24.2 27.7 4.7 11.7 8.5 16.3 7.0 100.0 4,512 3.2
Second 24.4 29.3 5.6 10.8 8.1 15.5 6.3 100.0 3,907 3.1
Middle 25.1 29.6 5.9 10.4 8.2 15.5 5.2 100.0 3,435 2.9
Fourth 27.5 28.9 6.9 11.2 7.5 13.4 4.7 100.0 3,133 2.7
Highest 30.9 29.0 6.8 10.4 5.9 12.1 4.8 100.0 3,130 2.1

Total 26.2 28.8 5.9 10.9 7.7 14.7 5.7 100.0 18,117 2.8
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
a
Median not calculable and/or less than 6 hours.

Maternal Health Problems and Treatment-seeking Behavior | 83


Table 5.11.2 Delay in recognizing non-life-threatening complications

Among live births and stillbirths in the last three years with last occurring non-life-threatening complication during pregnancy, during deliv-
ery, or after delivery, percent distribution by timing of recognition of the complication, according to type of complication and background
characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Delay in recognizing non-life-threatening complication
Type of –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
complication/ No delay/ Don’t
Background Imme- <6 6-23 1-2 3-6 3+ know/ Median
characteristic diate hours hours days days days missing Total Number hours
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Grouped complications
One or more symptoms
of preeclampsia 21.6 8.9 0.9 12.4 13.6 30.0 12.6 100.0 3,636 49.0
Excessive bleeding 28.7 26.6 1.8 12.1 9.2 7.4 14.1 100.0 595 1.7
High fever with discharge 21.3 13.3 5.5 18.0 10.9 21.0 10.0 100.0 129 24.7
Convulsions 32.9 28.6 2.7 3.2 2.0 1.9 28.8 100.0 91 a
Malpresentation and
prolonged/obstructed labor 23.4 41.4 13.6 7.3 1.6 0.8 11.9 100.0 708 2.3
Retained placenta 34.7 51.8 1.5 2.0 0.5 0.0 9.4 100.0 129 a
Other 26.8 15.6 2.8 13.3 9.2 24.4 8.0 100.0 1,109 24.1
Missing 28.4 21.4 5.7 11.8 6.0 17.2 9.5 100.0 103 2.9

Mother's age at birth


<20 22.5 16.9 2.9 12.0 11.7 21.1 12.9 100.0 2,241 24.2
20-34 24.6 16.4 2.9 11.7 10.0 22.8 11.5 100.0 3,874 24.1
35+ 24.7 16.9 2.4 9.8 9.4 26.2 10.5 100.0 386 24.2

Birth order
1 22.7 17.3 3.9 12.1 12.1 20.1 11.7 100.0 1,964 24.0
2-3 23.2 17.1 2.6 12.3 9.8 23.3 11.7 100.0 2,730 24.2
4-5 25.7 15.5 2.5 9.7 10.6 23.3 12.7 100.0 1,046 20.9
6+ 25.6 15.2 2.0 10.8 9.1 25.8 11.6 100.0 613 24.3

Residence
Urban 24.3 17.1 3.3 11.2 11.7 21.6 10.8 100.0 1,185 20.9
Metropolitan/town 23.8 17.4 3.2 12.4 11.1 20.1 12.1 100.0 688 14.7
Other urban 25.0 16.7 3.3 9.6 12.6 23.7 9.1 100.0 496 24.1
Rural 23.8 16.5 2.8 11.8 10.3 22.6 12.2 100.0 5,316 24.2

Mother’s education
No education 22.9 16.2 2.6 11.1 10.0 23.5 13.6 100.0 2,848 24.3
Primary incomplete 22.0 17.3 2.7 11.0 10.8 22.7 13.5 100.0 1,205 24.2
Primary complete 23.1 16.6 3.6 13.0 9.9 22.6 11.2 100.0 633 24.2
Secondary+ 26.9 16.9 3.2 12.7 11.3 20.5 8.5 100.0 1,814 10.1

Wealth quintile
Lowest 21.1 16.7 3.0 10.7 9.6 23.7 15.1 100.0 1,566 24.3
Second 24.7 15.6 2.7 11.7 9.7 23.2 12.4 100.0 1,386 24.1
Middle 21.7 17.0 2.5 12.5 13.1 21.8 11.3 100.0 1,196 24.6
Fourth 23.2 17.9 3.4 11.7 11.4 22.6 9.8 100.0 1,151 24.1
Highest 29.3 16.1 2.9 12.3 9.1 20.4 9.9 100.0 1,201 5.8

Total 23.9 16.6 2.9 11.7 10.5 22.4 11.9 100.0 6,501 24.1
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
a
Median not calculable and/or less than 6 hours.

5.4.2 Delay in Seeking Treatment

Tables 5.12.1 and 5.12.2 show the delays between recognition of the complication and the deci-
sion to seek treatment, among women who ultimately sought treatment. For women with life threatening
conditions, 45 percent made the decision to seek treatment immediately after recognizing the complica-
tion, and 64 percent decided within 6 hours (Table 5.12.1). Substantial variation in deciding to seek treat-
ment was evident according to the type of perceived life-threatening complication: While 93 and 80
percent of women reported deciding to seek treatment within six hours of recognizing the problem for

84 | Maternal Health Problems and Treatment-seeking Behavior


retained placenta and prolonged/obstructed labor, respectively, only 67 percent of women recognizing
excessive bleeding and 41 percent of women recognizing symptoms of preeclampsia sought treatment in a
timely manner. Younger women, low parity women, women residing in metropolitan areas/towns, more
educated women, and women in wealthier households are more likely to decide to seek treatment after
recognizing a complication and to report lower median delays in deciding to seek treatment (Table
5.12.2).

Table 5.12.1 Delay between recognizing life-threatening complications and deciding to seek treatment

Among live births and stillbirths in the last three years for which women sought treatment for the last occurring life-threatening complica-
tion during pregnancy, during delivery, or after delivery, percent distribution by timing of making the decision to seek treatment for the
complication, according to type of complication and background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Delay in making decision to seek treatment
Type of –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
complicaton/ No delay/ Don’t
Background Imme- <6 6-23 1-2 3-6 3+ know/ Median
characteristic diate hours hours days days days missing Total Number hours
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Grouped complications
One or more symptoms
of preeclampsia 30.6 10.6 2.0 20.6 14.1 22.0 0.1 100.0 2,570 24.7
Excessive bleeding 47.9 19.5 3.7 16.7 6.3 5.9 0.0 100.0 1,727 1.3
High fever with discharge 31.5 16.5 3.7 22.4 11.2 14.3 0.4 100.0 288 11.1
Convulsions 67.9 18.5 3.7 6.1 1.0 2.0 0.8 100.0 737 a
Malpresentation and
prolonged/obstructed labor 52.2 27.0 9.1 8.7 1.8 1.1 0.1 100.0 3,263 a
Retained placenta 75.5 17.5 2.1 2.5 0.7 1.1 0.6 100.0 483 a
Other 40.1 13.0 4.2 18.1 9.3 15.2 0.2 100.0 2,135 3.5

Mother's age at birth


<20 48.1 19.3 5.6 13.0 6.2 7.6 0.2 100.0 3,527 1.2
20-34 44.9 17.7 4.6 15.1 7.1 10.4 0.2 100.0 6,870 1.7
35+ 42.8 17.2 4.4 14.3 8.0 13.3 0.2 100.0 806 2.0

Birth order
1 50.1 19.5 5.8 13.3 5.3 5.8 0.2 100.0 3,655 a
2-3 44.3 17.7 4.7 14.8 7.4 10.9 0.2 100.0 3,953 1.8
4-5 41.8 16.9 3.8 16.0 8.2 13.1 0.1 100.0 1,850 2.3
6+ 41.0 16.2 3.3 15.8 9.2 14.3 0.2 100.0 1,182 2.7

Residence
Urban 53.2 16.6 4.4 13.4 4.9 7.2 0.3 100.0 2,193 a
Metropolitan/town 57.5 15.3 4.2 12.0 4.0 6.4 0.5 100.0 1,241 a
Other urban 47.6 18.3 4.7 15.1 6.1 8.2 0.0 100.0 952 1.3
Rural 44.0 18.6 5.0 14.6 7.4 10.3 0.2 100.0 9,010 1.8

Mother’s education
No education 40.5 18.9 4.7 15.6 8.5 11.6 0.1 100.0 4,184 2.3
Primary incomplete 44.6 17.8 4.9 14.8 6.8 10.7 0.4 100.0 2,061 1.8
Primary complete 45.6 18.5 4.5 14.4 6.6 10.4 0.1 100.0 1,241 1.6
Secondary+ 52.4 17.5 5.2 12.7 5.2 6.7 0.2 100.0 3,717 a

Wealth quintile
Lowest 37.6 19.6 5.3 15.9 8.4 12.8 0.3 100.0 2,317 2.9
Second 41.0 19.8 4.3 15.0 9.3 10.5 0.2 100.0 2,190 2.1
Middle 45.3 17.9 5.0 14.5 7.1 10.1 0.1 100.0 2,108 1.6
Fourth 49.1 17.3 4.8 14.2 6.0 8.4 0.2 100.0 2,141 1.1
Highest 55.3 16.5 5.0 12.3 3.9 6.8 0.1 100.0 2,447 a

Total 45.8 18.2 4.9 14.4 6.9 9.7 0.2 100.0 11,203 1.6
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
a
Median not calculable and/or less than 6 hours.

Maternal Health Problems and Treatment-seeking Behavior | 85


Table 5.12.2 Delay between recognizing non-life-threatening complications and deciding to seek treatment

Among live births and stillbirths in the last three years for which women sought treatment for the last occurring non-life-threatening compli-
cation during pregnancy, during delivery, or after delivery, percent distribution by timing of making the decision to seek treatment for the
complication, according to type of complication and background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Delay in making decision to seek treatment
Type of –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
complication/ Don’t
Background Imme- <6 6-23 1-2 3-6 3+ know/ Median
characteristic diate hours hours days days days missing Total Number hours
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Grouped complications
One or more symptoms
of preeclampsia 29.0 8.0 2.0 22.0 14.5 24.4 0.1 100.0 1,238 48.0
Excessive bleeding 42.7 17.3 6.0 20.4 5.1 8.6 0.0 100.0 228 2.4
High fever with discharge 30.3 6.0 3.6 33.6 11.7 14.8 0.0 100.0 71 24.5
Convulsions 62.2 21.3 2.5 9.7 2.6 1.7 0.0 100.0 54 a
Malpresentation and
prolonged/obstructed labor 54.9 29.5 7.3 6.0 1.0 1.3 0.0 100.0 300 a
Retained placenta 76.7 14.6 3.7 0.0 0.0 5.0 0.0 100.0 26 a
Other 38.9 12.0 3.1 22.4 8.6 14.5 0.5 100.0 772 5.0
Missing 42.8 12.8 6.5 20.2 6.2 11.5 0.0 100.0 60 2.1

Mother's age at birth


<20 35.0 15.0 4.3 19.5 9.8 16.1 0.3 100.0 901 5.9
20-34 39.0 11.1 3.0 20.6 9.5 16.7 0.2 100.0 1,710 5.8
35+ 28.6 16.1 2.4 17.2 15.9 19.7 0.0 100.0 138 24.4

Birth order
1 40.9 12.8 4.6 18.7 8.3 14.4 0.3 100.0 888 3.5
2-3 36.9 12.2 2.7 20.1 9.9 18.0 0.1 100.0 1,158 8.4
4-5 32.2 13.7 3.1 22.8 10.8 17.4 0.0 100.0 402 24.1
6+ 31.6 14.0 1.2 20.2 15.3 17.3 0.5 100.0 240 24.3

Residence
Urban 43.3 14.9 2.7 17.6 10.1 11.2 0.2 100.0 624 2.1
Metropolitan/town 47.7 12.0 2.7 17.5 8.0 11.8 0.4 100.0 395 1.4
Other urban 35.7 20.0 2.7 17.6 13.8 10.2 0.0 100.0 229 4.2
Rural 35.4 12.0 3.6 20.8 9.9 18.2 0.2 100.0 2,125 11.6

Mother’s education
No education 31.3 13.5 3.1 21.7 11.7 18.6 0.1 100.0 941 24.2
Primary incomplete 30.8 14.3 4.4 21.6 11.8 17.1 0.0 100.0 471 24.0
Primary complete 38.3 12.3 3.6 19.5 7.7 18.7 0.0 100.0 285 5.6
Secondary+ 44.9 11.2 3.2 18.0 8.1 14.1 0.4 100.0 1,052 2.2

Wealth quintile
Lowest 30.1 13.1 3.0 22.7 11.6 19.4 0.0 100.0 475 24.3
Second 28.4 14.5 4.0 22.4 11.1 19.4 0.3 100.0 496 24.2
Middle 35.2 13.5 4.5 19.0 9.6 18.2 0.0 100.0 472 7.4
Fourth 38.1 11.9 3.3 20.8 8.8 16.7 0.5 100.0 560 5.7
Highest 48.0 11.1 2.7 16.9 9.2 11.9 0.2 100.0 747 1.5

Total 37.2 12.6 3.4 20.0 9.9 16.6 0.2 100.0 2,749 6.2
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
a
Median not calculable and/or less than 6 hours.

5.4.3 Travel Time To Facility

Table 5.13.1 and 5.13.2 show the reported travel times to health facilities for women who re-
ported seeking treatment outside the home for the reference complication. For reported life-threatening
complications, 34 percent of respondents reported traveling less than 30 minutes to a facility, and 73 per-
cent reported traveling less than 60 minutes (Table 5.13.1). Only 7 percent reported traveling two hours or
more to reach the facility.

86 | Maternal Health Problems and Treatment-seeking Behavior


Table 5.13.1 Travel time to facility for treatment of life-threatening complications

Among live births and stillbirths in the last three years for which women sought treatment for the last occur-
ring life-threatening complication during pregnancy, during delivery, or after delivery, percent distribution
by travel time to a health facility for treatment, according to type of complication and background charac-
teristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Travel time to facility
Type of –––––––––––––––––––––––––––––––––––––––––––
complication/ Don’t
Background <30 30-60 61-120 >120 know/
characteristic minutes minutes minutes minutes missing Total Number
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Grouped complications
One or more symptoms
of preeclampsia 37.0 38.8 12.9 5.4 5.9 100.0 1,568
Excessive bleeding 31.6 39.3 12.9 8.1 8.2 100.0 531
High fever with discharge 41.6 40.1 10.1 5.1 3.1 100.0 140
Convulsions 25.0 39.0 17.3 7.4 11.4 100.0 257
Malpresentation and
prolonged/obstructed labor 33.8 37.3 14.9 7.7 6.2 100.0 1,217
Retained placenta 22.3 31.7 24.4 8.4 13.1 100.0 131
Other 34.2 39.8 13.3 7.4 5.3 100.0 1,246

Mother's age at birth


<20 30.5 40.4 14.9 7.4 6.8 100.0 1,533
20-34 36.6 37.2 13.5 6.6 6.1 100.0 3,231
35+ 26.8 43.3 13.9 7.7 8.4 100.0 326

Birth order
1 36.3 36.8 13.7 7.2 6.0 100.0 1,784
2-3 36.9 38.4 13.4 5.6 5.6 100.0 1,804
4-5 30.5 39.4 15.5 7.7 6.9 100.0 766
6+ 27.3 43.3 12.4 6.7 10.2 100.0 435

Residence
Urban 58.7 27.9 5.6 2.0 5.7 100.0 1,305
Metropolitan/town 64.0 24.9 4.1 1.4 5.6 100.0 814
Other urban 49.9 32.9 8.2 3.0 5.9 100.0 491
Rural 25.7 42.2 16.8 8.6 6.7 100.0 3,785

Mother’s education
No education 27.7 41.2 15.4 7.9 7.9 100.0 1,552
Primary incomplete 29.8 40.9 14.7 6.6 8.1 100.0 865
Primary complete 32.0 39.5 14.1 8.1 6.2 100.0 565
Secondary+ 41.3 35.5 12.5 6.0 4.8 100.0 2,108

Wealth quintile
Lowest 23.3 45.0 15.9 8.9 6.9 100.0 836
Second 25.2 42.2 16.1 7.5 9.0 100.0 838
Middle 29.2 41.4 14.8 7.1 7.5 100.0 853
Fourth 29.3 40.0 15.9 9.2 5.6 100.0 990
Highest 50.4 30.7 10.0 3.9 4.8 100.0 1,574

Total 34.1 38.6 13.9 6.9 6.4 100.0 5,090

The results of Table 5.13 show a strong urban-rural differential: 59 percent of urban respondents,
but only 26 percent of rural respondents, reported traveling less than 30 minutes to reach a provider or
facility. The most educated women (secondary school or higher) and women in the wealthiest households
have substantially shorter travel times to reach a facility or provider. Travel times were even shorter for
women with non-life-threatening complications, possibly because of differences in the type of provider/
facility sought for treatment (Table 5.13.2).

Maternal Health Problems and Treatment-seeking Behavior | 87


Table 5.13.2 Travel time to facility for treatment of non-life threatening complication

Among live births and stillbirths in the last three years for which women sought treatment for the last occur-
ring non-life-threatening complication during pregnancy, during delivery, or after delivery, percent distribu-
tion by travel time to a health facility for treatment, according to type of complication and background
characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Travel time to facility
Type of –––––––––––––––––––––––––––––––––––––––––––
complication/ Don’t
Background <30 30-60 61-120 >120 know/
characteristic minutes minutes minutes minutes missing Total Number
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Grouped complications
One or more symptoms
of preeclampsia 41.7 38.4 9.5 3.6 6.7 100.0 738
Excessive bleeding 48.3 33.3 10.3 1.8 6.2 100.0 70
High fever with discharge 27.3 36.0 17.6 9.5 9.6 100.0 33
Convulsions 21.9 42.8 7.0 7.0 21.3 100.0 18
Malpresentation and
prolonged/obstructed labor 50.7 33.1 7.7 3.9 4.6 100.0 110
Retained placenta 19.1 42.9 16.6 0.0 21.4 100.0 8
Other 43.9 39.4 9.8 3.1 3.8 100.0 416
Missing 44.8 26.3 15.7 7.4 5.9 100.0 45

Mother's age at birth


<20 40.9 37.9 9.3 4.7 7.2 100.0 456
20-34 44.2 38.0 9.5 3.1 5.1 100.0 915
35+ 35.3 32.3 18.7 3.9 9.8 100.0 68

Birth order
1 46.4 35.8 8.8 3.3 5.8 100.0 513
2-3 43.9 39.0 8.2 3.3 5.6 100.0 602
4-5 36.0 39.1 14.7 4.3 5.9 100.0 182
6+ 33.8 36.3 16.7 4.9 8.2 100.0 99

Residence
Urban 68.3 22.8 3.0 1.0 4.9 100.0 426
Metropolitan/town 70.3 21.4 2.7 0.9 4.7 100.0 298
Other urban 63.7 26.0 3.8 1.1 5.5 100.0 128
Rural 32.0 44.0 12.8 4.8 6.4 100.0 1,013

Mother’s education
No education 35.3 41.0 12.0 4.0 7.7 100.0 372
Primary incomplete 39.5 43.4 7.4 4.3 5.4 100.0 225
Primary complete 34.1 43.7 11.6 3.9 6.7 100.0 135
Secondary+ 49.3 33.0 9.2 3.2 5.2 100.0 706

Wealth quintile
Lowest 27.4 47.4 12.8 3.7 8.6 100.0 185
Second 31.9 46.0 10.2 6.6 5.2 100.0 209
Middle 35.9 38.9 14.2 4.2 6.8 100.0 223
Fourth 39.4 37.8 11.7 4.9 6.2 100.0 275
Highest 56.5 30.7 6.1 1.7 5.0 100.0 547

Total 42.7 37.7 9.9 3.7 6.0 100.0 1,439

5.4.4 Waiting Time at Facility

Table 5.14 shows the distribution of reported waiting times at health facilities for women who
sought treatment at a facility for the reference complication. Almost two-thirds of women with perceived
life-threatening complications reported being seen immediately at the facility; 85 percent of such women
were seen within one hour of arrival at the facility. Similar results were evident for the smaller group of
women with complications that were perceived as non-life threatening.

88 | Maternal Health Problems and Treatment-seeking Behavior


Table 5.14 Waiting time at facility

Among live births and stillbirths in the last three years for which women sought treatment for the last occurring complication
during pregnancy, during delivery, or after delivery, percent distribution by waiting time at the health facility before treatment
was received for the complication, according to background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Waiting time at facility
–––––––––––––––––––––––––––––––––––––––––––
Seen Don’t
Background immedi- More than know/ Number
characteristic ately 1 hour 1-2 hours 2 hours missing Total of births
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
LIFE-THREATENING COMPLICATIONS
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Mother's age at birth
<20 67.2 20.1 10.2 2.0 0.5 100.0 1,533
20-34 64.7 20.3 12.0 2.3 0.8 100.0 3,231
35+ 61.5 19.1 17.1 2.3 0.0 100.0 326

Birth order
1 67.9 19.5 9.9 2.1 0.6 100.0 1,784
2-3 63.4 20.5 13.1 2.2 0.8 100.0 1,804
4-5 61.0 22.6 13.6 2.6 0.2 100.0 766
6+ 65.0 19.3 13.3 1.8 0.6 100.0 435

Residence
Urban 66.5 19.7 10.5 2.3 0.9 100.0 1,305
Metropolitan/town 64.7 19.2 11.9 2.9 1.2 100.0 814
Other urban 69.4 20.6 8.2 1.4 0.4 100.0 491
Rural 64.8 20.3 12.2 2.1 0.6 100.0 3,785

Mother’s education
No education 65.7 18.2 13.6 1.9 0.6 100.0 1,552
Primary incomplete 63.8 20.6 12.5 2.5 0.7 100.0 865
Primary complete 65.6 22.2 9.1 2.1 0.9 100.0 565
Secondary+ 65.3 20.8 10.8 2.3 0.7 100.0 2,108

Wealth quintile
Lowest 66.7 19.0 11.3 2.0 1.1 100.0 836
Second 66.4 17.6 13.2 2.3 0.5 100.0 838
Middle 59.4 23.4 14.1 2.6 0.5 100.0 853
Fourth 65.6 20.6 11.3 2.0 0.4 100.0 990
Highest 66.6 20.1 10.3 2.2 0.8 100.0 1,574

Total 65.2 20.2 11.8 2.2 0.7 100.0 5,090


–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
NON-LIFE-THREATENING COMPLICATIONS
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Mother's age at birth
<20 62.0 24.3 11.2 2.3 0.3 100.0 456
20-34 60.5 25.9 11.2 1.7 0.6 100.0 915
35+ 66.7 20.1 11.8 1.4 0.0 100.0 68

Birth order
1 61.9 24.4 11.4 1.8 0.5 100.0 513
2-3 60.3 26.4 10.7 2.0 0.6 100.0 602
4-5 59.4 24.4 13.7 2.1 0.4 100.0 182
6+ 66.9 23.2 8.0 1.9 0.0 100.0 99

Residence
Urban 60.6 27.5 9.0 1.8 1.0 100.0 426
Metropolitan/town 61.1 26.5 9.6 1.7 1.2 100.0 298
Other urban 59.6 29.9 7.7 2.2 0.6 100.0 128
Rural 61.6 24.1 12.2 1.9 0.2 100.0 1,013

Mother’s education
No education 65.1 21.3 10.9 2.2 0.5 100.0 372
Primary incomplete 61.3 25.5 11.7 0.0 1.5 100.0 225
Primary complete 64.3 21.8 11.5 1.9 0.5 100.0 135
Secondary+ 58.7 27.7 11.2 2.3 0.1 100.0 706

Wealth quintile
Lowest 65.8 17.7 13.9 2.6 0.0 100.0 185
Second 65.8 23.0 9.4 1.5 0.3 100.0 209
Middle 63.2 23.5 11.5 1.0 0.9 100.0 223
Fourth 55.2 29.2 12.9 2.1 0.5 100.0 275
Highest 60.3 27.1 10.1 2.0 0.5 100.0 547

Total 61.3 25.1 11.2 1.9 0.5 100.0 1,439

Maternal Health Problems and Treatment-seeking Behavior | 89


There was little variation in waiting time at the facility/provider by type of life-threatening com-
plications. For all categories of complications, between 82 and 90 percent of women waited less than one
hour at a facility before being seen. Waiting time at the facility showed little variation by background
characteristics.

Figure 5.7 summarizes the four major delays for women seeking treatment for reference compli-
cations (life-threatening complications and non-life-threatening complications). These estimates of delays
are based on very different subsamples of women. Just over half of women (55 percent) with a life-
threatening complication recognized the complication within six hours of onset; this percentage was
lower among women with non-life-threatening complications (40 percent). Among the subsample of
women who decided to seek treatment, the delay in deciding to seek treatment was six hours or less in
almost two-thirds (64 percent) of cases but was lower among those with non-life-threatening complica-
tions (50 percent). For life-threatening cases in which women sought treatment outside the home, almost
three-fourths (73 percent) reported traveling one hour or less to reach a health facility or provider; 80 per-
cent of women with a non-life-threatening complication reported traveling one hour or less. A very high
proportion of women with life-threatening complications and non-life-threatening complications (85 and
86 percent, respectively) reported having been seen by a provider within an hour of reaching the facil-
ity/provider.

It is important to emphasize that these findings may, to a considerable degree, reflect self-
selection—only women who sought treatment outside the home are included in this analysis. Women re-
siding closer to providers/facilities may be more likely to actually travel outside to seek care, and women
for whom treatment is less accessible—not part of the present sample—may be less likely to seek treat-
ment for their complication, mostly because of access constraints. Similarly, with respect to waiting times
to see providers, clients may be more likely to avoid facilities known for having longer waiting times and,
conversely, may be more likely to seek services from facilities with shorter waiting times.

Figure 5.7 Summary of Delays in


Treatment-Seeking Behavior for Reference
Life-Threatening Complications
100

85 86
80
80
73

64

60 55
Percent

50

40
40

20

0
<6 hours delay in <6 hours delay in <1 hour travel time <1 hour waiting
recognition of deciding to to facility/provider time at
complication seek treatment facility/provider

BMMS 2001

90 | Maternal Health Problems and Treatment-seeking Behavior


5.5 DELIVERY EXPENDITURES

Table 5.15 shows the reported total household expenditures for all deliveries/complications dur-
ing the three years preceding the survey (N=40,645). The median costs of delivery vary considerably by
whether there were complications associated with the pregnancy and by the type of treatment sought. For
pregnancies/deliveries without complications, 43 percent of cases involved no treatment costs, and me-
dian expenditures were only 26 taka (US$1.00 = 48 taka); however, median expenditures were substantial
among the relatively small number of deliveries without complications that took place in either public or
private facilities (1,001 or 2,501 taka, respectively).

Table 5.15 Treatment costs for deliveries

Among live births and stillbirths in the last three years, percent distribution by amount spent for delivery (in takas), according to type of delivery
and treatment, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Amount spent for delivery (takas)
––––––––––––––––––––––––––––––––––––––––––––––––––––
5,000 Don’t
1,000- or know/
Type of delivery Nothing <500 500-999 4,999 more missing Total Number Mean Median
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Delivery without complications 43.2 39.8 7.1 6.1 1.7 2.0 100.0 16,022 403 26
Delivered at home 45.3 41.2 6.9 4.3 0.3 2.0 100.0 15,227 189 21
Delivered in facility 3.3 12.7 11.2 40.0 29.5 3.3 100.0 795 4,562 1,500
Public facility 3.8 17.0 14.6 40.2 20.8 3.7 100.0 520 3,191 1,001
Other facility 2.3 4.7 4.8 39.7 46.0 2.5 100.0 274 7,132 2,501

Delivery with complications 16.9 39.3 14.4 18.3 7.9 3.2 100.0 24,623 1,512 300
Did not seek treatment 35.3 46.5 8.4 6.2 1.2 2.4 100.0 10,656 357 51
Sought treatment, but
not in a facility 3.7 45.7 21.4 22.1 2.7 4.3 100.0 7,423 857 401
Sought treatment in a facility 1.9 20.4 16.1 33.6 24.8 3.2 100.0 6,543 4,142 1,000
Public facility 2.3 16.1 15.0 37.9 25.7 3.1 100.0 3,043 3,967 1,001
Other facility 1.5 24.2 17.2 29.8 24.0 3.3 100.0 3,500 4,294 801

Total 27.3 39.5 11.5 13.5 5.5 2.8 100.0 40,645 1,072 151
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Table excludes 10 cases with missing information on complications and/or sought treatment and/or place of treatment.
US$1.00=48 taka

For pregnancies/deliveries with complications, median costs were substantially higher (overall
median of 300 taka). Among the large proportion of pregnancies with complications where no treatment
was sought, expenditures were low (median of 50 taka). Seeking treatment from a source other than a fa-
cility was associated with substantially higher expenditures (median of 401 taka); however, these expen-
ditures remained substantially lower than those associated with seeking treatment for complications from
a facility (median of 1,000 taka). Of particular interest, is the finding that median expenditures for deliv-
eries with complications are actually higher in public facilities than in private facilities (1,001 taka and
800 taka, respectively), despite government policy that public services are free of charge. The expenditure
data provide part of the explanation why a significant percentage of women opt for the private sector in-
stead of the public sector for treatment of pregnancy-related complications.

Maternal Health Problems and Treatment-seeking Behavior | 91


5.6 SOURCE OF FUNDS FOR DELIVERY/TREATMENT OF COMPLICATIONS

Table 5.16 presents data on the source of funds for payment of delivery costs. For all deliveries,
83 percent of women cited existing family funds as the source of payment for delivery costs. An addi-
tional 16 percent mentioned money from relatives and 10 percent cited borrowing money as sources of
funds. As might be expected, the percentage citing borrowing money or obtaining money from relatives
increased among those with complications who sought treatment either in a facility or elsewhere.

Table 5.16 Source of funds for delivery costs

Among live births and stillbirths in the last three years for which payment was made for delivery, percentage for which women
reported specific sources of money for delivery/treatment costs, by type of delivery and background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Source of money for delivery costs
Type of delivery/ ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Background Family Sold From Don’t
characteristic funds Borrowed assets relatives Mortgage Other know missing Number
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Type of delivery
Delivery without complications 87.4 5.3 0.3 11.5 0.0 0.3 0.3 0.6 9,098
Delivery with complications
Did not seek treatment 83.3 7.8 0.6 14.3 0.2 0.4 0.3 0.8 6,923
Sought treatment at a facility 83.3 15.1 2.2 20.1 0.7 0.7 0.1 0.2 6,406
Sought treatment, but
not at a facility 78.0 13.7 1.1 20.5 0.2 0.4 0.3 0.3 7,147

Mother's age at birth


<20 77.8 7.5 0.8 26.0 0.3 0.7 0.2 0.4 9,686
20-34 85.8 10.8 1.0 12.1 0.2 0.3 0.3 0.5 17,982
35+ 87.5 16.0 1.9 4.9 0.5 0.3 0.3 0.4 1,905

Birth order
1 77.4 7.3 0.8 27.9 0.2 0.7 0.2 0.3 9,186
2-3 86.3 8.4 0.8 12.9 0.2 0.3 0.2 0.5 11,817
4-5 86.9 13.5 0.9 7.2 0.1 0.2 0.4 0.6 4,759
6+ 86.7 16.7 1.5 4.7 0.4 0.2 0.2 0.4 2,930

Residence
Urban 86.2 8.7 0.6 14.8 0.2 0.5 0.2 0.4 5,605
Metropolitan/town 85.9 9.0 0.4 16.3 0.2 0.5 0.2 0.3 3,136
Other urban 86.7 8.3 1.0 12.9 0.3 0.5 0.2 0.4 2,469
Rural 82.6 10.3 1.1 16.5 0.3 0.4 0.3 0.5 23,968

Division
Barisal 81.8 13.1 0.6 14.8 0.2 0.0 0.5 0.0 1,641
Chittagong 85.9 14.9 0.7 13.0 0.3 0.0 0.4 0.0 5,874
Dhaka 84.5 7.6 0.8 15.8 0.3 0.6 0.1 0.8 11,266
Khulna 78.6 8.3 1.5 21.9 0.2 1.4 0.3 0.9 3,323
Rajshahi 81.3 9.1 1.5 19.7 0.2 0.0 0.2 0.0 5,164
Sylhet 83.0 11.9 1.0 10.7 0.1 0.4 0.3 1.1 2,304

Mother’s education
No education 82.2 13.7 1.2 12.5 0.3 0.4 0.3 0.6 11,921
Primary incomplete 81.9 10.8 1.4 17.3 0.4 0.3 0.2 0.5 5,466
Primary complete 83.3 9.2 0.9 16.8 0.2 0.3 0.5 0.4 3,224
Secondary+ 85.6 5.1 0.4 20.1 0.2 0.5 0.1 0.4 8,961

Wealth quintile
Lowest 77.8 17.5 1.5 15.1 0.3 0.4 0.3 0.6 6,478
Second 81.2 11.9 1.3 16.2 0.3 0.4 0.2 0.5 6,088
Middle 82.8 9.1 1.0 17.2 0.3 0.4 0.4 0.5 5,558
Fourth 86.7 6.3 0.6 16.5 0.2 0.3 0.2 0.4 5,546
Highest 88.6 4.3 0.3 16.1 0.2 0.5 0.2 0.4 5,904

Total 83.3 10.0 1.0 16.2 0.3 0.4 0.3 0.5 29,573

92 | Maternal Health Problems and Treatment-seeking Behavior


REPRODUCTIVE AND CHILD HEALTH 6
Tulshi D. Saha and Kenneth Hill

The primary objective of the Bangladesh Maternal Health Services and Maternal Mortality Sur-
vey (BMMS) was to obtain quantitative information about maternal health and mortality in Bangladesh.
Previous chapters have described the major findings of the survey. For the measurement of maternal
health and mortality, however, a substantial amount of related information had to be collected—
specifically, it was necessary to collect a complete birth history (since births are the denominators of the
maternal mortality ratio) and a recent pregnancy history (to ensure that all pregnancy completions were
included). The birth history and pregnancy history information makes it possible to calculate measures of
fertility and of perinatal, infant, and child mortality. These data are important in the overall study of re-
productive health. This chapter presents the BMMS findings on fertility, current use of contraception, and
childhood mortality. Information on reproductive behaviors and risks can be used to identify women who
are at risk of maternal health problems and can provide information to assist in planning appropriate im-
provements in health and family planning services, access, and delivery.

6.1 FERTILITY

6.1.1 Introduction

Fertility is the most important component of population dynamics and plays a major role in de-
termining the size and structure of the population of Bangladesh. Current fertility levels, trends, and dif-
ferentials in fertility, cumulative fertility, birth intervals, and adolescent fertility are examined in this
chapter.

Most of the fertility measures presented here are based on the complete birth histories collected
from ever-married women age 13-49. Several measures and procedures were used to obtain complete and
accurate reporting of births, deaths, and the timing of these events. Each woman was asked to provide
information on the number of sons and daughters to whom she had given birth who were living with her,
the number living elsewhere, and the number who had died. The women were then asked for a history of
all their live births, including such information as name, month and year of birth, sex, and survival status.
For children who had died, information on age at death was solicited. Interviewers were given extensive
training in probing techniques designed to help respondents report this information accurately.

Despite the measures to improve data quality, BMMS information is subject to the same types of
error that are inherent in all retrospective sample surveys, namely, the omission of some births (especially
births of children who died at a young age) and the difficulty of determining the date of birth of each child
accurately. These difficulties can bias estimates of fertility trends. Indicators of the quality of the BMMS
fertility data appear in Appendix E, Table E.2 and suggest that such errors are minimal.

6.1.2 Current Fertility

The level of current fertility is one of the most important indicators for health and family planning
policymakers and professionals in Bangladesh because of its direct relevance to population policy and
programs. The most widely used measures of current fertility are the total fertility rate (TFR) and its com-
ponent age-specific fertility rates (ASFRs). The TFR is defined as the number of children a woman
would have by the end of her childbearing years if she were to pass through those years bearing children

Reproductive and Child Health | 93


at the currently observed age-specific rates.1 Another common measure is the general fertility rate (GFR),
which represents the annual number of births in a population per 1,000 women age 15-44. The crude
birth rate (CBR) is the annual number of births in a population per 1,000 people. Both of these measures
are calculated using the birth history data for the three-year period before the survey and the age and sex
distribution of the household population.

The results in Table 6.1 indicate that the total fertility rate for the three years before the survey
(approximately 1998 through early 2001) is 3.2 children per woman age 15-49. The age-specific rates
indicate a pattern of early childbearing, with a peak at age group 20-24. Three-fourths of childbearing
occurs before age 30.

Table 6.1 Current fertility

Age-specific and cumulative fertility rates and crude birth rates for the three years
preceding the survey, by urban-rural residence, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Residence
–––––––––––––––––––––––––––––––––––
Metro-
All politan/ Other
Age group urban town urban Rural Total
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
13-14 11 12 10 17 16
15-19 105 100 112 141 134
20-24 158 157 159 193 185
25-29 136 127 149 152 149
30-34 86 83 90 99 97
35-39 39 30 50 57 53
40-44 12 8 18 22 20
45-49 2 2 3 7 6

TFR 13-49 2.72 2.55 2.92 3.39 3.25


TFR 15-49 2.69 2.53 2.90 3.36 3.22
TFR 15-44 2.68 2.52 2.89 3.32 3.19
GFR 103 98 109 126 122
CBR 26.0 26.0 25.8 28.9 28.4
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Rates are for the period 1-36 months preceding the survey. Rates for age
group 45-49 may be slightly biased due to truncation.
TFR: Total fertility rate, expressed per woman
GFR: General fertility rate (births divided by number of women 15-44), ex-
pressed per 1,000 women
CBR: Crude birth rate, expressed per 1,000 population

The total fertility rate is higher in rural areas (3.4 children per woman) than in urban areas (2.7
children per woman). The difference in fertility is especially large at younger ages, which probably re-
flects later marriage of women in urban areas. Like the TFR, the GFR and CBR also vary by urban-rural

1
Numerators of the ASFRs are calculated by summing the number of live births that occurred 1 to 36 months pre-
ceding the survey (determined by the date of interview and the date of birth of the child) and classifying them by the
age (in five-year groups) of the mother at the time of birth (determined by the mother’s date of birth). The denomi-
nators of the rates are the number of woman-years lived in each of the specified five-year age groups during the 1 to
36 months preceding the survey. Since only women who had ever married were interviewed in the BMMS survey,
the numbers of women in the denominators of the rates were inflated by factors calculated from information in the
household questionnaire on proportions ever married in order to produce a count of all women. Never-married
women are presumed not to have given birth.

94 | Reproductive and Child Health


residence. Thus, with a GFR of 126 per 1,000, the average annual number of births to rural women is
about 25 percent higher than that for urban women (103 per 1,000). Similarly, the CBR in the rural areas
(29 per 1,000) is also higher than the CBR in the urban areas (26 per 1,000).

6.1.3 Pregnancy Outcomes

In addition to a complete birth history, the BMMS collected a history of recent pregnancies. This
history, for the three-year period before the interview, was collected using a calendar: respondents were
asked to report the outcome of each pregnancy. The possible outcomes considered are live birth, stillbirth,
miscarriage/abortion, and menstrual regulation (MR). Table 6.2 shows the percent distribution of preg-
nancy outcomes occurring during the three-year period preceding the survey (roughly 1998-2000). In
Bangladesh, 90 percent of pregnancies result in a live birth, and 5 percent result in a miscarriage/abortion.
Stillbirths and MRs compose another 5 percent of all pregnancy outcomes. Miscarriages and abortions
occur at a higher rate among younger and older women.

Table 6.2 Pregnancy outcomes

Percent distribution of pregnancies that ended in the three years preceding the survey, by
pregnancy outcome, according to age of mother at end of pregnancy, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Pregnancy outcome
––––––––––––––––––––––––––––––––––––––
Age of mother Mis- Number
at end of Live Still- carriage/ Menstrual of
pregnancy birth birth abortion regulation Total pregnancies
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
13-14 87.6 3.8 7.3 1.3 100.0 1,281
15-19 90.9 3.1 4.6 1.4 100.0 12,844
20-24 91.8 2.0 4.2 2.0 100.0 13,027
25-29 90.2 2.2 4.6 3.0 100.0 9,267
30-34 88.3 2.3 5.5 3.8 100.0 5,140
35-39 85.5 2.6 7.3 4.6 100.0 2,364
40-44 83.1 4.3 8.1 4.6 100.0 722
45-49 80.4 1.5 11.7 6.3 100.0 119

Total 90.2 2.5 4.9 2.4 100.0 44,764

6.1.4 Fertility Differentials

Table 6.3 presents the current level of fertility by residence, division, level of education, and
household wealth. The figures show large differences in the level of fertility among divisions. Fertility is
lowest in Khulna (2.6) and Rajshahi (2.9) divisions and highest in Sylhet (4.3) and Chittagong (3.7) divi-
sions. Dhaka and Barisal divisions have intermediate levels of fertility, with total fertility rates of about
3.2 children per woman. This pattern is similar to that found in the 1999-2000 BDHS (NIPORT et al.,
2001) and the 1996-1997 BDHS (Mitra et al., 1997).

There is a strong association between fertility and education, with the TFR declining as the level
of education increases. At current rates, a woman with no formal education will give birth to an average
of 3.8 children in her lifetime, compared with 2.5 for a woman with at least some secondary education.
Women with either incomplete primary or complete primary education have intermediate fertility rates.

Like education, household wealth is strongly related to fertility. Women in poorer households
have more children than women in wealthier households. With a TFR of 4.2, women in the poorest
households are likely to have about two children more than women in the wealthiest households (TFR of
2.4).

Reproductive and Child Health | 95


At the time of the survey, 5 percent of Table 6.3 Fertility by background characteristics
the women interviewed reported that they were
pregnant. This proportion is probably an under- Total fertility rates for the three years preceding the survey, per-
estimate because some women who are early in centage of women currently pregnant, and mean number of
children ever born to women age 40-49, by background charac-
the pregnancy do not yet know that they are teristics, Bangladesh 2001
pregnant, and some women may not want to –––––––––––––––––––––––––––––––––––––––––––––––––––
declare that they are pregnant. Khulna division Mean number
of children
has the lowest proportion currently pregnant (5 Total Percentage ever born
percent), whereas the highest proportion preg- Background fertility currently to women
nant is reported in Sylhet division (6 percent). characteristic rate1 pregnant age 40-49
Interestingly, the proportions pregnant by divi- –––––––––––––––––––––––––––––––––––––––––––––––––––
Residence
sion and by wealth quintile track the TFR All urban 2.7 4.8 4.8
differentials closely, but the proportions preg- Metropolitan/town 2.5 4.8 4.5
Other urban 2.9 4.8 5.2
nant by level of education show no clear Rural 3.4 5.5 5.6
pattern.
Division
Barisal 3.3 5.0 5.6
Table 6.3 also allows a crude assess- Chittagong 3.7 6.1 6.0
ment of differential trends in fertility over time Dhaka 3.2 5.4 5.4
among population subgroups. The mean number Khulna 2.6 4.6 5.0
Rajshahi 2.9 5.0 5.2
of children ever born to women by the end of Sylhet 4.3 6.4 5.8
their reproductive period, age 40-49, is a
measure of the average completed fertility. If Education
No education 3.8 5.3 5.6
fertility remained constant in the recent past and Primary incomplete 3.4 5.2 5.6
if the reported data on children ever born and Primary complete 3.2 6.0 5.5
births during the three years preceding the Secondary+ 2.5 5.4 4.3
survey are reasonably accurate, the average Wealth quintile
completed fertility should be equal to the total Lowest 4.2 6.5 5.4
fertility rate. Comparison of the mean number Second 3.7 5.8 5.7
Middle 3.2 5.2 5.7
of children ever born to women age 40-49 with Fourth 2.9 5.3 5.6
the total fertility rate suggests a decline of about Highest 2.4 4.4 4.8
two children per woman in Bangladesh over the
Total 3.2 5.4 5.4
past 10 to 15 years. There has been a substantial –––––––––––––––––––––––––––––––––––––––––––––––––––
decline in urban and rural areas, in all divisions, 1 Rate for women age 15-49 years
and in the four education categories. Except in
Sylhet division, the decline is more than two children per woman in all divisions. Fertility decline is also
more pronounced for women from the wealthier households than for women from the poorer households.
As fertility has declined, differentials on all dimensions have become more pronounced.

6.1.5 Fertility Trends

More direct evidence of the declining trend in fertility is obtained by looking at changes in age-
specific fertility rates across the demographic surveys that were conducted in Bangladesh since the mid-
1970s: the 1975 Bangladesh Fertility Survey, the 1989 Bangladesh Fertility Survey, the 1991 Contracep-
tive Prevalence Survey, and three Bangladesh Demographic Health Surveys (1993-1994, 1996-1997, and
1999-2000). The results shown in Table 6.4 describe the ongoing fertility transition in Bangladesh. The
TFR has declined dramatically from 6.3 children per woman in 1971-1975 to 3.2 in 1998-2000, a decline
of 49 percent over a 26-year period. The pace of fertility decline has slowed in the most recent period,
compared with the rapid decline during the late 1980s and early 1990s. The total fertility rate dropped
only marginally from 3.4 in 1991-1993 to 3.3 in 1994-1996, remained steady in 1997-1999, and then

96 | Reproductive and Child Health


Table 6.4 Trends in current fertility rates

Age-specific and total fertility rates (TFR) among women age 15-49, selected sources, Bangladesh, 1975-2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Survey and approximate time period
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
1993-1994 1996-1997 1999-2000
1975 BFS 1989 BFS 1991 CPS BDHS BDHS BDHS 2001 BMMS
Age group (1971-1975) (1984-1988) (1989-1991) (1991-1993) (1994-1996) (1997-1999) (1998-2000)
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
15-19 109 182 179 140 147 144 134
20-24 289 260 230 196 192 188 185
25-29 291 225 188 158 150 165 149
30-34 250 169 129 105 96 99 97
35-39 185 114 78 56 44 44 53
40-44 107 56 36 19 18 18 20
45-49 35 18 13 14 6 3 6

TFR 15-49 6.3 5.1 4.3 3.4 3.3 3.3 3.2


––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: For the 1975 and 1989 BFS surveys, the rates refer to the five-year period preceding the survey; for the other surveys,
the rates refer to the three-year period preceding the survey. The BFS and BDHS surveys utilized full birth histories, while
the 1991 CPS used an eight-year truncated birth history.
Source: 1975 BFS (MHPC, 1978:73); 1989 BFS (Huq and Cleland, 1990:103); 1991 CPS (Mitra et al., 1993 :34); 1993-94
BDHS (Mitra et al., 1994: 24); 1996-97 BDHS (Mitra et al.,1997:30), 1999-2000 BDHS (NIPORT et al., 2001:33)

edged lower again to 3.2 in 1998-2000. Investigation of the age pattern of fertility shows no anomalies; as
expected, the declines since the mid-1980s have been smallest for the youngest age groups and largest for
the oldest age groups (Figure 6.1).

Figure 6.1 Age-Specific Fertility Rates 1989 - 2001

Births per 1,000 Women

250
!
% !
200
&*
$
% %
%!
$* !
150 & %&
$
%* %
!
100 &*
$
%
%
50 *
% !
$
& %
%
&*
$ !
0 &*
%
%
$
15-19 20-24 25-29 30-34 35-39 40-44 45-49

Age
! 1989 BFS % 1991 CPS * 1993-1994 BDHS
& 1996-1997 BDHS $ 1999-2000 BDHS % 2001 BMMS
Note: The 1989 rates refer to the 5-year period preceding the survey; all others are 5-year rates.

6.1.6 Birth Intervals

Information on the length of birth intervals provides insight into birth spacing patterns. Research
suggests that children born too soon after a previous birth are at an increased risk of poor health and, con-
sequently, an increased risk of dying, particularly when the interval between births is less than 24 months.
Maternal health is also jeopardized when births are close together.

Reproductive and Child Health | 97


The data show that birth intervals are generally long in Bangladesh. Among nonfirst births, only
one in six children (16 percent) is born after a “too short” interval (less than 24 months). More than half
(57 percent) of nonfirst births occur three or more years after the previous birth, while 27 percent of such
births take place 24 to 35 months after the previous birth. The overall median length of birth interval is
38.8, the same as found in the 1999-2000 BDHS survey (NIPORT et al., 2001); however, this birth inter-
val is slightly longer than the birth intervals reported in the 1993-1994 BDHS survey (35 months) (Mitra
et al., 1994:34) and the birth interval reported in the 1996-1997 BDHS survey (37 months) (Mitra et al.,
1997:38) (Table 6.5).

Table 6.5 Trends in length of birth interval

Percent distribution of non-first births in the five years preceding the survey by number of months since previous
birth, Bangladesh 1993-2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Median
number
Months since previous birth of months
––––––––––––––––––––––––––––––––––––––––––––––– since previous
Survey 7-17 18-23 24-35 36-47 48+ Total previous birth
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
1993-1994 BDHS 8.3 12.0 33.5 22.2 24.0 100.0 34.7
1996-1997 BDHS 7.1 10.6 30.3 23.1 28.9 100.0 36.6
1999-2000 BDHS 6.6 9.7 26.9 21.8 35.0 100.0 38.8
2001 BMMS 7.1 9.0 26.8 21.7 35.4 100.0 38.8

6.1.7 Age of Mothers at Their First Birth

One of the factors that determines the level of current fertility in a population is the age of women
at first birth. Early childbearing can lead to a large family size and may be associated with increased
health risks for the mother and potential health hazards for the children. A rise in the median age at first
birth is typically a sign of transition to lower fertility levels.

Childbearing begins early in Bangladesh, with most women becoming mothers before age 20.
The median age at first birth is 19 years for the youngest cohort for which a median could be computed
(age 20-24) and varies between 17 and 18 for the older cohorts, indicating a modest rise in the median age
at first birth during the most recent period (not shown).

Comparisons with data from other sources show that the age at which women in Bangladesh have
their first child has increased steadily over time. For example, in 1975, the median age at first birth among
women age 20-24 was 16.8, rising to 18.0 in 1991-1993, 18.4 in 1996-1997, and 18.7 in 1998-2000.

6.1.8 Adolescent Fertility and Motherhood

The issue of adolescent fertility is important for both health and social reasons. Children born to
very young mothers may face an increased risk of illness and death. Adolescent mothers themselves may
be more likely to experience adverse pregnancy outcomes and maternity-related mortality than more ma-
ture women, and they are more constrained in their ability to pursue educational opportunities than their
counterparts who delay childbearing.

Table 6.6 shows the percentage of adolescent women (age 15-19) who are mothers or pregnant
with their first child, by background characteristics. Almost 30 percent of adolescent women in Bangla-
desh are already mothers with at least one child, and 5 percent are currently pregnant, for a total of 34

98 | Reproductive and Child Health


percent who have started childbearing. The proportion of teenagers who have begun childbearing rises
rapidly with age. Only about 13 percent of women age 15 have started childbearing, but by age 19, about
60 percent are pregnant or have had a baby.

In rural areas, 35 percent of the adolescents have begun childbearing, compared with 27 percent
in urban areas. There are also divisional variations: 40 percent of the adolescents in Rajshahi or Khulna
divisions are either mothers or are pregnant with their first child, compared with about 25 percent of their
counterparts in Sylhet and Chittagong divisions. It is interesting to note that the divisions with the earliest
childbearing are also the divisions with the lowest fertility, and those with the latest childbearing are those
with the highest fertility.

Table 6.6 Adolescent fertility

Percentage of women age 15-19 who are mothers or pregnant with their first child, by back-
ground characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Percentage who are:
––––––––––––––––––– Percentage
Pregnant who Number
Background with have begun of women
characteristic Mothers first child childbearing 15-19
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Age
15 8.5 4.8 13.3 6,938
16 17.7 5.8 23.4 6,853
17 31.3 6.0 37.3 5,973
18 38.9 5.4 44.3 6,796
19 54.6 4.3 58.9 4,733

Residence
Urban 22.6 4.4 26.9 6,348
Metropolitan/town 22.3 4.6 26.9 3,136
Other urban 22.8 4.2 27.0 3,212
Rural 29.9 5.5 35.4 24,987

Division
Barisal 27.5 5.0 32.5 2,114
Chittagong 20.8 4.9 25.7 6,420
Dhaka 29.0 5.5 34.6 10,597
Khulna 34.7 5.4 40.1 3,346
Rajshahi 33.9 5.7 39.7 6,816
Sylhet 20.6 4.0 24.6 2,085

Education
No education 49.2 5.9 55.1 5,504
Primary incomplete 37.3 5.2 42.5 5,251
Primary complete 34.4 6.7 41.2 3,706
Secondary+ 17.5 4.9 22.4 16,835

Wealth quintile
Lowest 40.9 5.0 45.9 4,965
Second 37.0 5.7 42.8 5,685
Middle 30.1 5.8 35.9 6,434
Fourth 23.1 5.9 29.0 7,005
Highest 16.6 4.1 20.7 7,261

Total 28.4 5.3 33.7 31,293

Reproductive and Child Health | 99


A strong association between education and initiation of childbearing is clear from the survey re-
sults (Table 6.6). Whereas 55 percent of adolescents with no formal education have started childbearing,
only 22 percent of their counterparts with secondary education or higher have done so. Like education,
household socioeconomic status is strongly related to early childbearing. Adolescents in the poorest
households are far more likely to have begun childbearing than those in the wealthiest households (46 and
21 percent, respectively).

There has been a slight decline in the proportion of teenage women who have begun childbearing
since the 1996-1997 BDHS survey, which indicated that 36 percent of women age 15-19 had begun
childbearing (Figure 6.2); however, the 1993-1994 BDHS reported a proportion (33 percent) lower than
that of the 2001 BMMS (34 percent).

Figure 6.2 Trends in Teenage Pregnancy and


Motherhood among Women Age 15-19, 1993-2001
36
35
34
33

1993-1994 BDHS 1996-1997 BDHS 1999-2000 BDHS 2001 BMMS

Mothers Pregnant with first child

BMMS 2001

6.2 FERTILITY REGULATION

In the 2001 BMMS, only information on the current use of contraception was collected. Although
ever-married women age 13-49 were interviewed, only women who were currently married at the time of
the survey were asked the questions on current use of family planning. Table 6.7 shows the percent distri-
bution of currently married women interviewed in the 2001 BMMS survey by their current contraceptive
use status, according to background characteristics.

The 2001 BMMS indicates that 50 percent of currently married women in Bangladesh are using a
method of family planning. Modern methods are much more widely used (44 percent of married women)
than traditional methods (6 percent). The increase in use of family planning from 8 percent of married
women in the 1975 BFS to 54 percent in the 1999-2000 BDHS has declined to 50 percent in the 2001
BMMS (Figure 6.3). The decline in overall use is due entirely to a decline in traditional method use (from
10 to 6 percent). Modern method use has not changed since 1999-2000.

100 | Reproductive and Child Health


Table 6.7 Current use of contraception by background characteristics

Percent distribution of currently married women by contraceptive method currently used, according to background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Modern method Traditional method
–––––––––––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––
Using Female Male Any
any Any steri- steri- In- tradi- Periodic Folk Not Number
Background meth- modern liza- liza- ject- Nor- Con- tional absti- With- meth- currently of
characteristic od method tion tion Pill IUD ables plant dom method nence drawal ods using Total women
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Age
13-14 24.7 20.3 0.0 0.0 15.4 0.0 0.5 0.0 4.3 4.5 2.8 1.5 0.2 75.3 100.0 1,579
15-19 34.5 31.3 0.0 0.1 23.1 0.2 4.3 0.2 3.3 3.2 2.3 0.9 0.0 65.5 100.0 14,652
20-24 45.8 42.1 0.6 0.1 29.1 0.6 7.9 0.4 3.2 3.7 2.7 0.9 0.2 54.2 100.0 18,752
25-29 54.7 50.1 2.4 0.3 32.1 1.0 10.0 0.6 3.6 4.6 3.3 1.0 0.3 45.3 100.0 17,126
30-34 61.4 54.2 6.2 0.7 30.9 1.2 10.8 0.7 3.7 7.2 5.2 1.5 0.5 38.6 100.0 15,693
35-39 62.5 52.5 10.8 0.9 25.9 1.1 10.1 0.5 3.2 10.1 7.4 2.0 0.8 37.5 100.0 12,630
40-44 53.7 42.4 14.1 1.2 16.8 0.8 6.5 0.3 2.6 11.3 8.7 1.8 0.9 46.3 100.0 9,698
45-49 35.9 27.3 13.8 1.0 8.0 0.3 3.2 0.2 0.9 8.6 6.8 1.2 0.7 64.1 100.0 6,815

Residence
Urban 56.2 47.9 5.5 0.5 27.2 1.2 6.1 0.5 6.9 8.3 5.9 2.1 0.3 43.8 100.0 18,355
Metropolitan/town 59.1 50.2 5.7 0.6 26.6 1.3 6.4 0.5 9.3 8.8 5.9 2.6 0.3 40.9 100.0 10,180
Other urban 52.6 45.0 5.4 0.3 28.0 1.1 5.8 0.5 3.8 7.7 5.8 1.5 0.3 47.4 100.0 8,175
Rural 48.7 42.9 5.3 0.5 25.3 0.7 8.3 0.4 2.3 5.8 4.3 1.1 0.4 51.3 100.0 78,590

Division
Barisal 47.8 41.5 4.0 0.6 23.3 0.8 10.5 0.4 1.8 6.3 5.3 0.7 0.3 52.2 100.0 6,486
Chittagong 37.6 33.5 3.6 0.2 19.2 0.6 7.4 0.4 2.1 4.1 3.3 0.5 0.3 62.4 100.0 17,226
Dhaka 52.2 44.5 6.0 0.3 26.0 0.9 6.7 0.5 4.2 7.7 5.3 1.8 0.6 47.8 100.0 33,274
Khulna 61.7 52.2 5.9 0.9 29.7 1.1 10.0 0.5 4.2 9.6 6.2 2.9 0.6 38.3 100.0 11,454
Rajshahi 56.4 52.1 6.4 1.0 32.3 0.7 8.8 0.5 2.6 4.3 3.5 0.5 0.3 43.6 100.0 23,113
Sylhet 28.1 21.4 2.6 0.2 10.5 0.5 5.0 0.3 2.2 6.7 5.3 1.0 0.3 71.9 100.0 5,393

Education
No education 48.8 43.0 7.9 0.8 22.5 0.7 9.5 0.5 1.0 5.7 4.4 0.8 0.6 51.2 100.0 43,670
Primary incomplete 50.7 44.2 4.8 0.5 26.4 0.8 9.1 0.6 2.0 6.5 4.6 1.5 0.4 49.3 100.0 17,554
Primary complete 49.0 42.7 3.2 0.3 28.0 0.7 7.5 0.4 2.5 6.3 4.8 1.2 0.3 51.0 100.0 10,329
Secondary+ 52.5 45.3 2.1 0.2 29.6 0.9 4.4 0.3 7.9 7.2 5.0 2.0 0.2 47.5 100.0 25,392

Number of living children


0 16.0 13.6 0.2 0.3 9.2 0.0 0.1 0.0 3.7 2.5 1.5 1.0 0.0 84.0 100.0 11,882
1 45.1 41.0 1.3 0.4 29.1 0.5 5.5 0.3 3.8 4.1 2.9 1.0 0.1 54.9 100.0 18,889
2 60.1 54.1 5.2 0.6 33.0 1.1 9.6 0.6 4.1 6.1 4.4 1.4 0.3 39.9 100.0 21,660
3-4 60.9 53.1 9.8 0.7 27.9 1.0 10.5 0.6 2.6 7.8 5.7 1.4 0.7 39.1 100.0 29,233
5+ 48.0 38.4 6.0 0.4 19.5 0.7 9.5 0.5 1.7 9.6 7.5 1.3 0.9 52.0 100.0 15,281

Wealth quintile
Lowest 43.3 38.7 6.2 0.8 20.6 0.6 9.2 0.6 0.7 4.6 3.4 0.7 0.5 56.7 100.0 19,159
Second 48.8 43.2 6.1 0.6 24.7 0.6 9.6 0.5 1.1 5.7 4.2 1.0 0.5 51.2 100.0 19,557
Middle 50.3 44.1 5.6 0.6 26.4 0.8 8.5 0.4 1.9 6.1 4.6 1.0 0.5 49.7 100.0 19,313
Fourth 50.3 43.7 4.4 0.4 27.3 0.7 7.4 0.5 3.0 6.6 5.0 1.2 0.3 49.7 100.0 19,260
Highest 57.8 49.2 4.4 0.2 29.3 1.1 4.8 0.4 9.0 8.5 5.9 2.4 0.2 42.2 100.0 19,657

Total 50.1 43.8 5.3 0.5 25.7 0.8 7.9 0.5 3.2 6.3 4.6 1.3 0.4 49.9 100.0 96,945

Reproductive and Child Health | 101


The pill continues to be by far the most popular method of contraception, used by 26 percent of
women. Eight percent of currently married women are using injectables, 6 percent are using female or
male sterilization, and 3 percent are using condoms. The most popular traditional method is periodic ab-
stinence, used by 5 percent of women.

Current use varies by women’s age and is lowest among currently married women age 13-19 and
highest among women age 30-39. Use of modern methods is 54 percent among women age 30-34. There
are also variations by age in the methods that women use. The pill is the most popular modern method
among married women under age 20 as well as among women in their twenties and thirties. Injectables
are the second most popular method among women age 15-34. With a gradual shift to long-term methods
among older women, the popularity of female sterilization has increased, becoming second to the pill by
age 35 39 and the most widely used method among women in their late forties.

Figure 6.3 Trends in Contraceptive Use


Among Currently Married Women under Age 50

10.3
6.3
7.6
8.4
8.7

7.6
6.9 41.6 43.5 43.8
36.2
5.3 31.2
23.2
18.4
2.7 13.8
5

1975 1983 1985 1989 1991 1993-1994 1996-1997 1999-2000 2001


BFS CPS CPS BFS CPS BDHS BDHS BDHS BMMS
Modern methods Traditional methods

BMMS 2001

Differences in contraceptive use by socioeconomic characteristics are not large. Contraceptive


use varies moderately by residence (urban-rural) but greatly by division. Contraceptive use is highest in
Khulna division (62 percent), closely followed by Rajshahi and Dhaka divisions (56 and 52 percent, re-
spectively), and lowest in Sylhet division (28 percent). Secondary education is correlated with greater use
of family planning, although the differences are small. Use of any method differs by only four percentage
points between currently married women with no education (49 percent) and those with secondary educa-
tion or above (53 percent). By household wealth, contraceptive prevalence ranges from 43 percent among
women living in the poorest households to 58 percent among women living in the wealthiest households.

There is a strong association between use of family planning and the number of living children a
woman has. As expected, fewer women use a contraceptive method before having their first child. Con-
traceptive use increases sharply from 16 percent for women with no living children to 61 percent for
women with three to four children and then falls to 48 percent for women with five or more living chil-
dren. This latter decline is expected because age and number of living children are positively correlated,
and contraceptive use declines as women reach the end of their fertile years.

102 | Reproductive and Child Health


6.3 CHILDHOOD MORTALITY

Infant and child mortality rates reflect a country’s level of socioeconomic development and qual-
ity of life and are used for monitoring and evaluating population and health programs and policies. The
BMMS asked all ever-married women age 13-49 to provide a complete history of their births including,
for each live birth, the sex, month and year of birth, survival status, and age at the time of the survey or
age at death. Age at death was recorded in days for children dying in the first month of life, in months for
children dying before their second birthday, and in years for children dying at later ages. This informa-
tion was used to calculate the following direct estimates of infant and child mortality.2

Neonatal mortality: The probability of dying in the first month of life


Postneonatal mortality: The probability that a child will die after the first month
of life but before the first birthday
Infant mortality (1q0): The probability of dying before the first birthday
Child mortality (4q1): The probability of dying between the first and fifth birthdays
Under-five mortality (5q0): The probability of dying before the fifth birthday.

6.3.1 Early Childhood Mortality Rates: Levels and Trends

Neonatal, postneonatal, infant, child, and under-five mortality rates, by two-year and five-year
periods preceding the survey, are shown in Table 6.8. Examining the most recent five-year period (0-4
years before the survey or 1996-2000), under-five mortality is estimated at 95 per 1,000 live births, and
infant mortality is estimated at 72 per 1,000 live births. This means that 1 in every 14 children born in
Bangladesh during 1996-2000 died within the first year of life, and 1 in every 10 children died before
reaching age five. The age pattern of mortality shows that half of the deaths under-five occur during the
neonatal period, while about one-quarter occur during the postneonatal period, and another one-quarter of
deaths occur at age 1-4 years.

Evidence of a decline in childhood mortality comes from comparison of data from the BMMS
with data from previous BDHS surveys (Figure 6.4). The strength of this comparison derives from the
fact that these surveys used identical data collection instruments. The estimate for under-five mortality
calculated from the 1993-1994 BDHS data (for the period 1989-1993) is 133 deaths per 1,000, compared
with 85 per 1,000 from the 2001 BMMS (for the period 1999-2000). This represents a 36 percent decline,
or nearly 5 percent per year during the 1990s. The internal data from the BMMS show that under-five
mortality decreased by one-third from the period 1986-1990 to 1996-2000.

2
A detailed description of the method for calculating the probabilities presented here is given by Rutstein (1984).
The mortality estimates are not rates but are true probabilities calculated according to the conventional life-table
approach. Deaths and exposure in any calendar period are first tabulated for the age intervals 0, 1-2, 3-5, 6-11, 12-
23, 24-35, 36-47, and 48-59 months. Then age-interval-specific probabilities of survival are calculated. Finally,
probabilities of mortality for larger age segments are produced by multiplying the relevant age-interval survival
probabilities together and subtracting the product from 1:
i=x+n
nqx = 1–∏(1 – qi)
i=x

Reproductive and Child Health | 103


Table 6.8 Early childhood mortality rates

Neonatal, postneonatal, infant, child, and under-five mortality for two and five-year periods preceding the
survey, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Years Approximate Neonatal Postneonatal Infant Child Under-five
preceding reference mortality mortality1 mortality mortality mortality
the survey period (NN) (PNN) (1q0) (4q1) (5q0)
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
0-1 1999-2000 45.4 21.3 66.7 19.1 84.6
2-3 1997-1998 44.9 24.8 69.7 25.0 93.0
4-5 1995-1996 53.8 30.2 83.9 30.4 111.8
6-7 1993-1994 56.3 30.6 86.9 33.9 117.9
8-9 1991-1992 62.5 34.0 96.4 38.9 131.6
10-11 1989-1990 65.9 32.6 98.5 42.1 136.5
12-13 1987-1988 64.1 38.2 102.3 49.9 147.1
14-15 1985-1986 74.9 41.8 116.7 59.9 169.6

0-4 1996-2000 47.2 24.3 71.5 25.6 95.2


5-9 1991-1995 58.0 32.1 90.2 35.7 122.6
10-14 1986-1990 66.7 36.2 102.9 48.2 146.1
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Month of interview is excluded from the analysis.
1
Computed as the difference between the infant and the neonatal mortality rates

Figure 6.4 Trends in Infant and Childhood Mortality,


1989-2000
133

116

94
87 85
82

66 67
52 50
48 45
42
37
30
19

Neonatal mortality Infant mortality Child mortality Under-five mortality


1989-1993 (1993-1994 BDHS) 1992-1996 (1996-1997 BDHS)
1995-1999 (1999-2000 BDHS) 1999-2000 (2001 BMMS)

6.3.2 Socioeconomic and Maternal Health Differentials in Childhood Mortality

Infant and child mortality is also related to demographic characteristics of mothers and children.
Table 6.9 shows that male children experience higher neonatal and infant mortality than female children,
whereas female children age 1-4 experience higher mortality than male children the same age. The pattern
of gender differentials in neonatal mortality is expected because neonatal mortality (which reflects largely
congenital conditions) tends to be higher for boys than girls in most populations. However, the pattern of
higher female postneonatal and child mortality (which reflects largely behavioral and environmental con-
ditions) is far from universal.

104 | Reproductive and Child Health


As expected, the relationship between maternal age at birth and childhood mortality is a U-shaped
curve, being relatively higher among children born to the youngest and oldest mothers than among chil-
dren whose mothers are in the prime reproductive ages. Children born to young mothers are more likely
to be of low birth weight, which is probably an important factor contributing to their higher neonatal mor-
tality rate. Similarly, children born to mothers above age 30 are at a higher risk of experiencing congenital
problems.

Childhood death rates tend to have a U-shaped pattern by birth order, with first births and high-
order births having elevated mortality rates. For example, infant mortality for first births and births of or-
der seven and higher is 85 deaths per 1,000 births and 88 per 1,000 births, respectively, compared with 61
deaths per 1,000 births to 70 per 1,000 births for second- to sixth-order births, respectively.

The variable most strongly associated with variation in under-five mortality is the length of the
interval between births. As the birth interval gets shorter, the risk of child death increases. For example,
the neonatal mortality rate for children born less than 24 months after a previous sibling is twice that for
children born after 24 months or more (72 compared with 35). The differences in risk are even larger for
child mortality (age 1-4).

Table 6.9 shows that infant and child survival is influenced by the socioeconomic characteristics
of mothers. Almost all rural mortality rates are higher than urban mortality rates, though the differences
are not large. Differences in mortality by division are more marked. Sylhet division has extremely high
mortality rates: neonatal, postneonatal, infant, and under-five mortality in Sylhet is about 40 percent
higher than the national average. Rajshahi and Dhaka divisions also have relatively high under-five mor-
tality rates of about 100 deaths per 1,000 live births.

Maternal education is strongly related to mortality. Children born to mothers with no education
have much higher levels of mortality than children born to mothers with some education. The overall un-
der-five mortality rate declines sharply with increasing education of mothers, ranging from 113 deaths per
1,000 live births for uneducated mothers to a low of 59 deaths per 1,000 live births for mothers who have
some secondary education. Other mortality indicators also decline similarly with increasing mother’s
education. However, as expected, mother’s education has a stronger negative effect on postneonatal and
child mortality than on neonatal mortality (which is more strongly related to biological factors).

All indicators of infant and child mortality decline substantially as household wealth increases.
For example, the under-five mortality rate for children in the wealthiest households is 58 deaths per 1,000
live births, whereas the corresponding rate for children in the poorest households is 122 deaths per 1,000
live births.

Reproductive and Child Health | 105


Table 6.9 Infant and child mortality by background characteristics

Neonatal, postneonatal, infant, child, and under-five mortality rates for the five-year period preceding
the survey, by background characteristics, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Neonatal Postneonatal Infant Child Under-five
Background mortality mortality1 mortality mortality mortality
characteristic (NN) (PNN) (1q0) (4q1) (5q0)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Sex of child
Male 52.4 23.0 75.4 22.5 96.2
Female 41.7 25.7 67.3 28.7 94.1

Mother's age at birth


<20 63.6 25.8 89.4 23.1 110.4
20-29 38.6 21.3 59.9 24.5 82.9
30-39 41.5 28.8 70.2 32.1 100.1
40-49 47.3 40.1 87.4 36.1 120.4

Birth order
1 60.9 23.7 84.6 18.3 101.4
2-3 41.3 19.2 60.5 22.8 81.9
4-6 41.0 28.6 69.6 33.0 100.3
7+ 47.0 41.1 88.1 39.4 124.0

Previous birth interval


< 2 years 71.9 40.0 111.8 40.4 147.8
2-3 years 34.8 24.2 59.0 30.8 87.9
4 years or more 34.5 17.3 51.8 16.2 67.2

Residence
Urban 41.6 23.1 64.6 22.1 85.3
Metropolitan/town 38.8 21.2 60.0 21.1 79.9
Other urban 44.6 25.1 69.7 23.2 91.3
Rural 48.3 24.6 72.9 26.3 97.3

Division
Barisal 39.5 22.3 61.8 31.2 91.0
Chittagong 34.8 20.1 54.9 29.9 83.1
Dhaka 48.9 26.9 75.8 26.5 100.3
Khulna 42.4 16.6 59.1 15.9 74.0
Rajshahi 54.4 24.4 78.8 20.0 97.1
Sylhet 65.9 35.5 101.4 33.0 131.1

Mother’s education
No education 52.5 30.3 82.7 33.3 113.3
Some primary 47.8 23.9 71.7 23.3 93.3
Completed primary 46.4 22.6 69.0 17.8 85.6
Secondary+ 36.4 12.8 49.2 10.6 59.3

Wealth quintile
Lowest 56.5 31.1 87.6 38.0 122.3
Second 52.1 28.7 80.9 29.2 107.7
Middle 48.1 24.7 72.8 21.1 92.4
Fourth 39.7 18.9 58.6 19.2 76.7
Highest 32.5 12.7 45.3 13.1 57.7

Total 47.2 24.3 71.5 25.6 95.2

6.4 PERINATAL MORTALITY

The 2001 BMMS survey asked women to report on pregnancy losses and the duration of the
pregnancy for each loss, for all such pregnancies ending in the three years before the survey; this informa-
tion was recorded in the calendar section of the women’s questionnaire. Pregnancy losses occurring after
seven completed months of gestation (stillbirths) plus deaths among live births within the first seven days
of life (early neonatal deaths) constitute perinatal deaths. The perinatal mortality rate is calculated by di-
viding the total number of perinatal deaths by the total number of pregnancies reaching seven months ges-
tation. An important consideration in the evaluation is the quality or completeness of reports on still-

106 | Reproductive and Child Health


births, which are susceptible to omission, underreporting, or misclassification (as early neonatal deaths,
though the misclassification may also go from early neonatal death to stillbirth). The distinction between
a stillbirth and an early neonatal death may be a fine one, often depending on the observed presence or
absence of some faint signs of life after delivery. The causes of stillbirths and early neonatal deaths are
overlapping, and examining just one or the other can understate the true level of mortality around deliv-
ery. For this reason, it is suggested that both event types be combined and examined together.

Table 6.10 Perinatal mortality

Stillbirth rates, early neonatal death rates, and perinatal mortality rates for the three years preceding the
survey, by background characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of
Early Perinatal pregnancies
Background Stillbirth neonatal mortality of 7 or more Number of
characteristic rate1 death rate2 rate3 months duration live births
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Mother's age at birth
<18 37 50 85 7,718 7,436
18-19 34 36 68 5,395 5,211
20-29 24 24 47 20,578 20,078
30-39 29 28 57 6,684 6,489
40-49 44 25 68 720 689

Previous pregnancy
interval in months
First pregnancy 44 46 88 11,263 10,767
<15 37 44 79 1,897 1,827
15-26 22 28 50 6,268 6,129
27-38 19 24 43 7,184 7,045
39+ 24 22 46 14,482 14,134

Complications4
No complication 12 22 34 16,103 15,901
Any complication 38 36 73 24,951 23,993
Did not seek care 29 31 60 10,787 10,470
Sought care at facility 53 43 94 6,625 6,274
Sought care elsewhere 38 38 75 7,539 7,249

Residence
Urban 25 27 52 7,061 6,885
Metropolitan/town 23 25 47 3,719 3,632
Other urban 26 30 56 3,342 3,253
Rural 30 32 60 34,034 33,017

Division
Barisal 22 27 48 2,694 2,635
Chittagong 24 24 48 8,535 8,329
Dhaka 33 30 62 14,134 13,669
Khulna 34 30 63 3,953 3,820
Rajshahi 25 38 62 8,650 8,434
Sylhet 36 39 74 3,129 3,015

Mother’s education
No education 28 32 59 18,379 17,858
Some primary 35 36 69 7,619 7,354
Completed primary 26 32 57 4,368 4,254
Secondary+ 27 25 51 10,729 10,437

Total 29 31 59 41,095 39,903


––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
1
Stillbirths are fetal deaths occurring in pregnancies of seven or more months. The stillbirth rate is the
number of stillbirths divided by the number of pregnancies of seven or more months’ duration, ex-
pressed in thousands.
2
Early neonatal deaths are deaths to live-born children at days 0 to 6 since birth. Early neonatal death
rate is the number of early neonatal deaths divided by number of live births, expressed in thousands.
3
The perinatal mortality rate is the sum of the number of stillbirths and early neonatal deaths divided
by the number of pregnancies of seven or more months of duration, expressed in thousands.
4
The complications background characteristic excludes cases with missing data on complications and
28 terminations with pregnancy duration of 7 or more months that were not coded as stillbirth in the
calendar.

Reproductive and Child Health | 107


Table 6.10 shows stillbirth rates, early neonatal mortality rates, and perinatal mortality rates, ac-
cording to demographic and socioeconomic characteristics. At the national level, the perinatal mortality
rate is estimated to be 59 perinatal deaths per 1,000 qualifying pregnancies. Perinatal mortality displays
the expected U-shaped pattern in relation to age of the mother, with the youngest and oldest women hav-
ing the highest rates. First pregnancies and pregnancies with a short preceding interpregnancy interval are
also at high perinatal risk. First pregnancies have a risk of 88 perinatal deaths per 1,000, and pregnancies
with a interpregnancy interval of less than 15 months carry a risk of 79 perinatal deaths per 1,000, com-
pared with a risk of just 46 per 1,000 for pregnancies with an interpregnancy interval of 39 months or
more.

Perinatal mortality is higher in rural areas (60 deaths per 1,000 pregnancies) than in urban areas
(52 per 1,000). At the divisional level, perinatal mortality rates range from 48 per 1,000 to 74 per 1,000
pregnancies. Perinatal mortality is the highest in Sylhet division (74 per 1,000 pregnancies) and the low-
est in Barisal and Chittagong divisions (48 per 1,000). Perinatal mortality is higher for less educated
women than for women with at least some secondary education. In general, differentials in perinatal mor-
tality are smaller than those in neonatal mortality.

6.5 HIGH-RISK CHILDBEARING

The survival of infants and children depends in part on the demographic and biological character-
istics of their mothers. Typically, the probability of dying in infancy is much greater among children born
to mothers who are too young (under age 18) or too old (over age 34), children born after a short birth
interval (less than 24 months after the preceding birth), and children born to mothers of high parity (more
than three children). The risk is further elevated when a child is born to a mother who has a combination
of these risk characteristics.

Table 6.11 shows the percentages of live births in the five years preceding the survey that fall into
different child survival risk categories, as well as the distribution of all currently married women across
these categories. It also shows the relative risks of children dying across the different risk categories.
The purpose of this table is to identify areas in which changed reproductive behavior would be likely to
effect a reduction in infant and child mortality. Mortality risks are represented by the proportion of chil-
dren who were born during the five years preceding the survey and who had died by the time of the sur-
vey. The “risk ratio” is the ratio of the proportion of dead children in a given high-risk category to the
proportion of dead children not in any high-risk category.

Among children born in the five years preceding the survey, about one-third (32 percent) of births
were not in any high-risk category. Thirteen percent were first births—considered an unavoidable risk
category—while 42 percent were in single high-risk categories and 12 percent were in multiple high-risk
categories. The most common single high-risk category was births order three and higher (20 percent),
while the most common multiple high-risk category was births to mothers older than 34 years and birth
order three and higher (6 percent).

108 | Reproductive and Child Health


Table 6.11 High-risk fertility behavior

Percent distribution of children born in the five years preceding the survey by category of
elevated risk of dying and the risk ratio, and the percent distribution of currently married
women by category of risk if they were to conceive a child at the time of the survey, Bangla-
desh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Births in the 5 years Percentage
preceding the survey of
–––––––––––––––––––– currently
Percentage Risk married
Risk category of births ratio women1
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Not in any high-risk category 32.1 1.00 28.4a

Unavoidable risk category: first birth 13.1 1.33 6.1

Single high-risk category


Mother’s age <18 17.2 1.85 5.3
Mother’s age >34 0.4 1.53 3.3
Birth interval <24 months 4.8 1.91 7.5
Birth order >3 19.9 1.27 16.5

Subtotal 42.4 1.58 32.6

Multiple high-risk category


Age <18 & birth interval <24 months2 .7 2.49 1.7
Age >34 & birth interval <24 months 0.0 1.87 0.1
Age >34 & birth order >3 5.7 1.58 23.0
Age >34 & birth interval <24 months
& birth order >3 0.6 2.75 1.6
Birth interval <24 months & birth order >3 4.3 2.52 6.4

Subtotal 12.4 2.10 32.8

In any avoidable high-risk category 54.8 1.70 65.4

Total 100.0 na 100.0


Number of births 67,133 na 96,945
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Risk ratio is the ratio of the proportion dead of births in a specific high-risk category to
the proportion dead of births not in any high-risk category.
na = Not applicable
1
Women are assigned to risk categories according to the status they would have at the birth
of a child if they were to conceive at the time of the survey: current age less than 17 years
and 3 months or older than 34 years and 2 months, latest birth occurred less than 15 months
ago, or latest birth being of order 3 or higher.
2
Includes the combined categories age <18 & BO >3
a
Includes sterilized women

Risk ratios, which describe the relationship between a particular risk category and a reference
category, are used to compare risk categories (Table 6.11). While the “not in any high-risk category” has
a risk ratio of 1.00, the unavoidable risk category (first births) has a risk ratio of 1.33. Most risk ratios are
higher for children in multiple high-risk categories than for those in single high-risk categories. The most
vulnerable births are those to women age 35 and older, those with a birth interval less than 24 months,
and those of birth order three or higher. These children are nearly 2.8 times more likely to die young than
children not in any high-risk category. Fortunately, less than 1 percent of births are in this category. Four
percent of births occur among women who have three or more children and a short preceding birth inter-
val; these children are more than twice as likely to die as children who are not in any high-risk category.
Another 6 percent of births occur among women over 35 with more than three births; these infants are
also subject to more than twice the risk of dying of children who are not in any high-risk category.

Reproductive and Child Health | 109


POLICY IMPLICATIONS 7
Peter Kim Streatfield and Ahmed Al-Sabir

7.1 INTRODUCTION

Maternal mortality in Bangladesh is often depicted as among the highest in the world. This view
is based partly on estimates from various non-national, local area studies conducted during the 1970s and
1980s, and partly on the WHO estimate for Bangladesh in 1990 (WHO, 1996). These sources produced a
range of estimates of maternal mortality from 500 to 850 per 100,000 live births.

The findings of the nationally representative Bangladesh Maternal Health Services and Maternal
Mortality Survey (BMMS) show that maternal mortality is still relatively high at 320 per 100,000 live
births. However, of the 171 countries included in a recent joint review of maternal mortality ratio (MMR)
estimates for 2000 by WHO, UNICEF and UNFPA (2001), 51 countries (30 percent) had higher levels of
maternal mortality than Bangladesh—some three to five times higher. The trend data also show an en-
couraging reduction of the MMR in Bangladesh of 22 percent over the past 12 years.

Because maternal deaths are a relatively rare event, the BMMS required a large sample—ten
times larger than the BDHS sample—with associated high costs. Thus, this survey approach cannot be
used for monitoring purposes to determine regular estimates of the maternal mortality ratio (MMR). It is
important to examine these data to identify suitable proxy indicators that closely reflect the MMR, and are
measurable by standard information systems for that purpose in future.

The Government of Bangladesh has reaffirmed its commitment to reducing maternal mortality in
the recently finalized Poverty Reduction Strategy Paper (PRSP), which points to the slow decline in the
MMR together with the decade-long plateau in fertility as having negative implications for poverty reduc-
tion. The study provides clear evidence of persisting disparities in health-seeking behavior by maternal
education and wealth status, with less educated and poorer women being less likely to seek qualified pre-
ventive and emergency obstetric care. Greater efforts are needed to ensure that the poorest women have
equitable access to high-quality safe motherhood services. The challenge is not only to reach poorer
women, but also to reach the two million pregnant women each year who do not receive any antenatal
care.

Safe motherhood services have to be designed and promoted differently from other health ser-
vices. Providers need to recognize that childbirth is significantly different from other conditions that re-
quire preventive and curative services, although it includes elements of both. While childbirth is a natural
process that most women go through, it has the potential for serious problems, and various service provi-
sion strategies have been developed over the decades to deal with the problems associated with childbirth.

Since the Nairobi Safe Motherhood Conference in 1987, when the world focused on the impera-
tive of making childbearing safer, the philosophy of service provision has evolved from the “risk” ap-
proach to the “three delays” approach. The risk approach was useful at the public health level, but has
been less useful for assessing risks for individual women.

Unlike the risk approach, which attempted to attach a risk estimate to individual pregnant women
based on certain characteristics (e.g. young or old age, high parity, short stature, etc.), the three delays
approach accepts that all pregnancies are potentially at risk of complications and that arrangements need
to be set in place to ensure that those pregnancies that do develop complications receive appropriate care.

Policy Implications | 111


The childbirth process can be divided into three components in regard to the development of
complications. First is the recognition by the pregnant woman and her family members or birth attendant
that a complication has arisen, and a decision is made to take action. Some agencies are now subdividing
this first delay into two sub-components: recognition and decisionmaking. Second, action is taken to
transfer or transport the pregnant woman to a facility that can provide the necessary treatment. Third, the
facility must manage the complication in an appropriate and timely manner to prevent consequent mor-
bidity or death.

As a household-level survey, the BMMS focuses primarily on the first delay—decisionmaking


within the household, although it also throws light on the second and third components (or delays) from
the patient’s perspective. This chapter will explore the policy implications of the BMMS findings in rela-
tion to the three delays, following the natural sequence of antenatal care, delivery care, and postnatal care.
This constitutes the “demand” side of the safe motherhood equation, and where data are available from
other sources, information on the “supply” side, or facility side, will be reviewed.

Other surveys have provided information on the sequence of steps in safe motherhood. For ex-
ample, the three Bangladesh DHS surveys have provided data on antenatal care, place of delivery, deliv-
ery assistance, and limited information on postnatal care. One important limitation of this type of house-
hold survey information though, is that it is usually not possible to know if the respondents who utilized
antenatal care (ANC) or institutional delivery services were the ones at risk of complications. Con-
versely, it cannot be known if the respondents who did not utilize safe motherhood facilities were at risk
or not.

The BMMS provides additional information on women’s knowledge of serious complications, on


their experience with such complications, and on actions taken in response to that experience, as well as
barriers to such actions. This greatly enriches the data, although further analysis beyond that presented in
this report will be required to take full advantage of it. This will be particularly helpful in separating sup-
ply side issues (emergency obstetrics (EOC) facility construction and upgrading, service provider train-
ing, equipment and medicine logistics, etc.) from demand side issues (awareness of risk by pregnant
women and their families, recognition of complications, the decisionmaking process, transportation is-
sues, attitudes toward providers, ability to pay for services where applicable, etc.).

In the following section, the behavior of survey respondents through the sequential phases of
pregnancy will be reviewed in the context of where future efforts to reduce maternal morbidity and mor-
tality might be focused.

7.1.1 Maternal Mortality

Comparison of overall adult mortality in the BMMS with other sources of mortality data indicate
that the survey produced reliable mortality estimates. The data suggest an adult mortality decline of one-
third for females and one-fourth for males in the decade before the survey. These declines are considered
extraordinary and require further examination. Certain aspects of the cause-specific mortality rates are
also noteworthy. Suicide accounts for 10 percent of adult female deaths, and malignancies and circula-
tory diseases separately account for more deaths of women of reproductive age than infectious diseases.
Maternal deaths remain the single most important cause of death among adult females, and the estimates
appear robust because several different approaches (household survey, sisterhood, and verbal autopsy)
have produced consistent results.

Trends: The survey shows that there was a gradual decline in maternal mortality during the late
1980s and early 1990s (around 1 percent annually). This decline accelerated in the late 1990s to around 3
percent per year (faster at decade end). The pattern parallels government efforts to increase the availabil-

112 | Policy Implications


ity of basic and comprehensive EOC facilities, in particular the maternal and child welfare centers
(MCWCs) and district hospitals.

It was thought that some proportion of the decline in maternal mortality must be due to the dra-
matic fertility decline of the 1980s. The downward trend in fertility resulted in fewer high parity births
among older women—both older age and high parity are well-documented risk factors for maternal com-
plications. Unfortunately, birth rates amongst young (teenage) women have shown little change.

The pattern of maternal mortality by parity is a U-shaped curve, highest for first pregnancies,
lowest for second pregnancies, and rising steadily thereafter. Fertility decline resulted in a change in the
pattern of births. In the 1970s, first, second, third, fourth, and fifth births were almost equally distributed,
each accounting for about one in seven of all births. The current low fertility pattern has first births ac-
counting for 30 percent of total, second births 25 percent, third 20 percent, etc. Overall, this decline in
fertility should produce a decline in the number of maternal deaths; however, the doubling of the propor-
tion of high-risk first pregnancies may have neutralized the benefits of the reduction in higher order preg-
nancies. Further analysis can estimate the impact of the fertility decline on maternal mortality, but will
have to take careful account of the maternal age changes as well as parity shifts in fertility over recent
decades.

There is a paradox in maternal mortality patterns by maternal age and parity. The data show a
monotonic increase in the risk of maternal death, as measured by the MMR, from women age 15-19 to
women age 45-49. At the same time, first births have a high risk of maternal death—two and a half times
higher than parity two births—and first births are concentrated among young married women. Teenage
mothers, who might be expected to experience high mortality due to the high proportion of first births in
this age group, actually show the lowest maternal mortality ratios. The pattern is seen for both the MMR
and the MMRrate, so it is not simply a consequence of lower fertility among teenage women than among
women in their twenties. Regarding future declines in the MMR, even with the current fertility patterns,
if age at first birth is increased from the current 18 years, it is unclear what the impact would be on the
current high MMR for first births.

Causes of maternal deaths: The patterns of age-specific deaths suggest that data quality for ma-
ternal deaths is good. The data on cause of death appear reasonable, with only 12 percent having no spe-
cific cause assigned. Among all causes of death for women of reproductive age, maternal deaths account
for 20 percent, which is similar to the proportions found in the Matlab field site of the ICDDR,B.

Regarding specific causes of maternal death, the verbal autopsy analysis shows that hemorrhage
(antepartum and postpartum) is the leading cause of death (29 percent), with eclampsia close behind (24
percent). Compared with data recently released by UMIS for deliveries at EOC facilities in the year
through June 2003, the proportion of deaths due to hemorrhage is high, and the proportion due to eclamp-
sia is low. The higher proportion of deaths due to hemorrhage is not surprising because many of these
women never reach a facility; the problem can quickly become fatal. Eclampsia exerts its effect more
slowly, and it is possible that eclampsia sufferers may be preferentially referred to an EOC facility, some
of which may be unable to resolve the problem.

Other direct causes of maternal death account for smaller proportions—for prolonged/obstructed
labor and puerperal sepsis the levels are similar to the national levels, and survey data for abortion-related
deaths (one in twenty maternal deaths) is about half the national facility-based figure. Again, this may be
because abortion-related deaths imply previous contact with a service provider of some kind (e.g., to carry
out an MR) and that contact may result in preferential referral to a facility if complications arise. In addi-
tion to direct causes, 15 percent of maternal deaths are due to indirect causes, and another 16 percent are
due to causes not yet classified.

Policy Implications | 113


It is possible that declines in abortion-related deaths (to the low level found in this study) may
have contributed to the decline in maternal mortality. There is anecdotal evidence that numbers of pa-
tients admitted to facilities with incomplete or septic abortions have declined dramatically over the past
two decades, presumably due to the expanded provision of safer and more accessible MR services.

Maternal deaths in relation to delivery: According to the verbal autopsy, two-thirds of mater-
nal deaths occurred after delivery, only one in ten occurred during delivery, and the remaining one in five
occurred before delivery. The timing would suggest that retained placenta, postpartum/puerperal sepsis,
and postpartum hemorrhage are the major causes of maternal death and not eclampsia, preeclampsia, an-
tepartum hemorrhage, ruptured uterus, etc. This pattern does not match well with the pattern of complica-
tions reported by respondents who survived childbirth. Thus, the pattern of complications experienced by
nonsurvivors may differ from that of survivors.

The low proportion of deaths during delivery also does not match with the high proportion of
women reporting malpresentation or prolonged/obstructed labour (22 percent) which could potentially be
fatal. It may be that the rapidly increasing availability of C-sections is reducing the risk of death for
women with this complication.

7.1.2 Antenatal Care

The national maternal health strategy recommends that all pregnant women should make three or
more antenatal visits to a medically trained or skilled provider, and the first visit should take place within
the first trimester of pregnancy.

Numbers and timing of visits: About half of all pregnant women now make at least one ANC
visit. This is almost double the level in the early 1990s, and is encouraging because the increase has been
concentrated in rural areas (especially Sylhet, Khulna, and Rajshahi). The improvement has generally
been among women visiting nurse/midwife/family welfare visitor (FWV)/paramedics, except in Sylhet
where it reflects more visits to doctors. The increase may partially reflect recent efforts to train more fe-
male service providers: for example, a limited number of FWVs have received six months of training.

To predict future levels of service utilization, it is necessary to examine differentials, especially


education and socioeconomic differentials. There have always been sociodemographic differences, and
these persist, but during the 1990s there was no improvement by age, parity, or mother’s level of educa-
tion. Even among wealthy, educated, and urban couples, one in four women was still not making even
one ANC visit. This suggests that further improvements due to factors within the society, for example
diffusion of progressive ideas from educated to uneducated couples, will be slow to occur.

External efforts will be needed to motivate and encourage couples to use the maternal health ser-
vices. That the results of the Bangladesh Demographic and Health Survey (BDHS) show that more than
four out of five women obtain tetanus toxoid (TT) vaccination to prevent maternal tetanus, indicates that
the concept of protection against complications is not an unfamiliar concept. Perhaps ANC services could
be promoted through the TT vaccination sites, usually satellite clinics that women visit for their TT vac-
cinations.

While it is encouraging that more women are now making at least one visit, there are two other
areas of concern. Only one in seven women made their first ANC visit in the first trimester as recom-
mended, the usual time being late second trimester (a median of 5.4 months). Also, only one in five
women makes the recommended three ANC visits (the median is unchanged at 1.8 visits). Greater effort
will be needed to ensure that women make their first ANC visit early in pregnancy, and that they com-
plete at least three visits.

114 | Policy Implications


All three aspects of ANC require greater attention—half of pregnant women still do not receive
any ANC; among those who do, the women start late in pregnancy; and few women complete the full
(minimum) recommended number of visits.

Reasons for ANC visit: The ideal situation is that all pregnant women receive ANC regardless
of whether they have a problem or not. This is to detect problems early, to give information about the
danger signs of pregnancy, and to advise how the woman should respond if complications occur. Almost
half of women experienced some problem, some potentially very serious, so if all women received ANC
then it would be expected that half would report problems during a visit.

Since only half of the women made any ANC visits, it is difficult to interpret the observation that
only one in four ANC visits was motivated by a specific problem. Nevertheless, efforts must be made to
better understand why some women who experience problems do not visit any facility for assistance.

Reasons for not using ANC services: There were multiple reasons why women did not seek
ANC, but the most common (three out of four) and most worrisome one is lack of perceived need for
ANC, or the belief that ANC is “not customary.” It is reassuring that service-related factors do not appear
to be barriers to seeking ANC. Cost is mentioned in one in five cases, and transportation one in ten—the
latter implying cost concerns also. Clearly, the major constraints to seeking ANC are in the household.

The “no need” response may reflect a lack of recognition of the potential dangers of the problem,
or it could reflect ideas about the cause of the problem and the appropriate response. Such ideas may dif-
fer from modern allopathic medical views, thus making a visit to a health facility seem irrelevant or “un-
necessary.” Better understanding of this issue is needed because other evidence on treatment of compli-
cations suggests that unqualified providers (in the modern, allopathic sense) are the first choice for many
women.

Procedures conducted during ANC visits: It is surprising and reassuring that so many ANC
clients reported receiving a range of tests. This suggests that the service provision side is functioning as
planned, although it is not possible to know if testing resulted in identification of possible complicated
pregnancies, with appropriate actions (e.g., referral) being taken. It is not mentioned in the findings, but
hopefully iron supplementation is also given to reduce the widespread problem of anemia. In addition to
availability of safe blood transfusion facilities, this intervention (iron supplementation) could significantly
reduce the number of deaths from hemorrhage.

The procedures that do not require laboratory equipment, e.g., measurement of weight, height,
and blood pressure, are the most likely to be carried out. External physical checks such as abdominal ex-
aminations are common, but internal (pelvic) examinations much less so. Lab-based tests of urine and
blood are moderately common, while ultrasound is not. The use of relatively costly lab-based tests is
strongly linked to level of education and economic status, but is also associated with first pregnancies and
urban residence.

It is likely that many ANC visits are made to lower-level facilities, such as family welfare centers
(FWCs), that are not equipped to provide a full range of checks. Further research is needed to know what
proportion of women could not obtain the full complement of ANC checks because these were not avail-
able from their nearest ANC facility. The choices are either to upgrade the lower-level facilities, which is
not a current policy, or to ensure that ANC clients are referred to higher-level facilities when more com-
prehensive testing is required.

Information content of ANC visits: In terms of preparing women for possible complications
during ANC visits, fewer than half of visiting women were told of the danger signs that may occur during
pregnancy, and slightly more than half were told where to go if they experienced complications. These

Policy Implications | 115


are the two crucial items of information to be conveyed during ANC, and more effort is needed to ensure
that all women receive such information.

The differentials in awareness of the danger signs during pregnancy suggest that younger women
and women who are pregnant for the first time are not more likely than other women to receive such in-
formation, although they should be targeted. This information should be repeated at each opportunity,
even if older women have heard it before. Typically, more educated women and women in wealthier
households are much more likely to receive, or to recall receiving, such information. It may be that
poorly educated women are given information in a form that they do not understand, and therefore do not
remember and act upon.

Birth Planning: In addition to informing women and their family members about the danger
signs of pregnancy, the most important advice that could be given during ANC visits is to plan for all
contingencies during late pregnancy and childbirth—i.e., birth planning. As complications can arise
quickly and without warning, it is wise to plan a response if such complications occur. This involves se-
lecting possible service providers, planning transportation, ensuring sources of money for medical ex-
penses, covering domestic duties, etc. Families could be more actively encouraged to maintain a savings
program during the pregnancy to create a contingency fund in case of need during the pregnancy and de-
livery. But the national program could usefully give more thought to the provision of some form of health
card or health insurance scheme for safe delivery, to reassure families that EOC treatment for severe
complications will not plunge the family into poverty. These options have been discussed and piloted
over many years, but have not been implemented on a large scale.

Many clients received some information during ANC visits, but on no subject did more than half
of respondents report having received information or advice. About half received information on the lo-
cation of a facility to go to if delivery complications occurred, one in three on hygiene, but only one in
seven on making transport arrangements.

Planning for childbirth can of course take place independently of making ANC visits, though
overall levels of planning are low. Among currently pregnant women (including those who did and did
not make any ANC visits) two-thirds had not discussed delivery, nor made a decision about who they in-
tended to seek assistance from. Among the few who did plan, most commonly it was to use an untrained
traditional birth attendant (TBA) (22 percent) or less commonly a trained TBA (5 percent). The probabil-
ity of having discussed the issue increased later in pregnancy, but even in the third trimester half of re-
spondents had still not discussed delivery nor made a decision. Women in their first pregnancy were less
likely to discuss delivery than those in a later pregnancy. Plans to use medically trained persons were
more common for urban women, more educated women, and women in wealthier households.

This is a vital area for future policy. Women and their families must be encouraged to make con-
tingency plans if complications arise, particularly as there are implications for household financial re-
sources, and because time to respond may be short—in many cases an emergency. Safe motherhood in-
formation to raise awareness of the danger signs of pregnancy, treatment options, and the importance of
birth planning can also be disseminated through the mass media. In addition to low cost and wide cover-
age, mass media campaigns have the added advantage that contact can be made specifically with the
many pregnant women who are not coming into contact with ANC and related services.

If the husband can be motivated to take an interest and to share responsibility, particularly in first
pregnancies, then preparedness could be greatly increased. Some avenue or mechanism to convey infor-
mation to husbands is needed, either through village or Union Parishad council meetings, or through the
media, or through community visits by male health assistants. Women pregnant for the first time must
receive special attention with information and motivation, possibly through selective household visits by
FWAs early in pregnancy.

116 | Policy Implications


7.1.3 Delivery Care

Annually in Bangladesh there are around 3.8 million births, and even more pregnancies. About
570,000 (15 percent) of these are expected to have complications requiring facility-based care: two-thirds
will need basic EOC (B-EOC) and one-third will need comprehensive EOC (C-EOC) for life-threatening
conditions, particularly C-sections or blood transfusions.

The recommended ratio of EOC facilities is one C-EOC plus four B-EOC facilities per 500,000
population, which translates in Bangladesh to 270 C-EOC and 1,080 B-EOC facilities. Bangladesh has
progressed rapidly in building and upgrading facilities to basic and comprehensive EOC standards, but
the latest ratios (provided by the Unified Management Information System (UMIS) and UNICEF) as per-
centages of the above targets are 54 percent for C-EOC (in 2003) and 60 percent for B-EOC (1999, status
in 2003 not known) facilities compared with this goal. While current ratios for B-EOC are almost cer-
tainly higher than in 1999, the implication is that each EOC facility would need to deal with an average of
about five complicated cases per working day, assuming all such cases attended the facilities. This is a
heavy load, and has implications for drug and equipment supplies, and staff availability for providing
other services.

Recent efforts in upgrading facilities must continue, especially at Upazila and levels below the
district headquarters. This needs to be combined with strengthening the referral system so that screening
occurs at lower levels and complicated cases with different degrees of severity are referred upwards to the
appropriate level of facility.

Place of delivery: The data on place of delivery indicates a persisting problem with home deliv-
ery, which still account for 91 percent of all deliveries—unchanged during the 1990s. Among the 9 per-
cent of deliveries in a facility (6 percent public sector, 3 percent private or NGO), it is not known how
many were complicated cases. However, even if they were all complicated cases, the proportion of facil-
ity deliveries is still well below recommended levels.

Over the past decade there has been a strategy to upgrade EOC facilities. This strategy has fo-
cused on 59 district hospitals, 60 MCWCs, and a selection of the upazila health complexes— thus far
about 42. There are encouraging signs from the Unified Management Information System (UMIS) of the
Ministry of Health and Family Welfare (MOHFW) that complicated cases are being selectively referred
to these upgraded EOC facilities. In 123 EOC facilities nationwide (59 DHs, plus 64 UHCs), the UMIS
(with UNICEF support) shows that in the year through June 2002, the numbers of facility births has in-
creased by 25 percent, but at the same time the number of complicated deliveries has increased 88 per-
cent, and the number of C-sections has increased 44 percent.

This is the trend when so few deliveries take place in institutions, but no country with limited safe
home delivery capacity can expect to substantially reduce maternal mortality with fewer than one in ten
deliveries in a clinic or hospital. The low proportion of deliveries in EOC facilities raises the question as
to why so many complicated cases do not deliver in a facility.

Reasons for not delivering in an EOC facility: Without further analysis it cannot be deter-
mined which responses about nonfacility deliveries relate to complicated cases and which to normal de-
liveries. Basically, three out of four cite “no need” or “not customary.” This implies that supply side is-
sues such as cost (one in six cases) and access (one in sixteen cases) are not major barriers. It is encour-
aging that since most doctors are male (except the OB/GYNs in the MCWCs), reluctance to be examined
by male doctors is not a significant barrier.

A number of conditions may require a C-section, but in fact only 3 percent of respondents re-
ported C-section at delivery. While this figure is lower than the estimated 5 percent of life-threatening

Policy Implications | 117


complications requiring C-section, there are unmet obstetric need studies currently underway to review
the evidence on which that estimate is based.

Of course not all cases with complications require a C-section; some may be resolved with sim-
pler interventions. Some of the one in six cases of prolonged or obstructed labor, for example, may be
dealt with by forceps delivery, but this only accounts for one in fifty of all deliveries, suggesting that
more may be needed.

Delivery attendant: The data on who attended the delivery are limited to the highest-level pro-
vider (in terms of training and skills). During a long delivery a number of different people may come and
go, so this may not give a complete picture of what took place, and how decisions were made. For exam-
ple, a doctor may have visited early in the labor but not have been present at the actual birth; however,
based on the criteria “highest skill level present at any time,” the attendant would be listed as a doctor.

During the 1990s there was virtually no increase in the presence of skilled attendants at births
(still only one in eight), but there was some increase in TBAs (mostly untrained) taking over delivery re-
sponsibilities from family members. The reliance on TBAs is probably preferable to family members
alone, but the 1980s program that trained 42,000 TBAs was widely regarded as ineffective in raising
standards for safe delivery, partly because of resistance to changing traditional (unhealthy) practices, and
partly because of the difficulty of maintaining skill levels while doing few deliveries.

In addition to upgrading EOC facilities, there is a recent approach promoted by the Obstetrics and
Gynaecology Society of Bangladesh (OGSB) based on the fact that most deliveries and most maternal
deaths take place at home, and therefore it is logical to invest in an approach in which lower-level health
workers are present for home deliveries.

The workers selected in the application of this approach are the 24,000 family welfare assistants
(FWAs) and the 5,000 female health assistants (HA). Although these health workers used to make regu-
lar home visits (pre-HPSP), overall, they perform an average of only one delivery every four years. To
take responsibility for a substantial proportion of the 3.5 million home deliveries annually, each FWA/HA
would have to perform up to 110 or more deliveries annually (of course referring the complicated cases to
higher levels). It is not clear how they will identify newly pregnant women in the communities unless
they resume making household visits. This is expecting a great deal, and the program, which has so far
trained 90 candidates from six upazilas, is likely to experience the same problems as the TBA training
program in which the workers were unable to keep up sufficient numbers of deliveries to maintain their
skill levels. It may be preferable for this cadre to focus on playing motivational and referral roles.

If this approach to training field-level workers is followed, it is imperative that they receive not
only training, as is the case at present, but full back-up in terms of safe delivery kits, equipment to main-
tain proper hygiene (e.g., gloves), and most importantly, referral slips so that complications when identi-
fied can be transported from the home to be managed at the appropriate higher level. The experience
from the Indonesian village midwife scheme indicates that continued supervision and support is necessary
for this approach to maintain its effectiveness.

7.1.4 Postnatal Care

It is clear that postnatal care (PNC) is not considered routine by mothers, either for themselves or
their babies. But since two-thirds of maternal deaths occur in this period, and three-quarters of neonatal
deaths occur in the first three days after birth, it would be wise to encourage PNC checkups.

Only one in six mothers accessed such care for themselves, with strong differentials by region,
education, and economic status. The strongest predictor of PNC use was the experience of problems dur-

118 | Policy Implications


ing pregnancy or delivery, but even among these women only around one in four sought postnatal care,
and then they often visited an unqualified doctor. One in four mothers took their babies for PNC, half to
qualified doctors and one-fourth to unqualified practitioners.

The primary reason for not seeking PNC was the perceived absence of need by the woman or
family members—four out of five saying “not necessary,” “unaware of need,” “not customary,” or “fam-
ily did not allow,” the latter possibly reflecting competing household duties. Cost was a significant ob-
stacle mentioned by the remaining one in five respondents.

As with nonuse of ANC and facility-based delivery, absence of perceived need for PNC means
that the majority of mothers did not receive a postnatal checkup for themselves or their child, even though
a substantial proportion of childbearing problems arise at that time. Greater effort is needed to raise
awareness that the danger period for childbirth is not over immediately after the baby is born. With such
low use rates of facility delivery and PNC, it is not surprising that only one in twenty women used all
three facility-based services—ANC, delivery, and PNC—and half did not use any.

This section has described the patterns of use of safe motherhood services, and highlighted where
further efforts need to be made. The survey also provides a great deal of new information on awareness
of complications, and experience of and responses to such complications. This will contribute to better
understanding of how individual women and their families make preventive and curative care decisions in
relation to childbearing.

7.1.5 Awareness of Complications

Awareness of the risks of certain conditions associated with childbearing plays a role in the deci-
sion to seek safe motherhood services, both preventative and curative. That awareness may reside with
the woman herself or with those caring for the woman, who take responsibility for the delivery.

Awareness of the risks of specific complications may derive from personal experience, from the
experience of other women, family members, neighbors, service providers, etc. It is possible to believe
that a condition is potentially dangerous, but it is unlikely to “happen to me” for whatever reason. It is
possible that a woman is aware that a particular condition is potentially dangerous, but the way to avoid it
or manage it, may be through certain religious or spiritual rituals, or avoiding certain behaviors, foods,
locations, persons, or times of day, rather than turning to modern, allopathic health services.

It should also be said that selected symptoms of certain complications can be present without be-
ing perceived as a danger, but with greater severity, or in combination with other symptoms, they may
trigger awareness of a problem. In the case of preeclampsia, edema is an symptom where alone it may be
widely regarded as a normal consequence of pregnancy, but together with severe headache and convul-
sions, will (hopefully) be seen as posing a serious threat.

The survey findings on awareness of specific conditions by the respondents do not appear to be
closely tied to their personal experience of complications. The highest level of awareness—about one in
two women—is about the dangers of tetanus, which is relatively rare these days, and prolonged or ob-
structed labor, which is more common. Retained placenta is seen as potentially life threatening by one in
three women, and convulsions/eclampsia, and abnormal presentation by only one in four women. The
latter levels of awareness are disturbingly low for such important danger signs.

The study findings also show that awareness cannot be readily used to predict whether a woman
or her family will seek treatment, and if so, from which type of service provider. Further analysis of the
survey data should look carefully at women’s views and perceptions of dangerous conditions—i.e., their
explanatory models—in the context of their actual experience.

Policy Implications | 119


Intervention programs should focus on raising awareness of the dangers of these conditions, par-
ticularly conditions requiring rapid management, because so many women are not delivering in a health
facility.

7.1.6 Treatment for Complications

Of the 40,000 plus birth outcomes in the past three years, 60 percent had one or more complica-
tions. Of these 24,618 birth events, three-fourths (18,117) had what women considered a life-threatening
complication, while the remainder (6,501) had a non-life threatening complication.

The survey presents information on treatment for both life-threatening and non-life-threatening
complications. The patterns of treatment seeking are similar, although the levels are generally lower for
the less dangerous conditions. Thus, to simplify the present discussion, only life-threatening conditions
will be discussed. Seeking treatment can be inside or outside the home. If outside, it can be facility based,
or non-facility based. If non-facility based, it can be with a qualified or an unqualified provider.

Among births for which women reported experiencing life-threatening complications, treatment
was sought in six out of ten cases. Retained placenta was reported by four out of ten women, while three-
fourths of women reported convulsions and high fever with discharge. Treatment was sought in half to
two-thirds of cases for the following conditions: preeclampsia, malpresentation and prolonged/obstructed
labor, and excessive bleeding.

Overall, the level of six out of ten seeking treatment for complications held for all subgroups, al-
though more educated women and women in wealthier households were more likely to seek treatment.
Only retained placenta was left untreated in more than half the cases.

While the majority of women seek treatment for complications, the source of treatment raises
concern. In about half of the cases treatment was sought only within the home, in most cases (three out of
four) from unqualified providers. Such home-based treatment may be the only option if the condition
occurs as an emergency during a home-based delivery. But if the complication arises before or after de-
livery, then facility-based treatment by a qualified provider is the preferred option. In fact, for complica-
tions such as preeclampsia, or high fever with discharge, many women go to the private office of a doctor,
but this is as likely to be an unqualified doctor as a qualified one.

Among the three out of ten women who sought treatment for complications outside the home, the
vast majority (five out of six) did seek a qualified provider, the majority (four out of five) in a facility. It
is encouraging that in first pregnancies, medically trained providers are most likely to be called upon, al-
though the practice declines with later pregnancies. This pattern suggests that with so many home deliv-
eries occurring, greater effort is needed to ensure that service providers, trained to acceptable levels of
competence, will be available to visit homes and attend delivery emergencies.

Reasons for not seeking treatment: For conditions perceived as life-threatening, among the
four out of ten women who did not seek treatment, it is difficult to explain that a major reason they gave
for not seeking treatment (four out of ten) was that the condition was “not serious,” or treatment was “not
necessary.” Women are equally likely to report this reason for life-threatening conditions such as exces-
sive bleeding, malpresentation and prolonged/obstructed labor, and retained placenta, which elsewhere
they have described as potentially very dangerous.

The only reason more commonly reported for not seeking treatment than lack of need is “cost too
much” (or “lack of money”), especially for high fever with discharge, and excessive bleeding, possibly
reflecting the anticipated high cost of treatment. Transport problems and lack of permission from family
members are less important barriers (one in eight cases) to treatment overall. The relative importance of

120 | Policy Implications


each reason varies with the type of complication, transport being mentioned more often for delivery com-
plications, and lack of permission from family being more common with complications during pregnancy
and after delivery.

Decisionmakers: The participants in the decisionmaking process that takes place when an emer-
gency occurs may be different from those involved prior to the complication, when the pregnant woman
is more in control of her circumstances. In the case of life-threatening complications, the husband makes
the decision in two out of three cases. Among younger, low-parity couples, the woman’s parents also
play an important role, less so parents-in-law and other family members. As couples become older, and
have more children, the woman and her husband take on more decisionmaking responsibility, and family
members have less responsibility. The fact that for first pregnancies, the woman’s parents play as impor-
tant a decisionmaking role as the husband, and much more than the woman herself, suggests that aware-
ness raising should target these older community members.

7.1.7 Delays in Seeking Treatment for Complications

As mentioned at the beginning of this chapter, the first of the three delays has now been subdi-
vided into (i) delay in recognizing complications, and (ii) delay in decision to seek treatment. This sepa-
ration is practical, because the BMMS findings indicate that for one in three cases no decision was made
to seek treatment after recognizing a complication—or conversely, a decision may have been made to not
seek treatment.

Delay in recognizing complications: Taking all-life threatening complications together, recog-


nition that a complication had occurred came quickly, after only 2.8 hours on average. Of course, some
complications may be slow and insidious, e.g., preeclampsia or high fever, and may not have a distinct
recognizable starting point. Prolonged labor may be defined differently by different attendants, based on
experience or training. Other complications, such as convulsions, should be easily identified as having
started.

Although the median time prior to recognition is short for many complications, some such as ex-
cessive bleeding have distributions with long “tails.” The median duration was two hours for excessive
bleeding, but in one-third of cases, the duration exceeded a day, which is a dangerous delay for a hemor-
rhaging woman. The term “excessive” may refer to either duration or volume of bleeding, and slow rec-
ognition may occur with long duration but small volumes of blood loss. For preeclampsia, almost two-
thirds took at least one day for recognition, again the combination and severity of symptoms may vary
with this condition. Also, a commonly occurring symptom such as edema may be recognized early as
being present, but not recognized as a complication unless other symptoms are also present in combina-
tion with it.

It is surprising that the time delays in recognition of complications did not show the usual differ-
entials, except for level of education and socioeconomic status. Neither age nor childbearing experience
(birth order) had any significant impact on speed of recognition. This suggests that the characteristics of
the woman may be less important than the type of attendant present in the household during labor and
delivery, and more educated women and women in wealthier households are more likely to utilize medi-
cally trained attendants.

It cannot be determined from the existing data whether the immediate recognition of complica-
tions in one-fourth of cases, compared with delayed recognition of complications in the rest of the cases,
occurred because of greater severity of these cases, better-developed recognition skills of those present, or
other factors. Further analysis of the data may throw light on the question.

Policy Implications | 121


Delay in seeking treatment: This is the second subcomponent of the first delay. It is the time
delay between recognizing a complication and deciding to seek treatment, among the two out of three
women who ultimately sought treatment.

Among those who sought treatment for life-threatening conditions, almost half sought treatment
immediately upon recognizing the problem, the average wait being less than two hours. Only in cases of
preeclampsia and high fever with discharge did women wait a substantial length of time. Interestingly,
there are marked differentials, indicating that age, parity, urban residence, maternal education, and eco-
nomic status, all play a role in the speed of the decision to seek treatment.

This observation is consistent with the suggestion above that recognition of the occurrence of
complications depends more on the recognition skills of the attendant than on those of a woman herself,
but the decision to seek treatment is a matter for the individual patient and her family.

To minimize these two subcomponents of the first delay, interventions for improving recognition
of complications would need to include provision of information about the symptoms of complications
and greater effort to ensure that medically trained attendants are present throughout the delivery. Interven-
tions to reduce the time delay in deciding to seek treatment are more complex, and presumably include
allaying concerns about the potential financial burden of seeking care, about arranging transport, about
covering the other domestic responsibilities of the women, etc. A number of these matters could be an-
ticipated through birth planning during the pregnancy.

Travel time to facility: This refers to patients who recognized a complication, and decided to
seek treatment outside the home, rather than in the home. Of those going outside the home, two-thirds
went to a facility, and the remaining one-third went to nonfacility providers, qualified and nonqualified
equally (Figure 5.3.1).

That for life-threatening conditions, three-fourths of women could reach a facility within one
hour, and one-third within half an hour, suggests that access is good, but this can be misleading. It is
quite possible that many women do not attempt to go outside the home precisely because access is not
good. Also, if account is taken of the cumulative time spent in accessing inappropriate providers, and
“healer shopping,” sometimes never reaching an appropriate provider, then the contribution of the various
delays to poor childbearing outcomes might be much more significant. Further analysis should explore
the differences between women who go to a facility versus those who go to a nonfacility-based provider.

Waiting time at facility: It is striking that two-thirds of women who reached either a facility-
based or nonfacility-based provider were seen immediately, and almost all were seen within one hour. It
is also reassuring that there are almost no differentials by maternal education or wealth, suggesting that
the poor and less educated are not subject to discrimination by service providers. Nonfacility-based,
qualified and unqualified providers would be expected to involve little or no waiting time, compared with
attendance at a busy facility. Further analysis is needed to determine if poorer women are more likely
than wealthier women to go to unqualified providers.

A qualification here is that only one in four women who recognize a life-threatening complication
go directly to a qualified provider. Some proportion of the other three out of four women may eventually
reach a qualified provider, but only after trying various types of unqualified provider. This process of
“healer shopping” constitutes a further delay due to selecting an inappropriate provider in the first in-
stance. It would be useful to explore more about the “hierarchy of resort” in sequential use of different
types of providers, but those data are not available in this survey.

The relative contributions of the various delays in obtaining treatment for life-threatening condi-
tions are reviewed. In half the cases, patients recognized the complication within six hours. In two-thirds

122 | Policy Implications


of cases, they decided to seek treatment within six hours, on average much less than that. Having decided
to seek treatment, three-fourths of women reached the service provider within one hour, and very few
(one in seven) had to wait more than one hour to be treated.

Across the various phases then, it is clearly that the major delays take place at the household
level, and these are more in the recognition of complications than in the decision to seek treatment. This
pattern may be because family members do not have sufficient knowledge to recognize problems or, in
the presence of attendants, family members may defer to the judgment of the “specialist.” A deeper un-
derstanding of the decisionmaking process is needed.

It is necessary to reiterate an important feature of this analysis of time delays by pointing out that
in a substantial proportion of cases, the families and attendants recognize the problem, but do not seek
treatment from a qualified provider. The reasons for this inaction, or the choice of alternative action, may
have a cultural or economic basis, but further analysis and qualitative research are needed to understand
the barriers to women obtaining timely treatment for complications.

Of course these data on decisionmaking and subsequent behavior refer to “survivors” of child-
birth. There are comparable data for women who experienced these complications but did not survive,
and the behavior of these women may have been different. Further analysis of the patterns of behavior in
the households of women who did not survive childbirth, and comparison with those who did survive, in
particular the “near misses” if they can be identified, would be very informative.

7.2 CONCLUSIONS AND RECOMMENDATIONS

Under HPSP 1998-2003 there was a target to increase the proportion of women receiving at least
some ANC to 65 percent, but only a 48-percent level was achieved. Greater effort is needed to increase
the proportion of women receiving ANC. This will require more intensive outreach by fieldworkers, par-
ticularly for women with first pregnancies. This outreach system should encourage pregnant women to
make their first ANC visit as early as possible, certainly in the first trimester. Because more than four out
of five women receive TT vaccinations, this could be an opportunity to encourage them to come for ANC,
using the demonstrated effectiveness of the TT campaign in reducing maternal deaths as a motivational
point.

In addition, the follow-up system must be strengthened to ensure that among those women who
make a first ANC visit, as many as possible complete the recommended schedule of three or more visits.
A follow-up system would benefit from a functioning MIS system for reminders at the outreach levels,
but even a simple register system could be used effectively.

The follow-up system needs to ensure the full schedule of ANC visits, but also postnatal visits,
which currently occur rarely although the majority of maternal deaths take place after delivery, and most
neonatal deaths are concentrated in the first few days of life.

Because many women stated that there was “no need” for ANC, including women experiencing
pregnancy complications, a better understanding is needed of what the women believe are the causes and
appropriate responses to these complications. Also, functioning and effective ANC services need to be
readily accessible, and this may require strengthening lower-level facilities such as union health and fam-
ily welfare centers (UHFWCs).

It is encouraging that many ANC clients received a wide range of checkups, at least at higher-
level facilities. Better understanding is needed of what services are available and offered at lower levels,
e.g., UHFWCs and satellite clinics, where a number of women go for ANC.

Policy Implications | 123


Only half of women making ANC visits receive the necessary information on the danger signs of
pregnancy, and the appropriate response to such signs. This represents a serious missed opportunity to
convey essential information that can prepare women for complications. This knowledge forms a neces-
sary basis for birth planning in case of later complications. ANC service providers need to be trained to
be more proactive in recommending that women plan for transportation and financial and family support
in case they require EOC services in late pregnancy.

Rapid dissemination of this type of safe motherhood information can be carried out through the
mass media. While not every detail can be conveyed in this way, contact can be made with the many
pregnant women who are not currently utilizing ANC and related services. This approach has been very
effective in motivating mothers to bring their children to the National Immunization Days, and could be
effective in this context as well.

The persistent low levels of facility delivery are cause for concern. The HPSP target was 30 per-
cent of deliveries by skilled attendant, but achievement was less than half that. Although there are signs
that the selective referral of complicated deliveries is beginning to happen, numbers are still far below
what is necessary to ensure proper management of all complicated pregnancies. Continued efforts to up-
grade facilities to offer EOC services, especially below the district headquarters level, are required. This
means more than the current one in ten upazila health complexes needs to offer at least basic EOC. It
may be time to consider the advantages of upgrading UHFWCs for selected B-EOC services, especially
because FWVs posted at UHFWCs are currently being trained in safe delivery.

While every effort is needed to increase facility-based deliveries, many women will continue to
deliver at home for some time. Ways must be found to ensure that properly trained service providers are
present in the home throughout labor, delivery, and the postnatal period so that referrals to appropriate
facilities take place in a timely manner. The trained service provider is unlikely to be a qualified doctor in
most cases, so a female with some midwifery training is required. If the OGSB approach of training
FWAs and female HAs is followed, then a mechanism to increase training capacity is needed. Efforts are
currently being made in that regard. The issue of how these trained community-level service providers
will be posted and will actually function also needs to be determined.

Well over half the (surviving) women in the study experienced pregnancy complications. The
majority of these complications were perceived as life threatening by the women themselves. The analy-
sis of the three (or four) delays to receiving treatment for complications indicates that the major barriers
or delays occur in the household, not in travel to the provider, or waiting time at the service provider.
What is of concern is that many women recognized life-threatening complications but did not seek treat-
ment. And among those who sought treatment, many sought it from inappropriate service providers. Fur-
ther analysis of the data is necessary to understand the underlying reasons for these decisions. In addi-
tion, qualitative studies will be needed to throw light on what the women and the community understand
as the causes and appropriate responses to these complications.

From a positive perspective, it should be noted that among women who sought treatment for
complications, each of the individual delays did not appear to be great. If account is taken of the cumula-
tive time spent in accessing inappropriate providers, and “healer shopping,” sometimes without ever
reaching an appropriate provider, then the contribution of the various delays to poor childbearing out-
comes might be very different.

A related issue is that those women who did not seek treatment may have decided that the cost or
time barriers were too great for them to travel to the service provider.

It is clear that fear of high costs, possibly crippling for the family, is a barrier to seeking treatment
for certain complications, even at government facilities. More thought is needed regarding the provision

124 | Policy Implications


of some form of health card or health insurance scheme for safe delivery, to reassure families that high-
level EOC treatment for severe complications will not force the family into poverty. These options have
been discussed and piloted over many years, but have not been implemented at any scale. Meanwhile
families could be more actively encouraged to maintain a savings program during pregnancies to create a
contingency fund in case of need during pregnancy, during delivery, or after delivery.

Hemorrhage and eclampsia account for over half of maternal deaths. The responses to these con-
ditions differ, but both require some facility-based intervention provided quickly and skillfully. For hem-
orrhage, steps could be taken during ANC visits to assist and encourage women to identify potential com-
patible blood donors from the community who agree to be available at the time of delivery. The response
to eclampsia may be more varied, but the identification of the condition is the critical step, backed up by
access to a facility with the capacity to perform C-sections if the usual interventions are ineffective. As
maternal deaths from this condition are more common among younger women, information about
eclampsia symptoms and danger signs should be conveyed during ANC visits for the first pregnancy.

It is encouraging that abortion-related deaths are relatively low. This may be due to a combina-
tion of widespread use of family planning to prevent unwanted pregnancies, and better quality MR ser-
vices than the high-risk traditional approaches used in the past. Further strengthening of the national fam-
ily planning program has the potential to reduce the substantial number of unwanted pregnancies, which
contribute to the need for this service.

Further analysis of the survey data could provide an insight on which proxy indicators of mater-
nal mortality would be the most useful predictors for monitoring future progress in the national safe
motherhood program. In addition, alternative sources of information on maternal health could be drawn
upon. Maternal death audits could be instituted in district hospitals, MCWCs, and even upazila health
complexes. Because maternal deaths are relatively rare in any single facility, the most complicated cases,
sometimes called “near misses,” could also be audited.

Policy Implications | 125


REFERENCES

Abou Zahr, C. 1998. Chapters 4 and 7. In Health dimensions of sex and reproduction: The global burden
of sexually transmitted diseases, HIV, maternal -conditions, perinatal disorders, and congenital anoma-
lies, ed. C.J.L. Murray and A.D. Lopez. Cambridge, Massachusetts: The Harvard School of Public
Health.

Akhter, H.H., M.I. Chowdhury, and A. Sen. 1996. A cross sectional study on maternal mortality in Bang-
ladesh. Dhaka, Bangladesh: BIRPERHT.

Akhter, H.H., M.H. Rahman, I. Mannan, M.E. Chowdhury, and A.K. Khan. 1995. Review of performance
of trained TBAs. Bangladesh Institute of Research for Promotion of Essential and Reproductive Health
and Technologies [BIRPERHT], BIRPERHT Publication No. 10, Technical Report No. 53. Dhaka, Bang-
ladesh.

Allison, C. et al. 1999. End of project evaluation report: Fourth Population and Health Project. Dhaka,
Bangladesh.

Atrash, H., S. Alexander, and C. Berg. 1995. Maternal mortality in developed countries: Not just a con-
cern of the past. Obstetrics and Gynecolgy 86(4 Pt.2): 700-705.

Bhatia, J.C. and J. Cleland. 1996. Obstetric morbidity in South India: Results from a community survey.
Social Science and Medicine 43(10): 1507-1516.

Bouvier-Colle, M. et al. 1991. Reasons for the underreporting of maternal mortality in France, as indi-
cated by a survey of all deaths among women of reproductive age. International Journal of Epidemiology
20(3): 717-721.

Brass, W. 1975. Methods for estimating fertility and mortality from limited and defective data. Chapel
Hill, North Carolina: University of North Carolina Press.

Carroli, G., J. Villar, G. Piaggio, D. Khan-Neelofur, M. Gulmezoglu, M. Mugford, P. Lumbiganon, U.


Farnot, P. Bersgjo, and WHO Antenatal Care Trial Research Group. 2001a. WHO systematic review of
randomized controlled trials of routine antenatal care. Lancet 357(9268): 1565-1570.

Carroli, G., C. Rooney, and J. Villar. 2001b. How effective is antenatal care in preventing maternal mor-
tality and serious morbidity? An overview of the evidence. Paediatric and Perinatal Epidemiology
15(Suppl. 1): 1-42.

Chowdhury, A.M.R., A. Mahbub, A.S. Chowdhury. 2002. Skilled attendance at delivery in Bangladesh:
An ethnographic study. Dhaka, Bangladesh: BRAC RED.

Cleland, J. and S. Harlow. 2003. The value of the imperfect: The contribution of interview surveys to the
study of gynaecological ill health. In Reproductive tract infections and other gynaecological disorders,
ed. S.J. Jejeebhoy, M.A. Koenig, and C. Elias. Cambridge: Cambridge University Press. 283-321.

Fortney, J.A., and J.B. Smith. 1999. Measuring maternal morbidity. In Safe motherhood initiatives: Criti-
cal Issues, ed. M. Berer and T.K. Sundari Ravindran. Special issue of Reproductive Health Matters. 43-
50.

References | 127
Graham, W., W. Brass, and R. Snow. 1989. Indirect estimation of maternal mortality: The sisterhood
method. Studies in Family Planning 20(3): 125-135.

Graham, W.J., J.S. Bell, and C.H.W. Bullough. 2001. Can skilled attendance at delivery reduce maternal
mortality in developing countries? In Studies in health services organization and policy. 97-129.

Gwatkin, D.R., S. Rutstein, K. Johnson, R.P. Pande, and A. Wagstaff. 2000. Socioeconomic differences in
health, nutrition, and poverty. HNP/Poverty Thematic Group of the World Bank. Washington, D.C.: The
World Bank.

Hill, K., C. AbouZahr, and T. Wardlaw. 2001. Estimates of maternal mortality for 1995. Bulletin of the
World Health Organization 79(3): 182-193.

Huq, M.N. and J. Cleland. 1990. Bangladesh Fertility Survey 1989: Main report. Dhaka: National Insti-
tute of Population Research and Training (NIPORT).

Jejeebhoy, S.J., M.A. Koenig, and C. Elias (eds). 2003. Reproductive tract infections and other gynaeco-
logical disorders. Cambridge: Cambridge University Press.

Ministry of Health and Family Welfare (MOHFW) [Bangladesh]. 2001. Bangladesh National Strategy for
Maternal Health. Dhaka, Bangladesh: Ministry of Health and Family Welfare.

Ministry of Health and Population Control (MHPC) [Bangladesh]. 1978. Bangladesh Fertility Survey,
1975-1976: First report. Dhaka: Government of the People’s Republic of Bangladesh and the World Fer-
tility Survey.

Mitra, S.N., M.N. Ali, S. Islam, A.R. Cross, and T. Saha. 1994. Bangladesh Demographic and Health
Survey, 1993-1994. Calverton, Maryland and Dhaka, Bangladesh: National Institute of Population Re-
search and Training (NIPORT), Mitra and Associates, and Macro International Inc.

Mitra, S.N., A. Al-Sabir, A.R. Cross, and K. Jamil. 1997. Bangladesh Demographic and Health Survey,
1996-1997. Calverton, Maryland and Dhaka, Bangladesh: National Institute of Population Research and
Training (NIPORT), Mitra and Associates, and Macro International Inc.

Mitra, S.N., C. Lerman, and S. Islam. 1993. Bangladesh Contraceptive Prevalence Survey - 1991: Final
report. Dhaka: Mitra and Associates.

National Institute of Population Research and Training (NIPORT), Mitra and Associates (MA), and ORC
Macro. 2001. Bangladesh Demographic and Health Survey, 1999-2000. Dhaka, Bangladesh and Calver-
ton, Maryland: National Institute of Population Research and Training, Mitra and Associates, and ORC
Macro.

Quaiyum, M.A., S. Ahmed, A. Islam, and P.A. Khanum. 1999. Strategies for ensuring referral and link-
age for essential obstetric care: A review. ICDDR,B Special Publication No. 95. Dhaka, Bangladesh:
ICDDR,B: Centre for Health and Population Research.

Rutenberg, N. and J. Sullivan. 1991. Direct and indirect estimation of maternal mortality from the sister-
hood method. In Proceedings of the Demographic and Health Surveys World Conference, Washington,
D.C., August 5-7, 1991, Vol. 3. Columbia, Maryland: IRD/Macro International. 1669-1695.

Rutstein, S.O. 1984. Infant and child mortality: Levels, trends, and demographic differentials. Revised
edition. World Fertility Survey Comparative Studies No. 43. Voorburg, Netherland: International Statisti-
cal Institute.

128 | References
Shahidullah, M. 1995. The sisterhood method of estimating maternal mortality: The Matlab experience.
Studies in Family Planning 26(2): 101-106.

Sloan, N. et al. 2001. The etiology of maternal mortality in developing countries: What do verbal autop-
sies tell us? Bulletin of the World Health Organization 79(9): 805-810.

Stanton, C., N. Abderrahim, and K. Hill. 2000. An assessment of DHS maternal mortality indicators.
Studies in Family Planning 31(2): 11-125.

Stanton, C., et al. 2001. Every death counts: Measurement of maternal mortality via a census. Bulletin of
the World Health Organization 79(7): 657-664.

Stecklov, G. 1995. Maternal mortality estimation: Separating pregnancy-related and non-pregnancy-


related risks. Studies in Family Planning 26(1): 33-38.

Unified Management Information System (UMIS). 2003. Voice of UMIS. Issue 3, DGHS. Dhaka, Bang-
ladesh.

United Nations. 2002. Methods for estimating adult mortality. Working paper prepared by the Population
Division, Department of Economic and Social Affairs, ESA/P/WP.175. New York: United Nations.

United Nations Development Program (UNDP). 2003. Human development report – Millennium devel-
opment goals: A compact among nations to end human poverty. New York: Oxford University Press.

United Nations Population Fund (UNFPA). 2003. Achieving the millennium development goals: Popula-
tion and reproductive health as critical determinants. Population and Development Strategies No. 10.
New York: United Nations Population Fund.

World Health Organization (WHO). 1992. International statistical classification of diseases and related
health problems. Tenth revision. Geneva: WHO.

World Health Organization (WHO). 1996. Revised 1990 estimates of maternal mortality: A new approach
by WHO and UNICEF. Geneva: World Health Organization.

World Health Organization (WHO), UNICEF, and UNFPA. 2001. Maternal mortality in 1995: Estimates
developed by WHO and UNICEF. Geneva: World Health Organization.

References | 129
TABLES Appendix A
Table A.1 Household population by age, residence, and sex

Percent distribution of the de facto household population by five-year age groups, according to urban-rural residence and sex, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
All urban Metropolitan/town Other urban Rural Total
–––––––––––––––––––– –––––––––––––––––––– –––––––––––––––––––– ––––––––––––––––––––––– –––––––––––––––––––––
Age group Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
0-4 11.7 11.6 11.7 11.1 11.1 11.1 12.5 12.2 12.3 13.4 12.6 13.0 13.0 12.4 12.7
5-9 12.0 11.3 11.6 11.1 10.5 10.8 13.0 12.3 12.7 13.7 13.1 13.4 13.4 12.8 13.1
10-14 12.8 13.1 13.0 12.3 12.9 12.6 13.5 13.3 13.4 13.7 13.5 13.6 13.6 13.4 13.5
15-19 10.6 13.3 11.9 10.6 13.5 12.0 10.6 13.0 11.8 10.2 12.3 11.3 10.3 12.5 11.4
20-24 8.1 10.7 9.4 8.6 11.6 10.1 7.4 9.6 8.5 6.9 9.3 8.1 7.1 9.5 8.3
25-29 7.8 8.3 8.0 8.4 8.9 8.7 7.0 7.5 7.3 6.6 7.5 7.1 6.8 7.6 7.2
30-34 7.5 7.5 7.5 8.3 7.8 8.0 6.6 7.2 6.9 6.2 6.7 6.4 6.4 6.8 6.6
35-39 7.1 6.2 6.6 7.6 6.5 7.1 6.4 5.7 6.1 6.3 5.5 5.9 6.5 5.6 6.0
40-44 5.9 4.9 5.4 5.9 4.9 5.4 5.8 4.9 5.3 5.2 4.5 4.8 5.3 4.5 4.9
45-49 4.7 3.4 4.0 4.8 3.5 4.1 4.5 3.3 3.9 4.2 3.3 3.8 4.3 3.4 3.8
50-54 3.4 2.3 2.9 3.6 2.2 2.9 3.2 2.4 2.8 3.2 2.7 2.9 3.2 2.6 2.9
55-59 2.2 2.2 2.2 2.1 1.9 2.0 2.3 2.5 2.4 2.2 2.7 2.5 2.2 2.6 2.4
60-64 2.0 2.0 2.0 2.1 1.8 1.9 2.0 2.3 2.1 2.5 2.4 2.4 2.4 2.3 2.4
65-69 1.3 1.1 1.2 1.2 0.9 1.0 1.5 1.2 1.4 1.6 1.3 1.4 1.6 1.2 1.4
70-74 1.4 1.0 1.2 1.1 0.9 1.0 1.8 1.2 1.5 2.0 1.1 1.5 1.9 1.1 1.5
75-79 0.5 0.4 0.5 0.5 0.3 0.4 0.6 0.4 0.5 0.8 0.4 0.6 0.8 0.4 0.6
80 + 0.9 0.8 0.9 0.7 0.7 0.7 1.1 1.0 1.1 1.3 1.0 1.1 1.2 0.9 1.1
Missing /
Don’t know 0.1 0.1 0.1 0.0 0.0 0.0 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number 46,847 47,464 94,311 25,681 25,888 51,569 21,166 21,576 42,742 202,555 205,516 408,074 249,402 252,979 502,385

Appendix A | 131
Table A.2 Level of education by background characteristics

Percent distribution of ever-married women by highest level of education attended, according to background characteristics, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Level of education
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Background No Primary Primary Secondary Don’t Median
characteristic education incomplete complete or more know Total Number years
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
FEMALE
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Age
6-9 16.0 82.8 0.4 0.8 0.0 100.0 25,714 0.1
10-14 9.4 49.3 7.6 33.6 0.0 100.0 33,942 3.4
15-19 17.3 16.9 11.0 54.7 0.1 100.0 31,639 5.2
20-24 31.7 16.7 10.0 41.5 0.1 100.0 24,157 4.1
25-29 45.6 17.1 9.2 28.0 0.1 100.0 19,346 1.1
30-34 52.3 17.7 8.9 21.0 0.1 100.0 17,326 0.0
35-39 56.2 17.6 8.9 17.2 0.1 100.0 14,280 0.0
40-44 60.2 16.4 8.8 14.5 0.1 100.0 11,507 0.0
45-49 62.8 16.5 9.2 11.4 0.1 100.0 8,502 0.0
50-54 71.5 14.5 7.1 6.7 0.2 100.0 6,689 0.0
55-59 76.5 12.2 6.4 4.8 0.1 100.0 6,668 0.0
60-64 82.4 9.7 4.7 3.0 0.1 100.0 5,840 0.0
65+ 86.7 7.6 3.2 2.3 0.1 100.0 9,209 0.0
Residence
All urban 30.4 25.4 7.4 36.8 0.1 100.0 40,861 3.1
Metropolitan/town 26.9 23.1 7.4 42.5 0.1 100.0 22,484 4.0
Other urban 34.6 28.2 7.3 29.8 0.1 100.0 18,377 1.9
Rural 39.6 30.1 7.7 22.5 0.1 100.0 173,974 0.9
Division
Barisal 28.8 34.1 12.4 24.7 0.0 100.0 14,833 2.3
Chittagong 36.0 27.7 8.3 28.0 0.0 100.0 42,577 1.8
Dhaka 37.9 29.4 6.8 25.7 0.1 100.0 72,390 1.1
Khulna 33.5 31.8 6.4 28.2 0.1 100.0 23,525 1.8
Rajshahi 42.4 27.6 6.9 23.0 0.0 100.0 47,825 0.6
Sylhet 45.1 27.5 9.7 17.5 0.2 100.0 13,684 0.0
Wealth quintile
Lowest 60.4 30.3 4.3 4.9 0.1 100.0 41,704 0.0
Second 47.1 34.4 6.8 11.7 0.1 100.0 41,946 0.0
Middle 37.2 32.6 8.8 21.3 0.1 100.0 42,504 1.2
Fourth 27.5 28.2 9.9 34.4 0.1 100.0 43,800 3.3
Highest 19.0 21.0 8.3 51.6 0.1 100.0 44,881 4.9
Total 37.9 29.2 7.7 25.3 0.1 100.0 214,835 1.2
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
MALE
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Age
6-9 18.1 80.9 0.4 0.6 0.0 100.0 26,459 0.1
10-14 12.9 53.3 7.7 26.0 0.1 100.0 33,837 2.9
15-19 16.7 19.7 10.5 53.0 0.2 100.0 25,643 5.0
20-24 22.4 15.8 10.4 51.1 0.2 100.0 17,765 4.9
25-29 31.9 15.4 9.3 43.0 0.4 100.0 17,025 4.2
30-34 37.2 14.7 8.2 39.5 0.4 100.0 16,066 3.5
35-39 41.1 15.7 8.0 34.8 0.4 100.0 16,089 2.3
40-44 42.6 15.1 8.4 33.4 0.5 100.0 13,259 2.0
45-49 40.7 15.1 8.0 35.8 0.4 100.0 10,758 2.6
50-54 44.1 14.9 8.2 32.2 0.6 100.0 8,040 1.7
55-59 42.6 16.2 9.1 31.5 0.6 100.0 5,422 1.9
60-64 50.3 15.6 8.9 24.7 0.6 100.0 6,045 0.0
65+ 51.6 17.4 9.3 21.2 0.5 100.0 13,452 0.0
Residence
All urban 21.0 25.4 7.0 46.2 0.4 100.0 40,154 4.4
Metropolitan/town 17.4 22.6 6.7 52.8 0.5 100.0 22,212 5.2
Other urban 25.6 28.9 7.3 38.0 0.3 100.0 17,942 3.3
Rural 31.1 31.6 8.0 29.0 0.3 100.0 169,727 2.0
Division
Barisal 23.0 34.1 9.7 33.2 0.0 100.0 14,467 3.0
Chittagong 26.5 31.4 8.3 33.7 0.0 100.0 39,517 2.9
Dhaka 30.0 29.9 7.1 32.5 0.5 100.0 70,786 2.2
Khulna 26.0 31.5 6.2 35.8 0.5 100.0 23,656 2.9
Rajshahi 32.6 28.2 7.8 31.3 0.0 100.0 48,030 2.2
Sylhet 33.2 31.7 10.9 23.7 0.5 100.0 13,426 1.5
Wealth quintile
Lowest 53.6 33.9 5.3 6.8 0.4 100.0 38,918 0.0
Second 40.0 36.3 7.9 15.5 0.2 100.0 40,944 0.3
Middle 27.9 34.2 9.5 28.2 0.3 100.0 42,772 2.3
Fourth 18.0 28.7 9.7 43.5 0.2 100.0 43,350 4.3
Highest 9.9 19.8 6.4 63.6 0.3 100.0 43,898 7.3
Total 29.2 30.4 7.8 32.3 0.3 100.0 209,882 2.4
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: Educational attainment is missing for 16 females and 22 males.

132 | Appendix A
DATA QUALITY Appendix B
DATA QUALITY OF HOUSEHOLD DEATHS

Questions on household deaths suffer from a number of potential errors. First, deaths may be
omitted. One type of death—a death in a household consisting of one person—will inevitably be omitted
given the household-based data collection format. Deaths may also be omitted by misperception of the
reference period: For example, a death that actually occurred in June 1998 may be thought to have oc-
curred late in 1997 and, although reported, is thus excluded from the reference period. Another potential
source of error arises from age misreporting: if age at death is systematically misreported, estimates of
mortality rates based on age at death will be biased. For example, if the age at death of a person who died
at age 70 is reported as 80, death rates will be underestimated. Evaluation of data is thus essential. Re-
cent experience with this type of question in censuses and large surveys has, however, been encouraging
regarding data quality.

There are a number of approaches to data evaluation. One set of approaches evaluates the com-
pleteness of death reporting relative to population recording by comparing the age pattern of deaths to the
age pattern of the population. The most flexible of these approaches use age distributions from two or
more sources (e.g., successive censuses or large surveys) to allow for true irregularities in the age distri-
bution (United Nations, 2002). However, the age distribution from the 2001 Bangladesh Census is not
yet available, so we have been unable to conduct this check. An alternative, that assumes a demographi-
cally stable (smooth) population age distribution, compares the age distribution of deaths to the age dis-
tribution of the population from the same source (Brass, 1975). Figures B.1 and B.2 show these compari-
sons for the BMMS for males and females. A straight line relationship with a slope of 1.0 would indicate
equivalence between the death and population reporting; the observed points in Figures B.1 and B.2 do
not lie close to a straight line, and the slope of the relationship is less than 1.0, indicating that deaths are
more completely recorded than the population. However, because the age distribution of Bangladesh is
not stable, this conclusion is not reliable.

Another approach to evaluation is to compare an observed series of age-specific death rates to a


“gold standard” believed to be essentially correct. There is no national gold standard for adult mortality
in Bangladesh, but data are available from the Health and Demographic Surveillance System (HDSS) in
Matlab Thana, an intensive demographic surveillance system that has been in operation for over 30 years
and has a reputation for excellent data. Mortality rates from the BMMS have been calculated by five-year
age groups (<1, 1-4, <5) and sex, based on deaths of usual household members in the three years before
the survey. The rates are calculated as events (deaths) divided by exposure time, obtained from the age
distribution of the living population, plus the exposure time prior to death of the deceased. These rates
are shown in Table 3.9 (chapter 3), and are compared on a log scale in Figures B.3 and B.4, with the cor-
responding rates for males and females from the HDSS in Matlab, averaged over the years 1998 to 2000.
Although the rates from the BMMS show clear effects of age heaping (in the form of a saw-tooth pattern
by age), particularly for males and after age 60, overall levels and patterns of mortality are similar, par-
ticularly for males. For females, the BMMS rates tend to be somewhat higher than the Matlab rates, per-
haps because of the reproductive health interventions implemented in the Matlab area over the last 25
years. In terms of summary measures, the probability of dying between the age of 15 and 60 (45q15) for
males is 0.18 from the BMMS, compared with 0.19 from the HDSS. For females, the probability of dying
is 0.15 compared with 0.11 from the HDSS. The graphical comparison suggests digital preference in the
BMMS age at death reporting; further, the tendency for the BMMS rates to rise more slowly than the

Appendix B | 133
Figure B.1 Brass “Growth Balance” Analysis of Completeness of Male Death
Reporting in the BMMS

Figure B.2 Brass “Growth Balance” Analysis of Completeness of Female Death


Reporting in the BMMS

134 | Appendix B
Figure B.3 Male Age-Specific Mortality Rates: BMMS and Matlab HDSS

Figure B.4 Female Age-Specific Mortality Rates: BMMS and Matlab HDSS

Appendix B | 135
HDSS rates after age 60 may suggest some exaggeration of age. However, the similarity of BMMS rates
to HDSS rates (for males) or substantially higher BMMS rates than HDSS rates (for females) suggest no
major problems of coverage in BMMS deaths. Of course, it must be recognized that the Matlab data
come from one small part of the country and may not be representative, but it is reassuring that the
BMMS levels are broadly consistent with the only available “gold standard.”

Another consistency check is to compare childhood mortality estimates from household deaths
with the estimates from birth histories reported in Chapter 6. The infant mortality rate (IMR) per 1,000
live births estimated from the household deaths (for the period 1998-2001) is 70 for males and 58 for fe-
males; the birth history estimates for the five years before the survey are 75 and 67, respectively. The
probability of dying for children age 1-4 (4q1) from the BMMS is 21 per 1,000 for both males and fe-
males, compared with 23 for males and 29 for females from birth histories for the five years preceding the
survey. Thus, infant and child mortality estimates from household deaths for the three years preceding
the survey are lower than the estimates from the birth histories for the five years preceding the survey.
However, birth history estimates for the two-year period shown in Table 6.8 (chapter 6) indicate a very
rapid decline in infant and child mortality immediately before the survey: infant and child mortality rates
for the two years before the survey are 67 and 19, respectively, the latter value being lower than the
household deaths estimate.

In summary, the BMMS data on household deaths appear to be of good quality. The only formal
demographic analysis available indicates, if anything, that the deaths are overreported relative to popula-
tion, but this analysis makes the inappropriate assumption of population stability. Comparisons of the
BMMS mortality estimates with Matlab data are reassuring in terms of data quality, as are internal com-
parisons with child mortality estimates from the birth histories.

DATA QUALITY OF SIBLING HISTORIES

Data on sibling deaths suffer from many of the same potential errors as data on household deaths.
First, deaths may be omitted; the equivalent to omission of deaths of persons in single-person households
is the deaths of entire sibships. Omission may also occur as a result of the respondent being out of touch
with family members. With sibling deaths, there is no omission as a result of misperception of the refer-
ence period used, because all sibling deaths are reported. However, because the age range of estimation is
limited to persons under 50 years, an age at death reporting error that shifts a death to outside the age
range (or from outside to inside) will bias mortality estimates. In addition, estimates of mortality for par-
ticular periods preceding the survey can be distorted by misreporting the length of time in the past the
death occurred. As a result, both levels and age patterns of mortality can be distorted by misreporting age
at death. Recent experience with sibling histories in the DHS surveys suggests systematic underreporting
of mortality, particularly for the more distant past (Stanton et al., 2000).

No formal demographic evaluation techniques have been developed for mortality estimates from
sibling histories. Therefore, sibling estimates of mortality are compared with those from other sources,
specifically from the Matlab HDSS. Figures B.5 and B.6 compare the male and female age-specific rates
from sibling histories for the period 1998-2001 to the Matlab rates for 1998-2000. Two summary meas-
ures for each sex can also be compared: the age-specific under-five mortality rate and the probability of
dying between age 15 and 50 (35q15). For males, the age-specific under-five mortality rate from the
BMMS sibling histories is 12.4 per 1,000, compared with 16.2 from the HDSS; for females, the corre-
sponding values are 14.0 from the BMMS and 16.8 from the HDSS. The sibling history estimates aver-
age about 20 percent lower than the HDSS values. Agreement is much closer for 35q15: for males, the
BMMS sibling history value is 0.073, compared with 0.077 from the HDSS, and for females, the BMMS
value is also 0.073, compared with 0.055 from the HDSS. Thus, for males, the sibling estimate of adult
mortality is only marginally below the HDSS value, and for females it is substantially higher. Interest-
ingly, household deaths produce similar differentials, with higher adult mortality estimates for females

136 | Appendix B
and slightly lower estimates for males relative to the HDSS estimates. This finding is again consistent
with the conclusion that male adult mortality in the Matlab area may be very similar to the national level
but that female adult mortality in the Matlab area appears to be considerably below the national average.

To the extent that it is possible to evaluate the quality of the sibling mortality data, it appears that
the data are of good quality, at least after childhood.

Figure B.5 Male Age-Specific Mortality Rates: BMMS Sibling


Histories and Matlab HDSS

Appendix B | 137
Figure B.6 Female Age-Specific Mortality Rates: BMMS Sibling
Histories and Matlab HDSS

138 | Appendix B
ASSESSMENT OF DATA QUALITY
FOR CHILDHOOD MORTALITY Appendix C
The quality of mortality estimates calculated from retrospective birth histories depends on the
completeness and accuracy with which births and deaths are reported and recorded. The most potentially
serious data quality problem is the selective omission from the birth histories of births that did not sur-
vive, which will lead to underestimation of mortality rates. Other potential problems include displacement
of birth dates, which may cause a distortion of mortality trends, and misreporting of the age at death,
which may distort the age pattern of mortality. When selective omission of childhood deaths occurs, it is
usually most severe for deaths that occur very early in infancy. If early neonatal deaths were selectively
underreported, the result would be an unusually low ratio of deaths under seven days to all neonatal
deaths and an unusually low ratio of neonatal to infant mortality. Underreporting of early infant deaths is
more commonly observed as the time interval between the birth and the survey increases; hence, it is use-
ful to examine the ratios over time. Inspection of these ratios (shown in Tables C.5 and C.6) does not in-
dicate that significant numbers of early infant deaths have been omitted in the 2001 BMMS survey. First,
the proportion of neonatal deaths that occur in the first week of life is high (64 percent) and falls in the
range of 60 to 70 percent over the 20 years before the survey. Second, the proportion of infant deaths that
occur during the first month of life is entirely plausible (65 percent) and is stable over the 20 years before
the survey (varying between 63 and 68 percent). This inspection of the mortality data reveals no evidence
of selective underreporting or age at death misreporting that would significantly compromise the quality
of the BMMS rates of childhood mortality.

However, another problem inherent in most retrospective surveys is heaping of age at death on
certain digits (e.g., 6, 12, and 18 months). If the net result of misreporting is the transfer of deaths be-
tween age segments for which the rates are calculated, misreporting will bias estimates of the age pattern
of mortality. For instance, an overestimate of child mortality relative to infant mortality will result if
children dying during the first year of life are reported as having died at age one or older. Thus, heaping
at 12 months can bias the mortality estimates because a certain fraction of these deaths, which are re-
ported to have occurred after infancy (i.e., at age 12-23 months), may have actually occurred during in-
fancy (i.e., at age 0-11 months). In such cases, heaping would bias infant mortality (1q0) downward and
child mortality (4q1) upward.

In the 2001 BMMS survey, there appears to be a preference for reporting age at death at 3 days
and at 7 days (Table C.5). An examination of the distribution of deaths under age two during the 15 years
preceding the survey by month of death (Table C.6) indicates a slight heaping of deaths at 6 months and
substantial heaping at 12 and 18 months of age. Heaping on 12 months is found despite the strong em-
phasis on this problem during the training of interviewers for BMMS fieldwork.1 This could mean that
the infant mortality rates are somewhat underestimated and childhood mortality rates are somewhat over-
estimated. However, the digit preference will not alter the under-five mortality rate.

It is seldom possible to establish mortality levels with confidence for a period of more than 15
years before a survey. Even within the recent 15-year period considered here, apparent trends in mortality
rates should be interpreted with caution for several reasons. First, there may be differences in the com-
pleteness of death reporting related to the length of time before the survey. Second, the accuracy of re-
ports of age at death and of date of birth may deteriorate with time. Third, sampling variability of mortal-
ity rates tends to be high, especially for groups with relatively few births. Fourth, mortality rates are trun-
cated as they go back in time because women currently age 50 or older who were bearing children during

1
Interviewers were trained to probe for the exact number of months lived by the child if the age at death was re-
ported as “one year.”

Appendix C | 139
earlier periods were not included in the survey. This truncation affects mortality trends, in particular. For
example, for the period 10-14 years before the survey, the rates do not include any births for women age
40-49 since these women were over age 50 at the time of the survey and not eligible to be interviewed.
Since these excluded births to older women were likely to be at a somewhat greater risk of dying than
were births to younger women, the mortality rates for the period may be slightly underestimated. Esti-
mates for more recent periods are less affected by truncation bias since fewer older women are excluded.
The extent of this bias depends both on the proportion of births omitted and the differentials in child mor-
tality by age of mother.

140 | Appendix C
Table C.1 Household age distribution

Single-year age distribution of the de facto household population by sex


(weighted), Bangladesh 2001
——————————————————————————————————
Males Females
——————————— ———————————
Age Number Percent Number Percent
——————————————————————————————————
0 6,736 2.7 6,428 2.5
1 6,212 2.5 5,948 2.4
2 6,509 2.6 6,396 2.5
3 6,373 2.6 6,019 2.4
4 6,715 2.7 6,592 2.6
5 6,847 2.7 6,650 2.6
6 6,223 2.5 5,752 2.3
7 7,216 2.9 7,188 2.8
8 6,963 2.8 7,011 2.8
9 6,056 2.4 5,764 2.3
10 8,211 3.3 7,611 3.0
11 5,362 2.2 5,300 2.1
12 8,320 3.3 7,762 3.1
13 5,954 2.4 6,336 2.5
14 5,990 2.4 6,933 2.7
15 6,359 2.5 7,024 2.8
16 5,657 2.3 7,035 2.8
17 4,269 1.7 5,786 2.3
18 6,264 2.5 7,233 2.9
19 3,093 1.2 4,561 1.8
20 6,103 2.4 6,867 2.7
21 2,480 1.0 4,090 1.6
22 4,310 1.7 5,121 2.0
23 2,482 1.0 4,129 1.6
24 2,390 1.0 3,950 1.6
25 6,640 2.7 5,301 2.1
26 2,892 1.2 3,689 1.5
27 2,556 1.0 3,367 1.3
28 3,419 1.4 3,737 1.5
29 1,518 0.6 3,253 1.3
30 8,817 3.5 5,421 2.1
31 1,437 0.6 3,150 1.2
32 3,326 1.3 3,415 1.3
33 1,442 0.6 2,808 1.1
34 1,045 0.4 2,532 1.0
35 9,645 3.9 4,442 1.8
36 1,607 0.6 2,702 1.1
37 1,398 0.6 2,473 1.0
38 2,840 1.1 2,776 1.1
39 599 0.2 1,887 0.7
40 9,629 3.9 3,704 1.5
41 400 0.2 1,679 0.7
42 2,255 0.9 2,326 0.9
43 569 0.2 2,082 0.8
44 407 0.2 1,717 0.7
45 7,791 3.1 2,644 1.0
46 677 0.3 1,556 0.6
47 600 0.2 1,468 0.6
48 1,359 0.5 1,538 0.6
49 331 0.1 1,296 0.5
50 6,361 2.6 1,189 0.5
51 228 0.1 1,098 0.4
52 957 0.4 1,880 0.7
53 280 0.1 1,412 0.6
54 213 0.1 1,110 0.4
55 3,990 1.6 3,338 1.3
56 411 0.2 1,021 0.4
57 334 0.1 821 0.3
58 528 0.2 930 0.4
59 159 0.1 559 0.2
60 5,123 2.1 4,132 1.6
61 122 0.0 444 0.2
62 521 0.2 622 0.2
63 162 0.1 355 0.1
64 118 0.0 286 0.1
65 3,187 1.3 2,197 0.9
66 143 0.1 254 0.1
67 152 0.1 208 0.1
68 314 0.1 274 0.1
69 90 0.0 142 0.1
70+ 9,566 3.8 6,133 2.4
Don't know/missing 151 0.1 128 0.1

Total 249,402 100.0 252,979 100.0


——————————————————————————————————
Note: The de facto population includes all residents and nonresidents who slept in
the household the night before the interview.

Appendix C | 141
Table C.2 Age distribution of eligible and interviewed women

De facto household population of women age 10-54, interviewed women aged 13-49,
and percentage of eligible women who were interviewed (weighted), by five-year age
groups, Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Household Interviewed Percentage
population Ever-married women age 13-49 of eligible
of women women –––––––––––––––––––– women
Age group age 13-54 age 13-54 Number Percent interviewed
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
10-14 13,269 1,526 1,484 1.4 97.2
15-19 31,639 15,096 14,708 14.2 97.4
20-24 24,157 20,084 19,566 18.9 97.4
25-29 19,346 18,560 18,054 17.4 97.3
30-34 17,326 17,127 16,742 16.2 97.8
25-39 14,280 14,220 13,774 13.3 96.9
40-44 11,507 11,478 11,108 10.7 96.8
45-49 8,502 8,486 8,183 7.9 96.4
50-54 6,689 6,662 na na na

13-49 140,027 106,577 103,620 100.0 97.2


–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Note: The de facto population includes all residents and nonresidents who stayed in the
household the night before interview. Weights for both household population of women
and interviewed women are household weights. Age is based on the household schedule.
na = Not applicable

Table C.3 Completeness of reporting

Percentage of observations missing information for selected demographic and health questions
(weighted), Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Percentage
of reference
group with Number
missing of
Subject Reference group information cases
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Birth date Birth in last 15 years
Month only 0.31 204,593
Month and year 0.01 204,593

Age at death Deaths to births in last 15 years 0.23 23,954

Respondent's education All respondents 0.03 103,796

142 | Appendix C
Table C.4 Births by calendar years

Distribution of births by calendar years since birth for living, dead, and all children, according to completeness of birth dates, sex ratio
at birth, and ratio of births by calendar year (weighted), Bangladesh 2001
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Percentage with
Number of births complete birth date1 Sex ratio at birth2 Calendar year ratio3
––––––––––––––––––––––– ––––––––––––––––––––––– –––––––––––––––––––––– ––––––––––––––––––––––
Year Living Dead Total Living Dead Total Living Dead Total Living Dead Total
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
2001 3,213 160 3,374 100.0 100.0 100.0 102.9 136.6 104.3 na na na
2000 13,008 885 13,894 100.0 99.9 100.0 103.2 133.4 104.9 na na na
1999 11,948 869 12,817 100.0 99.9 100.0 108.0 110.1 108.1 93.6 90.2 93.3
1998 12,526 1,041 13,567 100.0 100.0 100.0 101.0 113.8 101.9 105.2 103.3 105.0
1997 11,869 1,147 13,017 100.0 100.0 100.0 105.3 111.4 105.8 92.5 88.4 92.1
1996 13,139 1,555 14,695 99.8 99.4 99.7 103.7 104.3 103.8 108.3 114.3 108.9
1995 12,402 1,573 13,975 99.8 99.2 99.7 103.1 108.3 103.7 98.8 98.3 98.7
1994 11,966 1,647 13,613 99.7 99.3 99.6 105.2 108.4 105.6 93.4 100.5 94.2
1993 13,220 1,704 14,924 99.6 98.8 99.5 99.3 109.7 100.4 109.6 98.5 108.2
1992 12,150 1,813 13,963 99.7 99.1 99.6 102.7 108.8 103.5 97.8 101.9 98.3
1997-2001 52,565 4,103 56,668 100.0 100.0 100.0 104.2 117.0 105.1 na na na
1992-1996 62,877 8,292 71,169 99.7 99.1 99.7 102.7 108.0 103.3 na na na
1987-1991 57,717 9,953 67,670 99.6 98.7 99.5 105.6 104.5 105.4 na na na
1982-1986 44,894 10,467 55,362 99.4 98.5 99.2 103.9 103.4 103.8 na na na
< 1982 50,284 15,488 65,772 99.2 97.8 98.9 110.2 110.3 110.2 na na na
All 268,337 48,304 316,641 99.6 98.5 99.4 105.2 107.7 105.6 na na na
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
1
Both year and month of birth given
2
(Bm/Bf)*100, where Bm and Bf are the numbers of male and female births, respectively
3
[2Bx/(Bx-1+Bx+1)]*100, where Bx is the number births in calendar year x
na = Not applicable

Appendix C | 143
Table C.5 Reporting of age at death in days

Distribution of reported deaths under one month of age by age at death in days
and the percentage of neonatal deaths reported to occur at ages 0-6 days, for
five year periods of birth preceding the survey (weighted), Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of years preceding the survey
Age at ––––––––––––––––––––––––––––––––––– Total
death (days) 0-4 5-9 10-14 15-19 0-19
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
<1 814 949 1,005 828 3,595
1 531 643 594 487 2,254
2 156 229 214 170 768
3 333 398 370 298 1,400
4 111 146 165 147 568
5 126 206 227 241 800
6 98 121 227 218 663
7 162 263 399 453 1,277
8 76 102 178 141 496
9 57 96 117 115 385
10 63 65 81 79 288
11 32 52 66 60 212
12 57 92 95 77 322
13 45 58 72 49 224
14 42 60 89 74 266
15 76 115 131 111 433
16 21 36 20 34 110
17 36 35 47 33 151
18 37 41 56 79 214
19 26 25 28 28 106
20 36 41 60 50 187
21 34 66 65 66 232
22 35 47 47 43 172
23 15 19 16 9 59
24 18 15 22 10 65
25 34 41 30 30 135
26 10 9 12 11 42
27 6 12 8 10 37
28 13 21 17 10 61
29 11 16 21 18 67
30 5 15 10 7 37
Missing 1 0 2 1 4

Total 0-30 3,118 4,034 4,491 3,985 15,628


Percent early
neonatal1 70 67 62 60 64
Percent early
neonatal 67 65 62 59 63
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
1
0-6 days/0-30 days

144 | Appendix C
Table C.6 Reporting of age at death in months

Distribution of reported deaths under one month of age by age at death in


months and the percentage of neonatal deaths reported to occur under one
month, for five-year periods of birth preceding the survey, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of years preceding the survey
Age at ––––––––––––––––––––––––––––––––––– Total
death (months) 0-4 5-9 10-14 15-19 0-19
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
<11 3,119 4,034 4,493 3,986 15,632
1 367 537 560 551 2,015
2 183 292 267 265 1,006
3 244 354 368 377 1,343
4 139 136 159 154 588
5 121 160 168 170 619
6 100 213 267 270 849
7 78 148 156 149 530
8 75 111 130 108 425
9 64 112 141 132 450
10 32 69 72 74 247
11 33 66 57 71 227
12 164 321 406 438 1,329
13 23 41 35 29 129
14 16 23 27 38 104
15 16 40 50 41 146
16 19 22 43 27 110
17 18 32 26 27 104
18 67 210 223 292 792
19 9 5 19 21 54
20 11 18 23 16 68
21 6 17 15 10 48
22 9 18 12 14 52
23 6 4 3 12 26
Missing 0 0 1 0 1
1 Year 0 0 0 3 3

Total 0-11 4,554 6,233 6,837 6,308 23,932


Percent neonatal2 68 65 66 63 65

Total 0-11 2,494 3,527 3,780 3,448 13,250


Percent neonatal 68 64 66 63 65
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
1
<1 includes deaths under one month reported in days
2
Percent neonatal = under one month/under one year

Appendix C | 145
SAMPLE IMPLEMENTATION Appendix D
Table D.1 Sample implementation

Percent distribution of households and eligible women in the sample by results of the interview, and household, eligible women and overall re-
sponse rates, according to residence and dividion, Bangladesh 2001
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Residence Division
–––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––
Metro-
Result of interview politan/ Other Chitta-
and response rate Urban town urban Rural Barisal gong Dhaka Khulna Rajshahi Sylhet Total
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Selected households
Completed (C) 94.3 93.2 95.6 95.3 92.1 93.1 96.7 97.4 93.8 96.6 95.1
Household present but no
competent respondent
at home (HP) 1.0 1.3 0.7 0.9 1.5 1.5 0.2 0.2 1.8 0.3 0.9
Postponed (P) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Refused (R) 0.1 0.2 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.1 0.1
Dwelling not found (DNF) 0.2 0.3 0.1 0.1 0.3 0.4 0.0 0.0 0.2 0.1 0.2
Household absent (HA) 2.2 2.5 1.9 2.3 4.1 3.2 1.2 1.3 3.0 1.2 2.3
Dwelling vacant/address
not a dwelling (DV) 1.7 2.1 1.3 1.0 1.5 1.2 1.2 0.8 0.9 1.4 1.1
Dwelling destroy (DD) 0.3 0.4 0.3 0.2 0.3 0.3 0.2 0.1 0.2 0.2 0.2
Other (O) 0.1 0.1 0.1 0.2 0.2 0.3 0.2 0.1 0.1 0.1 0.2

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number of sampled households 17,294 9,169 8,125 87,029 10,948 19,121 27,086 16,380 20,176 10,612 104,323
Household response rate (HRR) 98.6 98.2 99.1 98.9 98.0 98.0 99.6 99.7 97.9 99.5 98.8

Eligible women
Completed (EWC) 96.6 95.7 97.6 97.3 96.1 95.7 98.1 98.3 96.9 97.3 97.2
Not at home (EWNH) 3.0 3.9 2.0 2.3 3.5 3.9 1.5 1.4 2.8 2.1 2.4
Postponed (EWP) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Refused (EWR) 0.1 0.1 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.1 0.0
Partly completed (EWPC) 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Incapacitated (EWI) 0.3 0.2 0.3 0.3 0.3 0.3 0.3 0.2 0.3 0.3 0.3
Other (EWO) 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Number of women 17,943 9,502 8,441 88,846 10,615 19,473 28,100 17,370 19,920 11,311 106,789
Eligible women response
rate (EWRR) 96.6 95.7 97.6 97.3 96.1 95.7 98.1 98.3 96.9 97.3 97.2

Overall response rate (ORR) 95.2 94.0 96.7 96.2 94.2 93.7 97.7 98.1 94.9 96.8 96.1
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
1
Using the number of households falling into specific response categories, the household response rate (HRR) is calculated as:
100 x C
––––––––––––––––––––––
C + HP + R + DNF
2
Using the number of eligible women falling into specific response categories, the eligible woman response rate (EWRR) is calculated as:

100 x EWC
–––––––––––––––––––––––––––––––––––––––––
EWC + EWNH + EWR + EWPC + EWI + EWO
3
The overall response rate (ORR) is calculated as:

ORR = HRR * EWRR/100

Appendix D | 147
SAMPLING ERRORS Appendix E
Table E.1 List of selected variables for sampling errors, Bangladesh 2001

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Variable Description Base population
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
No education Proportion Ever-married women 13-49
With secondary education or higher Proportion Ever-married women 13-49
Currently married Proportion Ever-married women 13-49
Children ever born Mean Currently married women 15-49
Children surviving Mean Currently married women 15-49
Currently using any method Proportion Currently married women 13-49
Currently using a modern method Proportion Currently married women 13-49
Mothers received ANC from trained personnel Proportion Live births and stillbirths in the past 3 years
Mothers received medical care at birth Proportion Live births and stillbirths in the past 3 years
Mothers received PNC from trained personnel Proportion Live births and stillbirths in the past 3 years
One or more complications during pregnancy,
delivery or after delivery Proportion Live births and stillbirths in the past 3 years
Total fertility rate (3 years) Rate Women-years of exposure to childbearing
Neonatal mortality rate Rate Number of births exposed to death
Postneonatal mortality rate Rate Number of births exposed to death
Infant mortality rate Rate Number of births exposed to death
Child mortality rate Rate Number of births exposed to death
Under-five mortality rate Rate Number of births exposed to death

Table E.2 Sampling errors for selected variables, National sample, Bangladesh 2001

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of cases Confidence intervals
Stand- –––––––––––––––– Rela- ––––––––––––––––
ard Un- Weight- Design tive Value- Value+
Value error weighted ed effect error 2SE 2SE
Variable (R) (SE) (N) (WN) (DEFT) (SE/R) (R-2SE) (R+2SE)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
No education 0.465 0.003 103796 103796 1.953 0.007 0.459 0.471
With secondary education or higher 0.252 0.003 103796 103796 2.114 0.011 0.246 0.258
Currently married 0.934 0.001 103796 103796 1.183 0.001 0.932 0.936
Children ever born 3.107 0.010 95253 95366 1.305 0.003 3.088 3.127
Children surviving 2.645 0.008 95253 95366 1.244 0.003 2.630 2.661
Currently using any method 0.501 0.002 96805 96945 1.481 0.005 0.496 0.506
Currently using a modern method 0.438 0.002 96805 96945 1.433 0.005 0.434 0.443
Mothers received ANC from trained personnel 0.401 0.004 41272 40657 1.666 0.010 0.393 0.409
Mothers received medical care at birth 0.122 0.003 41272 40657 1.576 0.021 0.117 0.127
Mothers received PNC from trained personnel 0.105 0.002 41272 40657 1.306 0.019 0.101 0.109
One or more complications during pregnancy,
delivery or after delivery 0.605 0.003 41272 40657 1.311 0.005 0.599 0.612
Total fertility rate (3 years) 3.222 0.028 na na 1.736 0.009 3.165 3.278
Neonatal mortality rate 47.172 0.979 70293 69149 1.128 0.021 45.214 49.131
Postneonatal mortality rate 24.307 0.666 70416 69268 1.111 0.027 22.975 25.639
Infant mortality rate 71.479 1.205 70436 69288 1.157 0.017 69.068 73.890
Child mortality rate 25.556 0.693 71097 69914 1.104 0.027 24.170 26.942
Under-five mortality rate 95.208 1.395 71260 70073 1.187 0.015 92.418 97.999
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
na = Not applicable

Appendix E | 149
Table E.3 Sampling errors for selected variables, Urban sample, Bangladesh 2001

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of cases Confidence intervals
Stand- –––––––––––––––– Rela- ––––––––––––––––
ard Un- Weight- Design tive Value- Value+
Value error weighted ed effect error 2SE 2SE
Variable (R) (SE) (N) (WN) (DEFT) (SE/R) (R-2SE) (R+2SE)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
No education 0.359 0.008 17330 19896 2.251 0.023 0.343 0.376
With secondary education or higher 0.392 0.010 17330 19896 2.744 0.026 0.372 0.412
Currently married 0.923 0.003 17330 19896 1.267 0.003 0.917 0.928
Children ever born 3.107 0.010 95253 95366 1.305 0.003 3.088 3.127
Children surviving 2.433 0.018 15811 18163 1.283 0.007 2.397 2.469
Currently using any method 0.562 0.006 15981 18355 1.523 0.011 0.550 0.574
Currently using a modern method 0.479 0.006 15981 18355 1.407 0.012 0.468 0.490
Mothers received ANC from trained personnel 0.589 0.011 6127 6989 1.802 0.019 0.566 0.612
Mothers received medical care at birth 0.273 0.003 41272 40657 1.576 0.021 0.117 0.127
Mothers received PNC from trained personnel 0.199 0.008 6127 6989 1.525 0.039 0.184 0.215
One or more complications during pregnancy,
delivery or after delivery 0.625 0.009 6127 6989 1.412 0.014 0.607 0.642
Total fertility rate (3 years) 2.695 0.055 na na 1.649 0.020 2.584 2.805
Neonatal mortality rate 41.564 2.381 10393 11856 1.126 0.057 36.802 46.325
Postneonatal mortality rate 23.079 1.556 10406 11870 1.011 0.067 19.967 26.192
Infant mortality rate 64.643 2.895 10407 11872 1.116 0.045 58.853 70.434
Child mortality rate 22.089 1.601 10507 11985 1.095 0.072 18.886 25.292
Under-five mortality rate 85.304 3.320 10522 12001 1.140 0.039 78.664 91.944
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
na = Not applicable

Table E.4 Sampling errors for selected variables, Rural sample, Bangladesh 2001

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of cases Confidence intervals
Stand- –––––––––––––––– Rela- ––––––––––––––––
ard Un- Weight- Design tive Value- Value+
Value error weighted ed effect error 2SE 2SE
Variable (R) (SE) (N) (WN) (DEFT) (SE/R) (R-2SE) (R+2SE)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
No education 0.490 0.003 86466 83900 1.863 0.006 0.483 0.496
With secondary education or higher 0.219 0.003 86466 83900 1.795 0.012 0.214 0.224
Currently married 0.937 0.001 86466 83900 1.142 0.001 0.935 0.939
Children ever born 3.178 0.011 79442 77203 1.283 0.003 3.156 3.199
Children surviving 2.695 0.008 79442 77203 1.238 0.003 2.678 2.712
Currently using any method 0.487 0.003 80824 78590 1.465 0.005 0.482 0.492
Currently using a modern method 0.429 0.002 80824 78590 1.434 0.006 0.424 0.434
Mothers received ANC from trained personnel 0.362 0.004 35145 33669 1.669 0.012 0.354 0.371
Mothers received medical care at birth 0.090 0.003 41272 40657 1.576 0.021 0.117 0.127
Mothers received PNC from trained personnel 0.086 0.002 35145 33669 1.213 0.021 0.082 0.090
One or more complications during pregnancy,
delivery or after delivery 0.602 0.003 35145 33669 1.285 0.006 0.595 0.608
Total fertility rate (3 years) 3.355 0.032 na na 1.726 0.010 3.292 3.419
Neonatal mortality rate 48.335 1.073 59900 57293 1.129 0.022 46.190 50.481
Postneonatal mortality rate 24.560 0.737 60010 57397 1.134 0.030 23.087 26.034
Infant mortality rate 72.896 1.323 60029 57416 1.166 0.018 70.249 75.542
Child mortality rate 26.270 0.766 60590 57929 1.106 0.029 24.737 27.802
Under-five mortality rate 97.250 1.531 60738 58071 1.194 0.016 94.188 100.312
No education 0.359 0.008 17330 19896 2.251 0.023 0.343 0.376
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
na = Not applicable

150 | Appendix E
Table E.5 Sampling errors for selected variables, Barisol sample, Bangladesh 2001

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of cases Confidence intervals
Stand- –––––––––––––––– Rela- ––––––––––––––––
ard Un- Weight- Design tive Value- Value+
Value error weighted ed effect error 2SE 2SE
Variable (R) (SE) (N) (WN) (DEFT) (SE/R) (R-2SE) (R+2SE)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
No education 0.305 0.007 10202 6839 1.454 0.022 0.292 0.319
With secondary education or higher 0.265 0.008 10202 6839 1.763 0.029 0.249 0.280
Currently married 0.948 0.003 10202 6839 1.161 0.003 0.943 0.953
Children ever born 3.204 0.032 9514 6376 1.342 0.010 3.140 3.268
Children surviving 2.709 0.025 9514 6376 1.289 0.009 2.660 2.758
Currently using any method 0.478 0.007 9680 6486 1.393 0.015 0.463 0.492
Currently using a modern method 0.415 0.007 9680 6486 1.397 0.017 0.401 0.429
Mothers received ANC from trained personnel 0.298 0.012 4015 2672 1.674 0.041 0.274 0.322
Mothers received medical care at birth 0.088 0.007 4015 2672 1.481 0.075 0.074 0.101
Mothers received PNC from trained personnel 0.053 0.005 4015 2672 1.398 0.093 0.043 0.063
One or more complications during pregnancy,
delivery or after delivery 0.496 0.010 4015 2672 1.226 0.020 0.477 0.515
Total fertility rate (3 years) 3.316 0.079 na na 1.483 0.024 3.157 3.475
Neonatal mortality rate 39.502 2.653 6858 4572 1.062 0.067 34.196 44.807
Postneonatal mortality rate 22.250 1.881 6875 4583 1.004 0.085 18.487 26.013
Infant mortality rate 61.752 3.201 6875 4583 1.038 0.052 55.351 68.154
Child mortality rate 31.194 2.288 6954 4636 1.052 0.073 26.619 35.770
Under-five mortality rate 91.020 3.607 6971 4647 0.998 0.040 83.805 98.235
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
na = Not applicable

Table E.6 Sampling errors for selected variables, Chittagong sample, Bangladesh 2001

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of cases Confidence intervals
Stand- –––––––––––––––– Rela- ––––––––––––––––
ard Un- Weight- Design tive Value- Value+
Value error weighted ed effect error 2SE 2SE
Variable (R) (SE) (N) (WN) (DEFT) (SE/R) (R-2SE) (R+2SE)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
No education 0.432 0.006 18633 18275 1.711 0.014 0.420 0.445
With secondary education or higher 0.306 0.006 18633 18275 1.863 0.021 0.294 0.319
Currently married 0.943 0.002 18633 18275 1.210 0.002 0.938 0.947
Children ever born 3.413 0.021 17416 17078 1.134 0.006 3.370 3.455
Children surviving 2.963 0.017 17416 17078 1.077 0.006 2.930 2.997
Currently using any method 0.377 0.005 17569 17226 1.331 0.013 0.367 0.386
Currently using a modern method 0.336 0.005 17569 17226 1.357 0.014 0.326 0.345
Mothers received ANC from trained personnel 0.394 0.008 8639 8440 1.542 0.021 0.378 0.410
Mothers received medical care at birth 0.118 0.004 8639 8440 1.261 0.037 0.109 0.127
Mothers received PNC from trained personnel 0.075 0.003 8639 8440 1.231 0.047 0.068 0.082
One or more complications during pregnancy,
delivery or after delivery 0.496 0.007 8639 8440 1.303 0.014 0.482 0.510
Total fertility rate (3 years) 3.736 0.063 na na 1.598 0.017 3.610 3.862
Neonatal mortality rate 34.764 2.653 6858 4572 1.062 0.067 34.196 44.807
Postneonatal mortality rate 20.098 1.209 14694 14360 1.019 0.060 17.681 22.516
Infant mortality rate 54.862 2.042 14696 14362 1.025 0.037 50.779 58.945
Child mortality rate 29.925 1.642 14866 14528 1.145 0.055 26.641 33.208
Under-five mortality rate 83.145 2.591 14896 14557 1.094 0.031 77.963 88.328
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
na = Not applicable

Appendix E | 151
Table E.7 Sampling errors for selected variables, Dhaka sample, Bangladesh 2001

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of cases Confidence intervals
Stand- –––––––––––––––– Rela- ––––––––––––––––
ard Un- Weight- Design tive Value- Value+
Value error weighted ed effect error 2SE 2SE
Variable (R) (SE) (N) (WN) (DEFT) (SE/R) (R-2SE) (R+2SE)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
No education 0.471 0.007 27577 35848 2.228 0.014 0.457 0.484
With secondary education or higher 0.253 0.006 27577 35848 2.393 0.025 0.240 0.265
Currently married 0.928 0.002 27577 35848 1.176 0.002 0.925 0.932
Children ever born 3.123 0.021 25164 32705 1.437 0.007 3.081 3.165
Children surviving 2.624 0.016 25164 32705 1.374 0.006 2.591 2.656
Currently using any method 0.522 0.005 25604 33274 1.644 0.010 0.512 0.533
Currently using a modern method 0.445 0.005 25604 33274 1.568 0.011 0.436 0.455
Mothers received ANC from trained personnel 0.406 0.008 10773 13978 1.703 0.020 0.390 0.422
Mothers received medical care at birth 0.133 0.006 10773 13978 1.700 0.042 0.122 0.144
Mothers received PNC from trained personnel 0.140 0.005 10773 13978 1.369 0.033 0.131 0.149
One or more complications during pregnancy,
delivery or after delivery 0.722 0.006 10773 13978 1.329 0.008 0.710 0.733
Total fertility rate (3 years) 3.220 0.050 na na 1.616 0.016 3.120 3.320
Neonatal mortality rate 48.887 1.823 18209 23625 1.064 0.037 45.241 52.532
Postneonatal mortality rate 26.897 1.342 18240 23665 1.101 0.050 24.214 29.580
Infant mortality rate 75.784 2.261 18249 23677 1.090 0.030 71.261 80.306
Child mortality rate 26.539 1.325 18407 23881 1.044 0.050 23.889 29.188
Under-five mortality rate 100.311 2.679 18456 23945 1.147 0.027 94.953 105.669
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
na = Not applicable

Table E.8 Sampling errors for selected variables, Khulna sample, Bangladesh 2001

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of cases Confidence intervals
Stand- –––––––––––––––– Rela- ––––––––––––––––
ard Un- Weight- Design tive Value- Value+
Value error weighted ed effect error 2SE 2SE
Variable (R) (SE) (N) (WN) (DEFT) (SE/R) (R-2SE) (R+2SE)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
No education 0.402 0.006 17079 12307 1.605 0.015 0.390 0.414
With secondary education or higher 0.282 0.006 17079 12307 1.869 0.023 0.269 0.295
Currently married 0.931 0.002 17079 12307 1.023 0.002 0.927 0.935
Children ever born 2.791 0.018 15598 11240 1.083 0.007 2.754 2.827
Children surviving 2.424 0.015 15598 11240 1.035 0.006 2.395 2.453
Currently using any method 0.618 0.005 15896 11454 1.291 0.008 0.608 0.628
Currently using a modern method 0.522 0.005 15896 11454 1.219 0.009 0.512 0.531
Mothers received ANC from trained personnel 0.480 0.009 5444 3919 1.330 0.019 0.462 0.498
Mothers received medical care at birth 0.169 0.007 5444 3919 1.302 0.039 0.156 0.182
Mothers received PNC from trained personnel 0.148 0.005 5444 3919 1.103 0.036 0.138 0.159
One or more complications during pregnancy,
delivery or after delivery 0.746 0.006 5444 3919 1.057 0.008 0.733 0.758
Total fertility rate (3 years) 2.608 0.048 na na 1.368 0.019 2.511 2.704
Neonatal mortality rate 42.445 2.378 9384 6752 1.080 0.056 37.688 47.202
Postneonatal mortality rate 16.646 1.428 9391 6757 1.060 0.086 13.791 19.502
Infant mortality rate 59.091 2.897 9395 6760 1.139 0.049 53.297 64.886
Child mortality rate 15.879 1.284 9450 6800 1.001 0.081 13.311 18.448
Under-five mortality rate 74.032 3.241 9465 6810 1.171 0.044 67.551 80.513
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
na = Not applicable

152 | Appendix E
Table E.9 Sampling errors for selected variables, Rajshahi sample, Bangladesh 2001

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of cases Confidence intervals
Stand- –––––––––––––––– Rela- ––––––––––––––––
ard Un- Weight- Design tive Value- Value+
Value error weighted ed effect error 2SE 2SE
Variable (R) (SE) (N) (WN) (DEFT) (SE/R) (R-2SE) (R+2SE)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
No education 0.527 0.005 19296 24495 1.516 0.010 0.516 0.538
With secondary education or higher 0.217 0.005 19296 24495 1.604 0.022 0.208 0.227
Currently married 0.944 0.002 19296 24495 1.064 0.002 0.940 0.947
Children ever born 2.866 0.017 17834 22639 1.087 0.006 2.831 2.900
Children surviving 2.455 0.014 17834 22639 1.034 0.006 2.428 2.482
Currently using any method 0.564 0.004 18209 23113 1.191 0.008 0.555 0.573
Currently using a modern method 0.521 0.004 18209 23113 1.140 0.008 0.513 0.530
Mothers received ANC from trained personnel 0.401 0.009 6750 8559 1.527 0.023 0.383 0.420
Mothers received medical care at birth 0.107 0.005 6750 8559 1.403 0.049 0.097 0.118
Mothers received PNC from trained personnel 0.050 0.003 6750 8559 1.013 0.054 0.045 0.056
One or more complications during pregnancy,
delivery or after delivery 0.452 0.007 6750 8559 1.095 0.015 0.439 0.466
Total fertility rate (3 years) 2.854 0.051 na na 1.439 0.018 2.752 2.957
Neonatal mortality rate 54.388 2.455 11500 14582 1.073 0.045 49.479 59.297
Postneonatal mortality rate 24.366 1.460 11519 14606 0.983 0.060 21.446 27.285
Infant mortality rate 78.754 2.931 11521 14609 1.093 0.037 72.892 84.615
Child mortality rate 19.953 1.361 11595 14703 1.016 0.068 17.231 22.676
Under-five mortality rate 97.135 3.199 11618 14732 1.094 0.033 90.737 103.534
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
na = Not applicable

Table E.10 Sampling errors for selected variables, Sylhet sample, Bangladesh 2001

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Number of cases Confidence intervals
Stand- –––––––––––––––– Rela- ––––––––––––––––
ard Un- Weight- Design tive Value- Value+
Value error weighted ed effect error 2SE 2SE
Variable (R) (SE) (N) (WN) (DEFT) (SE/R) (R-2SE) (R+2SE)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
No education 0.587 0.009 11009 6032 1.964 0.016 0.568 0.605
With secondary education or higher 0.149 0.006 11009 6032 1.716 0.039 0.138 0.161
Currently married 0.894 0.004 11009 6032 1.202 0.004 0.887 0.901
Children ever born 3.613 0.030 9727 5327 1.113 0.008 3.553 3.673
Children surviving 2.961 0.026 9727 5327 1.157 0.009 2.910 3.012
Currently using any method 0.281 0.007 9847 5393 1.576 0.025 0.266 0.295
Currently using a modern method 0.214 0.007 9847 5393 1.619 0.031 0.200 0.227
Mothers received ANC from trained personnel 0.386 0.010 5651 3088 1.583 0.027 0.366 0.407
Mothers received medical care at birth 0.090 0.005 5651 3088 1.338 0.057 0.080 0.100
Mothers received PNC from trained personnel 0.175 0.006 5651 3088 1.284 0.037 0.162 0.188
One or more complications during pregnancy,
delivery or after delivery 0.719 0.008 5651 3088 1.319 0.011 0.703 0.735
Total fertility rate (3 years) 4.271 0.073 na na 1.311 0.017 4.125 4.416
Neonatal mortality rate 65.904 3.002 9674 5284 1.074 0.046 59.901 71.908
Postneonatal mortality rate 35.538 2.272 9697 5296 1.192 0.064 30.993 40.083
Infant mortality rate 101.443 3.554 9700 5298 1.053 0.035 94.335 108.550
Child mortality rate 32.973 2.241 9825 5366 1.114 0.068 28.492 37.455
Under-five mortality rate 131.071 4.482 9854 5381 1.176 0.034 122.107 140.035
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
na = Not applicable

Appendix E | 153
PERSONNEL INVOLVED IN BMMS 2001 Appendix F
Technical Review Committee (TRC)

Mr. Lokman Hakim, Director General, NIPORT Chairman


Dr. Ranjit Kumar Dey, Line Director (Planning and Research), Directorate of Health Services Member
Dr. A.S.M. Kamal, Line Director (ESP-RH), Directorate of Family Planning Member
Mr. Shaheruddin Mollah, Director (Planning), Directorate of Family Planning Member
Director, Census Wing, Bangladesh Bureau of Statistics (BBS) Member
Dr. Md. Bazlur Rahman, Director, PDEU, IME Division, Ministry of Planning Member
Mr. Md. Mozammel Haque, Deputy Chief (Health), Ministry of Health and Family Welfare Member
Mrs. Mobashera Begum, Director, BIRPERHT Member
Dr. S.M. Asib Nasim, Deputy Team Leader, Program Coordination Cell (PCC) Member
Dr. Enamul Karim, Consultant, Management Change Unit (MCU) Member
Professor M. Kabir, Department of Statistics, Jahangeer Nagar University Member
Professor M. Ataharul Islam, Department of Statistics, University of Dhaka Member
Professor M. Sekander H. Khan, Institute of Statistical Research and Training, University of Dhaka Member
Dr. Suniti Acharya, Country Representative, WHO Member
Mr. J.S. Kang, Sr. Population Specialist, Social Sector Team, World Bank Member
Ms. Janit E. Jackson, Deputy Representative, UNFPA-Bangladesh Member
Dr. A.N. Zafar Ullah, Senior Program Monitor, CIDA-Bangladesh Member
Dr. Peter Kim Streatfield, Head, Health and Demographic Surveillance Program, ICDDR,B Member
Dr. M. Alauddin, Chief of Party, Rural Service Delivery Program, Pathfinder International Member
Dr. Ahmed Al-Kabir, Chief of Party, Urban Family Health Partnership Member
Mr. Mohammad Shahjahan, Director, Bangladesh Centre for Communication Program Member
Dr. A.M.R. Chowdhury, Head, Research and Evaluation Division, BRAC Member
Dr. Fahrat Hossain, Assistant Professor, Department of Obstetric and Gynaecology, DMCH Member
Dr. Kanta Jamil, Program Coordinator for Research, PHN Team, USAID, Dhaka Member
Dr. Yasmin Ali Haque, Project Officer, Health and Nutrition Section, UNICEF-Bangladesh Member
Dr. Tulshi D. Saha, Demographer, ORC Macro, USA Member
Professor Michael Koenig, Johns Hopkins University, USA Member
Mr. S.N. Mitra, Executive Director, Mitra and Associates Member
Mrs. Haidary Kamal, Executive Director, Associates for Community and Population Research Member
Dr. Ahmed Al-Sabir, Director (Research), NIPORT Member-Secretary

Technical Task Force(TTF)

Dr. Ahmed Al-Sabir, Director (Research), NIPORT - Chairman


Dr. Jafar Ahmed Hakim, Deputy Director (CS), ESP-RH, Directorate of Family Planning
Dr. Momena Khatun, Deputy Director (MCH), ESP-RH, Directorate of Family Planning
Dr. Peter Kim Streatfield, Head, Health and Demographic Surveillance Program, ICDDR,B
Dr. Kanta Jamil, Program Coordinator for Research, Population, Health and Nutrition Team, USAID, Dhaka
Dr. Tulshi D. Saha, Demographer, ORC Macro, USA
Dr. Shams-El-Arifeen, Head, Child Health Program, PHSD, ICDDR,B
Dr. Yasmin Ali Haque, Project Officer, Health and Nutrition Section, UNICEF-Bangladesh

Appendix F | 155
NIPORT
Dr. Ahmed Al-Sabir, Country Coordinator
Mr. Subrata K. Bhadra
Mrs. Shahin Sultana

ORC Macro
Dr. Tulshi D. Saha
Ms. Anne Cross
Dr. Alfredo Aliaga
Mr. Han Raggers
Mr. Sushil Kumar
Dr. Sidney Moore
Kaye Mitchell

Associates for Community and Population Research (ACPR)


Dr. M. Sekandar H. Khan
Mr. A.P.M. Shafiur Rahman
Mrs. Tauhida Nasrin
Mr. Nitai Chakraborty

Mitra and Associates


Mr. S.N. Mitra
Mr. Shahidul Islam
Mr. S. Fuad Pasha

Johns Hopkins University


Prof. Kenneth Hill
Prof. Michael Koenig

ICDDR,B
Dr. Peter Kim Streatfield
Dr. Shams-El-Arifeen

USAID
Dr. Kanta Jamil

Others
Dr. Yasmin Ali Haque, UNICEF
Dr. Fahrat Hossain, Dhaka Medical College

156 | Appendix F
QUESTIONNAIRES Appendix G

Appendix G | 157
BANGLADESH MATERNAL HEALTH SERVICES AND MATERNAL MORTALITY SURVEY 2001
HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

DIVISION _____________________________________________________________________

DISTRICT _____________________________________________________________________

THANA ______________________________________________________________________

UNION/WARD __________________________________________________________________

MOUZA/MOHALLA_______________________________________________________________

VILLAGE/MOHALLA/BLOCK_______________________________________________________

SEGMENT NUMBER____________________________________________________________

TYPE OF ARE: Rural 1 Urban 2 Other Urban 3_________________________________________

CLUSTER NUMBER ................................................................................................................................

HOUSEHOLD NUMBER ..........................................................................................................................

NAME OF THE HOUSEHOLD HEAD ______________________________________________

INTERVIEWER VISITS

1 2 3 FINAL VISIT

DAY

DATE MONTH
YEAR
INTV. CODE
INTERVIEWER’S NAME RESULT*
RESULT*

NEXT VISIT: DATE ┌───┐


TOTAL NO. │░░░│
TIME OF VISITS └───┘

TOTAL ┌───┬───┐
PERSONS IN │░░░│░░░│
*RESULT CODES: HOUSEHOLD └───┴───┘
1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT
AT HOME AT TIME OF VISIT TOTAL ┌───┬───┐
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME ELIGIBLE │░░░│░░░│
4 POSTPONED WOMEN └───┴───┘
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED LINE NO. OF
8 DWELLING NOT FOUND RESP. TO ┌───┬───┐
9 OTHER HOUSEHOLD │░░░│░░░│
(SPECIFY) SCHEDULE └───┴───┘

SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY

NAME ┌───┬───┐ NAME ┌───┬───┐ ┌───┬───┐ ┌───┬───┐


│░░░│░░░│ │░░░│░░░│ │░░░│░░░│ │░░░│░░░│
DATE └───┴───┘ DATE └───┴───┘ └───┴───┘ └───┴───┘
INFORMED CONSENT

Hello

My name is _________________________________________________________. I have come from


___________________________, a non- government research organization. Our office is located in Dhaka. We
conduct different kind of socio-economic survey in Bangladesh. Currently, we are conducting a national level
survey under National Institute of Population Research and training (NIPORT) of Ministry of Health and Family
Welfare. For this reason, we are collecting health information for all women 13-49 years old from your household.
This information will help Government to improve the maternal and child health services and reduce maternal
mortality in Bangladesh. The information you will provide will keep secret and your household could not be
identified from this survey.

The participation in this survey is voluntary and you have liberty not to answer any part of the question or full
questionnaire. However, we hope that you will participate in this survey because your information in most
important.

Now you can ask me any questions regarding this survey.

May I start the interview?

Signature of interviewer:_________________________________ Date:____________________________

The respondent agreed to participate___________________1

The respondent did not agree to participate_______________2 END


HOUSEHOLD SCHEDULE

Now we would like some information about the people who usually live in your household or who are staying with you now.
LINE USUAL RESIDENTS AND RELATIONSHIP SEX RESIDENCE AGE MARITAL WOMAN EDUCATION EMPLOYMENT
NO. VISITORS TO HEAD OF STATUS ELIGI-
HOUSEHOLD BILITY
IF AGE 5 YEARS OR OLDER IF AGE 5 YEARS OR OLDER

Please give me the names of What is the Is (NAME) Does Did How old is FOR ALL AGED CIRCLE Has What is the highest Is (NAME) Does (NAME) receive
the persons who usually live in relationship of male or (NAME) (NAME) (NAME)? 13 OR ABOVE LINE (NAME) level of school currently wages/income in cash or kind?
your household and guests of (NAME) to the female? usually sleep here NUMBER ever (NAME) has working?
the household who stayed head of the live here? last night? OF ALL attended attended?***
here last night, starting with household?* WRITE '00' EVER school?
the head of the household. IF LESS MARRIED
THAN ONE. What is the highest
What is the current WOMEN class (NAME)
marital status of AGE completed at that
(NAME)?** 13-49 level?***
(Q4=2 &
Q8=1 OR
2)

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (13) (14)

CASH KIND BOTH NONE


M F YES NO YES NO IN YEARS CM FM NM YES NO LEVEL CLASS YES NO

1 2 ┌───┐ ┌───┬───┐ 1 2 1 2 3 4
┌───┬───┐ ┌───┬───┐
│░░░│░░░│ │░░░│░░░│ GO TO =┘ │░░░│ │░░░│░░░│ NEXT =┘
1 2 1 2 1 2 1 2 3 01 └───┘ └───┴───┘
01 └───┴───┘ └───┴───┘ 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 02 └───┘ └───┴───┘
02 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 03 └───┘ └───┴───┘
03 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 04 └───┘ └───┴───┘
04 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 05 └───┘ └───┴───┘
05 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 06 └───┘ └───┴───┘
06 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 07 └───┘ └───┴───┘
07 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 08 └───┘ └───┴───┘
08 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 09 └───┘ └───┴───┘
09 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 10 └───┘ └───┴───┘
10 13 LINE

HOUSEHOLD SCHEDULE CONTINUED

Bangladesh Maternal Health Services and Maternal Mortality Survey 2001 Household Section
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (13) (14)

CASH KIND BOTH NONE


M F YES NO YES NO IN YEARS CM FM NM YES NO LEVEL CLASS YES NO

1 2 ┌───┐ ┌───┬───┐ 1 2 1 2 3 4
┌───┬───┐ ┌───┬───┐
│░░░│░░░│ │░░░│░░░│ GO TO =┘ │░░░│ │░░░│░░░│ NEXT =┘
1 2 1 2 1 2 1 2 3 11 └───┘ └───┴───┘
11 └───┴───┘ └───┴───┘ 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 12 └───┘ └───┴───┘
12 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 13 └───┘ └───┴───┘
13 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 14 └───┘ └───┴───┘
14 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 15 └───┘ └───┴───┘
15 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 16 └───┘ └───┴───┘
16 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 17 └───┘ └───┴───┘
17 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 18 └───┘ └───┴───┘
18 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 19 └───┘ └───┴───┘
19 13 LINE

┌───┬───┐ ┌───┬───┐ 1 2 ┌───┐ ┌───┬───┐ 1 2


│░░░│ │░░░│░░░│ 1 2 3 4
│░░░│░░░│ │░░░│░░░│ 1 2 3 GO TO =┘ NEXT =┘
└───┴───┘ 1 2 1 2 1 2 └───┴───┘ 20 └───┘ └───┴───┘
20 13 LINE

TICK HERE IF CONTINUATION SHEET USED


Are there any other persons such as small children or infants that we have not ┌───┐
1) listed? YES └───┴──< ENTER EACH IN TABLE NO
2) In addition, are there any other people who may not be members of your family, such ┌───┐
as domestic servants, lodgers or friends who usually live here? YES └───┴──< ENTER EACH IN TABLE NO
3) Are there any guests or temporary visitors staying here, or anyone else who slept ┌───┐
here last night, who have not been listed? YES └───┴──< ENTER EACH IN TABLE NO

15. TOTAL NUMBER OF ELIGIBLE WOMEN (CIRCLED IN


COLUMN 9)

* CODES FOR Q.3 06=PARENT ** CODE FOR Q.8 ***CODES FOR Q11
RELATIONSHIP TO HEAD OF 07 = PARENT-IN-LAW MARITAL STATUS: EDUCATION LEVEL:
HOUSEHOLD: 08 = BROTHER OR SISTER 1 = PRIMARY
01 = HEAD 09 = OTHER RELATIVE 1 = CURRENTLY MARRIED (CM) 2 = SECONDARY
02 = WIFE OR HUSBAND 10 = ADOPTED/FOSTER/ 2 = FORMERLY MARRIED 3 = COLLEGE/UNIVERSITY
03 = SON OR DAUGHTER STEPCHILD (DIVORCED/WIDOWED/SEPARATED/ 8 = DON’T KNOW
04 = SON-IN-LAW OR 11 = NOT RELATED DESERTED) (FM) CLASS
DAUGHTER-IN-LAW 98 = DON’T KNOW 3 = NEVER MARRIED (NM) 00 = LOWER THAN FIRST
05 = GRANDCHILD GRADE
98 = DONOT KNOW

Bangladesh Maternal Health Services and Maternal Mortality Survey 2001 Household Section
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
What kind of toilet facility does your household have? SEPTIC TANK/MODERN TOILET ..........11
16
WATER SEALED/SLAB LATRINE ..........21
PIT LATRINE...........................................22
OPEN LATRINE ......................................23
HANGING LATRINE................................24
NO FACILITY ..........................................31 17
OTHER 96

16A Do you share this facility with other households? YES ...........................................................1
NO .............................................................2

17 Does your household (or any member of your household) have: YES NO
Electricity? ELECTRICITY ..............................1 2
Almirah (wardrobe/showcase)? ALMIRAH......................................1 2
A table or chair? TABLE/CHAIR ..............................1 2
A bench? BENCH .........................................1 2
A watch or clock? WATCH/CLOCK ...........................1 2
A cot or bed? COT/BED......................................1 2
A radio that is working? RADIO ..........................................1 2
A television that is working? TELEVISION ................................1 2
A bicycle? BICYCLE ......................................1 2
A Motorcycle? MOTORCYCLE ............................1 2
A Sewing machine? SEWING MACHINE .....................1 2
Telephone? TELEPHONE................................1 2

18A MAIN MATERIAL OF THE ROOF. NATURAL ROOF


KATCHA (BAMBOO/THATCH) ...........11
RUDIMENTARY ROOF
RECORD OBSERVATION. TIN.......................................................21
TILE .....................................................22
FINISHED ROOF (PUKKA)
CEMENT/CONCRETE ........................31
OTHER 96
(SPECIFY)

18B MAIN MATERIAL OF THE WALLS. NATURAL WALLS


JUTE/BAMBOO/MUD (KATCHA)........11
RUDIMENTARY WALLS
RECORD OBSERVATION. WOOD .................................................21
FINISHED WALLS
BRICK/CEMENT .................................31
TIN.......................................................32
OTHER 96
(SPECIFY)

18C MAIN MATERIAL OF THE FLOOR. NATURAL FLOOR


EARTH/BAMBOO (KATCHA)..............11
RUDIMENTARY FLOOR
RECORD OBSERVATION. WOOD .................................................21
FINISHED FLOOR (PUKKA)
CEMENT/CONCRETE ........................31
OTHER 96
(SPECIFY)
19 Does your household own any homestead? IF ‘NO’, PROBE: YES ...........................................................1
Does your household own homestead any other places? NO .............................................................2

20 Does your household own any land (other than the homestead land)? YES ...........................................................1
NO .............................................................2 22
How much land does your household own (other than the homestead AMOUNT
20A land)? AMOUNT __________________
UNIT __________________ ACRES DECIMALS
(SPECIFY)

22 Did any usual resident of this household die since April 1997 or YES ...........................................................1
Baishak 1404? NO .............................................................2 37

23 How many persons died? TOTAL PERSONS . ...............................

Bangladesh Maternal Health Services and Maternal Mortality Survey 2001 Household Section
I would like to know about the person died in your household since April 1997 (Baishak 1404). Please provide me the information first on recent death.

24 25 26 27 28 29 FOR 13-49 YEARS OLD WOMEN


30 31 32 33 34 35

What (was/were) the Was (NAME) a How old was he/she What did (NAME) CHECK 25 AND Was (NAME) ELIGIBILITY FOR
In what month and year did die of? 26: Was (NAME) Did (NAME) Did (NAME) Did (NAME)
name(s) of the male or female? when he/she died? pregnant when VERBAL
(NAME) die? married? die during die within die at home or
person(s) who died? she died? AUTOPSY:
RECORD DAYS IF DECEASED childbirth? six weeks IF CIRCLE '1' IN outside home?
LESS THAN ONE WAS FEMALE after the Q.29 THEN
MONTH, MONTHS IF AGED 13-49 AT end of a CIRCLE LINE
LESS THAN TWO THE TIME OF pregnancy NUMBER
YEARS, OR YEARS IF DEATH. or
TWO OR MORE childbirth?
YEARS.

01 AT
MALE ............... 1 DAYS.........1 MONTH YES........... 1 YES .......... 1 YES ...........1 YES........... 1 YES ........ 1 HOME
01 ........... 1
FEMALE........... 2 MONTHS...2 YEAR NO ............ 2 NO ............ 2 NO .......... 2
(GO TO 34) (GO TO 34) OUT
(NAME) SIDE
YEARS.......3 (GO TO NEXT (GO T0 34) NO.............2 NO ............ 2 HOME
DEATH) ........... 2

02 AT
MALE ............... 1 DAYS.........1 MONTH YES........... 1 YES .......... 1 YES ...........1 YES........... 1 YES ........ 1 HOME
02 ........... 1
FEMALE........... 2 MONTHS...2 YEAR NO ............ 2 NO ............ 2 NO .......... 2
(GO TO 34) (GO TO 34) OUT
(NAME) SIDE
YEARS.......3 (GO TO NEXT (GO T0 34) NO.............2 NO ............ 2 HOME
DEATH) ........... 2

03 AT
MALE ............... 1 DAYS.........1 MONTH YES........... 1 YES .......... 1 YES ...........1 YES........... 1 YES ........ 1 HOME
03 ........... 1
FEMALE........... 2 MONTHS...2 YEAR NO ............ 2 NO ............ 2 NO .......... 2
(GO TO 34) (GO TO 34) OUT
(NAME) ______________ SIDE
YEARS.......3 ______________ (GO TO NEXT (GO T0 34) NO.............2 NO ............ 2 HOME
DEATH) ........... 2

TOTAL NUMBER OF PERSONS CIRCLED IN Q.34 ……………….. (INTERVIEWERS: PLEASE INFORM YOUR SUPERVISOR ABOUT THE NUMBER OF ELIGIBLE VERBAL AUTOPSY CASES IN THIS HOUSEHOLD)
36

SUPERVISOR: ATTEMPT VERBAL AUTOPSY OF NUMBER OF CASES WROTE IN Q.36

INTERVIEWERS: INTERVIEW ALL WOMEN MENTIONED IN Q.15 USING THE WOMEN QUESTIONNAIRE.
37

Bangladesh Maternal Health Services and Maternal Mortality Survey 2001 Household Section
BANGLADESH MATERNAL HEALTH SERVICES AND MATERNAL MORTALITY SURVEY 2001
WOMAN’S QUESTIONNAIRE

IDENTIFICATION

DIVISION ____________________________________________________________________

DISTRICT ___________________________________________________________________

THANA ____________________________________________________________________

UNION/WARD ________________________________________________________________

MOUZA/MOHALLA___________________________________________________________

VILLAGE/MOHALLA/BLOCK___________________________________________________

SEGMENT NUMBER________________________________________________________

TYPE OF AREA: Rural 1 Urban 2 Other Urban 3_______________________________________

CLUSTER NUMBER ................................................................................................................................

HOUSEHOLD NUMBER ..........................................................................................................................

NAME OF THE HOUSEHOLD HEAD ______________________________________________

NAME AND LINE NUMBER OF ELIGIBLE WOMAN____________________________________

INTERVIEWER VISITS

1 2 3 FINAL VISIT

DAY

DATE MONTH
YEAR
INT. CODE
INTERVIEWER’S NAME RESULT*
RESULT*

NEXT VISIT: DATE ┌───┐


TOTAL NO. │░░░│
TIME OF VISITS └───┘
*RESULT CODES :
1 COMPLETED 4 REFUSED 7 OTHER
2 NOT AT HOME 5 PARTLY COMPLETED (SPECIFY)
3 POSTPONED 6 RESPONDENT INCAPACITATED

**MONTH CODES
01 JANUARY 04 APRIL 07 JULY 10 OCTOBER
02 FEBRUARY 05 MAY 08 AUGUST 11 NOVEMBER
03 MARCH 06 JUNE 09 SEPTEMBER 12 DECEMBER
SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY

NAME ┌───┬───┐ NAME ┌───┬───┐ ┌───┬───┐ ┌───┬───┐


│░░░│░░░│ │░░░│░░░│ │░░░│░░░│ │░░░│░░░│
DATE └───┴───┘ DATE └───┴───┘ └───┴───┘ └───┴───┘
SECTION 1. BACKGROUND CHARACTERISTICS

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

101 RECORD THE TIME STARTED.


HOUR

MINUTES

102 First I would like to ask some questions about you. For most of the time CITY/TOWN .............................................. 1
until you were 12 years old, did you live in a city, in a town, or in the VILLAGE.................................................... 2
countryside?
103 How long have you been living continuously in (NAME OF CURRENT NUMBER OF YEARS
PLACE OF RESIDENCE)?

ALWAYS 95
WRITE '00' IF LESS THAN ONE YEAR 105
VISITOR 96
104 Just before you moved here, did you live in a city, a town, or in the
country side? CITY/TOWN ............................................ 1
VILLAGE.................................................. 2

105 In what month and year were you born? ┌──┬──┐


MONTH ...................................... │░░│░░│
└──┴──┘
DON’T KNOW MONTH ......................... 98
┌──┬──┬──┬──┐
YEAR............................. │░░│░░│░░│░░│
└──┴──┴──┴──┘
DON’T KNOW YEAR......................... 9998
106 How old are you at your last birthday?
AGE IN COMPLETED YEARS

COMPARE AND CORRECT 105 AND /OR 106 IF INCONSISTENT

107 Are you now married, widowed, separated, divorced or deserted? CURRENTLY MARRIED 1
SEPARATED 2
DESERTED 3
DIVORCED 4
WIDOWED 5
NEVER MARRIED 6 END
108 What is your religion? ISLAM 1
HINDUISM 2
BUDDHISM 3
CHRISTIANITY 4
OTHER_________________________ 5

109 Have you ever attended school? YES 1


NO 2 111

109A What is the highest level of school you attended: primary, secondary, or PRIMARY 1
higher? SECONDARY 2
COLLEGE/UNIVERSITY 3

109B What is the highest class you completed?


CLASS ..............................
WRITE '00' IF NOT COMPLETED ANY CLASS

110 CHECK 109A:


SECONDARY
PRIMARY OR HIGHER 112

Bangladesh Maternal Health Services and Maternal Mortality Survey 2000 Section 1-2
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

111 YES, EASILY ............................................ 1


Can you read and write a letter? YES, WITH DIFFICULTY .......................... 2
NO............................................................. 3

112 Do you listen radio? YES ........................................................... 1


NO............................................................. 2 113
112A How often do you listen to the radio: every day, at least once a week, EVERY DAY ..............................................1
less than once a week? AT LEAST ONCE A WEEK .......................2
LESS THAN ONCE A WEEK ....................3

113 Do you watch television? YES ...........................................................1


NO .............................................................2 114

113A How often do you watch television: every day, at least once a week, EVERY DAY ..............................................1
less than once a week? AT LEAST ONCE A WEEK .......................2
LESS THAN ONCE A WEEK ....................3
114 Do you belong to any of the following organizations?
YES NO
Grameen Bank? GRAMEEN BANK ........................ 1 2
BRAC? BRAC ........................................... 1 2
BRDB? BRDB ........................................... 1 2
Mother’s Club? MOTHER’S CLUB........................ 1 2

Any other organization (such as micro credit)? OTHER____________________. 1 2


(SPECIFY)

115 CHECK Q. 5 IN THE HOUSEHOLD SECTION:


THE WOMAN THE WOMAN
INTERVIEWED IS NOT A INTERVIEWED IS A 201
USUAL RESIDENT USUSAL RESIDENT

116 Now I would like to ask about the place in which you usually live. Do TOWN/ CITY 1
you usually live in a town, or in a village? VILLAGE 2

117 What kind of toilet facility does your household have? SEPTIC TANK/MODERN TOILET.......... 11
WATER SEALED/SLAB LATRINE ......... 21
PIT LATRINE .......................................... 22
OPEN LATRINE...................................... 23
HANGING LATRINE ............................... 24
NO FACILITY.......................................... 31 118

OTHER 96
(SPECIFY)

117A Do you share this facility with other households? YES........................................................... 1


NO............................................................. 2

118 Does your household (or any member of your household) have: YES NO
Electricity? ELECTRICITY.............................. 1 2
Almirah (wardrobe/showcase)? ALMIRAH ..................................... 1 2
A table or chair? TABLE/CHAIR ............................. 1 2
A bench? BENCH ........................................ 1 2
A watch or clock? WATCH/CLOCK .......................... 1 2
A cot or bed? COT/BED ..................................... 1 2
A radio that is working? RADIO.......................................... 1 2
A television that is working? TELEVISION................................ 1 2
A bicycle? BICYCLE...................................... 1 2
A motorcycle? MOTORCYCLE............................ 1 2
A sewing machine? SEWING MACHINE..................... 1 2
Telephone? TELEPHONE ............................... 1 2
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
119 What is the material of the roof of your house?
NATURAL ROOF
KATCHA (BAMBOO/THATCH)........... 11
RUDIMENTARY ROOF
TIN ...................................................... 21
TILE..................................................... 22
FINISHED ROOF (PUKKA)
CEMENT/CONCRETE........................ 31

OTHER 96
(SPECIFY)
What is the material of the walls of your house?
119A NATURAL WALLS
JUTE/BAMBOO/MUD (KATCHA) ....... 11
RUDIMENTARY WALLS
WOOD ................................................ 21
FINISHED WALLS
BRICK/CEMENT................................. 31
TIN ...................................................... 32
OTHER 96
(SPECIFY)
What is the material of the floor of your house?
119B NATURAL FLOOR
EARTH/BAMBOO (KATCHA) ............. 11
RUDIMENTARY FLOOR
WOOD................................................. 21
FINISHED FLOOR (PUKKA)
CEMENT/CONCRETE........................ 31
OTHER 96
(SPECIFY)

120 Does your household own any homestead? YES ........................................................... 1


IF ‘NO’, PROBE: NO............................................................. 2
Does your household own homestead any other places?

120A Does your household own any land (other than the homestead land)? YES ........................................................... 1
NO............................................................. 2 201

How much land does your household own (other than the homestead
120B land)? AMOUNT

AMOUNT __________________
ACRES DECIMALS

UNIT_______________
(SPECIFY)

3
SECTION 2: MATERNAL MORTALITY (SISTERHOOD)

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP


201 Now I would like to ask you some questions about your brothers and
sisters, that is, all of the children born to your natural mother, including
those who are living with you, those living elsewhere and those who
have died.

201A How many children did your mother give birth to, including you? NUMBER OF BIRTHS ┌──┬──┐
TO NATURAL MOTHER ............ │░░│░░│
└──┴──┘
CHECK 201A TWO OR MORE ONLY ONE BIRTH
202 BIRTHS (RESPONDENT
ONLY)

SKIP TO 301

203 How many of these births did your mother have before you were born? NUMBER OF ┌──┬──┐
(WRITE '00' IF NONE) BIRTHS ...................................... │░░│░░│
└──┴──┘

203A How many of these births did your mother have after you were born? NUMBER OF ┌──┬──┐
(WRITE '00' IF NONE) BIRTHS ...................................... │░░│░░│
└──┴──┘
204 What was the name [1] [2] [3] [4] [5] [6]
given to your oldest
(next oldest) brother
or sister?

205 Is (NAME) male or MALE.................. 1 MALE ................. 1 MALE .................1 MALE................. 1 MALE .................1 MALE................. 1
female? FEMALE ............. 2 FEMALE............. 2 FEMALE............ 2 FEMALE ............ 2 FEMALE............ 2 FEMALE ............ 2

206 Is (NAME) still alive? YES .................... 1 YES.................... 1 YES....................1 YES ................... 1 YES....................1 YES ................... 1
NO ...................... 2 NO...................... 2 NO......................2 NO ..................... 2 NO......................2 NO ..................... 2
└─>GO TO 208 └─>GO TO 208 └─>GO TO 208 └─>GO TO 208 └─>GO TO 208 └─>GO TO 208
DK ...................... 8 DK ...................... 8 DK ......................8 DK ..................... 8 DK ......................8 DK ..................... 8
└─>GO TO [2] └─>GO TO [3] └─>GO TO [4] └─>GO TO [5] └─>GO TO [6] └─>GO TO [7]

207 How old is (NAME)? ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐
│░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│
└──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘
IF NO MORE IF NO MORE IF NO MORE IF NO MORE IF NO MORE IF NO MORE
SIBLING SKIP TO SIBLING SKIP TO SIBLING SKIP TO SIBLING SKIP TO SIBLING SKIP TO SIBLING SKIP TO
301 OTHERWISE GO 301 OTHERWISE 301 OTHERWISE 301 OTHERWISE 301 OTHERWISE 301 OTHERWISE
TO [2] GO TO [3] GO TO [4] GO TO [5] GO TO [6] GO TO [7]

208 How many years ago ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐
did (NAME) die? │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│
└──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘
WRITE '00' IF LESS
THAN 1 YEAR.

209 How old was ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐
(NAME) when │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│
he/she died? └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘
IF MALE OR FEMALE IF MALE OR IF MALE OR IF MALE OR IF MALE OR IF MALE OR
WRITE '00' IF LESS DIED BEFORE AGE FEMALE DIED FEMALE DIED FEMALE DIED FEMALE DIED FEMALE DIED
THAN 1 YEAR. 13 OR AFTER AGE BEFORE AGE 13 BEFORE AGE 13 BEFORE AGE 13 BEFORE AGE 13 BEFORE AGE 13
49 OR AFTER AGE 49 OR AFTER AGE OR AFTER AGE OR AFTER AGE OR AFTER AGE
GO TO [2] GO TO [3] 49 49 49 49
IF NO MORE IF NO MORE GO TO [4] GO TO [5] GO TO [6] GO TO [7]
SIBLING SKIP TO SIBLING SKIP TO IF NO MORE IF NO MORE IF NO MORE IF NO MORE
301 301 SIBLING SKIP TO SIBLING SKIP TO SIBLING SKIP TO SIBLING SKIP TO
301 301 301 301

210 Was (NAME) YES .................... 1 YES.................... 1 YES....................1 YES ................... 1 YES....................1 YES ................... 1
pregnant when she GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘
died? NO ...................... 2 NO...................... 2 NO..................... 2 NO ..................... 2 NO..................... 2 NO ..................... 2

211 Did (NAME) die YES .................... 1 YES.................... 1 YES....................1 YES ................... 1 YES....................1 YES ................... 1
during childbirth? GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘
NO ...................... 2 NO...................... 2 NO..................... 2 NO ..................... 2 NO..................... 2 NO ..................... 2

212 Did (NAME) die YES .................... 1 YES.................... 1 YES....................1 YES ................... 1 YES....................1 YES ................... 1
within one and half NO ...................... 2 NO...................... 2 NO......................2 NO ..................... 2 NO......................2 NO ..................... 2
months (six weeks)
after the end of a
pregnancy or
childbirth?

213 How many live born ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐
children did (NAME) │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│
give birth during her └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘
lifetime (before this NUMBER NUMBER NUMBER NUMBER NUMBER NUMBER
pregnancy)?

IF NO MORE BROTHERS OR SISTERS, GO TO 301


204 What was name [7] [8] [9] [10] [11] [12]
given to your oldest
(next oldest)
brother or sister?

205 Is (NAME) male or MALE ................. 1 MALE ................. 1 MALE .................1 MALE................. 1 MALE .................1 MALE................. 1
female? FEMALE............. 2 FEMALE............. 2 FEMALE............ 2 FEMALE ............ 2 FEMALE............ 2 FEMALE ............ 2

206 Is (NAME) still YES.................... 1 YES.................... 1 YES....................1 YES ................... 1 YES....................1 YES ................... 1
alive? NO...................... 2 NO...................... 2 NO......................2 NO ..................... 2 NO......................2 NO ..................... 2
└─>GO TO 208 └─>GO TO 208 └─>GO TO 208 └─>GO TO 208 └─>GO TO 208 └─>GO TO 208
DK ...................... 8 DK ...................... 8 DK ......................8 DK ..................... 8 DK ......................8 DK ..................... 8
└─>GO TO [8] └─>GO TO [9] └─>GO TO [10] └─>GO TO [11] └─>GO TO [12] └─>GO TO [13]

207 How old is ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐


(NAME)? │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│
└──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘
IF NO MORE SIBLING IF NO MORE IF NO MORE IF NO MORE IF NO MORE IF NO MORE
SKIP TO 301 SIBLING SKIP TO SIBLING SKIP TO SIBLING SKIP TO SIBLING SKIP TO SIBLING SKIP TO
OTHERWISE GO TO 301 OTHERWISE 301 OTHERWISE 301 OTHERWISE 301 OTHERWISE 301 OTHERWISE
[8] GO TO [9] GO TO [10] GO TO [11] GO TO [12] GO TO [13]

208 How many years ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐
ago did (NAME) │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│
die? └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘
WRITE '00' IF
LESS THAN 1
YEAR.

209 How old was ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐
(NAME) when │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│
he/she died? └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘
IF MALE OR FEMALE IF MALE OR IF MALE OR IF MALE OR IF MALE OR IF MALE OR
WRITE '00' IF DIED BEFORE AGE 13 FEMALE DIED FEMALE DIED FEMALE DIED FEMALE DIED FEMALE DIED
LESS THAN 1 OR AFTER AGE 49 BEFORE AGE 13 BEFORE AGE 13 BEFORE AGE 13 BEFORE AGE 13 BEFORE AGE 13
YEAR. GO TO [8] OR AFTER AGE 49 OR AFTER AGE OR AFTER AGE OR AFTER AGE OR AFTER AGE
IF NO MORE SIBLING GO TO [9] 49 49 49 49
SKIP TO 301 IF NO MORE GO TO [10] GO TO [11] GO TO [12] GO TO [13]
SIBLING SKIP TO IF NO MORE IF NO MORE IF NO MORE IF NO MORE
301 SIBLING SKIP TO SIBLING SKIP TO SIBLING SKIP TO SIBLING SKIP TO
301 301 301 301

210 Was (NAME) YES.................... 1 YES.................... 1 YES....................1 YES ................... 1 YES....................1 YES ................... 1
pregnant when she GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘
died? NO...................... 2 NO...................... 2 NO..................... 2 NO ..................... 2 NO..................... 2 NO ..................... 2

211 Did (NAME) die YES.................... 1 YES.................... 1 YES....................1 YES ................... 1 YES....................1 YES ................... 1
during childbirth? GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘ GO TO 213<─┘
NO...................... 2 NO...................... 2 NO..................... 2 NO ..................... 2 NO..................... 2 NO ..................... 2

212 Did (NAME) die YES.................... 1 YES.................... 1 YES....................1 YES ................... 1 YES....................1 YES ................... 1
within one and half NO...................... 2 NO...................... 2 NO......................2 NO ..................... 2 NO......................2 NO ..................... 2
months (six weeks)
after the end of a
pregnancy or
childbirth?

213 How many live ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐ ┌──┬──┐
born children did │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│ │░░│░░│
(NAME) give birth └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘ └──┴──┘
during her lifetime NUMBER NUMBER NUMBER NUMBER NUMBER NUMBER
(before this
pregnancy)?

IF NO MORE BROTHERS OR SISTERS, GO TO 301

5
SECTION 3. REPRODUCTION

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

301 Now I would like to ask about all the births you have had during your life. YES 1
Have you ever given birth? NO 2 306

302 Do you have any sons or daughters to whom you have given birth who YES 1
are now living with you? NO 2 304

303 How many sons live with you?


SONS AT HOME
And how many daughters live with you?
DAUGHTERS AT HOME
IF NONE, RECORD “00”.
304 Do you have any sons or daughters to whom you have given birth who YES 1
are alive but do not live with you? NO 2 306

305 How many sons are alive but do not live with you?
SONS ELSEWHERE

And how many daughters are alive but do not live with you?
DAUGHTERS
ELSEWHERE
IF NONE, RECORD “00”.
306 Have you ever given birth to a boy or girl who was born alive but later YES 1
died? NO 2 308

IF NO, PROBE: Any baby who cried or showed signs of life but
survived only a few hours or days?

307 In all, how many boys have died?


BOYS DEAD
And how many girls have died?
GIRLS DEAD
IF NONE, RECORD “00”.

308 SUM ANSWERS TO 303, 305 AND 307, AND ENTER TOTAL.
TOTAL
IF NONE, RECORD “00”.

309 CHECK 308:

Just to make sure that I have this right: you have had in TOTAL
_____ births during your life. Is that correct?

PROBE AND
YES NO CORRECT
301-308 AS
NECESSARY

310 CHECK 308:


ONE OR MORE NO BIRTHS
BIRTHS 325
311 Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.
RECORD NAMES OF ALL THE BIRTHS IN 312 . IF NO NAME WAS GIVEN, RECORD ‘NO NAME’ IN 312. RECORD TWINS AND TRIPLETS ON SEPARATE
LINES.
312 313 314 315 316 317 318 319 320 321
IF ALIVE: IF ALIVE: IF ALIVE: IF DEAD:

What Were any Is (NAME) In what month Is How old was Is (NAME) RECORD How old was (NAME) Were there
name of these a boy or a and year was (NAME) (NAME) at living with HOUSEHOLD when he/she died? any other
was births girls? (NAME) born? still his/her last you? LINE NUMBER IF '1 YR.', PROBE: live births
given to twins? alive? birthday? OF CHILD How many months old between
your (first RECORD (RECORD '00' IF was (NAME)? (NAME OF
/next) AGE IN CHILD NOT RECORD DAYS IF PREVIOUS
baby? COMPLE- LISTED IN LESS THAN 1 BIRTH) and
TED YEARS. HOUSEHOLD) MONTH; MONTHS IF (NAME)?
LESS THAN TWO
YEARS; OR YEARS.
(NAME)
01 LINE NUMBER
YES ....... 1 BOY. .. 1 MONTH YES. 1 AGE IN YES. .. 1 DAYS.........1
NO…… GIRL.... 2 NO..... 2 YEARS NO...... 2
2 YEAR MONTHS...2

320 (NEXT BIRTH) YEARS.......3

02 LINE NUMBER
YES ....... 1 BOY. .. 1 MONTH YES. 1 AGE IN YES. .. 1 DAYS.........1 YES. .. 1
NO…… GIRL.... 2 NO..... 2 YEARS NO...... 2 NO...... 2
2 YEAR MONTHS...2

320 (GO TO 321) YEARS.......3

03 LINE NUMBER
YES ....... 1 BOY. .. 1 MONTH YES. 1 AGE IN YES. .. 1 DAYS.........1 YES. .. 1
NO…… GIRL.... 2 NO..... 2 YEARS NO...... 2 NO...... 2
2 YEAR MONTHS...2

320 (GO TO 321) YEARS.......3

04 LINE NUMBER
YES ....... 1 BOY. .. 1 MONTH YES. 1 AGE IN YES. .. 1 DAYS.........1 YES. .. 1
NO…… GIRL.... 2 NO..... 2 YEARS NO...... 2 NO...... 2
2 YEAR MONTHS...2

320 (GO TO 321) YEARS.......3

05 LINE NUMBER
YES ....... 1 BOY. .. 1 MONTH YES. 1 AGE IN YES. .. 1 DAYS.........1 YES. .. 1
NO…… GIRL.... 2 NO..... 2 YEARS NO...... 2 NO...... 2
2 YEAR MONTHS...2

320 (GO TO 321) YEARS.......3

06 LINE NUMBER
YES ....... 1 BOY. .. 1 MONTH YES. 1 AGE IN YES. .. 1 DAYS.........1 YES. .. 1
NO…… GIRL.... 2 NO..... 2 YEARS NO...... 2 NO...... 2
2 YEAR MONTHS...2

320 (GO TO 321) YEARS.......3

07 LINE NUMBER
YES ....... 1 BOY. .. 1 MONTH YES. 1 AGE IN YES. .. 1 DAYS.........1 YES. .. 1
NO…… GIRL.... 2 NO..... 2 YEARS NO...... 2 NO...... 2
2 YEAR MONTHS...2

320 (GO TO 321) YEARS.......3

08 LINE NUMBER
YES ....... 1 BOY. .. 1 MONTH YES. 1 AGE IN YES. .. 1 DAYS.........1 YES. .. 1
NO…… GIRL.... 2 NO..... 2 YEARS NO...... 2 NO...... 2
2 YEAR MONTHS...2

320 (GO TO 321) YEARS.......3

7
312 313 314 315 316 317 318 319 320 321
IF ALIVE: IF ALIVE: IF ALIVE: IF DEAD:

What Were any Is (NAME) In what month Is How old was Is (NAME) RECORD How old was (NAME) Were there
name of these a boy or a and year was (NAME) (NAME) at living with HOUSEHOLD when he/she died? any other
was births girl? (NAME) born? still his/her last you? LINE NUMBER IF '1 YR', PROBE: live births
given to twins? alive? birthday? OF CHILD How many months old between
your next PROBE: RECORD (RECORD '00' IF was (NAME)? (NAME OF
baby? What is his/her AGE IN CHILD NOT RECORD DAYS IF PREVIOUS
birthday? COMPLE- LISTED IN LESS THAN 1 BIRTH) and
TED YEARS. HOUSEHOLD) MONTH; MONTHS IF (NAME)?
LESS THAN TWO
NAME YEARS; OR YEARS.
09 LINE NUMBER
YES ....... 1 BOY. .. 1 MONTH YES. 1 AGE IN YES. .. 1 DAYS.........1 YES. .. 1
NO…… GIRL.... 2 NO..... 2 YEARS NO...... 2 NO...... 2
2 YEAR MONTHS...2

320 (GO TO 321) YEARS.......3

10 LINE NUMBER
YES ....... 1 BOY. .. 1 MONTH YES. 1 AGE IN YES. .. 1 DAYS.........1 YES. .. 1
NO…… GIRL.... 2 NO..... 2 YEARS NO...... 2 NO...... 2
2 YEAR MONTHS...2

320 (GO TO 321) YEARS.......3

11 LINE NUMBER
YES ....... 1 BOY. .. 1 MONTH YES. 1 AGE IN YES. .. 1 DAYS.........1 YES. .. 1
NO…… GIRL.... 2 NO..... 2 YEARS NO...... 2 NO...... 2
2 YEAR MONTHS...2

320 (GO TO 321) YEARS.......3

12 LINE NUMBER
YES ....... 1 BOY. .. 1 MONTH YES. 1 AGE IN YES. .. 1 DAYS.........1 YES. .. 1
NO…… GIRL.... 2 NO..... 2 YEARS NO...... 2 NO...... 2
2 YEAR MONTHS...2

320 (GO TO 321) YEARS.......3

322 Have you had any live birth since the birth of (NAME OF LAST BIRTH)?
YES............................................................1
NO..............................................................2
323 COMPARE 308 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:

NUMBERS NUMBERS ARE


ARE SAME DIFFERENT (PROBE AND RECONCILE 312-321)

CHECK: FOR EACH BIRTH: YEAR OF BIRTH IS RECORDED (CHECK 315).

FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED (CHECK 317).

FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED (CHECK 320).

FOR AGE AT DEATH 12 MONTHS OR 1 YR.: PROBE TO DETERMINE EXACT


NUMBER OF MONTHS (CHECK 320)

324 CHECK 315 AND ENTER THE NUMBER OF BIRTHS SINCE APRIL 1997 (BAISHAK 1404).
IF NONE, RECORD ‘0'.

324A AFTER CHECKING 315, FOR EACH BIRTH SINCE APRIL 1997 (BAISHAK 1404) ENTER 'B' IN THE
MONTH OF BIRTH IN COLUMN 1 OF THE CALENDAR AND 'P' IN EACH OF THE 8 PRECEDING
MONTHS. WRITE NAME TO THE LEFT OF THE 'B' CODE. WRITE THE NAME OF THE OLDER ONE IN
CASE OF TWIN.
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

325 Are you pregnant now? YES............................................................1


NO .............................................................2
UNSURE....................................................8 326
325A How many months pregnant are you?
(RECORD NUMBER OF COMPLETED MONTHS.) MONTHS .......................................
ENTER 'P' IN COLUMN 1 OF CALENDAR IN MONTH OF
INTERVIEW AND IN EACH RECORDING MONTH PREGNANT.
325B Has decision been made regarding who will assist in your delivery? YES............................................................1
NO .............................................................2 325F
ONLY DISCUSSED ...................................8
HEALTH PROFESSIONAL
325C Who will assist in the delivery that was decided or discussed? QUALIFIED DOCTOR (MBBS) 01
NURSE/MIDWIFE/PARAMEDIC 02
FAMILY WELFARE VISITOR 03
MO/SACMO 04
HEALTH ASST (HA) 05
FIELD WELFARE ASST (FWA) 06

OTHER PERSON
TRAINED TRADITIONAL BIRTH
ATTENDANT (TTBA) 07
UNTRAINED TBA (DAI) 08
UNQUALIFIED DOCTOR 09
RELATIVES 10
NEIGHBOUR/FRIEND 11
OTHER 96
(SPECIFY)
325D CHECK 325B
YES ONLY DISCUSSED
325F

RESPONDENT....................................... 01
325E Who mainly made the decision? HUSBAND .............................................. 02
IN-LAWS ................................................ 03
PARENTS .............................................. 04
SISTER/SISTER-IN-LAW....................... 05
OTHER MEMBER IN HUSBAND
FAMILY................................................... 06
OTHER MEMBER IN RESPONDENT
FAMILY................................................... 07
RELATIVES............................................ 08
FRIEND/NEIGHBOUR ........................... 09
TBA/FIELD WORKER/DAI ..................... 10
OTHER __________ _____________ 96
(SPECIFY)
325F Has decision been made regarding where will you have your delivery? YES............................................................1
NO .............................................................2
ONLY DISCUSSED ...................................8 326
HOME 11
325G Where will you have your delivery that was decided or discussed? PUBLIC SECTOR
GOVT. HOSPITAL 21
THANA HEALTH COMPLEX 22
MATERNAL AND CHILD
WELFARE CENTER (MCWC) 23
UNION FAMILY WELFARE
CENTER (UHFWC) 24
NGO SECTOR
NGO STATIC CLINIC 31
NGO HOSPITAL 32
PRIVATE SECTOR
PVT. HOSPITAL 41
PVT. CLINIC 42

OTHER 96
(SPECIFY)
325H CHECK 325F
YES ONLY DISCUSSED
326

RESPONDENT....................................... 01
325I Who mainly made the decision? HUSBAND .............................................. 02
IN-LAWS ................................................ 03
PARENTS .............................................. 04
SISTER/SISTER-IN-LAW....................... 05
OTHER MEMBER IN HUSBAND
9
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
FAMILY................................................... 06
OTHER MEMBER IN RESPONDENT
FAMILY................................................... 07
RELATIVES............................................ 08
FRIEND/NEIGHBOUR ........................... 09
TBA/FIELD WORKER/DAI ..................... 10
OTHER __________ _____________ 96
(SPECIFY)
326 ASK QUESTIONS SEPARATELY FOR PREGNANCY, DELIVERY SEVERE HEADACHE
AND AFTER DELIVERY BUT RECORD RESPONSES IN SAME /BLURRY VISION/
CODING CATEGORY. HIGH BLOOD PRESSURE ...................... A
PRE-ECLAMSIA....................................... B
CONVULSION/ECLAMSIA.......................C
What are the problems at the time of pregnancy which are life EXCESSIVE VAGINAL BLEEDING .........D
threatening? FOUL-SMELLING DISCHARGE
WITH HIGH FEVER ................................. E
JAUNDICE ............................................... F
What are the problems at the time of delivery which are life TETANUS.................................................G
threatening?
BABY'S HAND OR FEET COME/
BABY IN BAD POSITION ........................H
What are the problems after the delivery which are life threatening? PROLONG LABOR ................................... I
OBSTRUCTED LABOR.............................J
RETAINED PLACENTA ........................... K
TORNED UTEROUS................................ L
OTHER_________________________ X
(SPECIFY)
DON'T KNOW .......................................... Y

327 Do you think that women should have a medical checkup when they YES .......................................................... 1
are pregnant even though they are not sick? NO ............................................................ 2
DON'T KNOW .......................................... 8
328 CHECK 107
CURRENTLY MARRIED SEPARATED/WIDOWED/DIVORCED
330
328A CHECK 325
NO/NOT SURE YES (PREGNANT)
330

329 Are you currently doing something or using any family planning method YES .......................................................... 1
to delay or avoid getting pregnant? NO ............................................................ 2 330

329A Which method are you using? FEMALE STERILIZATION ..................... 01


MALE STERILIZATION .......................... 02
PILL ........................................................ 03
IUD ......................................................... 04
INJECTIONS .......................................... 05
IMPLANTS/NORPLANTS....................... 06
CONDOM ............................................... 07
PERIODIC ABSTINENCE ...................... 08
WITHDRAWAL ....................................... 09
LACT. AMEN. METHOD ........................ 10
OTHER 96
(SPECIFY)
330 Have you ever hand a pregnancy that was miscarried, aborted, or YES ........................................................ 1
ended in a stillbirth or have you ever done a MR? NO.......................................................... 2 337A
331 When did the last such pregnancy end?

MONTH .........................

YEAR ......................

332 CHECK 331: LAST PREGNANCY ENDED BEFORE BAISHAK


LAST PREGNANCY ENDED 1404 OR APRIL 1997
SINCE BAISHAK 1404 OR APRIL 1997
337A

333 Was that a stillbirth, a miscarriage/abortion, or you had a menstrual STILLBIRTH........................................... 1


regulation? MISCARRIAGE/ABORTION .................. 2
MENSTRUAL REGULATION................. 3
334 How many months pregnant were you when the pregnancy ended?
(RECORD IN FULL MONTH) MONTHS.......................................
ENTER 'S' FOR STILL BIRTH, 'A' FOR MISCARRIAGE OR
ABORTION 'M' FOR MENUSTRUAL REGULATION IN COLUMN 1
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

OF CALENDAR IN THE MONTH THAT THE PREGNANCY


TERMINATED, AND 'P' IN EACH PRECEDING MONTH
PREGNANT.

11
335 Did you ever have any other such pregnancies that did not end with YES ........................................................ 1
live birth? NO.......................................................... 2 337A
336 ASK FOR DATES AND DURATIONS OF ANY OTHERS PREGNANCIES BACK TO 1404 BAISAK/1997
APRIL

ENTER 'S' FOR STILL BIRTH, 'A' FOR MISCARRIAGE OR ABORTION, 'M' FOR MENUSTRUAL
REGULATION IN COLUMN 1 OF CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED,
AND 'P' IN EACH PRECEDING MONTH PREGNANT.

INSTRUCTIONS:
1 2
ONLY ONE CODE SHOULD APPEAR IN COLUMN 1. 1 04 SRABAN 01 01 07 JUL 2
4 03 ASHAR 02 02 06 JUN 0
337A: LIVE BIRTHS 0 02 JAISTHA 03 03 05 MAY 0
FOR EACH BIRTH SINCE APRIL 1997 (BAISHAK 1404) ENTER 8 01 BAISHAK 04 04 04 APR 1
'B' IN THE MONTH OF BIRTH IN COLUMN 1 OF THE 12 CHOITRA 05 05 03 MAR
CALENDAR AND 'P' IN EACH OF THE 8 PRECEDING MONTHS. 11 FALGUN 00 00 02 FEB
10 MAGH 07 07 01 JAN
09 POUSH 08 08 12 DEC
337B: OUTCOME OF PREGNANCY OTHER THAN LIVE BIRTHS:
08 AGRAHAYAN 09 09 11 NOV
ENTER 'S' FOR STILL BIRTH, 'A' FOR MISCARRIAGE OR
1 07 KARTIK 10 10 10 OCT
ABORTION, 'M' FOR MENUSTRUAL REGULATION IN COLUMN
4 06 ASHWIN 11 11 09 SEP 2
1 OF CALENDAR IN THE MONTH THAT THE PREGNANCY 0 05 BADHRA 12 12 08 AUG 0
TERMINATED, AND 'P' IN EACH PRECEDING MONTH 7 04 SRABAN 13 13 07 JUL 0
PREGNANT. 03 ASHAR 14 14 06 JUN 0
02 JAISTHA 15 15 05 MAY
COLUMN 2: 337C: 01 BAISHAK 16 16 04 APR
FOR EACH LIVE BIRTH (B) AND STILL BIRTH (S) SINCE APRIL 12 CHOITRA 17 17 03 MAR
1997 (BAISHAK 1404), ENTER THE SERIAL NUMBER 1,2 …… 11 FALGUN 18 18 02 FEB
IN COLUMN 2 STARTING WITH LAST PREGNANCY. FOR STILL 10 MAGH 19 19 01 JAN
BIRTH, RESPONDENT SHOULD HAVE ATLEAST 7 MONTH OF 09 POUSH 20 20 12 DEC
PREGNANT.FOR OTHER THAN LIVE AND STILL BIRTH, THERE 08 AGRAHAYAN 21 21 11 NOV 1
IS NO NEED TO GIVE THE SERIAL NUMBER. 1 07 KARTIK 22 22 10 OCT 9
4 06 ASHWIN 23 23 09 SEP 9
0 05 BADHRA 24 24 08 AUG 9
6 04 SRABAN 25 25 07 JUL
03 ASHAR 26 26 06 JUN
02 JAISTHA 27 27 05 MAY
01 BAISHAK 28 28 04 APR
12 CHOITRA 29 29 03 MAR
11 FALGUN 30 30 02 FEB
10 MAGH 31 31 01 JAN
09 POUSH 32 32 12 DEC
08 AGRAHAYAN 33 33 11 NOV
1 07 KARTIK 34 34 10 OCT
4 06 ASHWIN 35 35 09 SEP 1
0 05 BADHRA 36 36 08 AUG 9
5 04 SRABAN 37 37 07 JUL 9
03 ASHAR 38 38 06 JUN 8
02 JAISTHA 39 39 05 MAY
01 BAISHAK 40 40 04 APR
12 CHOITRA 41 41 03 MAR
11 FALGUN 42 42 02 FEB
10 MAGH 43 43 01 JAN
09 POUSH 44 44 12 DEC
08 AGRAHAYAN 45 45 11 NOV
1 07 KARTIK 46 46 10 OCT 1
4 06 ASHWIN 47 47 09 SEP 9
0 05 BADHRA 48 48 08 AUG 9
4 04 SRABAN 49 49 07 JUL 7
03 ASHAR 50 50 06 JUN
02 JAISTHA 51 51 05 MAY
01 BAISHAK 52 52 04 APR
SECTION 4. PRE AND POSTNATAL CARE

401 CHECK CALENDAR:


NO LIVE BIRTH OR STILL
ONE OR MORE LIVE BIRTHS/ BIRTHS SINCE APRIL 1997 430
STILL BIRTH SINCE APRIL 1997 (BAISHAK 1401)
(BAISHAK 1404)
401A ENTER IN THE TABLE THE LINE NUMBER AND NAME OF EACH BIRTH SINCE APRIL 1997 OR BAISHAK 1404. FOR STILL
BIRTH WRITE '00' IN THE LINE NUMBER.

ASK THE QUESTIONS ABOUT ALL OF THESE PREGNANCIES. BEGIN WITH THE LAST PREGNANCY. MENTION NAME FOR
ALL CHILDREN IF THEY ARE ALIVE.
(IF THERE ARE MORE THAN 2 PREGNANCIES, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES).

402 Now I would like to ask you some questions about your health during all pregnancies since Baishak 1404 or April 1997. I will ask first
for last pregnancy and then next-to-last pregnancy.

LAST PREGNANCY NEXT-TO-LAST PREGNANCY


403 CHECK CALENDAR AND WRITE THE SERIAL NUMBER.. ......................... SERIAL NUMBER .. .........................
SERIAL NUMBER
403A WRITE NAME AND LINE NUMBER LINE NUMBER ...... LINE NUMBER .......
FROM Q312. FOR STILL BIRTH WRITE
'00'
NAME..................... NAME .....................

404 When you were pregnant with (NAME), YES 1 YES 1


did you see anyone for antenatal care NO 2 NO 2
(pregnancy checkup)?
(SKIP TO 405) (SKIP TO 405)

404A Whom did you see? HEALTH PROFESSIONAL HEALTH PROFESSIONAL


QUALIFIED DOCTOR (MBBS) A QUALIFIED DOCTOR (MBBS) A
NURSE/MIDWIFE/PARAMEDIC B NURSE/MIDWIFE/PARAMEDIC B
Anyone else? FAMILY WELFARE VISITOR C FAMILY WELFARE VISITOR C
MA/SACMO D MA/SACMO D
PROBE FOR THE TYPE OF PERSON HEALTH ASSISTANT(HA) E HEALTH ASSISTANT(HA) E
AND RECORD ALL PERSONS SEEN. FAMILY WELFARE ASST(FWA) F FAMILY WELFARE ASST(FWA) F
OTHER PERSON OTHER PERSON
TRAINED TRADITIONAL BIRTH TRAINED TRADITIONAL BIRTH
ATTENDANT (TTBA) G ATTENDANT (TTBA) G
UNTRAINED TBA H UNTRAINED TBA H
UNQUALIFIED DOCTOR I UNQUALIFIED DOCTOR I

OTHER X OTHER X
(SPECIFY) (SPECIFY)

(SKIP TO 406) (SKIP TO 406)

405 Why did you not see anyone? NOT NEEDED A NOT NEEDED A
NOT CUSTOMERY B NOT CUSTOMERY B
EXPENSIVE C EXPENSIVE C
LACK OF MONEY D LACK OF MONEY D
TOO FAR E TOO FAR E
TRANSPORTATION PROBLEM F TRANSPORTATION PROBLEM F
Any other reason? NO ONE TO ACCOMPANY G NO ONE TO ACCOMPANY G
GOOD SERVICE UNAVAILABLE H GOOD SERVICE UNAVAILABLE H
NOT PERMITTED FROM FAMILY I NOT PERMITTED FROM FAMILY I
BETTER SERVICE AT HOME J BETTER SERVICE AT HOME J
DID NOT KNOW HOW TO GO K DID NOT KNOW HOW TO GO K
NO TIME TO TAKE SERVICE L NO TIME TO TAKE SERVICE L
RECORD ALL MENTIONED. DID NOT KNOW WHERE TO GO M DID NOT KNOW WHERE TO GO M
NOT WANTED SERVICE FROM NOT WANTED SERVICE FROM
MALE DOCTOR N MALE DOCTOR N
INCONVENIENT SERVICE HOUR O INCONVENIENT SERVICE HOUR O
LACK OF PRIVACY P LACK OF PRIVACY P
FEAR Q FEAR Q
INADEQUATE DRUG SUPPLY......... R INADEQUATE DRUG SUPPLY......... R
LONG WAITING TIME S LONG WAITING TIME S
RELIGIOUS REASONS T RELIGIOUS REASONS T
DID NOT KNOW THE NEED FOR DID NOT KNOW THE NEED FOR
SERVICE U SERVICE U
OTHER X OTHER X
(SPECIFY) (SPECIFY)
(SKIP TO 407E) (SKIP TO 407E)
406 When you were pregnant with (NAME), BECAUSE OF PROBLEM 1 BECAUSE OF PROBLEM 1
the first time you go for antenatal care, did FOR CHECKUP ONLY 2 FOR CHECKUP ONLY 2
you go for just to checkup or you had a
problem? (SKIP TO 407) (SKIP TO 407)

1
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER................... SERIAL NUMBER...................

LINE NUMBER LINE NUMBER

406A For what problem did you first go for HEADACHE/BLURRY VISION HEADACHE/BLURRY VISION
antenatal care? HIGH BLOOD PRESSURE ................. A HIGH BLOOD PRESSURE ................. A
EDEMA/PRE-ECLAMSIA......................... B EDEMA/PRE-ECLAMSIA......................... B
VAGINAL BLEEDING...............................C VAGINAL BLEEDING...............................C
CONVULSION/ECLAMSIA ......................D CONVULSION/ECLAMSIA ......................D
TETANUS................................................. E TETANUS................................................. E
FOUL-SMELLING DISCHARGE FOUL-SMELLING DISCHARGE
WITH HIGH FEVER ............................. F WITH HIGH FEVER ............................. F
LOWER ABDOMINAL PAIN.....................G LOWER ABDOMINAL PAIN.....................G
FELL DOWN ............................................H FELL DOWN ............................................H
BABY MOVEMENT WAS LOW................. I BABY MOVEMENT WAS LOW................. I
VARICUS VEIN ........................................J VARICUS VEIN ........................................J
EXCESSIVE VOMITING .......................... K EXCESSIVE VOMITING .......................... K

OTHER__________________________X OTHER__________________________X
(SPECIFY) (SPECIFY)
407 How many months pregnant were you
when you first received medical checkup MONTHS
MONTHS
i.e., antenatal care for this pregnancy?
DON'T KNOW 98 DON'T KNOW 98

407A How many times did you receive medical


checkup during this pregnancy? NO. OF TIMES
NO. OF TIMES

DON'T KNOW 98 DON'T KNOW 98


407B When you were pregnant with (NAME),
did you receive advice on any of the
following during at least one of your
antenatal check-ups for this pregnancy:
(READ ALL) YES NO YES NO
Advise about diet? DIET 1 2 DIET 1 2
Talked about danger sign of
pregnancy? DANGER SIGN 1 2 DANGER SIGN 1 2
Told where to go for complications? COMPLICATIONS 1 2 COMPLICATIONS 1 2
407C When you were pregnant with (NAME),
were you or your husband/relatives told
about the following birth planning items:
(MENTION ALL) YES NO YES NO
The place where you would like to have DELIVERY PLACE 1 2 DELIVERY PLACE 1 2
delivery
The person who will delivery your baby. DELIVERY PERSON 1 2 DELIVERY PERSON 1 2
The hospital /clinic you can go if you HOSPITAL 1 2 HOSPITAL 1 2
have delivery complication.
Arrangement for transport TRANSPORT 1 2 TRANSPORT 1 2
Arrangement for money for delivery MONEY 1 2 MONEY 1 2
Arrangement for safe delivery kit for
delivery at home SAFE DELIVERY KIT 1 2 SAFE DELIVERY KIT 1 2
Complication during pregnancy and COMPLICATIONS 1 2 COMPLICATIONS 1 2
delivery
407D When you were pregnant with (NAME),
were you or your husband/relatives told
about safe delivery such as:
YES NO YES NO
Dai (delivery person) should wash USING GLOVES 1 2 USING GLOVES 1 2
hands or use gloves
Using of new and cleaned blade. STERLIED BLADE 1 2 STERLIED BLADE 1 2
Using clean thread to tie cod. CLEANED THREAD 1 2 CLEANED THREAD 1 2
Using savlon/dettle SAVLON/DETTLE 1 2 SAVLON/DETTLE 1 2
Keeping safe delivery kit at home. SAFE DELIVERY KIT 1 2 SAFE DELIVERY KIT 1 2

2
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER .................. SERIAL NUMBER ..................

LINE NUMBER LINE NUMBER

407E During this pregnancy, did you have the


following::
YES NO DK YES NO DK
Weight measured? WEIGHT 1 2 8 WEIGHT 1 2 8

Height measured? HEIGHT 1 2 8 HEIGHT 1 2 8

Blood pressure checked? BLOOD PRESSURE 1 2 8 BLOOD PRESSURE 1 2 8

Blood test? BLOOD TEST 1 2 8 BLOOD TEST 1 2 8

Urine test? URINE TEST 1 2 8 URINE TEST 1 2 8

Abdomen examined? ABDOMEN EXAMINED 1 2 8 ABDOMEN EXAMINED 1 2 8

Internal exam? INTERNAL EXAM 1 2 8 INTERNAL EXAM 1 2 8

Sonogram or ultrasound? SONOGRAM 1 2 8 SONOGRAM 1 2 8


408 Who assisted with the delivery of HEALTH PROFESSIONAL HEALTH PROFESSIONAL
(NAME)? QUALIFIED DOCTOR (MBBS) A QUALIFIED DOCTOR (MBBS) A
NURSE/MIDWIFE/PARAMEDIC B NURSE/MIDWIFE/PARAMEDIC B
Anyone else? FAMILY WELFARE VISITOR C FAMILY WELFARE VISITOR C
MA/SACMO D MA/SACMO D
HEALTH ASST (HA) E HEALTH ASST (HA) E
PROBE FOR THE TYPE OF PERSON FIELD WELFARE ASST (FWA) F FIELD WELFARE ASST (FWA) F
AND RECORD ALL PERSONS OTHER PERSON OTHER PERSON
ASSISTING. TRAINED TRADITIONAL BIRTH TRAINED TRADITIONAL BIRTH
ATTENDANT (TTBA) G ATTENDANT (TTBA) G
UNTRAINED TBA (DAI) H UNTRAINED TBA (DAI) H
UNQUALIFIED DOCTOR I UNQUALIFIED DOCTOR I
RELATIVES J RELATIVES J
NEIGHBOURS/FRIENDS K NEIGHBOURS/FRIENDS K

OTHER X OTHER X
(SPECIFY) (SPECIFY)
NO ONE................................................. Y NO ONE................................................. Y

408A Where did you give birth (NAME)? HOME 11 HOME 11

PUBLIC SECTOR PUBLIC SECTOR


GOVT. HOSPITAL 21 GOVT. HOSPITAL 21
THANA HEALTH COMPLEX 22 THANA HEALTH COMPLEX 22
MATERNAL AND CHILD MATERNAL AND CHILD
WELFARE CENTER (MCWC) 23 WELFARE CENTER (MCWC) 23
UNION FAMILY UNION FAMILY
WELFARE CENTER (UHFWC) 24 WELFARE CENTER (UHFWC) 24
NGO SECTOR NGO SECTOR
NGO STATIC CLINIC 31 NGO STATIC CLINIC 31
NGO HOSPITAL 32 NGO HOSPITAL 32

PRIVATE SECTOR PRIVATE SECTOR


PVT. HOSPITAL 41 PVT. HOSPITAL 41
PVT. CLINIC 42 PVT. CLINIC 42

OTHER 96 OTHER 96
(SPECIFY) (SPECIFY)
(SKIP TO 410) (SKIP TO 410)

3
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER .................. SERIAL NUMBER ..................

LINE NUMBER LINE NUMBER

409 What are the reasons you did not go to a NOT NECESSARY A NOT NECESSARY A
health facility for delivery? NOT CUSTOMERY B NOT CUSTOMERY B
COST TOO MUCH C COST TOO MUCH C
LACK OF MONEY D LACK OF MONEY D
TOO FAR E TOO FAR E
TRANSPORT PROBLEM F TRANSPORT PROBLEM F
NO ONE TO ACCOMPANY G NO ONE TO ACCOMPANY G
POOR QUALITY SERVICE H POOR QUALITY SERVICE H
FAMILY DID NOT ALLOW I FAMILY DID NOT ALLOW I

BETTER CARE AT HOME J BETTER CARE AT HOME J

NOT KNOWN HOW TO GO K NOT KNOWN HOW TO GO K

NO TIME TO GET SERVICES L NO TIME TO GET SERVICES L


NOT KNOWN WHERE TO GO M NOT KNOWN WHERE TO GO M
NOT WANT SERVICE NOT WANT SERVICE
FROM MALE DOCTOR N FROM MALE DOCTOR N
FOR FEAR Q FOR FEAR Q
CLINIC/HOSPITAL INSIST FOR CLINIC/HOSPITAL INSIST FOR
CISAREAN V CISAREAN V
OTHER_________________________ X OTHER_________________________ X
(SPECIFY) (SPECIFY)
(SKIP 411) (SKIP 411)

410 Why did you choose to deliver at the FIRST CHILD WAS CAESARIAN A FIRST CHILD WAS CAESARIAN A
hospital/health center? CUSTOMERY B CUSTOMERY B
MODERN FACILITY/DOCTOR C MODERN FACILITY/DOCTOR C
DELIVERY/HEALTH RELATED DELIVERY /HEALTH RELATED
PROBLEM D PROBLEM D
BABY OVERDUE E BABY OVERDUE E
DOCTOR/HEALTH WORKER TOLD F DOCTOR/HEALTH WORKER TOLD F
FOR SAFE DELIVERY G FOR SAFE DELIVERY G
OTHER________________________ X OTHER________________________ X

(SPECIFY) (SPECIFY)
411 Were any of the following procedures
performed at the time of delivery?
YES NO DK YES NO DK
a. Instruments to used to get the baby
out (FORCEP) FORCEP 1 2 8 FORCEP 1 2 8
b. You had an abdominal operation to ABDOMINAL OPERATION/ ABDOMINAL OPERATION/
get the baby out (C-SECTION)
C-SECTION 1 2 8 C-SECTION 1 2 8
c. Received blood transfusion BLOOD BLOOD
TRANSFUSION 1 2 8 TRANSFUSION 1 2 8
d. Received intravenous fluid INTRAVENOUS 1 2 8 INTRAVENOUS 1 2 8

4
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER .................. SERIAL NUMBER ..................

LINE NUMBER LINE NUMBER

412 Did you experience any of the following


problems at any time of pregnancy
(pregnant with NAME), delivery or after
delivery?
(P=PREGNANCY, D=AT THE TIME OF (P=PREGNANCY, D=AT THE TIME OF
CIRCLE ALL RESPONDENT DELIVERY, AD=AFTER DELIVERY) DELIVERY, AD=AFTER DELIVERY)
MENTIONED.
P D AD P D AD

Had headache, blurred vision and high


blood pressure? HEADACHE A1 A2 A3 HEADACHE A1 A2 A3

Edema/Pre-eclamsia? PREECLAMSIA B1 B2 B3 PREECLAMSIA B1 B2 B3


Excessive bleeding was so much which EXCESSIVE EXCESSIVE
wet your clothes that you feared it was BLEEDING .. C1 C2 C3 BLEEDING... C1 C2 C3
life threatening?
A high fever with bad smelling vaginal HIGH FEVER D1 D2 D3 HIGH FEVER D1 D2 D3
discharge?
Convulsions/eclamsia? CONVULSIONS E1 E2 E3 CONVULSIONS E1 E2 E3
Baby’s hands and feet came first during
delivery? HANDS AND FEET -- F2 -- HANDS AND FEET -- F2 --

Prolong labor? LONG LABOR -- G2 -- LONG LABOR -- G2 --


Tetanus? TETANUS H1 H2 H3 TETANUS H1 H2 H3
Placenta previa/retained placenta? PLACENTA -- I2 I3 PLACENTA -- I2 I3
Torned uterus? TORNED UTERUS -- J2 - TORNED UTERUS -- J2 -
Obstructed labor? OBSTRUCTED LABOR -- K2 - OBSTRUCTED LABOR -- K2 -
Other? OTHER X1 X2 X3 OTHER X1 X2 X3
Nothing happened. NONE Y1 Y2 Y3 NONE Y1 Y2 Y3
412A CHECK 412 : CODE G2 (PROLONG CIRCLE 'G2' NOT CIRCLE 'G2' CIRCLE 'G2' NOT CIRCLE 'G2'
LABOR)

(SKIP TO 413) (SKIP TO 413)


412B How many hours was the labor?
HOURS HOURS
WRITE '00' IF LESS THAN AN HOUR
DON'T KNOW 98 DON'T KNOW 98

413 Who can tell us about the circumstances RESPONDENT A RESPONDENT A


around the delivery?
HUSBAND B HUSBAND B
PARENT-IN-LAW C PARENT-IN-LAW C
PARENT D PARENT D
SISTER/SISTER-IN-LAW E SISTER/SISTER-IN-LAW E
OTHER MEMBER OF HUSBAND OTHER MEMBER OF HUSBAND
FAMILY F FAMILY F

OTHER MEMBER OF RESPONDENT OTHER MEMBER OF RESPONDENT


FAMILY G FAMILY G
RELATIVES H RELATIVES H
NEIGHBOUR/FRIEND I NEIGHBOUR/FRIEND I
TBA/FIELD WORKER/DAI J TBA/FIELD WORKER/DAI J
OTHER X OTHER X
(SPECIFY) (SPECIFY)

5
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER .................. SERIAL NUMBER...................

LINE NUMBER LINE NUMBER

413A RESPONDENT A RESPONDENT A


TAKE HELP FROM PEOPLE
MENTIONED IN 413.
HUSBAND B HUSBAND B
CIRCLE THE CODE FOR PRESONS PARENT-IN-LAW C PARENT-IN-LAW C
PRESENCE AT THE TIME OF
INTERVIEW. PARENT D PARENT D
SISTER/SISTER-IN-LAW E SISTER/SISTER-IN-LAW E
OTHER MEMBER OF HUSBAND OTHER MEMBER OF HUSBAND
FAMILY F FAMILY F

OTHER MEMBER OF RESPONDENT OTHER MEMBER OF RESPONDENT


FAMILY G FAMILY G
RELATIVES H RELATIVES H
NEIGHBOUR/FRIEND I NEIGHBOUR/FRIEND I
TBA/FIELD WORKER/DAI J TBA/FIELD WORKER/DAI J
OTHER X OTHER X
(SPECIFY) (SPECIFY)
414 CHECK 412 AND CHECK IN WRIGHT EXCEPT EXCEPT CIRCLE EXCEPT EXCEPT CIRCLE
BOX. Y1, Y2, Y3 ONLY Y1, Y2, Y3 ONLY
Y1, Y2, Y1, Y2,
CIRCLE Y1, Y2, Y3 CIRCLE Y1, Y2, Y3
ONE Y3 ONE Y3
CIRCLE CIRCLE
MORE MORE
THAN THAN
ONE ONE

SKIP TO SKIP TO 428 SKIP TO SKIP TO 428


416 416
415 Do you think that (RESPONSE FROM YES 1 YES 1
Q.412) was potentially dangerous or life
threatening? NO 2 NO 2
DONOT KNOW 8 DONOT KNOW 8

(SKIP TO 418B) (SKIP TO 418B)

416 You have just mentioned that you had HEADACHE/HIGH BLOOD PRSR A HEADACHE/HIGH BLOOD PRSR A
(RESPONSE FROM Q412) EDEMA/PREECLAMSIA ........................ B EDEMA/PREECLAMSIA ........................ B
complications. Was there any
complication potentially dangerous or life EXCESSIVE BLEEDING ........................C EXCESSIVE BLEEDING ........................C
threatening? FOUL-SMELLING DISCHARGE FOUL-SMELLING DISCHARGE
WITH HIGH FEVER............................D WITH HIGH FEVER............................D
IF YES: CONVULSIONS/ECLAMSIA E CONVULSIONS/ECLAMSIA E
Which complication(s) was/were life HANDS AND FEET CAME OUT HANDS AND FEET CAME OUT
threatening? /BABY'S WRONG POSITION F /BABY'S WRONG POSITION F
PRO LONG LABOR ...............................G PRO LONG LABOR ...............................G
TETANUS H TETANUS H
RETAINED PLACENTA............................. I RETAINED PLACENTA............................. I
TORNED UTERUS J TORNED UTERUS J
OBSTRUCTED LABOR.......................... K OBSTRUCTED LABOR.......................... K
OTHER X OTHER X
(SPECIFY) (SPECIFY)
NONE/DON'T KNOW Y NONE/DON'T KNOW Y

6
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER .................. SERIAL NUMBER ..................

LINE NUMBER LINE NUMBER

417 CHECK 416. EXCEPT 'Y' ONLY 'Y' EXCEPT 'Y' EXCEPT 'Y' ONLY 'Y' EXCEPT 'Y'
MORE CIRCLE ONLY ONE MORE CIRCLE ONLY ONE
THAN ONE CIRCLE THAN ONE CIRCLE
CIRCLE CIRCLE

SKIP TO SKIP TO SKIP TO SKIP TO


418A 418B 418A 418B
418 Which complication (FROM Q. 416) was HEADACHE/HIGH BLOOD PRSR 01 HEADACHE/HIGH BLOOD PRSR 01
occurred last? EDEMA/PREECLAMSIA ...................... 02 EDEMA/PREECLAMSIA .......................02
EXCESSIVE BLEEDING ...................... 03 EXCESSIVE BLEEDING.......................03
FOUL-SMELLING DISCHARGE FOUL-SMELLING DISCHARGE
WITH HIGH FEVER.......................... 04 WITH HIGH FEVER ..........................04
CONVULSIONS/ECLAMSIA 05 CONVULSIONS/ECLAMSIA 05
HANDS AND FEET CAME OUT HANDS AND FEET CAME OUT
/BABY'S WRONG POSITION 06 /BABY'S WRONG POSITION 06
PRO LONG LABOR ............................. 07 PRO LONG LABOR .............................07
TETANUS 08 TETANUS 08
RETAINED PLACENTA................ 09 RETAINED PLACENTA ............... 09
TORNED UTERUS 10 TORNED UTERUS 10
OBSTRUCTED LABOR........................ 11 OBSTRUCTED LABOR ........................11
OTHER 96 OTHER 96
(SPECIFY) (SPECIFY)
(SKIP TO 418B) (SKIP TO 418B)
418A Which complication (FROM Q. 412) was HEADACHE/HIGH BLOOD PRSR 01 HEADACHE/HIGH BLOOD PRSR 01
occurred last? EDEMA/PREECLAMSIA ...................... 02 EDEMA/PREECLAMSIA .......................02
EXCESSIVE BLEEDING ...................... 03 EXCESSIVE BLEEDING.......................03
FOUL-SMELLING DISCHARGE FOUL-SMELLING DISCHARGE
WITH HIGH FEVER.......................... 04 WITH HIGH FEVER ..........................04
CONVULSIONS/ECLAMSIA 05 CONVULSIONS/ECLAMSIA 05
HANDS AND FEET CAME OUT HANDS AND FEET CAME OUT
/BABY'S WRONG POSITION 06 /BABY'S WRONG POSITION 06
PRO LONG LABOR ............................. 07 PRO LONG LABOR .............................07
TETANUS 08 TETANUS 08
RETAINED PLACENTA................ 09 RETAINED PLACENTA ............... 09
TORNED UTERUS 10 TORNED UTERUS 10
OBSTRUCTED LABOR........................ 11 OBSTRUCTED LABOR ........................11
OTHER 96 OTHER 96
(SPECIFY) (SPECIFY)
418B After how much time from the beginning of
this complication you recognize that you HOURS...................1 HOURS...................1
were having problem?

DAYS ......................2 DAYS......................2

MONTHS ................3 MONTHS ................3

IMMEDIATELY ....... ...............000 IMMEDIATELY ....... ............... 000

DON'T KNOW......... ...............998 DON'T KNOW......... ............... 998

7
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER .................. SERIAL NUMBER ..................

LINE NUMBER LINE NUMBER

418C When you had this complication, did any HUSBAND B HUSBAND B
member of your household become
concerned about the condition? PARENT-IN-LAW C PARENT-IN-LAW C
IF YES: Who? PARENT D PARENT D
SISTER/SISTER-IN-LAW E SISTER/SISTER-IN-LAW E
OTHER MEMBER OF HUSBAND OTHER MEMBER OF HUSBAND
FAMILY F FAMILY F

OTHER MEMBER OF RESPONDENT OTHER MEMBER OF RESPONDENT


FAMILY G FAMILY G
RELATIVES H RELATIVES H
CHILDREN K CHILDREN K
OTHER X OTHER X
(SPECIFY) (SPECIFY)
NONE Y NONE Y

418D Did you see seek any assistance for this YES 1 YES 1
complication? (SKIP TO 418G) (SKIP TO 418G)
NO 2 NO 2

418E Why you did not seek treatment? NOT NECESSARY A NOT NECESSARY A
Any other reason? NOT CUSTOMERY B NOT CUSTOMERY B
COST TOO MUCH C COST TOO MUCH C
PROBE FOR THE TYPE OF PERSON LACK OF MONEY D LACK OF MONEY D
AND RECORD ALL PERSONS SEEN.
TOO FAR E TOO FAR E
TRANSPORT PROBLEM F TRANSPORT PROBLEM F
NO ONE TO ACCOMPANY G NO ONE TO ACCOMPANY G
POOR QUALITY SERVICE H POOR QUALITY SERVICE H
FAMILY DID NOT ALLOW I FAMILY DID NOT ALLOW I

BETTER CARE AT HOME J BETTER CARE AT HOME J

NOT KNOWN HOW TO GO K NOT KNOWN HOW TO GO K

NO TIME TO GET SERVICES L NO TIME TO GET SERVICES L


NOT KNOWN WHERE TO GO M NOT KNOWN WHERE TO GO M
NOT WANT SERVICE NOT WANT SERVICE
FROM MALE DOCTOR N FROM MALE DOCTOR N
DID NOT THINK OF SERIOUSNESS DID NOT THINK OF SERIOUSNESS
OF COMPLICATION W OF COMPLICATION W
OTHER_________________________ X OTHER________________________X
(SPECIFY) (SPECIFY)

418F Who took the decision that you should not RESPONDENT A RESPONDENT A
seek treatment? HUSBAND B HUSBAND B
Anyone else? PARENT-IN-LAW C PARENT-IN-LAW C
PARENT D PARENT D
SISTER/SISTER-IN-LAW E SISTER/SISTER-IN-LAW E
OTHER MEMBER OF HUSBAND OTHER MEMBER OF HUSBAND
FAMILY F FAMILY F
OTHER MEMBER OF OTHER MEMBER OF
RESPONDENT FAMILY G RESPONDENT FAMILY G
RELATIVES H RELATIVES H
NEIGHBOUR/FRIEND I NEIGHBOUR/FRIEND I
TBA/FIELD WORKER/DAI J TBA/FIELD WORKER/DAI J
OTHER X OTHER X
(SPECIFY) (SPECIFY)
NONE Y NONE Y
(SKIP TO 428) ( SKIP TO 428)

8
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER.................. SERIAL NUMBER ..................

LINE NUMBER LINE NUMBER

418G Whom did you see? HEALTH PROFESSIONAL HEALTH PROFESSIONAL


QUALIFIED DOCTOR (MBBS) A QUALIFIED DOCTOR (MBBS) A
Anyone else? NURSE/MIDWIFE/PARAMEDIC B NURSE/MIDWIFE/PARAMEDIC B
FAMILY WELFARE VISITOR C FAMILY WELFARE VISITOR C
MA/SACMO D MA/SACMO D
HEALTH ASST (HA) E HEALTH ASST (HA) E
FIELD WELFARE ASST (FWA) F FIELD WELFARE ASST (FWA) F

OTHER PERSON OTHER PERSON


TRAINED TRADITIONAL BIRTH TRAINED TRADITIONAL BIRTH
ATTENDANT (TTBA) G ATTENDANT (TTBA) G
UNTRAINED TBA H UNTRAINED TBA H
UNQUALIFIED DOCTOR I UNQUALIFIED DOCTOR I

OTHER X OTHER X
(SPECIFY) (SPECIFY)
418H Where did you receive treatment? HOME A HOME A
PUBLIC SECTOR PUBLIC SECTOR
GOVT. HOSPITAL B GOVT. HOSPITAL B
Any other places? THANA HEALTH COMPLEX C THANA HEALTH COMPLEX C
MATERNAL AND CHILD MATERNAL AND CHILD
WELFARE CENTER (MCWC) D WELFARE CENTER (MCWC) D
UNION FAMILY WELFARE UNION FAMILY WELFARE
CENTER (UFWC) E CENTER (UFWC) E
SATELITTE /EPI OUTREACH F SATELITTE /EPI OUTREACH F
COMMUNITY CLINIC G COMMUNITY CLINIC G

NGO SECTOR NGO SECTOR


NGO STATIC CLINIC H NGO STATIC CLINIC H
NGO HOSPITAL I NGO HOSPITAL I
NGO SATELITTE CLINIC J NGO SATELITTE CLINIC J

PRIVATE SECTOR PRIVATE SECTOR


PVT. HOSPITAL K PVT. HOSPITAL K
PVT. CLINIC L PVT. CLINIC L
QUALITFIED DOCTOR'S QUALITFIED DOCTOR'S
CHAMBER /PHARMACY M CHAMBER /PHARMACY M
TRADITIONAL DOCTOR'S TRADITIONAL DOCTOR'S
CHAMBER /PHARMACY N CHAMBER /PHARMACY N

OTHER X OTHER X
(SPECIFY) (SPECIFY)
419 Who took the decision that you should RESPONDENT A RESPONDENT A
seek treatment? HUSBAND B HUSBAND B
PARENT-IN-LAW C PARENT-IN-LAW C
PARENT D PARENT D
SISTER/SISTER-IN-LAW E SISTER/SISTER-IN-LAW E
OTHER MEMBER OF OTHER MEMBER OF
HUSBAND FAMILY F HUSBAND FAMILY F
OTHER MEMBER OF OTHER MEMBER OF
RESPONDENT FAMILY G RESPONDENT FAMILY G
RELATIVES H RELATIVES H
NEIGHBOUR/FRIEND I NEIGHBOUR/FRIEND I
TBA/FIELD WORKER/DAI J TBA/FIELD WORKER/DAI J
OTHER X OTHER X
(SPECIFY) (SPECIFY)
NONE Y NONE Y
DON’T KNOW Z DON’T KNOW Z
419A After how much time from the beginning
of this complication it was decided that HOURS...................1 HOURS ...................1
you need treatment?

IF IMMEDIATELY, WRITE '00' IN DAYS ......................2 DAYS ......................2


HOURS BOX, WRITE IN HOURS IF
LESS THAN A DAY AND WRITE IN
MONTH IF MORE THAN 30 DAYS. MONTHS ................3 MONTHS ................3

9
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER.................. SERIAL NUMBER ..................

LINE NUMBER LINE NUMBER

419B Did you seek treatment soon after the YES 1 YES 1
decision made?
(SKIP TO 420) (SKIP TO 420)
NO, LATE 2 NO, LATE 2

DON'T KNOW 8 DON'T KNOW 8


(SKIP TO 420) (SKIP TO 420)
419C Why the treatment was not sought HOSPITAL TOO FAR A HOSPITAL TOO FAR A
immediately?
DID NOT THINK SERIOUSLY B DID NOT THINK SERIOUSLY B
LACK OF MONEY C LACK OF MONEY C
NOT WANT SERVICE NOT WANT SERVICE
FROM MALE DOCTOR D FROM MALE DOCTOR D

OTHER_________________________ X OTHER________________________ X
(SPECIFY) (SPECIFY)

419D How much time after a decision was


made, was the treatment sought? HOURS………… ..................................... HOURS………… .....................................
WRITE '00' IF LESS THAN AN HOUR.
DON'T KNOW………… ....................... 98 DON'T KNOW………… ....................... 98

420 How many hospital/clinic/dispensary did


you visit for this treatment? NUMBERS………… ............................... NUMBERS………… ...............................
.
DID NOT GO ANY PLACE ................... 0 DID NOT GO ANY PLACE ................... 0

(SKIP TO 428) (SKIP TO 428)

420A INTERVIEWER: Qs. 421-423 ARE APPLICABLE FOR FIRST TREATMENT FACILITY

421 Where did you go first to seek treatment? PUBLIC SECTOR PUBLIC SECTOR
GOVT. HOSPITAL 21 GOVT. HOSPITAL 21
THANA HEALTH COMPLEX 22 THANA HEALTH COMPLEX 22
MATERNAL AND CHILD MATERNAL AND CHILD
WELFARE CENTER (MCWC) 23 WELFARE CENTER (MCWC) 23
UNION FAMILY WELFARE UNION FAMILY WELFARE
CENTER (UFWC) 24 CENTER (UFWC) 24
SATELITTE/EPI OUTREACH 25 SATELITTE/EPI OUTREACH 25
COMMUNITY CLINIC 26 COMMUNITY CLINIC 26
NGO SECTOR NGO SECTOR
NGO STATIC CLINIC 31 NGO STATIC CLINIC 31
NGO HOSPITAL 32 NGO HOSPITAL 32
NGO SATELITTE CLINIC 33 NGO SATELITTE CLINIC 33
PRIVATE SECTOR PRIVATE SECTOR
PVT. HOSPITAL 41 PVT. HOSPITAL 41
PVT. CLINIC 42 PVT. CLINIC 42
CHAMBER/PHARMACY OF CHAMBER/PHARMACY OF
QUALIFIED DOCTOR 43 QUALIFIED DOCTOR 43
CHAMBER/PHARMACY OF CHAMBER/PHARMACY OF
TRADITIONAL DOCTOR 44 TRADITIONAL DOCTOR 44

OTHER 96 OTHER 96
(SPECIFY) (SPECIFY)
DON'T KNOW 98 DON'T KNOW 98
421A Who accompanied you to go the HUSBAND B HUSBAND B
treatment center (NAME FROM 421)? PARENT-IN-LAW C PARENT-IN-LAW C
PARENT D PARENT D
CIRCLE ALL THE PERSONS SISTER/SISTER-IN-LAW E SISTER/SISTER-IN-LAW E
ACCOMPANIED OTHER MEMBER OF OTHER MEMBER OF
HUSBAND FAMILY F HUSBAND FAMILY F
OTHER MEMBER OF OTHER MEMBER OF
RESPONDENT FAMILY G RESPONDENT FAMILY G
RELATIVES H RELATIVES H
NEIGHBOUR/FRIEND I NEIGHBOUR/FRIEND I
TBA/FIELD WORKER/DAI J TBA/FIELD WORKER/DAI J
OTHER X OTHER X
(SPECIFY) (SPECIFY)
NONE Y NONE Y

10
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER.................. SERIAL NUMBER ..................

LINE NUMBER LINE NUMBER

421B How far is hospital/health center/clinic


(treatment center) from your MILE………… .......................................... MILE………… ..........................................
house/house you were present?
OUTSIDE UPAZILA/TOWN...…………95 OUTSIDE UPAZILA/TOWN...…………95
DON'T KNOW...................................... 98 DON'T KNOW...................................... 98
WRITE '00' IF LESS THAN A MILE
421C CAR A CAR A
How did you go to the hospital/health BUS B BUS B
center? TRAIN C TRAIN C
AMBULANCE D AMBULANCE D
BOAT E BOAT E
ENGINE BOAT F ENGINE BOAT F
OX CART G OX CART G
RICKSHAW/VAN H RICKSHAW/VAN H
BABY TAXI/TEMPO I BABY TAXI/TEMPO I
ON FOOT J ON FOOT J
OTHER________________________X OTHER________________________X
(SPECIFY) (SPECIFY)
(SKIP TO 421E) (SKIP TO 421E)
421D VERY MUCH 1 VERY MUCH 1
Did you have difficulty in obtaining
__________transportation? SOMEWHAT 2 SOMEWHAT 2
NOT AT ALL 3 NOT AT ALL 3
DON'T KNOW 8 DON'T KNOW 8

421E How long did it take to reach there?

HOURS MINUTES HOURS MINUTES


DON'T KNOW................................. 9998 DON'T KNOW................................. 9998

421F
How long did you wait between the time
you first arrived at the hospital/clinic and
the time you were examined by a health
care provider (doctor/nurse/health HOURS MINUTES HOURS MINUTES
worker)? IMMEDIATELY ............................... 0000 IMMEDIATELY ............................... 0000

421G NO CHANGE 1 NO CHANGE 1


Did your condition improve after IMPROVED 2 IMPROVED 2
treatment in this place, or did it stay the WORSNED 3 WORSNED 3
same? DON'T KNOW 8 DON'T KNOW 8
422 YES........................................................ 1 YES........................................................ 1
Were you referred or told to go any other
place for treatment/advice? NO ......................................................... 2 NO ......................................................... 2
(SKIP TO 424) (SKIP TO 424)

422A Where were you told to go? PUBLIC SECTOR PUBLIC SECTOR
GOVT. HOSPITAL 21 GOVT. HOSPITAL 21
THANA HEALTH COMPLEX 22 THANA HEALTH COMPLEX 22
MATERNAL AND CHILD MATERNAL AND CHILD
WELFARE CENTER (MCWC) 23 WELFARE CENTER (MCWC) 23
UNION FAMILY WELFARE UNION FAMILY WELFARE
CENTER (UFWC) 24 CENTER (UFWC) 24
SATELITTE/EPI OUTREACH 25 SATELITTE/EPI OUTREACH 25
COMMUNITY CLINIC 26 COMMUNITY CLINIC 26
NGO SECTOR NGO SECTOR
NGO STATIC CLINIC 31 NGO STATIC CLINIC 31
NGO HOSPITAL 32 NGO HOSPITAL 32
NGO SATEITTE CLINIC 33 NGO SATEITTE CLINIC 33
PRIVATE SECTOR PRIVATE SECTOR
PVT. HOSPITAL 41 PVT. HOSPITAL 41
PVT. CLINIC 42 PVT. CLINIC 42
CHAMBER/PHARMACY OF CHAMBER/PHARMACY OF
QUALIFIED DOCTOR 43 QUALIFIED DOCTOR 43
CHAMBER/PHARMACY OF CHAMBER/PHARMACY OF
TRADITIONAL DOCTOR 44 TRADITIONAL DOCTOR 44
OTHER 96 OTHER 96
(SPECIFY) (SPECIFY)
DON'T KNOW 98 DON'T KNOW 98

11
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER .................. SERIAL NUMBER ..................

LINE NUMBER LINE NUMBER

422B How long after you reached the place


(PLACE IN 421), were you told to go the
place (PLACE in 422A)?
HOURS MINUTES HOURS MINUTES

IMMEDIATELY ................................ 0000 IMMEDIATELY ............................... 0000

422C NO SURGERY EQUIPMENT A NO SURGERY EQUIPMENT A


Why were you told to seek
treatment/advice to another place? HIGH BLOOD PRESSURE B HIGH BLOOD PRESSURE B
FOR BETTER TREATMENT C FOR BETTER TREATMENT C
DOCTOR UNAVAILABLE D DOCTOR UNAVAILABLE D
NO ARRANGEMENT FOR BLOOD NO ARRANGEMENT FOR BLOOD
TRANSFUSION E TRANSFUSION E
DID NOT HAVE NECESSARY DID NOT HAVE NECESSARY
ARRANGEMENT TO ARRANGEMENT TO
SOLVE PROBLEM F SOLVE PROBLEM F
BABY'S UPWARD POSITION G BABY'S UPWARD POSITION G
SOME PART OF BABY CAME OUT H SOME PART OF BABY CAME OUT H
BABY URINATED INSIDE I BABY URINATED INSIDE I
UTERUS DID NOT OPEN J UTERUS DID NOT OPEN J
OTHER_________________________X OTHER_________________________X

422D Did you go the place where you were YES........................................................ 1 YES........................................................ 1
referred or told to go? (SKIP TO 424) (SKIP TO 424)

NO ......................................................... 2 NO ......................................................... 2

423 Why you did not go the referred place? NOT NECESSARY A NOT NECESSARY A
Any other reason? NOT CUSTOMERY B NOT CUSTOMERY B
COST TOO MUCH C COST TOO MUCH C
PROBE FOR THE TYPE OF PERSON LACK OF MONEY D LACK OF MONEY D
AND RECORD ALL PERSONS SEEN.
TOO FAR E TOO FAR E
TRANSPORT PROBLEM F TRANSPORT PROBLEM F
NO ONE TO ACCOMPANY G NO ONE TO ACCOMPANY G
POOR QUALITY SERVICE H POOR QUALITY SERVICE H
FAMILY DID NOT ALLOW I FAMILY DID NOT ALLOW I

BETTER CARE AT HOME J BETTER CARE AT HOME J

NOT KNOWN HOW TO GO K NOT KNOWN HOW TO GO K

NO TIME TO GET SERVICE L NO TIME TO GET SERVICE L


NOT WANT SERVICE NOT WANT SERVICE
FROM MALE DOCTOR N FROM MALE DOCTOR N
DID NOT THINK OF SERIOUSNESS DID NOT THINK OF SERIOUSNESS
OF COMPLICATION W OF COMPLICATION W
OTHER_________________________ X OTHER_________________________ X
(SPECIFY) (SPECIFY)

424 CHECK 420 WENT MORE THAN ONE PLACES 1 WENT MORE THAN ONE PLACES 1
WENT ONLY ONE PLACE 2 WENT ONLY ONE PLACE 2
(SKIP TO 427) (SKIP TO 427)
424A INTERVIEWER: Qs. 425-426E ARE APPLICABLE FOR THE LAST TREATMENT FACILITY

12
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER .................. SERIAL NUMBER...................

LINE NUMBER LINE NUMBER

425 Where did you go at last? PUBLIC SECTOR PUBLIC SECTOR


GOVT. HOSPITAL 21 GOVT. HOSPITAL 21
THANA HEALTH COMPLEX 22 THANA HEALTH COMPLEX 22
MATERNAL AND CHILD MATERNAL AND CHILD
WELFARE CENTER (MCWC) 23 WELFARE CENTER (MCWC) 23
UNION FAMILY WELFARE UNION FAMILY WELFARE
CENTER (UFWC) 24 CENTER (UFWC) 24
SATELITTE/EPI OUTREACH 25 SATELITTE/EPI OUTREACH 25
COMMUNITY CLINIC 26 COMMUNITY CLINIC 26
NGO SECTOR NGO SECTOR
NGO STATIC CLINIC 31 NGO STATIC CLINIC 31
NGO HOSPITAL 32 NGO HOSPITAL 32
NGO SATEITTE CLINIC 33 NGO SATEITTE CLINIC 33
PRIVATE SECTOR PRIVATE SECTOR
PVT. HOSPITAL 41 PVT. HOSPITAL 41
PVT. CLINIC 42 PVT. CLINIC 42
CHAMBER/PHARMACY OF CHAMBER/PHARMACY OF
QUALIFIED DOCTOR 43 QUALIFIED DOCTOR 43
CHAMBER/PHARMACY OF CHAMBER/PHARMACY OF
TRADITIONAL DOCTOR 44 TRADITIONAL DOCTOR 44

OTHER 96 OTHER 96
(SPECIFY) (SPECIFY)
DON'T KNOW 98 DON'T KNOW 98
425A Who accompanied you to go the HUSBAND B HUSBAND B
treatment center (NAME FROM 425? PARENT-IN-LAW C PARENT-IN-LAW C
PARENT D PARENT D
CIRCLE ALL THE PERSONS SISTER/SISTER-IN-LAW E SISTER/SISTER-IN-LAW E
ACCOMPANIED
OTHER MEMBER OF OTHER MEMBER OF
HUSBAND FAMILY F HUSBAND FAMILY F
OTHER MEMBER OF OTHER MEMBER OF
RESPONDENT FAMILY G RESPONDENT FAMILY G
RELATIVES H RELATIVES H
NEIGHBOUR/FRIEND I NEIGHBOUR/FRIEND I
TBA/FIELD WORKER/DAI J TBA/FIELD WORKER/DAI J
OTHER X OTHER X
(SPECIFY) (SPECIFY)
NONE Y NONE Y
425B CAR A CAR A
How did you get to the hospital/health BUS B BUS B
center? TRAIN C TRAIN C
AMBULANCE D AMBULANCE D
BOAT E BOAT E
ENGINE BOAT F ENGINE BOAT F
OX CART G OX CART G
RICKSHAWVAN H RICKSHAWVAN H
BABY TAXI/TEMPO I BABY TAXI/TEMPO I
ON FOOT J ON FOOT J
OTHER________________________X OTHER________________________X
(SPECIFY) (SPECIFY)
(SKIP TO 425D) (SKIP TO 425D)
425C VERY MUCH 1 VERY MUCH 1
Did you have difficulty in obtaining
SOMEWHAT 2 SOMEWHAT 2
transportation?
NOT AT ALL 3 NOT AT ALL 3
DON'T KNOW 8 DON'T KNOW 8
425D
How long did you wait between the time
you arrived at the hospital/clinic and the
time you were examined by a health care
provider (doctor/health worker)? HOURS MINUTES HOURS MINUTES

IMMEDIATELY ............................... 0000 IMMEDIATELY ............................... 0000

DON'T KNOW.................................. 9998 DON'T KNOW.................................. 9998

13
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER .................. SERIAL NUMBER ..................

LINE NUMBER LINE NUMBER

425E
Did your condition improve after treatment
in this place, or did it stay the same? NO CHANGE 1 NO CHANGE 1
IMPROVED 2 IMPROVED 2

WORSNED 3 WORSNED 3
DON'T KNOW 8 DON'T KNOW 8

426 Were you told to go any other place after


this last place? YES........................................................ 1 YES ........................................................1
NO ......................................................... 2 NO ..........................................................2
(SKIP TO 426E) (SKIP TO 426E)
426A Where were you told to go? PUBLIC SECTOR PUBLIC SECTOR
GOVT. HOSPITAL 21 GOVT. HOSPITAL 21
THANA HEALTH COMPLEX 22 THANA HEALTH COMPLEX 22
MATERNAL AND CHILD MATERNAL AND CHILD
WELFARE CENTER (MCWC) 23 WELFARE CENTER (MCWC) 23
UNION FAMILY WELFARE UNION FAMILY WELFARE
CENTER (UFWC) 24 CENTER (UFWC) 24
SATELITTE/EPI OUTREACH 25 SATELITTE/EPI OUTREACH 25
COMMUNITY CLINIC 26 COMMUNITY CLINIC 26
NGO SECTOR NGO SECTOR
NGO STATIC CLINIC 31 NGO STATIC CLINIC 31
NGO HOSPITAL 32 NGO HOSPITAL 32
NGO SATEITTE CLINIC 33 NGO SATEITTE CLINIC 33
PRIVATE SECTOR PRIVATE SECTOR
PVT. HOSPITAL 41 PVT. HOSPITAL 41
PVT. CLINIC 42 PVT. CLINIC 42
CHAMBER/PHARMACY OF CHAMBER/PHARMACY OF
QUALIFIED DOCTOR 43 QUALIFIED DOCTOR 43
CHAMBER/PHARMACY OF CHAMBER/PHARMACY OF
TRADITIONAL DOCTOR 44 TRADITIONAL DOCTOR 44

OTHER 96 OTHER 96
(SPECIFY) (SPECIFY)
DON'T KNOW 98 DON'T KNOW 98
426B NO SURGERY EQUIPMENT A NO SURGERY EQUIPMENT A
Why were you told to seek
treatment/advice to another place? HIGH BLOOD PRESSURE B HIGH BLOOD PRESSURE B
FOR BETTER TREATMENT C FOR BETTER TREATMENT C
DOCTOR UNAVAILABLE D DOCTOR UNAVAILABLE D
NO ARRANGEMENT FOR BLOOD NO ARRANGEMENT FOR BLOOD
TRANSFUSION E TRANSFUSION E
DID NOT HAVE NECESSARY DID NOT HAVE NECESSARY
ARRANGEMENT TO ARRANGEMENT TO
SOLVE PROBLEM F SOLVE PROBLEM F
BABY'S UPWARD POSITION G BABY'S UPWARD POSITION G
SOME PART OF BABY CAME OUT H SOME PART OF BABY CAME OUT H
BABY URINATED I BABY URINATED I
UTERUS DID NOT OPEN J UTERUS DID NOT OPEN J
OTHER_________________________X OTHER_________________________X

426C YES 1 YES 1


Did you go the referred place? NO 2 NO 2

426C1
CHECK 426C NO YES NO YES

TO GET THE TO GET THE


INFORMATION FOR INFORMATION FOR
LAST TREATMENT, LAST TREATMENT,
REPEAT Q425 TO 425E REPEAT Q425 TO 425E

14
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER .................. SERIAL NUMBER...................

LINE NUMBER LINE NUMBER

426D Why you did not go the referred place? NOT NECESSARY A NOT NECESSARY A
Any other reason? NOT CUSTOMERY B NOT CUSTOMERY B
COST TOO MUCH C COST TOO MUCH C
PROBE FOR THE TYPE OF PERSON LACK OF MONEY D LACK OF MONEY D
AND RECORD ALL PERSONS SEEN.
TOO FAR E TOO FAR E
TRANSPORT PROBLEM F TRANSPORT PROBLEM F
NO ONE TO ACCOMPANY G NO ONE TO ACCOMPANY G
POOR QUALITY SERVICE H POOR QUALITY SERVICE H
FAMILY DID NOT ALLOW I FAMILY DID NOT ALLOW I

BETTER CARE AT HOME J BETTER CARE AT HOME J

NOT KNOWN HOW TO GO K NOT KNOWN HOW TO GO K

NO TIME TO GET SERVICE L NO TIME TO GET SERVICE L


NOT WANT SERVICE NOT WANT SERVICE
FROM MALE DOCTOR N FROM MALE DOCTOR N
DID NOT THINK OF SERIOUSNESS DID NOT THINK OF SERIOUSNESS
OF COMPLICATION W OF COMPLICATION W
OTHER_________________________ X OTHER_________________________ X
(SPECIFY) (SPECIFY)
426E When did you go to this place (PLACE IN
425), after you left the place (PLACE IN HOURS...................1 HOURS .................. 1
421?

DAYS ......................2 DAYS...................... 2

DON'T KNOW.................................. 998 DON'T KNOW ................................. 998


427 Will you refer to any of your known YES 1 YES 1
pregnant woman to go for delivery in this NO 2 NO 2
(last) place?
428 How much total did you spend for this
complication/delivery?
(EXPLAIN : TOTAL COST FROM TAKA TAKA
STARTING TO END OF THE NOTHING ...................................... 00000 NOTHING.......................................00000
DELIVERY/TREATMENT)
SKIP TO 429) SKIP TO 429)

DON'T KNOW................................ 99998 DON'T KNOW ................................99998


428A FAMILY FUNDS A FAMILY FUNDS A
How did you get this money for treatment? BORROWED B BORROWED B
SOLD ASSETS C SOLD ASSETS C
FROM RELATIVES D FROM RELATIVES D
MORTGAGE E MORTGAGE E
OTHER_______________________X OTHER_______________________X
DON'T KNOW Y DON'T KNOW Y

429 YES........................................................ 1 YES ........................................................1


Did you check your health two months NO ......................................................... 2 NO ..........................................................2
after the delivery?
(SKIP TO 429C) (SKIP TO 429C)

429A Whom did you see? HEALTH PROFESSIONAL HEALTH PROFESSIONAL


QUALIFIED DOCTOR A QUALIFIED DOCTOR A
Anyone else? NURSE/MIDWIFE/PARAMEDIC B NURSE/MIDWIFE/PARAMEDIC B
FAMILY WELFARE VISITOR C FAMILY WELFARE VISITOR C
PROBE FOR THE TYPE OF PERSON MA/SACMO D MA/SACMO D
AND RECORD ALL PERSONS SEEN. HEALTH ASST (HA) E HEALTH ASST (HA) E
FIELD WELFARE ASST (FWA) F FIELD WELFARE ASST (FWA) F
OTHER PERSON OTHER PERSON
TRAINED TRADITIONAL BIRTH TRAINED TRADITIONAL BIRTH
ATTENDANT (TTBA) G ATTENDANT (TTBA) G
UNTRAINED TBA H UNTRAINED TBA H
UNQUALIFIED DOCTOR I UNQUALIFIED DOCTOR I
OTHER X OTHER X
(SPECIFY) (SPECIFY)

15
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER .................. SERIAL NUMBER...................

LINE NUMBER LINE NUMBER

429B Where did you receive checkup?


HOME ............................................. A HOME ............................................. A
PUBLIC SECTOR PUBLIC SECTOR
Any other places? GOVT. HOSPITAL......................... B GOVT. HOSPITAL......................... B
THANA HEALTH COMPLEX..........C THANA HEALTH COMPLEX..........C
MATERNAL AND CHILD MATERNAL AND CHILD
WELFARE CENTER (MCWC).......D WELFARE CENTER (MCWC).......D
UNION FAMILY WELFARE UNION FAMILY WELFARE
CENTER (UFWC)...................... E CENTER (UFWC)...................... E
SATELITTE /EPI OUTREACH........ F SATELITTE /EPI OUTREACH........ F
COMMUNITY CLINIC.....................G COMMUNITY CLINIC.....................G

NGO SECTOR NGO SECTOR


NGO STATIC CLINIC .....................H NGO STATIC CLINIC .....................H
NGO HOSPITAL.............................. I NGO HOSPITAL.............................. I
NGO SATELITTE CLINIC................J NGO SATELITTE CLINIC................J

PRIVATE SECTOR PRIVATE SECTOR


PVT. HOSPITAL ............................ K PVT. HOSPITAL ............................ K
PVT. CLINIC .................................. L PVT. CLINIC .................................. L
QUALITFIED DOCTOR'S QUALITFIED DOCTOR'S
CHAMBER /PHARMACY .............. M CHAMBER /PHARMACY .............. M
TRADITIONAL DOCTOR'S TRADITIONAL DOCTOR'S
CHAMBER /PHARMACY ...............N CHAMBER /PHARMACY ...............N

OTHER ......................................... X OTHER ......................................... X


(SPECIFY) (SPECIFY)
(SKIP TO 429D) (SKIP TO 429D)
429C Why you did not check your health? NOT NECESSARY A NOT NECESSARY A
NOT CUSTOMERY B NOT CUSTOMERY B
COST TOO MUCH C COST TOO MUCH C
LACK OF MONEY D LACK OF MONEY D
TOO FAR E TOO FAR E
TRANSPORT PROBLEM F TRANSPORT PROBLEM F
NO ONE TO ACCOMPANY G NO ONE TO ACCOMPANY G
POOR QUALITY SERVICE H POOR QUALITY SERVICE H
FAMILY DID NOT ALLOW I FAMILY DID NOT ALLOW I

BETTER CARE AT HOME J BETTER CARE AT HOME J

NOT KNOWN HOW TO GO K NOT KNOWN HOW TO GO K

NO TIME TO GET SERVICE L NO TIME TO GET SERVICE L


DID NOT KNOW WHERE TO GO M DID NOT KNOW WHERE TO GO M
NOT WANT SERVICE NOT WANT SERVICE
FROM MALE DOCTOR N FROM MALE DOCTOR N
DID NOT KNOW NEEDTO CHECK U DID NOT KNOW NEEDTO CHECK U
OTHER_________________________ X OTHER_________________________ X
(SPECIFY) (SPECIFY)

429D YES 1 YES 1


Did you check your baby's health two NO 2 NO 2
months after the delivery? DON'T KNOW 8 DON'T KNOW 8
(SKIP TO 429G) (SKIP TO 429G)

16
LAST PREGNANCY NEXT-TO-LAST PREGNANCY
SERIAL NUMBER .................. SERIAL NUMBER ..................

LINE NUMBER LINE NUMBER

429E Whom did you see for baby's health HEALTH PROFESSIONAL HEALTH PROFESSIONAL
checkup? QUALIFIED DOCTOR (MBBS) A QUALIFIED DOCTOR (MBBS) A
NURSE/MIDWIFE/PARAMEDIC B NURSE/MIDWIFE/PARAMEDIC B
Anyone else? FAMILY WELFARE VISITOR C FAMILY WELFARE VISITOR C
MA/SACMO D MA/SACMO D
HEALTH ASST (HA) E HEALTH ASST (HA) E
FIELD WELFARE ASST (FWA) F FIELD WELFARE ASST (FWA) F
OTHER PERSON OTHER PERSON
TRAINED TRADITIONAL BIRTH TRAINED TRADITIONAL BIRTH
ATTENDANT (TTBA) G ATTENDANT (TTBA) G
UNTRAINED TBA H UNTRAINED TBA H
UNQUALIFIED DOCTOR I UNQUALIFIED DOCTOR I
OTHER X OTHER X
(SPECIFY) (SPECIFY)
429F Where did you receive baby's checkup? OWN HOME A OWN HOME A
PUBLIC SECTOR PUBLIC SECTOR
GOVT. HOSPITAL B GOVT. HOSPITAL B
Any other places? THANA HEALTH COMPLEX C THANA HEALTH COMPLEX C
MATERNAL AND CHILD MATERNAL AND CHILD
WELFARE CENTER (MCWC) D WELFARE CENTER (MCWC) D
UNION FAMILY WELFARE UNION FAMILY WELFARE
CENTER (UFWC) E CENTER (UFWC) E
SATELITE/EPI CLINIC F SATELITE/EPI CLINIC F
COMMUNITY CLINIC G COMMUNITY CLINIC G

NGO SECTOR NGO SECTOR


NGO STATIC CLINIC H NGO STATIC CLINIC H
NGO HOSPITAL I NGO HOSPITAL I
NGO SATELITTE CLINIC J NGO SATELITTE CLINIC J
PRIVATE SECTOR PRIVATE SECTOR
PVT. HOSPITAL K PVT. HOSPITAL K
PVT. CLINIC L PVT. CLINIC L
QUALITFIED DOCTOR'S QUALITFIED DOCTOR'S
CHAMBER /PHARMACY M CHAMBER /PHARMACY M
TRADITIONAL DOCTOR'S TRADITIONAL DOCTOR'S
CHAMBER /PHARMACY N CHAMBER /PHARMACY N
OTHER X OTHER X
(SPECIFY) (SPECIFY)
(SKIP TO 430) (SKIP TO 430)
429G What are the reasons that you did not NOT NECESSARY A NOT NECESSARY A
check your baby's health?
NOT CUSTOMERY B NOT CUSTOMERY B
COST TOO MUCH C COST TOO MUCH C
LACK OF MONEY D LACK OF MONEY D
TOO FAR E TOO FAR E
TRANSPORT PROBLEM F TRANSPORT PROBLEM F
NO ONE TO ACCOMPANY G NO ONE TO ACCOMPANY G
POOR QUALITY SERVICE H POOR QUALITY SERVICE H
FAMILY DID NOT ALLOW I FAMILY DID NOT ALLOW I

BETTER CARE AT HOME J BETTER CARE AT HOME J

NOT KNOWN HOW TO GO K NOT KNOWN HOW TO GO K

NO TIME TO GO L NO TIME TO GO L
DID NOT KNOW WHERE TO GO M DID NOT KNOW WHERE TO GO M
NOT WANT SERVICE NOT WANT SERVICE
FROM MALE DOCTOR N FROM MALE DOCTOR N
DID NOT KNOW NEEDTO CHECK U DID NOT KNOW NEEDTO CHECK U
OTHER_________________________ X OTHER_________________________ X
(SPECIFY) (SPECIFY)

430. GIVE THANKS FOR THE INTERVIEW


431 RECORD THE TIME HOURS………… MINUTES…….

17
BANGLADESH MATERNAL HEALTH SERVICES AND MATERNAL MORTALITY SURVEY 2001
VERBAL AUTOPSY QUESTIONNAIRE

IDENTIFICATION

DIVISION __________________________________________________________________________

DISTRICT _________________________________________________________________________

THANA ___________________________________________________________________________

UNION/WARD______________________________________________________________________

MOUZA/MAHALLA___________________________________________________________________

VILLAGE/MOHALLA/BLOCK___________________________________________________________

SEGMENT NUMBER

TYPE OF AREA: RURAL=1, URBAN=2, OTHER URBAN=3

HOUSEHOLD NUMBER

CLUSTER NUMBER

NAME OF RESPONDENT

NAME OF DECEASED

INTERVIEWER VISITS
1 2 3 FINAL VISIT

DATE DAY

MONTH*

YEAR

INTERVIEWER’S NAME CODE

RESULT* RESULT**

NEXT VISIT: DATE TOTAL NO.


OF VISITS
TIME

**RESULT CODES:
1 COMPLETED 4 REFUSED 7 OTHER
2 NOT AT HOME 5 PARTLY COMPLETED (SPECIFY)
3 POSTPONED 6 RESPONDENT INCAPACITATED

*MONTH CODES
01 JANUARY 04 APRIL 07 JULY 10 OCTOBER
02 FEBRUARY 05 MAY 08 AUGUST 11 NOVEMBER
03 MARCH 06 JUNE 09 SEPTEMBER 12 DECEMBER

SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BY


NAME NAME

DATE DATE

1
SECTION 1. SELECTION OF PEOPLE TO BE INTERVIEWED

101. Who were around during the woman’s last illness and at the time of the woman’s death?

101A 101B 101C 101D 101E 101F 101G 101H


Relationship to woman and Was ______ Was ______ Of those who know Does Is this person's Circle 1 for
name (column 1) (column 1) about the cause of her _______ house in your those in
present present at death and last illness (column 1) union? column 1
during last the time of record 1, 2, 3,... in this live in this Those circled 2 if who were
illness of death of column to indicate the household? absent at the present
_________ _________ relative degree of their If 1 is circled time of interview during the
Name Relationship
(NAME)? (NAME)? knowledge. The same then ask will not be interview
number can be used for about next eligible as a
2 persons to indicate person respondent
same knowledge
1 2 3 4 5 6 7 8
Yes 1
Yes 1 Yes 1 Yes 1 Yes 1
No 2
No 2 No 2 No 2 No 2
NA 7
Yes 1
Yes 1 Yes 1 Yes 1 Yes 1
No 2
No 2 No 2 No 2 No 2
NA 7
Yes 1
Yes 1 Yes 1 Yes 1 Yes 1
No 2
No 2 No 2 No 2 No 2
NA 7
Yes 1
Yes 1 Yes 1 Yes 1 Yes 1
No 2
No 2 No 2 No 2 No 2
NA 7
Yes 1
Yes 1 Yes 1 Yes 1 Yes 1
No 2
No 2 No 2 No 2 No 2
NA 7

Husband=01 Mother=03 Father-in-law=05 Sister=07 Sister in law=09 Son=11 Grand-mother=13 FWA=15 Non-relative=18
Co-wife=02 Father=04 Mother-in-law=06 Brother=08 Brother in law=10 Daughter=12 Grand-father=14 TBA/Dai =16 Other relative
Neighbour/Friend=17 _____________=19
(specify)

Interview must be conducted with those who know the most about the woman's last illness and her death
(101E) and who are available for the interview. During the interview, others in the list above may be
present and their help may be sought

Record the full address of the selected best respondent if he/she lives in another house but in the same union, so that he/she
can be located later according to the address for conducting the interview
Address:

2
SECTION 2. BACKGROUND INFORMATION

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

201 Time of starting interview: |____|____| hrs |____|____| mins


202 How old was _____________(NAME) at the time of her death? |____|____| years
(write in completed years)
203 Did _____________(NAME) ever study in a school or madrassah? YES ...........................................................1
NO .............................................................2 204
DON’T KNOW ...........................................8 204
203A How many years of schooling did she complete? Class ............................... |____|____| years

DON’T KNOW .........................................98

204 Did _____________(NAME) do any work, other than her own household YES ...........................................................1
chores? NO .............................................................2 205
DON’T KNOW ...........................................8 205

204A Did __________ receive any payment or things for the work, or did she RECEIVED NOTHING 0
receive nothing?
RECEIVED CASH 1
RECEIVED OTHER THINGS 3
RECEIVED CASH AND OTHER THINGS 4
DON'T KNOW/UNSURE 8

205 What was her marital status? MARRIED 1


SEPARATED 2 208
DESERTED 3 208
DIVORCED 4 208
WIDOWED 5 208
NEVER MARRIED 6 301

206 How old was her husband/you when ___________ died? Years .........................................|____|____|

DON’T KNOW .........................................98

207 Did her husband/you ever study in a school or madrassah? YES ...........................................................1
NO .............................................................2 208
DON’T KNOW ...........................................8 208

207A How many years of schooling did he/you complete? Class ............................... |____|____| years

DON’T KNOW .........................................98

208 Did _____________(NAME) have any children? YES ...........................................................1


NO .............................................................2 208F
DON’T KNOW ...........................................8 208F

208A How many live births did she have? Number of live births ...................|____|____|
(If none, write =00)
DON’T KNOW .........................................98

208B How many still births did she have? Number of still births ...................|____|____|
(If none, write =00)
DON’T KNOW .........................................98

208C How many of the live births were still alive at the time of her death? Number still alive ........................|____|____|
(If none, write =00)
DON’T KNOW .........................................98

208D Did she ever have any complication in a previous pregnancy? YES ...........................................................1
NO .............................................................2
DON'T KNOW/UNSURE ...........................8

208E Did she have a cesarean section in a previous pregnancy? YES ...........................................................1
NO .............................................................2
DON'T KNOW/UNSURE ...........................8

208F Did _____________(NAME) ever have any miscarriages/abortions/ Times ................................................. |____|
MRs? If yes, how many?
DON’T KNOW ...........................................8
(If none, write =0)

3
SECTION 3. GENERAL INFORMATION ABOUT EVENTS PRECEDING DEATH

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

301 In what month and year did she die? YEAR |___|___|___|___|
DON’T KNOW YEAR...........................9998

MONTH .................................. |___|___|

DON’T KNOW MONTH ...........................98

302 Was the deceased woman ill before death or did she have any health YES ...........................................................1
problem before death?
NO .............................................................2 304

DON'T KNOW/UNSURE ...........................8 304

303 For how many days was she ill or did she have the health problem DAYS ........................... 1 |____|____|
before she died?
(If less than 1 day write 00) MONTHS ..................... 2 |____|____|
DON'T KNOW/UNSURE .........................98

304 Where did she die? HUSBAND’S HOME.................................. 1 307

HER PARENT’S HOME ............................ 2 307

HOSPITAL /CLINIC ................................... 3

IN-TRANSIT .............................................. 4 307

OTHERS ................................................... 7 307

305 What is the name of hospital/clinic where she died? NAME OF HOSPITAL /CLINIC

___________________________

306 Did anyone from the hospital/clinic tell you why she died? YES ...........................................................1

NO .............................................................2 307

DON'T KNOW/UNSURE ...........................8 307

306A What was/were the reason(s) given by the hospital/clinic as to why she
died? Tell us the two main reasons.
|_____|_____|
__________________________________________________
|_____|_____|
__________________________________________________

307 What do you think is the cause(s) of her death? Tell us the two main
reasons.
|_____|_____|
CAUSE (1)_________________________
|_____|_____|
CAUSE (2)_________________________

308 Did any doctor/health care provider ever tell you or YES NO DK
_____________(NAME) that she had _______________:

Hypertension? HYPERTENSION 1 2 8
Diabetes? DIABETES 1 2 8
Epilepsy? EPILEPSY 1 2 8
TB? TB 1 2 8
Heart disease? HEART DISEASE 1 2 8
Disease of the blood? DISEASE OF BLOOD 1 2 8
Asthma? ASTHMA 1 2 8
Cancer (Please specify______________________________) CANCER ___________ 1 2 8
HIV/AIDS? HIV/AIDS 1 2 8
Other chronic illness (Please specify____________________) OTHER CHRONIC
DISEASE_____________ 1 2 8

309 Was she ever hospitalized? YES ...........................................................1

NO .............................................................2 311

DON’T KNOW ...........................................8 311

4
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

309A How long (day/month) before her death was she last hospitalized? If DAYS ........................... 1 |____|____|
time is less than 1 day than write 00 days. If time is less than 1 month
than write in completed days. If time is less than 1 year than write in
completed months. If time is 12 months or more than write in completed
MONTHS ..................... 2 |____|____|
years.
YEARS ........................ 3 |____|____|
DON'T KNOW/UNSURE .........................98

309B Why was she last hospitalized? |_____|_____|

Verbatim: _____________________________________________ |_____|_____|

_____________________________________________________ DON'T KNOW/UNSURE .........................98

310 Did she have any operation/surgery before death? YES ...........................................................1

NO .............................................................2 311

DON’T KNOW ...........................................8 311

310A How long before her death did she have the last operation? If time is
less than 1 day than write 00 days. If time is less than 1 month than write DAYS ........................... 1 |____|____|
in completed days. If time is less than 1 year than write in completed
months. If time is 12 months or more than write in completed years. MONTHS ..................... 2 |____|____|
YEARS ........................ 3 |____|____|
DON'T KNOW/UNSURE .........................98

310B Why did she have the operation/surgery? |_____|_____|

Verbatim: _____________________________________________ |_____|_____|

_____________________________________________________ DON'T KNOW/UNSURE ......................... 98

311 Was the woman pregnant at the time of death? YES ...........................................................1

NO .............................................................2 313

PROBABLY YES .......................................3

DON’T KNOW ...........................................8 313

311A How many months was she pregnant at the time of death? MONTH ......................... |____|____|

DON’T KNOW .......................................98

312 Did the woman die before labour pain began or did she die after labour MOTHER DIED BEFORE LABOUR BEGAN..1 401
pain began
MOTHER DIED AFTER LABOUR BEGAN
BUT BEFORE BIRTH OF CHILD....................2 401

DON'T KNOW/UNSURE .................................8 401

313 Was _____________(NAME) ever pregnant while still alive? YES ...........................................................1

NO .............................................................2 401

Interviewer: Compare response to Q313 with that of Q208 and Q208F. If inconsistent, then probe and correct the responses.

313A What was the outcome of her last pregnancy? LIVE BIRTH ...............................................1

STILL BIRTH .............................................2 313E

ABORTION/MISCARRIAGE/MR ...............3 313E

DON'T KNOW/UNSURE ...........................8 313E

313B Is the child from this pregnancy still alive? YES ...........................................................1 313D

NO .............................................................2

313C At what age did that child die? If age is less than 1 month than write in DAYS........................... 1 |____|____| 313E
completed days. If time is less than 1 year than write in completed
months. If time is 12 months or more than write in completed years.
MONTHS ..................... 2 |____|____| 313E

YEARS ........................ 3 |____|____| 313E


DON'T KNOW/UNSURE ......................... 98 313E

5
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

313D How old is this child now? If age is less than 1 month than write in DAYS ........................... 1 |____|____|
completed days. If time is less than 1 year than write in completed
months. If time is 12 months or more than write in completed years.
MONTHS ..................... 2 |____|____|
YEARS ........................ 3 |____|____|
DON'T KNOW/UNSURE .........................98

313E How long after her delivery/last birth/still birth/abortion/miscarriage/MR DAYS ........................... 1 |____|____|
did she die? If time is less than 1 day than write 00 days. If time is less
than 60 days then write in completed days, if more then write in
completed months. If time is 12 months or more than write in completed
MONTHS ..................... 2 |____|____|
years.
YEARS ........................ 3 |____|____|
DON'T KNOW/UNSURE .........................98

6
SECTION 4. DESCRIPTIVE REPORT OF ILLNESS AND EVENTS THAT LED TO THE DEATH

401. Explain to the respondent that we would like to hear the details about everything that happened during the last illness
before ___________ death starting from the beginning of the ilness and also about what happened during the final hours of
the woman’s death.

Verbatim:

7
SUMMARY OF SYMPTOMS AND SIGNS OBSERVED DURING THE LAST ILLNESS BEFORE DEATH
AS REPORTED BY RESPONDENT. PLEASE LIST IN THE ORDER THEY APPEARED

Symptoms Duration Severity


1.
VERY SEVERE.............. 1

MODERATE................... 2

MILD............................... 3
2.
VERY SEVERE.............. 1

MODERATE................... 2

MILD............................... 3
3.
VERY SEVERE.............. 1

MODERATE................... 2

MILD............................... 3
4.
VERY SEVERE.............. 1

MODERATE................... 2

MILD............................... 3
5.
VERY SEVERE.............. 1

MODERATE................... 2

MILD............................... 3
6.
VERY SEVERE.............. 1

MODERATE................... 2

MILD............................... 3
7.
VERY SEVERE.............. 1

MODERATE................... 2

MILD............................... 3
8.
VERY SEVERE.............. 1

MODERATE................... 2

MILD............................... 3
9.
VERY SEVERE.............. 1

MODERATE................... 2

MILD............................... 3

8
SECTION 5
MODULE 1. GENERAL ILLNESS LEADING TO DEATH
SPECIFIC QUESTIONS TO ELICIT SYMPTOMS AND SIGNS OF THE LAST ILLNESS

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

501 Did _________(NAME) have fever during her last illness? YES............................................................1

NO .............................................................2 502

DON’T KNOW............................................8 502

501A How many days/months before her death did the fever start and end? START |____|____| |____|____|
mons days

END |____|____| |____|____|


mons days

DIED WITH FEVER ....................................9995

DON'T KNOW/UNSURE.............................9998

501B How was the fever like? HIGH ......................................................... 1

MILD ......................................................... 2

DON'T KNOW/UNSURE........................... 8

501C Was the fever continuous or on and off? CONTINUOUS.......................................... 1

AFTER EVERY 1 - 2 DAYS...................... 2

AT NIGHT ONLY ...................................... 3

OTHER________________________ ..... 7

DON'T KNOW/UNSURE........................... 8

501D Did the fever come with severe chills? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

502 Did she have a reddish rash at anytime during her last illness? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

503 Was she losing weight before death? YES............................................................1

NO .............................................................2 504

DON’T KNOW............................................8 504

503A Was the loss of weight severe or moderate? SEVERE ................................................... 1

MODERATE ............................................. 2

DON'T KNOW/UNSURE........................... 8

504 Did she have poor appetite at anytime during her last illness? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

505 Did she have swelling around ankles during her last illness? YES............................................................1

NO .............................................................2 506

DON’T KNOW............................................8 506

505A How many days/months before her death did the swelling around her START |____|____| |____|____|
ankles start? mons days
(Write in months and days. If less than 1 month, then write 00 for
months and only write in days DON'T KNOW/UNSURE.............................9998

506 Did she have puffiness of the face during her last illness? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

9
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

507 Did she have a swelling in the neck during her last illness? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

508 Did she have any other swelling on her body? YES........................................................... 1

(Probe) NO ............................................................ 2 509

DON'T KNOW/UNSURE........................... 8 509

508A Where was the swelling on her body? HEAD ---------------------------------------------------A


FACE ---------------------------------------------------B
MOUTH ------------------------------------------------C
NECK ---------------------------------------------------D
UPPER ARM -----------------------------------------E
LOWER ARM----------------------------------------- F
AXILLA ------------------------------------------------G
HANDS-------------------------------------------------H
CHEST ------------------------------------------------- I
ABDOMEN -------------------------------------------- J
UPPER BACK ----------------------------------------K
LOWER BACK --------------------------------------- L
BUTTOCKS -------------------------------------------M
GROIN -------------------------------------------------N
GENITALS --------------------------------------------O
THIGHS ------------------------------------------------P
LEGS ---------------------------------------------------Q
FEET----------------------------------------------------R
OTHER_____________________ -------------X

509 Did the colour of her eye change to yellow (jaundice) during her last YES........................................................... 1
illness?
NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

510 Did she have itching of skin at anytime during her last illness? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

511 Did her eyes, face or palms look pale (anaemic) during her last illness? YES NO DK
PALE EYES----------------------- 1 ------- 2 ------- 8
PALE FACE----------------------- 1 ------- 2 ------- 8
PALE PALM ---------------------- 1 ------- 2 ------- 8

512 Did she have any ulcers on her body during her last illness? YES........................................................... 1

NO ............................................................ 2 513

DON'T KNOW/UNSURE........................... 8 513

10
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

512A Where were the ulcers on her body? HEAD ---------------------------------------------------A


FACE ---------------------------------------------------B
Anywhere else? (Do not probe)
MOUTH ------------------------------------------------C
NECK ---------------------------------------------------D
UPPER ARM -----------------------------------------E
LOWER ARM----------------------------------------- F
AXILLA ------------------------------------------------G
HANDS-------------------------------------------------H
CHEST ------------------------------------------------- I
ABDOMEN -------------------------------------------- J
UPPER BACK ----------------------------------------K
LOWER BACK --------------------------------------- L
BUTTOCKS -------------------------------------------M
GROIN -------------------------------------------------N
GENITALS --------------------------------------------O
THIGHS ------------------------------------------------P
LEGS ---------------------------------------------------Q
FEET----------------------------------------------------R
OTHER_____________________ -------------X

513 Did she have a cough during her last illness? YES............................................................1

NO .............................................................2 514

DON’T KNOW............................................8 514

513A How many days or months before her death did the cough start? START |____|____| |____|____|
(Write in months and days. If less than 1 month, then write 00 for mons days
months and only write in days
DON'T KNOW/UNSURE 9998

513B Did the cough produce sputum? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

513C Did she cough blood? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

514 Did she have difficulty in breathing during her last illness? YES............................................................1

NO .............................................................2 515

DON’T KNOW............................................8 515

514A Was the difficulty in breathing continuous or on and off? CONTINUOUS.......................................... 1

ON AND OFF............................................ 2

DON'T KNOW/UNSURE........................... 8

514B How many days/months before her death did the difficulty in breathing START |____|____| |____|____|
start and end? mons days
(Write in months and days. If less than 1 month, then write 00 for
months and only write in days END |____|____| |____|____|
mons days

DID NOT IMPROVE ...................................9995

DON'T KNOW/UNSURE.............................9998

515 Was she breathless even on light work? YES........................................................... 1

(Except what is normally seen in late pregnancy, if applicable) NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

11
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

516 Was she breathless on lying on her back? YES........................................................... 1

(Except what is normally seen in late pregnancy, if applicable) NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

517 Was there pain in the chest with breathing? YES............................................................1

NO .............................................................2

DON’T KNOW............................................8

518 Did she have palpitations during her last illness? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

519 Did she have chest pain during her last illness? YES............................................................1

NO .............................................................2 520

DON’T KNOW............................................8 520

519A Was the pain mild, moderate or severe? SEVERE ................................................... 1

MODERATE ............................................. 2

MILD ......................................................... 3

DON'T KNOW/UNSURE........................... 8

519B Did the pain start suddenly or gradually? SUDDENLY .............................................. 1

GRADUALLY ............................................ 2

DON'T KNOW/UNSURE........................... 8

519C Was the pain continuous or on and off? CONTINUOUS.......................................... 1

ON AND OFF............................................ 2

DON'T KNOW/UNSURE........................... 8

519D How many days/months before her death did the pain start and end? START |____|____| |____|____|
mons days
(Write in months and days. If less than 1 month, then write 00 for
months and only write in days)
END |____|____| |____|____|
mons days

DID NOT IMPROVE ...................................9995

DON'T KNOW/UNSURE.............................9998
SHOULDER ------------------------------------------ A
519E When she had the chest pain, did she also have pain elsewhere in her
body? If, yes, where else did she have pain at the same time? NECK --------------------------------------------------- B
ARMS---------------------------------------------------C
NO PAIN ANYWHERE-----------------------------D
OTHER_____________________ ------------- X

520 Did she have loose motion or diarrhoea before her death? YES............................................................1

NO .............................................................2 521

DON’T KNOW............................................8 521

520A How many days/months before her death did the loose motion or START |____|____| |____|____|
diarrhoea start and end? mons days
(Write in months and days. If less than 1 month, then write 00 for
months and only write in days) END |____|____| |____|____|
mons days

DIED WITH FEVER ....................................9995

DON'T KNOW/UNSURE.............................9998

520B When the diarrhoea was severe, how many times did she pass stool in a NUMBER OF TIMES |____|____|
day?
DON'T KNOW/UNSURE....................... 98

12
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

520C What did the stool look like? WATERY .................................................. 1

LOOSE BUT NOT WATERY .................... 2

OTHER________________________ ..... 7

DON'T KNOW/UNSURE........................... 8

520D Did she pass blood in the stool? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

521 Did she have vomiting during her last illness? YES............................................................1

NO .............................................................2 522

DON’T KNOW............................................8 522

521A How many days/months before her death did the vomiting start and START |____|____| |____|____|
end? mons days
(Write in months and days. If less than 1 month, then write 00 for
months and only write in days) END |____|____| |____|____|
mons days

DID NOT STOP ..........................................9995

DON'T KNOW/UNSURE.............................9998

521B When the vomiting was severe, how many times did she vomit in a day? NUMBER OF TIMES |____|____|
DON'T KNOW/UNSURE....................... 98

521C What did the vomits look like most of the time? WATERY FLUID ....................................... 1

YELLOWISH FLUID ................................. 2

DARK BROWN COLOURED FLUID ........ 3

LIKE BLOOD ............................................ 4

FAECAL LOOKING & SMELLING............ 5

OTHER_____________________ ........... 7

DON'T KNOW/UNSURE........................... 8

522 Did she have abdominal pain before her death? YES............................................................1

NO .............................................................2 523

DON’T KNOW............................................8 523

522A What was the type of pain? CRAMPS .................................................. 1

DULL ACHE.............................................. 2

BURNING PAIN........................................ 3

OTHERS _____________________........ 7

DON'T KNOW/UNSURE........................... 8

522B How many days/months before her death did the abdominal pain start START |____|____| |____|____|
and end? mons days
(Write in months and days. If less than 1 month, then write 00 for
months and only write in days) END |____|____| |____|____|
mons days

DID NOT IMPROVE ...................................9995

DON'T KNOW/UNSURE.............................9998

13
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

522C Where exactly was the pain? LOWER ABDOMEN .......................................1

UPPER ABDOMEN ........................................2

CENTRAL ABDOMEN (around umbilicus) .....3

ALL OVER THE ABDOMEN...........................4

DON'T KNOW/UNSURE.................................8

522D Was the pain mild, moderate or severe? SEVERE .........................................................1

MODERATE ...................................................2

MILD ...............................................................3

SOMETHIMES MILD/SOMETIMES MORE....4

DON'T KNOW/UNSURE.................................8

523 Was she unable to pass stool for some days before death? YES.................................................................1

NO ..................................................................2

DON'T KNOW/UNSURE.................................8

524 Did she have distension of abdomen before her death? YES.................................................................1

NO ..................................................................2 525

DON’T KNOW.................................................8 525

524A How many days/months before her death did the distension of abdomen START |____|____| |____|____|
start and end? mons days
(Write in months and days. If less than 1 month, then write 00 for
months and only write in days) END |____|____| |____|____|
mons days

DID NOT IMPROVE ...................................9995

DON'T KNOW/UNSURE.............................9998

524B Did the distension develop rapidly within days or slowly over weeks? RAPIDLY ........................................................1

SLOWLY.........................................................2

DON'T KNOW/UNSURE.................................8

525 Did she have any hard mass in the abdomen before her death? YES.................................................................1

NO ..................................................................2 526

DON’T KNOW.................................................8 526

525A Where exactly was the mass? RIGHT UPPER ABDOMEN ............................1

LEFT UPPER ABDOMEN ..............................2

LOWER ABDOMEN .......................................3

CENTRAL ABDOMEN (around umbilicus) .....4

DON'T KNOW/UNSURE.................................8

525B How long before her death did the mass in the abdomen start? START |____|____| |____|____|
mons days
(Write in months and days. If less than 1 month, then write 00 for
months and only write in days) DON'T KNOW/UNSURE.............................9998

526 Did she have headache during her last illness? YES........................................................... 1

NO ............................................................ 2 527

DON'T KNOW/UNSURE........................... 8 527

526A Was the headache continuous or on and off? CONTINUOUS.......................................... 1

ON AND OFF............................................ 2

DON'T KNOW/UNSURE........................... 8

14
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

526B How was the headache? SEVERE ................................................... 1

MODERATE ............................................. 2

MILD ......................................................... 3

SOMETIMES MILD AND


SOMETIMES SEVERE............................. 4

DON'T KNOW/UNSURE........................... 8

527 Did she have stiff neck during her last illness? YES............................................................1

NO .............................................................2 528

DON’T KNOW............................................8 528

527A How many days/months before her death did the stiff neck start? START |____|____| |____|____|
mons days
(Write in months and days. If less than 1 month, then write 00 for
months and only write in days) DON'T KNOW/UNSURE.............................9998

528 Did she have any loss of consciousness during her last illness? YES............................................................1

NO .............................................................2 529

DON’T KNOW............................................8 529

528A Did she become unconscious suddenly or gradually? SUDDENLY .............................................. 1

GRADUALLY ............................................ 2

DON'T KNOW/UNSURE........................... 8

529 Did she become mentally confused during her last illness? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

530 Did she have fits (convulsions) during her last illness? YES............................................................1

NO .............................................................2 531

DON’T KNOW............................................8 531

530A How many days/months before her death did the fits start? START |____|____| |____|____|
mons days
(Write in months and days. If less than 1 month, then write 00 for
months and only write in days) DON'T KNOW/UNSURE.............................9998

530B Can you describe the nature of fits? REPETITIVE JERKING OF WHOLE BODY..... 1

JERKING OF 1 OR 2 PARTS OF THE BODY . 2

OTHER____________________________ ..... 7

DON'T KNOW/UNSURE................................... 8

530C When fits were most frequent, how many times did she fit in a day? NUMBER OF TIMES |____|____|
DIED AFTER FITS STARTED.............. 95

DON'T KNOW/UNSURE....................... 98

530D Was she awake between fits? YES, ALWAYS.......................................... 1

YES, SOMETIMES ................................... 2

NO ............................................................ 3

DON'T KNOW/UNSURE........................... 8

531 Did she have difficulty in opening the mouth during her last illness? ABLE TO OPEN MOUTH ..........................1

UNABLE TO OPEN MOUTH .....................2

DON’T KNOW............................................8

15
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

532 Did she have stiffness of the whole body before death? YES............................................................1

NO .............................................................2 533

DON’T KNOW............................................8 533

532A How many days/months before her death did the stiffness start? START |____|____| |____|____|
mons days
(Write in months and days. If less than 1 month, then write 00 for
months and only write in days) DON'T KNOW/UNSURE.............................9998

533 Did she become paralyzed on one or both sides of the body before her YES............................................................1
death?
NO .............................................................2 534

DON’T KNOW............................................8 534

533A Which part of the body was paralyzed? LOWER LIMBS..........................................1

ARMS ........................................................2

ONE SIDE OF BODY ................................3

WHOLE BODY ..........................................4

OTHER_________________________ ....7

DON’T KNOW............................................8

533B How many days/months before her death did the paralysis start? START |____|____| |____|____|
mons days
(Write in months and days. If less than 1 month, then write 00 for
months and only write in days) DON'T KNOW/UNSURE.............................9998

534 Was there any change in the color of her urine before death? YES............................................................1

NO .............................................................2 534C

DON’T KNOW............................................8 534C

534A What color did the urine become? LIGHT YELLOW ....................................... 1
DARK YELLOW ........................................ 2
CHUNER PANI (CLOUDY)....................... 3
BHATER MAAR (THICK-WHITE)............. 4
BLOOD STAINED/RED ............................ 5
OTHER_________________________ ... 7
DON'T KNOW/UNSURE........................... 8

534B Since how many days/months before her death did her urine become START |____|____| |____|____|
____________ (ANSWER TO Q534A)? mons days
(Write in months and days. If less than 1 month, then write 00 for DON'T KNOW/UNSURE.............................9998
months and only write in days)
534C Was there any change in her daily frequency of urine before her death? YES............................................................1

NO .............................................................2 534F

DON’T KNOW............................................8 534F

534D Compared to before, how many times was she passing urine in a day - MORE THAN BEFORE ............................ 1
more than before, less than before, or no urine at all?
LESS THAN BEFORE .............................. 2

NO URINE AT ALL ................................... 3

DON'T KNOW/UNSURE........................... 8

534E Since how many days/months before her death did she start to pass START |____|____| |____|____|
urine ____________ (ANSWER TO Q534D)? mons days
(Write in months and days. If less than 1 month, then write 00 for DON'T KNOW/UNSURE.............................9998
months and only write in days)
534F Did she have difficulty in passing urine during her last illness? YES............................................................1

NO .............................................................2 535

DON’T KNOW/UNSURE ...........................8 535

16
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

534G What type of difficulty did she have: YES NO


Unable to pass urine? UNABLE TO PASS -----------------------1-------- 2
Continuous dribbling of urine? DRIBBLING OF URINE------------------1-------- 2
Burning sensation while passing urine? BURNING SENSATION -----------------1-------- 2
Others? OTHER_____________________ ---1-------- 2

535 Did she have a swelling in the breast before her death? YES........................................................... 1

NO ............................................................ 2 536

DON'T KNOW/UNSURE........................... 8 536

535A Was there pain in the breast along with the swelling? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

536 Did she have an ulcer in the breast before her death? YES........................................................... 1

NO ............................................................ 2 537

DON'T KNOW/UNSURE........................... 8 537

536A Was there pain in the breast along with the ulcer? YES........................................................... 1

NO ............................................................ 2

DON'T KNOW/UNSURE........................... 8

537 Did _________________(name) receive any injury or was there any YES........................................................... 1
untoward or violent event leading to death?
NO ............................................................ 2 541

DON'T KNOW/UNSURE........................... 8 541

537A Can you describe what happened exactly? (PROBE and ASK: anything else)

Verbatim____________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

538 Who else contributed to the information given in Q537-537A? NEIGHBOURS ---------------------------------------- A
FAMILY FRIENDS ----------------------------------- B
DECEASED’S FAMILY MEMBERS ------------- C
OTHER_____________________ -------------- X

17
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

539 To the interviewer: Please review the Yes No


response to Q537A and Code accordingly
Dog/animal bite .................................................. 1................. 2

Snake bite .......................................................... 1................. 2

Drowned as a consequence of epilepsy ............ 1................. 2


Intentionally Intentionally
self-inflicted caused by other Accidental No
Train/road accident .........1 ........................... 2..........................3 .............4
Drowning .........................1 ........................... 2..........................3 .............4
Burn .................................1 ........................... 2..........................3 .............4
Fall ...................................1 ........................... 2..........................3 .............4
Cut ...................................1 ........................... 2..........................3 .............4
Suffocation .......................1 ........................... 2..........................3 .............4
Punches, kicks, blows... xxxx......................... 2..........................3 .............4
Rape ............................. xxxx......................... 2....................... xxxx ...........4
Poisoning .........................1 ........................... 2..........................3 .............4
Acid burn .........................1 ........................... 2..........................3 .............4
Other ................................1 ........................... 2..........................3 .............4

_____________________________________________

If the interviewer has any suspicion regarding the accuracy of the information given in Q537-537A then additional information may be
collected from neighbours, family friends, members of the parent’s family of the deceased.

540 To the interviewer: What is your judgement of Dependable ................ 1 (Yes) ............... 2 (Partly) ...............3 (No)
the quality of the information gathered on the
violent events surrounding the woman’s Complete ................... 1 (Yes) ............... 2 (Partly) ...............3 (No)
death?

541 Interviewer: Check Q312, 313, Q313A and Q313E and circle the Q312 IS CODED EITHER 1 OR 8 ...................... 1 601
appropriate code:
Q312 IS CODED 2.............................................. 2 701

Q313 IS CODED 2.............................................. 3 801

Q313 IS CODED 1 AND


Q313E IS 1 YEAR OR MORE ............................ 4 801

Q313A IS CODED 1 OR 2 OR 8 AND


Q313E IS 11 MONTHS OR LESS...................... 5 701

Q313A IS CODED 3 AND


Q313E IS 11 MONTHS OR LESS...................... 6 601A

18
SECTION 6
MODULE 2. FOR DEATHS DURING PREGNANCY PRIOR TO ONSET OF LABOUR
OR WITHIN 1 YEAR OF ABORTION/MISCARRIAGE

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

601 Did _____________(NAME) ever go for antenatal care during that YES ........................................................... 1 601B
pregnancy?
NO ............................................................. 2 604A

DON’T KNOW ........................................... 8 604A

601A Did _____________(NAME) ever go for antenatal care during the last YES ........................................................... 1
pregnancy before she died?
NO ............................................................. 2 604A

DON’T KNOW ........................................... 8 604A

601B From whom did she receive the antenatal care when she was pregnant? HEALTH PROFESSIONAL
QUALIFIED DOCTOR (MBBS) ------------ A
(Anybody else)
NURSE/MIDWIFE/PARAMEDIC ---------- B
(Probe for each type of health professional and circle all who provided
FAMILY WELFARE VISITOR -------------- C
antenatal care)
MA/SACMO ------------------------------------- D
HEALTH ASSISTANT ------------------------ E
FAMILY WELFARE ASSISTANT-----------F
OTHER PERSON
TRAINED TBA ---------------------------------- G
UNTRAINED TBA ----------------------------- H
UNQUALIFIED DOCTOR -------------------- I
OTHER_______________________---------- X

602 Did she first seek antenatal care because she had a problem or just to BECAUSE OF PROBLEM......................... 1
check everything was fine?
TO CHECK ONLY ..................................... 2 603

DON’T KNOW ........................................... 8 603

602A For what problem did she first seek antenatal care? |____|____| |____|____|
Verbatim_________________________________________________ DON'T KNOW/UNSURE ---------------------- 98
_________________________________________________________

603 How many months pregnant was she at the time of her first antenatal MONTHS |____|____|
check-up?
DON'T KNOW/UNSURE ---------------------- 98

604 How many times did she get antenatal care? NUMBER OF TIMES |____|____|
DON'T KNOW/UNSURE ---------------------- 98

604A Did she have swelling around ankles during her pregnancy? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

604B Did she have puffiness of the face during her pregnancy? YES ...........................................................1

NO .............................................................2

DON'T KNOW/UNSURE ...........................8

605 Did she complain of blurred vision during her pregnancy? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

606 Did she have her blood pressure measured during her pregnancy? YES ........................................................... 1

NO ............................................................. 2 607

DON’T KNOW ........................................... 8 607

19
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

606A Do you know whether her blood pressure was normal or high or low? NORMAL ................................................... 1

HIGH ......................................................... 2

LOW .......................................................... 3

DON’T KNOW ........................................... 8

607 During her last illness, was she bleeding from the vagina? YES ........................................................... 1

NO ............................................................. 2 608

DON’T KNOW ........................................... 8 608

607A Did the bleeding stain her clothes, the bed or the floor? YES NO DK

CLOTHES ----------------------1----------2----------8

BED ------------------------------1----------2----------8

FLOOR--------------------------1----------2----------8

607B Was she in pain while bleeding? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

608 Did she have other episodes of bleeding during this pregnancy? YES ........................................................... 1

NO ............................................................. 2 609

DON’T KNOW ........................................... 8 609

608A Were those episodes of bleeding painful? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

609 Did she have a vaginal examination during her illness? YES ........................................................... 1

NO ............................................................. 2 610

DON’T KNOW ........................................... 8 610

609A Did the vaginal examination increase the bleeding? YES ........................................................... 1

NO ............................................................. 2

NOT APPLICABLE (no bleeding).............. 7

DON’T KNOW ........................................... 8

610 Was any attempt made during her pregnancy to induce abortion? YES ........................................................... 1

NO ............................................................. 2 801

DON’T KNOW ........................................... 8 801

610A Whose help did she seek to induce abortion? HEALTH PROFESSIONAL
QUALIFIED DOCTOR (MBBS) ------------ A
NURSE/MIDWIFE/PARAMEDIC ---------- B
FAMILY WELFARE VISITOR -------------- C
MA/SACMO ------------------------------------- D
HEALTH ASSISTANT ------------------------ E
FAMILY WELFARE ASSISTANT-----------F
OTHER PERSON
TRAINED TBA ---------------------------------- G
UNTRAINED TBA ----------------------------- H
UNQUALIFIED DOCTOR -------------------- I
HERBAL DOCTOR (kobiraj) -----------------J
HOMEOPATH ---------------------------------- K
SPIRITUAL HEALER --------------------------L
SELF ---------------------------------------------- M
OTHER_______________________---------- X
DON’T KNOW/UNSURE -------------------------- Y

20
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

610B Was any foreign object inserted inside the woman to induce abortion? YES ........................................................... 1

NO ............................................................. 2 610D

DON’T KNOW ........................................... 8 610D

610C What object was inserted? STICK........................................................ 1

TUBES ...................................................... 2

SYRINGES................................................ 3

OTHERS_______________________ ..... 7

DON’T KNOW ........................................... 8

610D Did the woman take any drugs or injections, or eat anything to induce YES ........................................................... 1
abortion?
NO ............................................................. 2 611

DON’T KNOW ........................................... 8 611

610E What drugs did she take? |____|____| |____|____|


Verbatim_________________________________________________ DON'T KNOW/UNSURE ---------------------- 98
_________________________________________________________

611 Did the woman do MR to induce abortion? YES ........................................................... 1

NO ............................................................. 2 612

DON’T KNOW ........................................... 8 612

611A To whom did did she go for MR? HEALTH PROFESSIONAL


QUALIFIED DOCTOR (MBBS) ------------ A
NURSE/MIDWIFE/PARAMEDIC ---------- B
FAMILY WELFARE VISITOR -------------- C
MA/SACMO ------------------------------------- D
HEALTH ASSISTANT ------------------------ E
FAMILY WELFARE ASSISTANT-----------F
OTHER PERSON
TRAINED TBA ---------------------------------- G
UNTRAINED TBA ----------------------------- H
UNQUALIFIED DOCTOR -------------------- I
OTHER_______________________---------- X

612 Did she have foul-smelling discharge from the vagina after inducing YES ........................................................... 1
abortion?
NO ............................................................. 2

DON’T KNOW ........................................... 8

613 Did she have fever after inducing abortion? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

614 Did she have abdominal distention after inducing abortion? YES ........................................................... 1 801

NO ............................................................. 2 801

DON’T KNOW ........................................... 8 801

21
SECTION 7
MODULE 3. FOR DEATHS DURING LABOUR, DELIVERY OR AFTER DELIVERY

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

701 Did _____________(NAME) ever go for antenatal care during the last YES ........................................................... 1
pregnancy before she died?
NO ............................................................. 2 702

DON’T KNOW ........................................... 8 702

701A From whom did she receive the antenatal care when she was pregnant? HEALTH PROFESSIONAL
QUALIFIED DOCTOR (MBBS) ------------ A
(Anybody else)
NURSE/MIDWIFE/PARAMEDIC ---------- B
(Probe for each type of health professional and circle all who provided
FAMILY WELFARE VISITOR -------------- C
antenatal care)
MA/SACMO ------------------------------------- D
HEALTH ASSISTANT ------------------------ E
FAMILY WELFARE ASSISTANT-----------F
OTHER PERSON
TRAINED TBA ---------------------------------- G
UNTRAINED TBA ----------------------------- H
UNQUALIFIED DOCTOR -------------------- I
OTHER_______________________---------- X

701B Did she first seek antenatal care because she had a problem or just to BECAUSE OF PROBLEM......................... 1
check everything was fine?
TO CHECK ONLY ..................................... 2 701D

DON’T KNOW ........................................... 8 701D

701C For what problem did she first seek antenatal care? |____|____| |____|____|
Verbatim_________________________________________________ DON'T KNOW/UNSURE ---------------------- 98
_________________________________________________________

701D How many months pregnant was she at the time of her first antenatal MONTHS |____|____|
check-up?
DON'T KNOW/UNSURE ---------------------- 98

701E How many times did she get antenatal care? NUMBER OF TIMES |____|____|
DON'T KNOW/UNSURE ---------------------- 98

702 Did she have swelling around ankles during her pregnancy? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

703 Did she have puffiness of the face during her pregnancy? YES ...........................................................1

NO .............................................................2

DON'T KNOW/UNSURE ...........................8

704 Did she complain of blurred vision during her pregnancy? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

705 Did she have her blood pressure measured during her pregnancy? YES ........................................................... 1

NO ............................................................. 2 706

DON’T KNOW ........................................... 8 706

705A Do you know whether her blood pressure was normal or high or low? NORMAL ................................................... 1

HIGH ......................................................... 2

LOW .......................................................... 3

DON’T KNOW ........................................... 8

22
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

706 Did she have bleeding from the vagina during her last pregnancy? YES ........................................................... 1

NO ............................................................. 2 707

DON’T KNOW ........................................... 8 707

706A Did the bleeding stain her clothes, the bed or the floor? YES NO DK

CLOTHES ----------------------1----------2----------8

BED ------------------------------1----------2----------8

FLOOR--------------------------1----------2----------8

706B Did the bleeding start before the birth of the child? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

706C Was she in pain while bleeding (not menses)? YES ........................................................... 1

NO ............................................................. 2 707

DON’T KNOW ........................................... 8 707

706D Did the pain start before the labour pains started? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

707 Did she have other episodes of bleeding during this pregnancy? YES ........................................................... 1

NO ............................................................. 2 708

DON’T KNOW ........................................... 8 708

707A Were those episodes of bleeding painful? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

708 Did she have a vaginal examination during her last pregnancy? YES ........................................................... 1

NO ............................................................. 2 709

DON’T KNOW ........................................... 8 709

708A Did the vaginal examination increase the bleeding? YES ........................................................... 1

NO ............................................................. 2

NOT APPLICABLE (no bleeding).............. 7

DON’T KNOW ........................................... 8

709 Where did she give birth? HOME --------------------------------------------------11


GOVT SECTOR
HOSPITAL ---------------------------------------21
UPAZILA HEALTH COMPLEX-------------23
MATERNAL AND CHILD
WELFARE CENTRE (MCWC) ------------ 24
UNION HEALTH AND FAMILY
WELFARE CENTRE ------------------------- 25
NGO SECTOR
NGO CLINIC ----------------------------------- 31
NGO HOSPITAL ------------------------------ 32
PRIVATE SECTOR
PRIVATE HOSPITAL -------------------------41
PRIVATE CLINIC ------------------------------42
OTHER_______________________----------96
DID NOT DELIVER ---------------------------------51 712

23
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

710 Who assisted with the delivery? HEALTH PROFESSIONAL


QUALIFIED DOCTOR (MBBS) ------------ A
(Anyone else?)
NURSE/MIDWIFE/PARAMEDIC ---------- B
FAMILY WELFARE VISITOR -------------- C
MA/SACMO ------------------------------------- D
HEALTH ASSISTANT ------------------------ E
FAMILY WELFARE ASSISTANT-----------F
OTHER PERSON
TRAINED TBA ---------------------------------- G
UNTRAINED TBA ----------------------------- H
UNQUALIFIED DOCTOR -------------------- I
RELATIVES --------------------------------------J
NEIGHBOURS/FRIENDS ------------------- K
OTHER_______________________---------- X
NOBODY -----------------------------------------------Z

711 During the delivery, were/was ________________ (topic): YES NO DK

a. Instruments used to help the baby out (forceps) FORCEPS/VACUUM ---------- 1 --------- 2 ------- 8

b. An operation done to get the baby out (cesarean section) CESAREAN SECTION -------- 1 --------- 2 ------- 8

c. A blood transfusion given BLOOD TRANSFUSION ------ 1 --------- 2 ------- 8

d. A saline infusion given SALINE INFUSION ------------- 1 --------- 2 ------- 8

712 How long was she in labour for? |____|____| HOURS


(if less than 1 hour write 00) NEVER IN LABOUR (C-SECTION) -------- 95 714B

DON’T KNOW------------------------------------ 98 714

713 Do you think she had prolonged labour? YES ...........................................................1

NO .............................................................2

DON'T KNOW/UNSURE ...........................8

714 Did she have too much bleeding during labour? YES ...........................................................1

NO .............................................................2 714B

DON'T KNOW/UNSURE ...........................8 714B

714A Did the bleeding stain her clothes, the bed or the floor? YES NO DK

CLOTHES ----------------------1----------2----------8

BED ------------------------------1----------2----------8 715

FLOOR--------------------------1----------2----------8

714B Did she have too much bleeding before delivering the baby? YES ...........................................................1

NO .............................................................2 715

DON'T KNOW/UNSURE ...........................8 715

714C Did the bleeding stain her clothes, the bed or the floor? YES NO DK

CLOTHES ----------------------1----------2----------8

BED ------------------------------1----------2----------8

FLOOR--------------------------1----------2----------8

715 Were any drugs used just before or during the labour? YES ...........................................................1

NO .............................................................2

NOT APPLICABLE (no bleeding)..............7

DON'T KNOW/UNSURE ...........................8

24
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

716 How many days or months before her death did she deliver? HOURS ....................... 1 |____|____|
(If less than 1 day then write in hours, if less than 30 days write in days
and if more, then in completed months) DAYS........................... 2 |____|____|
MONTHS ..................... 3 |____|____|
NEVER DELIVERED............................. 997 724

DON'T KNOW/UNSURE ....................... 998 724

717 Did she have difficulty in delivering the baby? YES ...........................................................1

NO .............................................................2

DON'T KNOW/UNSURE ...........................8

718 What part of the baby came out first? HEAD ........................................................1
LEGS .......................................................2
SHOULDER ..............................................3
ARMS ........................................................4
CESAREAN SECTION..............................5 720
DON'T KNOW ...........................................8

719 Was the placenta delivered? YES ........................................................... 1

NO ............................................................. 2 720

DON’T KNOW ........................................... 8 720

719A How long after the birth of the child was the placenta delivered? |____|____| HOURS
(If less than 1 hour write 00)

719B Did she have difficulty in delivering the placenta? YES ...........................................................1

NO .............................................................2

DON'T KNOW/UNSURE ...........................8

719C Was the placenta delivered completely or partially? COMPLETELY .......................................... 1

PARTIALLY ............................................... 2

DON’T KNOW ........................................... 8

720 Did she have too much bleeding after the baby was born? YES ...........................................................1

NO .............................................................2 721

DON'T KNOW/UNSURE ...........................8 721

720A Did the bleeding stain her clothes, the bed or the floor? YES NO DK

CLOTHES ----------------------1----------2----------8

BED ------------------------------1----------2----------8

FLOOR--------------------------1----------2----------8

721 Did she have foul-smelling discharge from the vagina after the baby was YES ........................................................... 1
born?
NO ............................................................. 2

DON’T KNOW ........................................... 8

722 Did she have pain in the legs after the baby was born? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

723 Did she have fever after the baby was born? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

25
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

724 Did she have fits (convulsions) during her pregnancy? YES ........................................................... 1

NO ............................................................. 2 725

DON’T KNOW ........................................... 8 725

724A Did the fits stop after the baby was born? YES ........................................................... 1

NO ............................................................. 2 726

NEVER DELIVERED................................. 3 801

DON’T KNOW ........................................... 8 726

725 Did she develop fits (convulsions) after the baby was born? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

726 Was the colour of her eyes yellow after the baby was born? YES ...........................................................1

NO .............................................................2 801

DON'T KNOW/UNSURE ...........................8 801

726A How many days after delivery did her eyes become yellow? |____|____|____| DAYS
DON'T KNOW/UNSURE .......................998

26
SECTION 8
MODULE 4. GENERAL CARE SEEKING

NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

801 During her last illness, after how much time from the beginning of AFTER HOURS........... 1 |____|____|
symptoms did you recognize that she was having a problem or illness?

[Write in days if less than one month] AFTER DAYS .............. 2 |____|____|
AFTER MONTHS ........ 3 |____|____|
IMMEDIATELY----------------------------------- 000

DON’T KNOW------------------------------------ 998 815

DIED IMMEDIATELY--------------------------- 995 815

802 How serious did you/your family perceive this complication or problem to NOT SERIOUS.......................................... 1
be?
SOMEWHAT SERIOUS ............................ 2
VERY SERIOUS ....................................... 3
803
LIFE THREATENING ................................ 4

802A Did you/your family think that she could have died because of her YES ........................................................... 1
problem or illness?
NO ............................................................. 2

803 During ____________(name) last illness/problem, did she or anyone YES ........................................................... 1
seek treatment for her illness?
NO ............................................................. 2 803C

DON’T KNOW ........................................... 8 803C

803A From whom did she receive treatment? HEALTH PROFESSIONAL


QUALIFIED DOCTOR (MBBS) ------------ A
(Anyone else?)
NURSE/MIDWIFE/PARAMEDIC ---------- B
FAMILY WELFARE VISITOR -------------- C
MA/SACMO ------------------------------------- D
HEALTH ASSISTANT ------------------------ E
FAMILY WELFARE ASSISTANT-----------F
OTHER PERSON
TRAINED TBA ---------------------------------- G
UNTRAINED TBA ----------------------------- H
UNQUALIFIED DOCTOR -------------------- I
OTHER_______________________---------- X

803B Where did she receive care/medical treatment? HOME ------------------------------------------------- A


GOVT SECTOR
(Anywhere else?)
HOSPITAL --------------------------------------- B
UPAZILA HEALTH COMPLEX------------- C
MATERNAL AND CHILD
WELFARE CENTRE (MCWC) ------------- D
UNION HEALTH AND FAMILY
WELFARE CENTRE -------------------------- E
SATELLITE/EPI OUTREACH SITE--------F
COMMUNITY CLINIC ------------------------ G
NGO SECTOR 805
NGO CLINIC ------------------------------------ H
NGO HOSPITAL -------------------------------- I
NGO SATELLITE CLINIC --------------------J
PRIVATE SECTOR
PRIVATE HOSPITAL ------------------------- K
PRIVATE CLINIC -------------------------------L
CHAMBER/ PHARMACY OF
QUALIFIED DOCTOR ------------------------ M
CHAMBER/ PHARMACY OF
UNQUALIFIED DOCTOR ------------------- N
OTHER_______________________---------- X

27
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

803C Why did you not take her to see anyone for treatment? NO TREATMENT NECESSARY------------------ A 804
NOT CUSTOMERY----------------------------------- B 804
(Any other reason?)
COST TOO MUCH ----------------------------------- C 804
LACK OF FUNDS ------------------------------------- D 804
TO FAR -------------------------------------------------- E 804
TRANSPORTATION NOT EASY ----------------- F 804
NO ONE AVAILABLE TO ACCOMPANY------- G 804
GOOD QUALITY CARE NOT AVAILABLE ---- H 804
FAMILY DID NOT ALLOW --------------------------I 804
BETTER CARE AT HOME ------------------------- J 804
DID NOT KNOW HOW TO GO THERE -------- K 804
NO TIME TO GO FOR CARE/ADVICE --------- L 815
DID NOT KNOW WHERE TO GO---------------- M 815
HAVE TO GO TO A MALE DOCTOR ----------- N 815
DID NOT REALIZE IT WAS SERIOUS ---------W 815
OTHER_______________________------------ X
DON'T KNOW/UNSURE ---------------------------- Y 804

803D Please specify "other" reason for not seeking care.

Verbatim_________________________________________________ |____|____| |____|____|


_________________________________________________________

804 Who was involved in making the decision that _________ (name) DECEASED HERSELF---------------------------- A
should NOT go for seek treatment?
HUSBAND -------------------------------------------- B
MOTHER -IN-LAW /FATHER -IN-LAW ------- C
MOTHER/FATHER --------------------------------- D
SISTER/ SISTER -IN-LAW ----------------------- E
OTHER FAMILY MEMBERS (husband’s) -----F
815
DECEASED'S FAMILY MEMBERS ------------ G
RELATIVES ------------------------------------------ H
FRIENDS/NEIGHBOURS-------------------------- I
TBA/FIELD WORKER ------------------------------J
OTHER______________________ ----------- X
NO ONE ----------------------------------------------- Y

DON'T KNOW/UNSURE ---------------------------Z

805 Who was involved in making the decision that _________ (name) DECEASED HERSELF---------------------------- A
SHOULD go for or seek treatment?
HUSBAND -------------------------------------------- B
MOTHER -IN-LAW /FATHER -IN-LAW ------- C
MOTHER/FATHER --------------------------------- D
SISTER/ SISTER -IN-LAW ----------------------- E
OTHER FAMILY MEMBERS (husband’s) -----F
DECEASED'S FAMILY MEMBERS ------------ G
RELATIVES ------------------------------------------ H
FRIENDS/NEIGHBOURS-------------------------- I
TBA/FIELD WORKER ------------------------------J
OTHER______________________ ----------- X
NO ONE ----------------------------------------------- Y

DON'T KNOW/UNSURE ---------------------------Z

805A What symptoms made you decide to go for treatment?

Verbatim_________________________________________________ |____|____| |____|____|


_________________________________________________________

28
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

806 How much time after the problem was recognized, was it decided that HOURS AFTER RECG ......... 1 |____|____|
she/you should go for care?

(If immediately then write 00 in hours, if less than 1 day then write in DAYS AFTER RECG ............ 2 |____|____|
hours, if less than 30 days then write in days, if more then write in
months) MOS. AFTER RECG ............ 3 |____|____|
DON’T KNOW ...............................................998

806A Once you decided to go for care, did you try for treatment immediately? YES ........................................................... 1 807

NO, WENT LATER.................................... 2

DON’T KNOW ........................................... 8 807

806B Why did she/you not try immediately? HOSPITAL TO FAR ---------------------------------- A
DID NOT REALIZE SERIOUSNESS ------------ B
LACK OF FUNDS ------------------------------------- C
HAVE TO GO TO A MALE DOCTOR ----------- D
OTHER_______________________------------ X

806C How long after the decision did she/you actually try for treatment? HOURS AFTER................. |____|____|
(If less than 1 hour then write 00) DON’T KNOW ......................................... 98

807 CHECK Q803B: Was care only received from HOME? Q803B IS ONLY CODED "A"................... 1 814

Q803B IS CODED BETWEEN "B" TO


"X" WITH OR WITHOUT "A" .................. 2

807A How many hospitals/clinics/care providers did __________(name) NUMBER ---------------------------------- |____|
actually go for the treatment of her last illness?
DID NOT GO ANYWHERE------------------- 0 814

DON’T KNOW/UNSURE ---------------------- 8

THE FOLLOWING QUESTIONS [Q808-810] APPLY TO THE FIRST HOSPITAL/CLINIC/DOCTOR SHE WENT FOR CARE

808 Where did she go first for care/medical treatment for her last illness? GOVT SECTOR
HOSPITAL ---------------------------------------21
UPAZILA HEALTH COMPLEX-------------22
MATERNAL AND CHILD
WELFARE CENTRE (MCWC) -------------23
UNION HEALTH AND FAMILY
WELFARE CENTRE --------------------------24
SATELLITE/EPI OUTREACH SITE-------25
COMMUNITY CLINIC ------------------------26
NGO SECTOR
NGO CLINIC ------------------------------------31
NGO HOSPITAL -------------------------------32
NGO SATELLITE CLINIC -------------------33
PRIVATE SECTOR
PRIVATE HOSPITAL -------------------------41
PRIVATE CLINIC ------------------------------42
CHAMBER/PHARMACY OF
QUALIFIED DOCTOR ------------------------43
CHAMBER/ PHARMACY OF
UNQUALIFIED DOCTOR -------------------44
OTHER_______________________----------96
DON’T KNOW/UNSURE --------------------------98

29
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

808A Who accompanied her when she went to _____________(name of HUSBAND -------------------------------------------- B
hospital/clinic/care provider) for treatment?
MOTHER -IN-LAW /FATHER -IN-LAW ------- C
(Record all persons who accompanied) MOTHER/FATHER --------------------------------- D
SISTER/ SISTER -IN-LAW ----------------------- E
OTHER FAMILY MEMBERS (husband’s) -----F
DECEASED'S FAMILY MEMBERS ------------ G
RELATIVES ------------------------------------------ H
FRIENDS/NEIGHBOURS-------------------------- I
TBA/FIELD WORKER ------------------------------J
OTHER______________________ ----------- X
NO ONE ----------------------------------------------- Y

808B How far is the hospital/clinic/care provider from her residence/or where MILES................................ |____|____|
she was staying?
OUTSIDE TOWN OR UPAZILA .............. 95
(If less than 1 mile then write 00)
DON’T KNOW ......................................... 98

808C How did she go to the hospital/clinic/care provider CAR A

BUS B

TRAIN C

AMBULANCE D

COUNTRY BOAT E

MECHANIZED WATER VEHICLE F

CART/BULLOCK CART G

RICKSHAW /RICKSHAW VAN H

BABY TAXI/TEMPO I

ON FOOT J 808E

OTHER_________________________ X

DON'T KNOW Y 808E

808D Was it difficult to find/get the __________________(name of transport) VERY MUCH.............................................1

SOMEWHAT .............................................2

NO PROBLEM ..........................................3

DON'T KNOW/UNSURE ...........................8

808E How much time did it take to go there? |____|____| |____|____|


HOURS MINUTES
DON’T KNOW------------------------------------ 9998

808F How long did she wait between the time she first arrived at the |____|____| |____|____|
hospital/clinic/care provider and the time she was examined by a health HOURS MINUTES
care provider/doctor?
IMMEDIATELY----------------------------------- 0000
(If less than 1 hour then write in minutes) DON’T KNOW------------------------------------ 9998

808G Who first examined/treated her? NURSE......................................................1

DOCTOR...................................................2

OTHER________________________......7

DON'T KNOW/UNSURE ...........................8

808H What treatment was given her? |____|____|


1._____________________________________________________
|____|____|
2._____________________________________________________
|____|____|
3._____________________________________________________

30
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

808I Did the woman's condition improve after treatment in this place, or did it NO CHANGE 1 809
stay the same or worsen? IMPROVED 2 809
WORSENED 3 809
DIED 4
DON'T KNOW 8 809

808J (If she died in the hospital/clinic) How long after she got there did she DAY .................................1 |____|____| 814
die?
MONTH............................2 |____|____| 814

DON’T KNOW------------------------------------ 998 814

809 Did the hospital/clinic/care provider refer her to another YES ........................................................... 1
hospital/clinic/care provider for care?
NO ............................................................. 2 810

DON’T KNOW ........................................... 8 810

809A Where was she referred? GOVT SECTOR


HOSPITAL ---------------------------------------21
UPAZILA HEALTH COMPLEX-------------22
MATERNAL AND CHILD
WELFARE CENTRE (MCWC) -------------23
UNION HEALTH AND FAMILY
WELFARE CENTRE --------------------------24
SATELLITE/EPI OUTREACH SITE-------25
COMMUNITY CLINIC ------------------------26
NGO SECTOR
NGO CLINIC ------------------------------------31
NGO HOSPITAL -------------------------------32
NGO SATELLITE CLINIC -------------------33
PRIVATE SECTOR
PRIVATE HOSPITAL -------------------------41
PRIVATE CLINIC ------------------------------42
CHAMBER/PHARMACY OF
QUALIFIED DOCTOR ------------------------43
CHAMBER/ PHARMACY OF
UNQUALIFIED DOCTOR -------------------44
OTHER_______________________----------96
DON’T KNOW/UNSURE --------------------------98

809B How long did after she arrived at _____________(hospital/clinic/care |____|____| |____|____|
provider in 808) was __________(name) asked to go to HOURS MINUTES
____________(hospital/clinic/care provider in 809A)?
IMMEDIATELY----------------------------------- 0000
DON’T KNOW------------------------------------ 9998

809C What was the reason given for the referral? NO EQUIPMENT FOR OPERATION ---------- A
HIGH BLOOD PRESSURE----------------------- B
TO GET BETTER CARE-------------------------- C
NO DOCTOR WAS AVAILABLE---------------- D
NO ARRANGEMENTS FOR GIVING
BLOOD------------------------------------------------- E
NO PROPER ARRANGEMENTS FOR
RESOLVING PROBLEM---------------------------F
BABY WENT HIGHER----------------------------- G
PART OF BABY CAME OUT -------------------- H
BABY PASSED STOOL INSIDE UTERUS---- I
CERVIX DID NOT OPEN --------------------------J
OTHER______________________ ----------- X
DON’T KNOW---------------------------------------- Y

31
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

809D Did she go to the place referred? YES ........................................................... 1 810

NO ............................................................. 2

DON’T KNOW ........................................... 8 810

809E Why did she not go there for treatment? NO TREATMENT NECESSARY------------------ A
NOT CUSTOMERY----------------------------------- B
COST TOO MUCH ----------------------------------- C
LACK OF FUNDS ------------------------------------- D
TO FAR -------------------------------------------------- E
TRANSPORTATION NOT EASY ----------------- F
NO ONE AVAILABLE TO ACCOMPANY------- G
GOOD QUALITY CARE NOT AVAILABLE ---- H
FAMILY DID NOT ALLOW --------------------------I
BETTER CARE AT HOME ------------------------- J
DID NOT KNOW HOW TO GO THERE -------- K
NO TIME TO GO FOR CARE/ADVICE --------- L
HAVE TO GO TO A MALE DOCTOR ----------- N
DID NOT REALIZE IT WAS SERIOUS ---------W
OTHER_______________________------------ X
DON'T KNOW/UNSURE ---------------------------- Y

810 Check Q807a and code appropriately RECEIVED CARE FROM MORE
THAN ONE HOSPITAL/CLINIC/CARE
PROVIDER................................................ 1

RECEIVED CARE FROM ONLY ONE


HOSPITAL/CLINIC/CARE PROVIDER .... 2 814

THE FOLLOWING QUESTIONS [Q811-812D] APPLY TO THE LAST PLACE SHE WENT FOR CARE

811 Where did she go last for care/medical treatment? GOVT SECTOR
HOSPITAL ---------------------------------------21
UPAZILA HEALTH COMPLEX-------------22
MATERNAL AND CHILD
WELFARE CENTRE (MCWC) -------------23
UNION HEALTH AND FAMILY
WELFARE CENTRE --------------------------24
SATELLITE/EPI OUTREACH SITE-------25
COMMUNITY CLINIC ------------------------26
NGO SECTOR
NGO CLINIC ------------------------------------31
NGO HOSPITAL -------------------------------32
NGO SATELLITE CLINIC -------------------33
PRIVATE SECTOR
PRIVATE HOSPITAL -------------------------41
PRIVATE CLINIC ------------------------------42
CHAMBER/PHARMACY OF
QUALIFIED DOCTOR ------------------------43
CHAMBER/ PHARMACY OF
UNQUALIFIED DOCTOR -------------------44
OTHER_______________________----------96
DON’T KNOW/UNSURE --------------------------98

32
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

811A Who accompanied her when she went for treatment to HUSBAND -------------------------------------------- B
_____________(name of hospital/clinic/care provider)?
MOTHER -IN-LAW /FATHER -IN-LAW ------- C
(Record all persons who accompanied) MOTHER/FATHER --------------------------------- D
SISTER/ SISTER -IN-LAW ----------------------- E
OTHER FAMILY MEMBERS (husband’s) -----F
DECEASED'S FAMILY MEMBERS ------------ G
RELATIVES ------------------------------------------ H
FRIENDS/NEIGHBOURS-------------------------- I
TBA/FIELD WORKER ------------------------------J
OTHER______________________ ----------- X
NO ONE ----------------------------------------------- Y

811B How did she go to the hospital/clinic/care provider CAR A

BUS B

TRAIN C

AMBULANCE D

COUNTRY BOAT E

MECHANIZED WATER VEHICLE F

CART/BULLOCK CART G

RICKSHAW /RICKSHAW VAN H

BABY TAXI/TEMPO I

ON FOOT J 811D

OTHER_________________________ X

DON'T KNOW Y 811D

811C Was it difficult to find/get the __________________(name of transport) VERY MUCH.............................................1

SOMEWHAT .............................................2

NO PROBLEM ..........................................3

DON'T KNOW/UNSURE ...........................8

811D How long did she wait between the time she first arrived at the last |____|____| |____|____|
hospital/clinic/care provider and the time she was examined by a health HOURS MINUTES
care provider/doctor?
IMMEDIATELY----------------------------------- 0000
(If less than 1 hour then write in minutes) DON’T KNOW------------------------------------ 9998

811E Who initially examined/treated she? NURSE......................................................1

DOCTOR...................................................2

OTHER________________________......7

DON'T KNOW/UNSURE ...........................8

811F What treatment was given her? |____|____|


1._____________________________________________________
|____|____|
2._____________________________________________________
|____|____|
3._____________________________________________________
DON’T KNOW .......................................98

811G Did the woman's condition improve after treatment in this place, or did it NO CHANGE 1 812
stay the same or worsen?
IMPROVED 2 812
WORSENED 3 812
DIED 4
DON'T KNOW 8 812

33
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

811H (If she died in the hospital/clinic) How long after she got there did she DAY .................................1 |____|____| 813
die?
MONTH............................2 |____|____| 813

DON’T KNOW------------------------------------ 998 813

812 Did the last hospital/clinic/care provider refer her to another YES ........................................................... 1
hospital/clinic/care provider for care?
NO ............................................................. 2 813
DON’T KNOW ........................................... 8 813

812A Where was she referred? GOVT SECTOR


HOSPITAL ---------------------------------------21
UPAZILA HEALTH COMPLEX-------------22
MATERNAL AND CHILD
WELFARE CENTRE (MCWC) -------------23
UNION HEALTH AND FAMILY
WELFARE CENTRE --------------------------24
SATELLITE/EPI OUTREACH SITE-------25
COMMUNITY CLINIC ------------------------26
NGO SECTOR
NGO CLINIC ------------------------------------31
NGO HOSPITAL -------------------------------32
NGO SATELLITE CLINIC -------------------33
PRIVATE SECTOR
PRIVATE HOSPITAL -------------------------41
PRIVATE CLINIC ------------------------------42
CHAMBER/PHARMACY OF
QUALIFIED DOCTOR ------------------------43
CHAMBER/ PHARMACY OF
UNQUALIFIED DOCTOR -------------------44
OTHER_______________________----------96
DON’T KNOW/UNSURE --------------------------98

812B What was the reason given for the referral? NO EQUIPMENT FOR OPERATION ---------- A
HIGH BLOOD PRESSURE----------------------- B
TO GET BETTER CARE-------------------------- C
NO DOCTOR WAS AVAILABLE---------------- D
NO ARRANGEMENTS FOR GIVING
BLOOD------------------------------------------------- E
NO PROPER ARRANGEMENTS FOR
RESOLVING PROBLEM---------------------------F
BABY WENT HIGHER----------------------------- G
PART OF BABY CAME OUT -------------------- H
BABY PASSED STOOL INSIDE UTERUS---- I
CERVIX DID NOT OPEN --------------------------J
OTHER______________________ ----------- X
DON’T KNOW---------------------------------------- Y

812C Did she go to the place referred? YES ........................................................... 1

NO ............................................................. 2

DON’T KNOW ........................................... 8

812C1 Check 812C and tick the correct box No/Don’t Know circled Yes circled

(Ask 811 to 811H again and


correct information given
about last provider)

34
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP

812D Why did she not go to the referral site? NO TREATMENT NECESSARY------------------ A
NOT CUSTOMERY----------------------------------- B
COST TOO MUCH ----------------------------------- C
LACK OF FUNDS ------------------------------------- D
TO FAR -------------------------------------------------- E
TRANSPORTATION NOT EASY ----------------- F
NO ONE AVAILABLE TO ACCOMPANY------- G
GOOD QUALITY CARE NOT AVAILABLE ---- H
FAMILY DID NOT ALLOW --------------------------I
BETTER CARE AT HOME ------------------------- J
DID NOT KNOW HOW TO GO THERE -------- K
NO TIME TO GO FOR CARE/ADVICE --------- L
HAVE TO GO TO A MALE DOCTOR ----------- N
DID NOT REALIZE IT WAS SERIOUS ---------W
OTHER_______________________------------ X
DON'T KNOW/UNSURE ---------------------------- Y

813 How many hours/days after leaving ________________ (the first DAY .................................1 |____|____|
hospital/clinic/care provider) did she/you reach ________________ (the
last hospital/clinic/care provider)?
MONTH............................2 |____|____|
DON’T KNOW------------------------------------ 998

814 How much did it cost in total for the treatment of her last illness? TAKA .... |____|____|____|____|____|
(Explain that you want expenses of all hospitals/clinics/care providers NO FUNDS WERE SPENT.......................00000 815
combined and including transportation, overnight stays, food, etc) DON'T KNOW/UNSURE ...........................99998

814A From where did you/she get the funds for her to go for treatment? FAMILY FUNDS ............................................... A
BORROWED.................................................... B
SOLD ASSETS ................................................ C
GIVEN BY RELATIVES/FRIENDS................... D
MORTGAGED PROPERTY ............................. E
OTHER________________________............. X
DON’T KNOW .................................................. Y

815 Thank the respondent(s) and finish the interview

816 Time of ending interview: |____|____| hrs |____|____| mins

35
INTERVIEWER'S COMMENTS AND OBSERVATION

INTERVIEWER'S ASSESSMENT OF CAUSE OF DEATH

36

You might also like