Socioeconomic inequalities in the use of delivery care services in Bangladesh: a comparative study between 2004 and 2007

doi:10.4236/health.2011.312127

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Vol.3, No.12, 762-771 (2011)

doi:10.4236/health.2011.312127

Health

Socioeconomic inequalities in the use of delivery care

services in Bangladesh: a comparative study between

2004 and 2007*

Jahan Shabnam1, Mervyn Gifford 2, Koustuv Dalal2#

1Independent Researcher, Denmark;

2Department of Public Health Science, School of Life Sciences, University of Skövde, Skövde, Sweden;

#Corresponding Author: koustuv2010@hotmail.com

Received 20 August 2011; revised 21 October 2011; accepted 29 October 2011.

ABSTRACT

The study explores inequalities in the utilization

of delivery care services in different administra-

tive divisions in Bangladesh, by key socioeco-

nomic factors. It estimates the extent of the re-

lationship between women’s socioeconomic in-

equalities and their place of delivery during

2004 and 2007. Trends in relation to place of

delivery in relation to residency and education

over a period of thirteen years (1993-2007) have

also been measured. The study analyzed the

trends and patterns in utilization of institutional

delivery care among mothers, using data from

the Bangladesh Demographic Health Survey

(BDHS) conducted during 1993-2007. The data

was disaggregated by area of residence in dif-

ferent divisions in Bangladesh. Bi-variate ana-

lyses, concentration curves and multivariate lo-

gistic regression w ere employed in the analysis

of the data. The study indicated slow progress

in the utilization of institutional delivery care

among mothers in Bangladesh between 1993

and 2007. Large variations in outcome meas-

ures were observed among the different divi-

sions. Multivariate analyses suggested grow ing

inequalities in utilization of delivery care ser-

vices between different economic groups and

parents with different educational levels. The

use of institutional delivery care remains sub-

stantially lower among poor and less educated

rural mothers in Bangladesh, irrespectiv e of age

and employment. Further studies are recom-

mended to explore the specific causes relating

to the non-utilization of institutional delivery

care.

Keyw ords: Home Delivery; Lorenz Curve;

Socioeconomic Status; Trend; Banglad esh

1. INTRODUCTION

Globally, 1500 women die every day because of prob-

lems in pregnancy and childbirth. The burden is highest

in Africa, followed by the South Asian region [1]. The

disparity between maternal mortality in low and high

income countries is striking, almost all (99%) maternal

deaths occur in low income countries [2,3]. The WHO

has identified the major causes of maternal mortality;

these are severe hemorrhage (25%), infection (15%),

eclampsia (12%), obstructed labor (8%) and/or unsafe

abortion (13%) [1]. However, it is evident that most of

these deaths could be prevented through timely care-

seeking during pregnancy and the presence of a Skilled

Birth Attendant (SBA) during delivery [4-6].

Morbidity and mortality are both serious public health

concerns in Bangladesh. According to data from UNI-

CEF, Bangladesh has a high Maternal Mortality Ratio

(MMR), with 320 deaths per 100,000 births [7]. Along

with the United Nations, the Government of Bangladesh

is committed to achieving the Millennium Development

Goal (MDG)-5, to reduce the MMR by 75% between

1990 and 2015. Despite the improvements in child health

and family planning outcomes in Bangladesh, the MMR

has reduced by only 38%, between 1991 and 2007, in

spite of the fact that making pregnancy and childbearing

safer for women has been identified as a central element

of the MDGs [8].

Emergency obstetric care (EmOC) can help address

the above mentioned delivery complications and the

mortality and morbidity of the pregnant women could be

reduced accordingly in Bangladesh. In the evolving stra-

tegy of the Safe Motherhood movement since 1990, the

Government of Bangladesh has implemented the EmOC

service throughout the country [9,10]. Despite the initia-

*Conflict of interest: declared none.

J. Shabnam et al. / Health 3 (2011) 762-771

763763

tives taken by the Government, the key question is

whether the women of all strata of the society actually

receive the level of care they require. The survey by Na-

tional Institute of Population Research and Training

(NIPORT) 2002 shows that about two thirds of the rural

deliveries are assisted by untrained Traditional Birth

Attendants (TBAs), about 12% by trained TBAs, and

another 12% by relatives/others [11,12]. In addition,

only 63% of pregnant women seek antenatal care. 15%

of deliveries took place in some kind of health facility,

and 18% of women received delivery care from health

care providers [13].

To achieve the MDG 5, the Government of Bangla-

desh should speed up the process of improving the over-

all situation of the women in the country by improving

their socioeconomic status [14]. As is the case in other

developing countries, maternal health care use in Bang-

ladesh varies between women with different socioeco-

nomic status, the demographic area, the educational level

of the parents, religious factors and decision making

power [13,15].

A study of Safe motherhood programs in Bangladesh

showed that the low status of women in society, the poor

quality of maternity care services, the lack of trained

providers, the low uptake of services by women and the

poor infrastructure all contribute to the high maternal

death rates [16]. The place of delivery is the key issue of

Safe Motherhood which remains a great challenge for

the policy makers of Bangladesh. This may be due to the

traditional view of rural societies. Culturally and tradi-

tionally, most of the deliveries take place at a woman’s

or her parents’ home. The majority of the homes are in

rural areas and are therefore quite far from the hosptials

or clinics where there are sufficient services for treating

pregnant women who are at risk of delivery complica-

tions [12]. Several studies showed that, in addition to the

availability of health care, socioeconomic factors―such

as women’s age, the education level of a woman and her

husband, religion, location, wealth, employment status

etc., also greatly influence maternal care utilization [12,

15,17,18].

There is wide variation in the utilization of health-re-

lated cares services between lower and higher economic

strata in Bangladesh. There is evidence that Socioeco-

nomic inequality-related utilization of delivery care ex-

ists both between countries and within countries [19,20].

Several studies have been carried out to examine the

relationship between increasing socioeconomic and the

utilization of delivery care in the context of low income

and high income countries [15]. Few studies though

have been conducted in Bangladesh which take into ac-

count the trends and regional patterns of disparities in

the utilization of delivery care services [20-22].

The study explores inequalities in the utilization of de-

livery care services in different administrative divisions

in Bangladesh, by key socioeconomic factors. It esti-

mates the extent of the relationship between women’s

socioeconomic inequalities and their place of delivery

during 2004 and 2007. Trends in relation to place of de-

livery in relation to residency and education over a pe-

riod of thirteen years (1993-2007) have also been meas-

ured.

2. METHODS

The study used data from the Bangladesh Demo-

graphic and Health Surveys (BDHS). This is a nationally

representative household survey based on structured

questionnaires [23]. The BDHS has been a vital source

of both individual and household-level data in relation to

health and health care since 1993. The study used BDHS

datasets, namely, BDHS 1993, BDHS 1997, BDHS 2000,

BDHS 2004 and BDHS 2007. Each data set contains

data from approximately 10,000 households and each

survey had questionnaires for both men and women. The

study was based upon the questionnaires for women

aged 15 - 49 years. The survey involved multistage clus-

ter sampling and it was based on the population census

Enumeration Areas (EAs) which include population and

household information. EAs were used as Primary Sam-

pling Units (PSUs) for the whole survey. Each PSU

contained 100 households, identified with locational

maps and geographical boundaries. In total 361 PSUs

(227 in rural and 134 in urban areas) were randomly

selected from the six divisions, namely, Barisal, Chit-

tagong, Dhaka, Khulna, Rajshahi and Sylhet.

Before conducting the main survey in the PSUs, a

household recording was carried out. This was used as

the sampling frame for the identification of households

in the second stage. In the next stage, 30 households

were selected from each PSU, using an equal probability

systematic sampling technique and using information

from the 2001 population census. Finally, 10,819 house-

holds were selected from the sample clusters for inclu-

sion in the survey.

2.1. Stud y Population

BDHS 2004: For the BDHS, 10,811 households were

included. From the selected households, 11,601 eligible

women aged between 10 - 49 years were identified. Of

these 11,601 women, 11,440 were interviewed (a re-

sponse rate of 98.6%). To simplify the data analysis, data

from women aged 10 - 14 years were merged with data

from the women aged 15 - 19 years.

BDHS 2007: For the BDHS 10,400 households were

selected. From the selected households, 11,178 suitable

J. Shabnam et al. / Health 3 (2011) 762-771

764

women aged 15 - 49 were selected. From this sample

10,996 were eventually interviewed (a response rate of

98.4%).

2.2. Sample Size

For this current study based upon the 2004 data set,

5366 eligible women (with at least one child delivery)

were included. This represents 47% of the total 11,440

women respondents. From the 2007 data set, 4925 eligi-

ble women (with at least one child delivery) were in-

cluded. This represents 45% of the total 10,996 women

respondents in the study.

2.3. Questionnaire

The questionnaire comprised demographics, repro-

ductive behavior and intentions, knowledge and use of

contraception, sexual life, nutrition, maternal and child

health, knowledge of HIV/AIDS and other sexually

transmitted diseases, etc. For this study questions relat-

ing to demographics, wealth index and history of deliv-

ery were also taken into account.

2.4. Description of the Variables of Interest

The utilization of health facilities during delivery took

into account the place of delivery, such as delivery at

home or at other health facilities. Other facilities in-

cluded Government hospitals, private hospitals/clinic

and NGOs.

The independent variables were age (groups divided

into seven categories 15 - 19, 20 - 24, 25 - 29, 30 - 34,

35 - 39, 40 - 44 and 45 - 49); residency (urban or rural);

the level of education of the women (no education, pri-

mary education, secondary education and higher educa-

tion); religion (Muslim or non-Muslim); divisional resi-

dence within Bangladesh (Dhaka, Barisal, Sylhet, Ra-

jshahi, Chittagong, Khulna); working status (working or

not working); partner’s level of education (no education,

primary education, secondary education and higher edu-

cation).

The economic statuses of the respondents were classi-

fied as: poorest, poorer, middle, richer and richest. The

economic statuses of the respondents were categorized

based on data from the wealth index. This is extensively

used to measure the economic status and to determine

the equity of health programs in public or private ser-

vices. Its major objectives are to assess both the ability

to pay for health services and the allocation of services

amongst the poor. Many demographic and health surveys

in different parts of the world have validated and used

the wealth index. It is a combined assessment of the cu-

mulative living standard of a household. It is measured

by using data on a household’s ownership of particular

assets, e.g. radios, televisions and bicycles; materials

used for construction of the house, types of water-access

and the use of sanitation facilities. A statistical procedure

called Principle Components Analysis is used in the

wealth index calculations and it places a household on a

point on a constant scale of relative wealth. The scale is

consistent with a standard normal distribution with a

mean of zero and a standard deviation of one. Thus, the

regularly distributed scores can be partitioned to gener-

ate the groups that classify wealth quintiles as: Poorest,

poorer, average, richer and richest. The wealth index was

introduced by Rutstein and Johnson and has been widely

used in several studies [24-26]. The term Wealth Index

comprises anything that may be a sign of economic

status, particularly the major household assets and utility

services, as well as country-specific items.

2.5. Ethical Issues

In Bangladesh, the Demographic Health Survey (DHS)

procedure (e.g. organization and sampling methods) and

the instruments applied in the study received ethical

permission from the Institutional Review Board of ORC

Macro Inc, which gave the major scientific support for

the whole survey. The consent to apply these data was

acquired from Measure DHS, the officially authorized

owner of the survey data under the main donor agency,

USAID after proper project applications.

This study is based on the secondary analysis of ex-

isting survey data. All the information that might be used

to identify the respondents was removed. The field in-

terviewers for the survey acquired informed consent

from the respondents and the respondents were assured

of strict confidentiality. The respondents had the auton-

omy to leave the study at any time.

2.6. Statistical Analysis

Differences between the values of the dependent vari-

ables (Place of delivery in 2004 and 2007) between the

participants on different categories of the explanatory

variables (i.e. demographics) were assessed using chi-

square tests. Inequalities in health in different divisions

were assessed by the Lorenz curve for 2004 and 2007

[27,28]. The X axis comprises the cumulative percentage

(%) of wealth index and the Y axis the cumulative per-

centage of utilization of delivery care. The trend of place

of delivery in different years, percentage of home deliv-

ery in 2004 and 2007 in six divisions and the trend of

home delivery in different years in relation to the level

of education were presented with line graphs. For as-

sessing possible confounding effects in predicting home

delivery, a multivariate logistic regression analysis was

employed in the adjusted model. Some of the predictor

J. Shabnam et al. / Health 3 (2011) 762-771

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variables included in the multivariate analysis, such as

economic status, partners education and working status

were not included in previous surveys, namely BDHS

1993, BDHS 1997 and BDHS 2000) but were included

in the surveys of BDHS 2004 and BDHS 2007. That is

the reason for including only two years data in multi-

level and bi-variate analyses. However, delivery trend

was estimated for all the five survey data (BDHSs: 1993,

1997, 2000, 2004 and 2007). The magnitude and direc-

tion of association were expressed through odds ratios

and significance levels were expressed as P values. Sta-

tistical significance was considered to be P < 0.05. SPSS

version 18.0 was used for all analyses.

3. RESULTS

The demographics of the women indicate that regard-

less of age, both in 2004 and 2007, more than 80% had

home deliveries. In 2004 the range varied from 86% to

98% and in 2007 the range varied from 80% to 96%. In

both years the highest percentage of women who had

home deliveries was in the 45 - 49 years age group. The

p value is not significant in relation to the age group and

delivery at home, in both 2004 and 2007.

In both 2004 and 2007 relatively more women in rural

areas had home deliveries compared with those in urban

areas. In both 2004 and 2007 the chi square test shows a

significant relationship between residency and home

deliveries.

The level of education shows a distinct difference in

relation to home deliveries. The women with least edu-

cation had the highest percentage of home deliveries,

both in 2004 and 2007 (97%). Higher education was

associated with the least percentage of home deliveries

in both 2004 (43%) and 2007 (33%). The p value is sig-

nificant in both 2004 and 2007 in relation to the level of

education and delivery at home. In both 2004 and 2007,

non-Muslim women had a fewer home deliveries com-

pared with Muslim women. The chi square test shows a

significant relationship between religion and delivery at

home, in both 2004 and 2007 (Table 1).

The trends of delivery in different years (Figure 1)

show that the number of home deliveries have reduced

moderately over the years. In contrast, the number of

deliveries in public hospitals, private hospitals and NGOs

increased over this period. To summarize; the trend

shows that the number of home deliveries decreased

while deliveries in other health facilities increased over

the time.

The trend of delivery in different divisions (Figure 2)

shows that in different years home delivery levels re-

mained lowest in Khulna in both 2004 and 2007. The

rate was highest in the Barisal division (91%) in 2004

and in the Sylhet division (87%) in the year 2007. The

Table 1. Demographics of the delivery at home in 2004 and

2007.

Demographics Home delivery 2004

N% of N

Home delivery 2007

N% of N

Age Group

15 - 19 years

20 - 24 years

25 - 29 years

30 - 34 years

35 - 39 years

40 - 44 years

45 - 49 years

892

1736

1338

837

389

126

P = 0.011

749

1627

1250

745

393

139

P = 0.015

Residency

Urban

Rural

1684

3682

P = 0.000

1748

3177

P = 0.000

Level of Education

No Education

Primary

Secondary

Higher

1866

1649

1512

339

P = 0.000

1267

1507

1742

406

P = 0.000

Partner’s Education

Level

No Education

Primary

Secondary

Higher

1991

1433

1335

604

P = 0.000

1584

1380

1319

636

P = 0.000

Religion

Muslim

Non Muslim

4876

490

P = 0.000

4472

453

P = 0.000

P-values of chi-square tests.

Figure 1. The trend of delivery in different years.

results show that Khulna maintained the lowest percent-

age of deliveries at home over time, whilst Barisal and

Sylhet had higher percentages of home deliveries.

The trend for home delivery in relation to education

follows almost the same trend throughout the whole pe-

riod (Figure 3). The women with no education mostly

tended to have home deliveries. 97% of women between

J. Shabnam et al. / Health 3 (2011) 762-771

766

Chittagong division in the year 2007, though the curve

was initially below the line of equality, which indicates

that home deliveries were concentrated among the poor.

In 2007, the concentration curves for home delivery in

Dhaka, Sylhet, Chittagong, Khulna all lie below that

those for Barisal and Rajshahi. This indicates that there

is less inequality at Dhaka, Sylhet, Chittagong, Khulna

than in Barisal or Rajshahi.

The Concentration curve (Lorenz) for the utilization

of delivery care in different divisions in 2004 shows that,

the concentration curves of all the six divisions lie above

(dominate) the line of equality, indicating that the home

deliveries are concentrated among the poor. The concen-

tration curves for home delivery for Dhaka, Sylhet,

Chittagong, Khulna for the period 2004 all lie below that

of Rajshahi (i.e. the Rajshahi curve dominates the other

mentioned curves), indicating there is less inequality at

Dhaka, Sylhet, Chittagong, Khulna than in Rajshahi.

Figure 2. The trend of delivery in different divisions.

1993 and 1994 had home deliveries, though this figure

fell to 91% in 2007. Women with secondary education

had comparatively fewer home deliveries than the other

two mentioned groups. 88% had home deliveries during

the period of the survey in 1993, while 72% had home

deliveries in 2007. Finally the women with higher edu-

cation had the smallest percentage of home deliveries

from the outset of the surveys. During the initial survey

the figure was 50%, reducing thereafter to 33% in 2007.

All the groups of women had fewer home deliveries over

time. The statistics show a sharp reduction in the number

of home deliveries amongst more highly educated

women. The reduction was only slightly reduced in rela-

tion to women with no education (Figure 3).

Table 2 indicated that respondents’ age and employ-

ment status had no significant relationship with delivery

at home. Respondents’ residency, education, economic

status and religion emerged as the strongest predictors of

delivery care. Compared with more highly educated

women, their uneducated peers were eight times more

likely and 12 times more likely to deliver at home in

2004 and 2007 respectively. Similarly, women educated

to primary level had more home deliveries in 2007

compared with 2004.

Figures 4(a)-(b) demonstrates the Lorenz curves.

The Concentration Curve (Lorenz) for the utilization of

delivery care in different divisions in 2007 shows that,

apart from Chittagong, all the concentration curves rep-

resenting all five divisions lie above (dominate) the line

of equality, indicating that the home deliveries are con-

centrated among the poor. The concentration curve shows

that the inequality in home delivery increased fairly in

4. DISCUSSION

The study showed that even after three years (2004-

2007) there was no such improved situation of deliveries

at home. The demographic factors of residency, level of

Figure 3. The trend of home delivery in relation to the maternal education level.

Openly accessible at

J. Shabnam et al. / Health 3 (2011) 762-771

767767

(a)

(b)

Figure 4. (a) Concentration (Lorenz) curve for delivery care utilization during

2004; (b) Concentration (Lorenz) curve for delivery care utilization during

2007.

education, wealth index and religion were associated

with the choice of delivery in a health facility rather than

delivery at home in both the years examined. Inequality

in health in relation to delivery was present in both years

in all six administrative areas. Multivariate logistic re-

gression showed that residency, level of education, part-

ner educational level, wealth index, and religion had a

strong relationship with delivery at home. The working

status of the respondent was shown not to have any in-

fluence in home delivery. The study showed that since

1993 the trend for home delivery is declining though it

showed highest percentage in all years. It can be con-

cluded from this result that home delivery had was the

most popular type of deliver throughout Bangladesh. It

is notable that the respondents with highest educational

levels had the fewest home deliveries. The findings of

the present study illustrate that in 2004 and 2007, eco-

nomic inequality in the utilization of maternal health

care was predominant in the Rajshahi and Barisal divi-

sions. Barisal has demonstrated the greatest inequality

for home delivery in recent years, indicating cultural

conservative issues and infrastructural problems [20].

During recent years, all divisions (except Dhaka) had

more inequalities than previous years. This indicates that

inequalities are still increasing in Bangladesh. The re-

gression analysis showed that the probability of home

delivery was higher for mothers with no, or only primary

education. Overall, an educated mother utilized more

J. Shabnam et al. / Health 3 (2011) 762-771

768

Ta b l e 2 . Multivariate logistic regression used to test the asso-

ciation between independent variables and home delivery.

Variables Ors (95% C.I.)

2007 2004

Age Group

15 - 19 years

20 - 24 years

25 - 29 years

30 - 34 years

35 - 39 years

40 - 44 years

45 - 49 years

0.57 (0.65 - 4.94)

0.61 (0.70 - 5.26)

0.64 (0.74 - 5.60)

0.65 (0.74 - 5.69)

0.45 (0.55 - 4.33)

0.73 (0.76 - 7.03)

1.0

0.29 (0.035 - 2.32)

0.39 (0.048 - 3.14)

0.31 (0.038 - 2.53)

0.31 (0.038 - 2.50)

0.40 (0.05 - 3.32)

0.30 (0.03 - 2.81)

1.0

Residency

Urban

Rural

0.52 (0.43 - 0.63)*

1.0

0.44 (0.36 - 11.16)*

1.0

Level of Education

No Education

Primary

Secondary

Higher

11.58 (7.31 - 18.33)*

4.83 (3.41 - 6.84)*

2.00 (1.50 - 2.66)*

1.0

7.18 (4.62 - 11.16)*

3.52 (2.44 - 5.09)*

2.56 (1.88 - 3.48)*

1.0

Partner’s Education Level

No Education

Primary

Secondary

Higher

2.86 (2.00 - 4.01)*

2.70 (2.00 - 3.63)*

1.86 (1.45 - 2.39)*

1.0

2.12 (1.47 - 3.06)*

2.40 (1.72 - 3.34)*

1.58 (1.21 - 3.06)*

1.0

Religion

Muslim

Non Muslim

1.72 (1.31 - 2.27)*

1.0

1.81 (1.37 - 2.40)*

1.0

Wealth Index

Poorert

Middle

Richer

Richest

3.02 (2.09 - 4.36)*

4.68 (3.31 - 6.62)*

3.15 (2.36 - 4.19)*

2.06 (1.64 - 2.60)*

1.0

5.40 (3.43 - 8.52)*

4.74 (3.20 - 7.04)*

2.84 (2.09 - 3.85)*

1.99 (1.55 - 2.57)*

1.0

Working Status

Not Working

Working

0.93 (0.75 - 1.15)

1.0

0.77 (0.56 - 1.01)

1.0

Significance level *P < 0.001. Reference category is denoted by 1.0.

delivery care services compared with a non-educated

mother. Another strong predictor was maternal economic

status. Respondents of higher socioeconomic status were

less likely to deliver at home, thus the women of higher

socioeconomic status mostly used the organizational

delivery care. The relationship showed similar, though

less prominent results, between the probabilities of edu-

cational level of the partner and organizational delivery

care. Respondents living in rural areas and of Muslim

religion were more likely to deliver at home. The order

of probabilities had the same magnitude in both 2004

and 2007. Over time though, level of education showed

more magnitude and the wealth index effect was reduced

in 2007 compared with 2004.

The demographic factors for home delivery found in

the current study are in line with earlier findings from

developing countries [12,15,17,18]. The multivariate

regression result from 2007 showed that the women with

no education were twelve times more likely to have

home deliveries, while in 2004 the women with no edu-

cation were seven times more likely to have home deliv-

eries. Therefore the likelihood of home delivery had

increased half-fold during 2004-2007 amongst the un-

educated women. This might be because of the huge

political crisis experienced by the Government of Bang-

ladesh during this period. At the beginning of 2004 a

state of emergency was declared by the President and an

interim caretaker government had govern the country for

the whole year [29]. The study findings also showed that

educational level is the strongest predictor of fewer

home deliveries. Similar findings were reported from

other developing countries [21,30,31]. Therefore, it is

suggested that female education should be prioritized in

order to help improve maternal health in the country. It

should be noted that there was a huge improvement in

the literacy rate of adult women in Bangladesh resulting

from focused efforts of the Government between 2001

and 2008: the literacy rate of women increased from

41% to 76% in this period [32,33]. The multivariate re-

gression analysis result showed that in 2007 women

from poorest quintile had relatively fewer home deliver-

ies than those from the poorer quintile. Whilst in 2004

the poorest women had the highest number of home de-

liveries, the richest had more institutional deliveries.

That the women from the wealthier quintile used mater-

nal health care most is not a new concept, though it was

reaffirmed in the study findings [15]. A reason for this

might be the hidden charges of the public sector services,

though they are officially free of charge. It may be so

that payment must be made for hidden out-of-pocket

charges for services provided in Bangladesh [34,35]. A

study in India using data from 1992-2006 showed that

poor women tended not to have skilled birth attendance,

even if it was available. They were more likely to use

private providers. The possible reason for this is that

they made rationale decisions according to their existing

economic constraints [36]. In present study the next pre-

dictor in the multivariate analysis for home delivery was

the education level of the partner (strength of associa-

tion). A similar finding was found in a community sur-

vey in Bangladesh in 2006, which also showed that the

partner’s educational level was a significant predictor of

utilization of maternal care [21]. The result of the re-

gression analysis showed that Muslim mothers were

more likely to have home deliveries compared with non-

Muslim mothers: 1.72 and 1.81 respectively in the years

2007 and 2004. This might be explained by the possible

influence of the views of local religious leaders in rural

areas. Some of these religious leaders hold the veiwpoint

that Muslim women are not permitted to be seen or

treated by a non-relative male doctor and they actively

J. Shabnam et al. / Health 3 (2011) 762-771

769769

discourage the women from seeking maternal care ser-

vices while they are pregnant [22]. The present study

showed that women living in urban areas had lower

probabilities for home deliveries. The chi square results

showed that the percentage declined in 2007 compared

with 2004. The multivariate analysis reconfirmed the

findings of fewer home deliveries in the case of women

in urban areas. The findings are in line results from the

systemic review conducted by Say and Raine [15]. In-

stitutional deliveries are possibly more common in urban

areas than rural areas because of better transport systems,

well-equipped hospitals and the provision of sufficient

trained professionals in the urban hospitals. There was

no significant relationship between the employment of

women and the utilization of delivery care. A study was

conducted in rural Bangladesh to identify the determi-

nants of the use of maternal health services, and this also

showed that the working status of women is not a posi-

tive factor for the uptake of maternal home delivery.

This might be because of the context and of the culture

of the country, which does not permit the women to

spend their money as they please [37].

Estimates of inequalities in the utilization of delivery

care in different divisions of Bangladesh were achieved

in the present study by plotting concentration curves.

The figures showed that there are inequalities between

the divisions. A study in Bangladesh was carried out to

identify the reason behind inequalities in EmOC Ser-

vices between the Khulna and Sylhet divisions―rela-

tively high and low-performing areas of Bangladesh

respectively [38]. The study showed that the major bar-

riers for maternal health in Sylhet were the human-re-

sources limitations, along with the poor quality of health

facilities available in the hospitals. Moreover, the find-

ings showed that the population in Sylhet was less liter-

ate, more conservative, and faced more geographical and

socio-cultural obstacles in accessing services [38]. More

such studies should be conducted in the future to identify

the barriers in different divisions and to plan interven-

tions accordingly. The results in from the current study

did not yield strong information on the influence of other

predisposing and enabling factors, such as age of the

women and their employment in the utilization of insti-

tutional delivery care. The chi square and the multivari-

ate logistic regression did not show any significant im-

pact of these factors on the use of utilization of institu-

tional delivery care. Regardless of all the findings,

women from a traditional culture like that in Bangladesh

might have a strong preference for home-based birth

traditions, and they might prefer to utilize TBAs with

whom they have better social relations. Such factors may

be important in influencing their decision to choose

home deliveries [21].

The current study has made a significant contribution

to the knowledge of the various factors that can have an

influence as to where women deliver their babies. A ma-

jor strength was that it was nationally representative,

thus allowing for conclusions to be relevant to the whole

nation. One weakness of the study is the cross-sectional

design which did not allow for causal attributions. A

longitudinal study design could more easily identify

causal links. The use of additional qualitative studies to

investigate women’s choices for the place of delivery is

necessary in order to study the influence of socioeco-

nomic inequalities and social norms. Moreover, studies

within the different divisions of Bangladesh are required

to help identify the reasons for inequalities in utilization

of maternal health care services. Another limitation of

the current study is that not all the same households were

followed in the survey over the period of time because of

several alterations to the administrative areas of Bangla-

desh.

The findings of the current study may be legitimately

generalized to some other South Asian, African and

Latin American countries, which have similar socioeco-

nomic conditions and inequitable delivery care services.

A notable important policy implication emerged from

the study findings. Most of the deliveries take place at

home, and since it will take a long time to change this

practice, maximum efforts should be made towards en-

hanced training of birth attendants. These birth atten-

dants could help in delivery at home and also help in

making referrals to the nearest health facility, should the

need arise.

It is timely that Government policy and programs

should aim to increase the uptake of professional deliv-

ery care. The study findings suggest some areas for pol-

icy makers to focus upon. The main finding of this study

is the excessively high number of home delivery among

mothers in Bangladesh, irrespective of age. There are

also noticeable socioeconomic inequities in the use of

delivery care services. To reach MDG-5 targets, de-

creasing the socioeconomic inequalities in maternal de-

livery care ought to be considered as a vital policy. Ad-

ditionally, improving the education of women must be a

priority since their educational levels have direct conse-

quences in determining their choices of childbirth deliv-

ery services. It is vital that women have the information

and knowledge to help them make informed and intelli-

gent choices about where they want to have their babies.

Better education should increase the uptake of institu-

tional delivery services and greatly enhance the concept

and practice of safe motherhood.

5. ACKNOWLEDGEMENTS

The authors acknowledge Measures DHS and their staff for data

J. Shabnam et al. / Health 3 (2011) 762-771

770

collection and permission to use the data.

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