Vol.3, No.12, 762-771 (2011)
opyright © 2011 SciRes. Openly accessible at http:// www.scirp.org/journal/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.
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
Keyw ords: Home Delivery; Lorenz Curve;
Socioeconomic Status; Trend; Banglad esh
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
Copyright © 2011 SciRes. Openly accessible at http:// www.scirp.org/journal/HEALTH/
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 factorssuch
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,
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-
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
Copyright © 2011 SciRes. Openly accessible at http:// www.scirp.org/journal/HEALTH/
women aged 15 - 49 were selected. From this sample
10,996 were eventually interviewed (a response rate of
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-
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
Copyright © 2011 SciRes. Openly accessible at http:// www.scirp.org/journal/HEALTH/
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.
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
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
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
P = 0.011
P = 0.015
P = 0.000
P = 0.000
Level of Education
No Education
P = 0.000
P = 0.000
Partners Education
No Education
P = 0.000
P = 0.000
Non Muslim
P = 0.000
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
Copyright © 2011 SciRes. http://www.scirp.org/journal/HEALTH/
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
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
Copyright © 2011 SciRes. Openly accessible at http:// www.scirp.org/journal/HEALTH/
Figure 4. (a) Concentration (Lorenz) curve for delivery care utilization during
2004; (b) Concentration (Lorenz) curve for delivery care utilization during
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
Copyright © 2011 SciRes. Openly accessible at http:// www.scirp.org/journal/HEALTH/
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)
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)
0.52 (0.43 - 0.63)*
0.44 (0.36 - 11.16)*
Level of Education
No Education
11.58 (7.31 - 18.33)*
4.83 (3.41 - 6.84)*
2.00 (1.50 - 2.66)*
7.18 (4.62 - 11.16)*
3.52 (2.44 - 5.09)*
2.56 (1.88 - 3.48)*
Partners Education Level
No Education
2.86 (2.00 - 4.01)*
2.70 (2.00 - 3.63)*
1.86 (1.45 - 2.39)*
2.12 (1.47 - 3.06)*
2.40 (1.72 - 3.34)*
1.58 (1.21 - 3.06)*
Non Muslim
1.72 (1.31 - 2.27)*
1.81 (1.37 - 2.40)*
Wealth Index
3.02 (2.09 - 4.36)*
4.68 (3.31 - 6.62)*
3.15 (2.36 - 4.19)*
2.06 (1.64 - 2.60)*
5.40 (3.43 - 8.52)*
4.74 (3.20 - 7.04)*
2.84 (2.09 - 3.85)*
1.99 (1.55 - 2.57)*
Working Status
Not Working
0.93 (0.75 - 1.15)
0.77 (0.56 - 1.01)
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
Copyright © 2011 SciRes. Openly accessible at http:// www.scirp.org/journal/HEALTH/
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 divisionsrela-
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-
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.
The authors acknowledge Measures DHS and their staff for data
J. Shabnam et al. / Health 3 (2011) 762-771
Copyright © 2011 SciRes. Openly accessible at http:// www.scirp.org/journal/HEALTH/
collection and permission to use the data.
[1] WHO (2008) Maternal mortality fact sheet.
[2] Paruzzolo, S., Mehra, R., Kes, A. and Ashbaugh, C.
(2010) Targeting poverty and gender inequality to im-
prove maternal health solutions for girls and women. 2nd
Global Conference, Washington DC, New York, 7-9 June
[3] Ahmed, S., Creanga, A.A., Gillespie, D.G. and Tsui, A.O.
(2010) Economic status, education and empowerment:
Implications for maternal health service utilization in
developing countries. PLoS One, 23, e11190.
[4] Rahman, M.H., Mosley, W.H., Ahmed, S. and Akhter,
H.H. (2008) Does service accessibility reduce socioeco-
nomic differentials in maternity care seeking? Evidence
from rural Bangladesh. Journal of Biosocial Science, 40,
19-33. doi:10.1017/S0021932007002258
[5] Houweling, J., Ronsmans, C., Campbell, O.M.R. and
Kunst, A.E. (2007) Huge poor rich inequalities in mater-
nity and child care in developing countries. Bulletin of
the World Health Organization, 85, 745-754.
[6] WHO (2003) Bangladesh: Skilled birth attendant.
[7] UNICEF (2010) Bangladesh: Statistics; women.
[8] UNDP (2010) Bangladesh. MDGs and Bangladesh.
[9] Colin, S.M., Anwar, I. and Ronsmans, C. (2007) A dec-
ade of inequality in maternity care: Antenatal care, pro-
fessional attendance at delivery, and caesarean section in
Bangladesh (1991-2004). International Journal for Eq-
uity in Health, 30, 6-9.
[10] Islam, M.T., Hossain, M.M., Islam, M.A. and Haque, Y.A.
(2005) Improvement of coverage and utilization of
EmOC services in southwestern Bangladesh. Interna-
tional Journal of Gynecology & Obstetrics, 91, 298-305.
[11] National Institute of Population Research and Training
(NIPROT). ORC Macro. (2002) Bangladesh maternal
health services and maternal mortality survey 2001. NI-
PORT, Dhaka.
[12] Islam, M.A., Chowdhury, R.I. and Akhter, H.H. (2006)
Complications during pregnancy, delivery, and postnatal
stages and place of delivery in rural Bangladesh. Health
Care for Women International, 27, 807-821.
[13] Bangladesh Demographic and Health Survey 2007.
[14] UNICEF. Bangladesh; health and nutrition; women’s
[15] Say, L. and Raine, R. (2007) A systematic review of ine-
qualities in the use of maternal health care in developing
countries: Examining the scale of the problem and the
importance of context. Bulletin of the World Health Or-
ganization, 85, 812-819.
[16] UNICEF. Maternal health in Bangladesh.
[17] Gage, A.J. (2007) Barriers to the utilization of maternal
health care in rural Mali. Social Science & Medicine, 65,
1666-1682. doi:10.1016/j.socscimed.2007.06.001
[18] Navaneetham, K. and Dharmalingam, A. (2020) Utiliza-
tion of maternal health care services in Southern India.
Social Science & Medicine, 55, 1849-1869.
[19] Kunst, A.E. and Houweling, T. (2001) A global picture of
poor-rich differences in the utilization of delivery care.
Studies in Health Services Organization and Policy, 17,
[20] Ahmed, S. and Hill, K. (2011) Maternal mortality esti-
mation at the sub national level: A model based method
with an application to Bangladesh. Bulletin of the World
Health Organization, 89, 12-21.
[21] Anwar, I., Sami, M., Akhtar, N., Chowdhury, M.E.,
Salma, U., Rahman, M. and Koblinskya, M. (2008) In-
equity in maternal health-care services: Evidence from
home-based skilled-birth-attendant programmes in Bang-
ladesh. Bulletin of the World Health Organization, 86,
252-259. doi:10.2471/BLT.07.042754
[22] Hossain, M.I. (2010) Inequality in the utilization of ma-
ternal care and the impact of a macroeconomic policy:
Evidence from Bangladesh. HEDG Working Paper 10/08,
The University of York, York, 1-31.
[23] Bangladesh Demographic and Health Survey (2004).
[24] Rutstein, S.O. and Johnson, K. (2004) The DHS wealth
index. ORC Macro, Calverton, MD.
[25] Dalal, K. (2011) Does economic empowerment protects
women from intimate partner violence? Journal of Injury
and Violence Research, 3, 35-44.
[26] Dalal, K. and Lindqvist, K. (2010) A National study of
the prevalence and correlates of domestic violence
among women in India. Asia-Pacific Journal of Public
Health, Nov 30. [Epub ahead of print]
[27] Wagstaff, A. and van Doorslaer, E. (2003) Watanabe N.
on decomposing the causes of health sector inequalities,
with an application to malnutrition inequalities in Viet-
nam. Journal of Econometrics, 112, 219-227.
[28] O’Donnell, O., van Doorslaer, E., Wagstaff, A. and Lin-
delow, M. (2008) Analysing health equity using house-
hold survey data: A guide to techniques and their imple-
mentation, Washington DC.
chapter link_
[29] Iqbal, J.M. (2007) In defence of Marxism, Bangladesh
and the crisis over the caretaker government.
J. Shabnam et al. / Health 3 (2011) 762-771
Copyright © 2011 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
[30] Ikeako, L.C., Onah, H.E. and Iloabachie, G.C. (2006)
Influence of formal maternal education on the use of for-
mal maternity services in Inagu, Nigeria. Journal of Ob-
stetrics & Gynaecology, 26, 30-34.
[31] Mekonnen, Y. and Mekonnen, A. (2003) Factors influ-
encing the use of maternal health care services in Ethio-
pia. Journal of Health, Population and Nutrition, 21,
[32] UNICEF (2010) Bangladesh: Statistics. Education.
[33] Bangladesh Bureau of Educational Information and Sta-
tistics (2006).
[34] Nahar, S. and Costello, A. (1998) The hidden cost of
“free” maternity care in Dhaka, Bangladesh. Health Pol-
icy Plan, 13, 417-422. doi:10.1093/heapol/13.4.417
[35] Killingsworth, J.R., Hossain, N., Hedrick-Wong, Y.,
Thomas, S.D., Rahman, A. and Begum, T. (1999) Unof-
ficial fees in Bangladesh: Price, equity and institutional
issues. Health Policy Plan, 14, 152-163.
[36] Pathak, P.K., Singh, A. and Subramanian, S.V. 2010)
Economic inequalities in maternal health care: Prenatal
care and skilled birth attendance in India, 1992-2006.
PLoS ONE, 27, e13593.
[37] Chakraborty, N., Islam, M.A., Chowdhury, R.I., Bari, W.
and Akhter, H.H. (2003) Determinants of the use of ma-
ternal health services in rural Bangladesh. Health Promo-
tion International, 18, 327-337.
[38] Anwar, I., Kalim, N. and Koblinsky, M. (2009) Quality
of obstetric care in public-sector facilities and constraints
to implementing emergency obstetric care services: Evi-
dence from high- and low-performing districts of Bang-
ladesh. Journal of Health, Population and Nutrition, 27,
139-155. doi:10.3329/jhpn.v27i2.3327