ABSTRACT
Aims: Behavior change communication (BCC) has been recommended in maternal health however, little is known about its effectiveness in improving knowledge and utilization of services. This paper presents findings from Matlab, a rural area of Bangladesh to inform policy about the effect of focused BCC on maternal knowledge and institutional delivery rates. Study Design: Cohort Study. Place and Duration of Study: The study took place in Matlab, Bangladesh from the period 2003 to 2006. Method: The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) introduced pictorial cards in 1996 to monitor all pregnant women in Matlab service area and to provide BCC during routine antenatal visits on pregnancy danger signs, birth planning and maternal nutrition. Maternal knowledge was measured by asking about complications shown on the pictorial cards during 1st and 2nd (or successive) antenatal visits. The pictorial card data were linked with the birth file data and the socioeconomic survey data of the year 2005 of Matlab Health and Demographic Surveillance Systems (HDSS) for analysis. Results: HDSS recorded 11,150 births during the study period but pictorial cards covered 10,657 women, and maternal knowledge data was available from 6,624 of these. Knowledge about all 5 danger signs increased from 8.9% to 34.2% between 1st and 2nd (or successive) antenatal visits (P <.001). Women with complete knowledge of all five pregnancy danger signs were 1.13 (Adjusted Odds: 1.13, 95% CI, 1.01-1.27) times more likely to have institutional deliveries than those without knowledge when the effect of socio-demographic co-variates were held constant. Conclusion: Focused BCC using pictorial cards during antenatal visits improves knowledge regarding 5 pregnancy danger signs which has clear implications for improving institutional delivery rates. We recommend implementation research to demonstrate the effect of focused BCC in improving knowledge and practice to address high maternal mortality in resource-poor settings.
ABSTRACT
Delay in accessing emergency obstetric-care facilities during life-threatening obstetric complications is a significant determinant of high maternal mortality in developing countries. To examine the factors associated with delays in seeking care for episodes of serious illness and their possible implications for safe motherhood interventions in rural Bangladesh, a cross-sectional study was initiated in Matlab sub-district on the perceptions of household heads regarding delays in seeking care for episodes of serious illness among household members. Of 2,177 households in the study, 881 (40.5%) reported at least one household member who experienced an illness perceived to be serious enough to warrant care-seeking either from health facilities or from providers. Of these, 775 (88.0%) actually visited some providers for treatment, of whom 79.1% used transport. Overall, 69.3% perceived a delay in deciding to seek care, while 12.1% and 24.6% perceived a delay in accessing transport and in reaching the provider respectively. The median time required to make a decision to seek care was 72 minutes, while the same was 10 minutes to get transport and 80 minutes to reach a facility or a provider. Time to decide to seek care was shortest for pregnancy-related conditions and longest for illnesses classified as chronic, while time to reach a facility was longest for pregnancy-related illnesses and shortest for illnesses classified as acute. However, the perceived delay in seeking care did not differ significantly across socioeconomic levels or gender categories but differed significantly between those seeking care from informal providers compared to formal providers. Reasons for the delay included waiting time for results of informal treatment, inability to judge the graveness of disease, and lack of money. For pregnancy-related morbidities, 45% reported 'inability to judge the graveness of the situation' as a reason for delay in making decision. After controlling for possible confounders in multivariate analysis, type of illness and facility visited were the strongest determinants of delay in making decision to seek care. To reduce delays in making decision to seek care in rural Bangladesh, safe motherhood interventions should intensify behaviour change-communication efforts to educate communities to recognize pregnancy-danger signs for which a prompt action must be taken to save life. This strategy should be combined with efforts to train community-based skilled birth attendants, upgrading public facilities to provide emergency obstetric care, introduce voucher schemes to improve access by the poorest of the poor, and improve the quality of care at all levels.