Factors associated with delivery complications in rural Bangladesh.

OBJECTIVES: There are only a few studies on maternal morbidity, delivery complications and maternal mortality in Bangladesh. This study analyzes data from a follow-up study conducted by the Bangladesh Institute of Research for Health and Technologies (BIRPERHT) on maternal morbidity in rural Bangladesh in 1993. METHODS: A total of 1020 pregnant women were interviewed in the follow-up component of the study. The survey collected information on socioeconomic and demographic characteristics, pregnancy-related care and practice, morbidity during the period of follow-up as well as in the past, information concerning complications at the time of delivery and during the postpartum period. For the purpose of this study, we selected 993 pregnant women with at least one antenatal follow-up. Both bivariate and multivariate analyses were conducted to identify the potential risk factors for complication during delivery and duration of labor. RESULTS AND CONCLUSIONS: It appears that complications during the antenatal period can result in various complications at the time of delivery. Some of the important findings are: hemorrhage during the antenatal period increases the risk of excessive hemorrhage during delivery, the risk of obstructed labor increases significantly if abdominal pain is observed during the antenatal period, prolonged labor appears to be significantly higher for the first pregnancy, and pregnancies suffering from abdominal pain during pregnancy tend to have a higher risk of prolonged labor during delivery. The duration of labor appears to be negatively associated with the number of previous pregnancies, being longest for the first pregnancies. The duration of labor pain is significantly higher for the respondents who reported the index pregnancy as undesired, and, similarly, the respondents who were reported to be involved with gainful employment would have a shorter duration of labor pain than those having no involvement with gainful employment.

Obstetric deaths in Bangladesh, 1996-1997.

OBJECTIVES: The purpose of this study was to measure and to describe obstetric deaths in Bangladesh. METHODS: We reviewed hospital records and interviewed health workers in clinic sites and field workers who cared for pregnant women. RESULTS: We obtained case reports of 28998 deaths of women aged 10-50, of which 8562 (29.5%) were maternal deaths. Most (7086, 82.8%) of these deaths were due to obstetric causes. The most common causes of direct obstetric death were eclampsia (34.3%), hemorrhage (27.9%), and obstructed and/or prolonged labor (11.3%). National direct obstetric death rate was estimated to be 16.9 per 100,000 women. CONCLUSIONS: Efforts to reduce fertility in Bangladesh have led to an estimated 49% reduction in the maternal mortality rate per 1000 women during the past 18 years. Variations in maternal mortality suggest the need to develop local strategies to improve obstetric care.

Injury-related deaths among women aged 10-50 years in Bangladesh, 1996-97.

BACKGROUND: Few studies have examined injury-related deaths among women in Bangladesh. We did a case-finding study to identify causes and the impact of intentional and unintentional injury-related deaths among women aged 10-50 years in Bangladesh. METHODS: Between 1996 and 1997, health care and other service providers at 4751 health facilities throughout Bangladesh were interviewed about their knowledge of deaths among women aged 10-50 years. In addition, at all public facilities providing inpatient service, medical records of women who died during the study period were reviewed. The reported circumstances surrounding each death were carefully reviewed to attribute the most likely cause of death. FINDINGS: 28,998 deaths among women aged 10-50 years were identified in our study, and, of these, 6610 (23%) were thought to be caused by intentional or unintentional injuries. About half (3317) of the injury deaths were attributable to suicide, 352 (5%) to homicide, 1100 (17%) to accidental injuries, and the intent was unknown for 1841 (28%) deaths. The unadjusted rate of suicides were higher in the Khulna administrative division (27.0 per 100,000) than the other four administrative divisions of Bangladesh (range 3.5-11.3 per 100,000). Poisoning (n=3971) was the commonest cause of injury-related death--60% of all injury deaths (6610) and 14% of all deaths (28,998). Other common causes of injury deaths in order of frequency were hanging or suffocation, road traffic accidents, burns, drowning, physical assault, firearm or sharp instrument injury, and snake or animal bite. INTERPRETATION: Intentional and unintentional injuries are a major cause of death among women aged 10-50 years in Bangladesh. Strategies to reduce injury-related deaths among women need to be devised.

Community-based self-reported symptoms of antepartum morbidities; the health burden and care-seeking patterns of rural Bangladeshi women.

In Bangladesh there is a dearth on information relating to complications during pregnancy. We followed up 1,019 pregnant women in rural Bangladesh sampled from all the 4 old administrative divisions of the country. Trained female interviewers visited households of the pregnant women at four-week intervals and interviewed them for their current pregnancy-related complications. Out of a total of 3,812 antepartum visits the percentage of reported symptoms of bleeding, fits and convulsions, excessive vomiting, fever >3 days, urinary problems, palpitations and symptomatic anemia were 0.3, 0.7, 1.4, 4.0, 26.8, 46.5 and 78.3 respectively. Morbidities were considered to cause a health burden if they imposed constraints in daily activities of the pregnant women and they were weighted according to intensity of the constraint. For each morbidity, the mean intensity of burden per episode and the population burden per 1,000 person months of observation of all the women were calculated. For common sustaining morbidities like symptomatic anemia and urinary problems the population burden was much heavier than that for more serious but rare morbidities like bleeding and convulsions. Among the visits in which the women had any symptoms, the percentages of care-seeking for less frequently reported morbidities such as fits and convulsions, bleeding, fever >3 days, excessive vomiting were about 74, 50, 34 and 33% respectively, whereas those for more commonly reported complications such as urinary problems, symptomatic anemia and palpitations were less than 20%. Care for these morbidities was mostly sought from untrained providers.

Tetanus and pregnancy-related mortality in Bangladesh.

A national survey of health-care providers in Bangladesh identified 298 women who died from pregnancy-related tetanus. Immunising all girls with tetanus toxoid and providing safe menstrual regulation services would prevent such deaths.

PIP: This letter discusses pregnancy-related tetanus mortality in Bangladesh. A national survey of health care providers identified 298 women from 5 urban infectious disease hospitals who had died from pregnancy-related tetanus after an induced abortion or during the postpartum period. In response to the problem, the Bangladesh government has provided a tetanus toxoid vaccination program for pregnant women to prevent neonatal and postpartum tetanus and has begun training health workers to perform menstrual regulation procedures. Considering the contribution of traditional abortion practices to tetanus death in Bangladesh, a proposal on maternal tetanus prevention policies would be most effective if it included safe menstrual regulation services and provision of tetanus toxoid immunization to all girls before they reach reproductive age (i.e., at age 12).

Hospital-based mortality and morbidity related to induced abortion.

PIP: During 1989-1990, 1301 women were admitted to 3 types of government hospitals in Bangladesh with a diagnosis of abortion. 32.3% (420) cases had had a miscarriage. About 90% of cases presented with an incomplete abortion and bleeding. Around 20% had clinical signs of infection. Serious clinical infections (e.g., generalized peritonitis and septicemic shock) were present in about 6% of induced abortion cases. Induced abortion cases at admission were more likely than spontaneous abortion cases to have mechanical injury, clinical signs of infection, life threatening infections, and signs of renal/cardiac failure and of hypovolemic shock. 90.6% of induced abortion cases were multigravida. Most abortion cases did not know where one can obtain menstrual regulation/abortion services (79.5% for spontaneous and 67.3% for induced abortion cases). Most induced abortion cases (61.7%) chose to terminate the pregnancy because they did not want any more children. Almost 75% experienced a surgical procedure while in the hospital. The case fatality rate for induced abortion was 2.1%. The risk of death was highest for cases who had a serious clinical infection, underwent dilatation and curettage, and whose abortion was induced by insertion of solid sticks and native medicines. Urban dwellers and educated cases were most likely to seek an induced abortion from physicians, nurse midwives, family planning workers, and pharmacists while rural dwellers and less educated cases tended to seek an induced abortion from traditional healers, village doctors, quacks, and their husband/relative/neighbor. The mean number of days in the hospital was 3.3 days for spontaneous abortion cases and 4.6 days for induced abortion cases. Induced abortion cases comprised 8.9% of total OB/GYN admissions and 8.3% of bed occupancy. Induced abortion cases were more likely to need a blood transfusion and more blood than spontaneous abortion cases (0.8 vs. 0.5 units).^ieng

Determinants of contraceptive continuation in rural Bangladesh.

A contraceptive study of rural Bangladeshi women indicated that the previous death of children, number of living children, desire for additional children and son preference were important determinants of contraceptive continuation. The importance of these factors varies to some extent with use of different contraceptive methods.

PIP: In 1988, the proportional hazards model method was used to analyze data on 2717 women from rural areas to examine determinants of contraceptive continuation in Bangladesh. The major determinants included total number of living children and total number of dead children (p.001) when all contraceptives used (oral contraceptives (OCs), IUD, condom, and rhythm/withdrawal) were combined. When individual contraceptives were examined however, living children was not significant for condoms. Children dead significant only for OCs but associated with all other methods. The coefficient value for son desired was higher than additional children desired for all methods combined and for OCs and IUDs (.1689 vs. .0472; .1113 vs.-.0232; and 1.5671 vs. -0.4019, respectively). This showed a higher desire for sons than daughters, but it was not significant, although it was significant in the 1985 Contraceptive Prevalence Survey. This may be because the 1988 study excluded women with no living children. Thus the desire for more children may affect contraceptive use more strongly among women of low parity. The desire for more children was significant only for condom users (p.05). Desire for more children was stronger than the desire for a son among condom and traditional/withdrawal users, suggesting that these users may be in an early phase of family formation when son preference is not yet crucial. Distance of hospital from a woman's home was significant only for condom users (p.05). Women's age and education of both spouses were weak predictors of contraception continuation.

The need for prophylactic antibiotics after female sterilization: tetracycline in Bangladesh.

All female sterilization patients in Bangladesh receive five-day courses of tetracycline capsules every six hours as a postoperative prophylactic. A double-blind randomized study was conducted by the Bangladesh Fertility Research Programme (BFRP) to determine whether prophylactic antibiotics reduced infection after minilaparotomy, and to compare the prophylactic effectiveness of tetracycline and ampicillin. Women recruited from throughout Bangladesh (N = 1350) received five-day courses of 250 mg tetracycline, 250 mg ampicillin, or placebo. The infection rate was significantly lower with tetracycline than with placebo (6% vs 10% with placebo), but did not differ significantly between the ampicillin and placebo groups or between the tetracycline and ampicillin groups.

Predictors of contraceptive continuation among urban family planning acceptors of Bangladesh.

PIP: A 1984 study among new acceptors at the Mohammadpur Family Planning Model Clinic in Dhaka, Bangladesh, found that contraceptive continuation was significantly related to age, parity, the desire for additional children, and the type of contraceptive method accepted. To further analyze predictors of contraceptive continuation, 769 women from this same urban clinic on whom 3 years of follow-up data were available were interviewed. This sample included 551 women who received menstrual regulation at their 1st clinic visit and 218 women whose 1st attendance was for contraceptives; the mean duration of contraceptive continuation was 29.2 months in the former group and 29.4 months in the latter group. Age, parity, maternal education, 1st method of contraception supplied by the clinic, desire for additional children, and distance travelled to the clinic together explained 18% of the variance in the contraceptive continuation rate in the menstrual regulation group compared with 9% of the variance in the other group. In the menstrual regulation group, desire for additional children was the most important predictor (explaining 10% of the variance, followed by high parity (9.4%), increasing maternal age (7.4%), and 1st method accepted (3.9%). In the non-menstrual regulation group, maternal age was most important (4% of the variance), followed by parity (3.9%) and desire for additional children (2.3%). Women who accepted IUDs, condoms, and foam as their 1st contraceptive method had the highest continuation rates.^ieng

Development of IEC program in Bangladesh.

PIP: The Bangladesh Fertility Research Programme (BFRP) views the dissemination of information on contraceptive technology and reproductive health as one of its main objectives. Users and potential users of contraception often hear rumors and bad publicity concerning contraceptive methods before receiving any useful information. Furthermore, researchers, clinicians and program planners often lack communication channels. To address some these problems, the BFRP has instituted the Information Dissemination Cell (IEC). The communication plan has identified target groups which could benefit from better information. The group of program planners, policy makers, organization chiefs and service receive information on advances in contraceptive technology and on recent reports and studies through a quarterly newsletter. BFRP also conducts seminars and lectures to instruct this group. For investigators, researchers and post-graduate students, the program hopes to provide a reference library and documentation center on contraceptive technology. BFRP also targets service providers by dispensing reports, books, and other publications to local government and non-government organizations. At the grassroots level, BFRP plans to develop a newsletter in Bengali for family planning workers. For users and prospective users, BFRP provides contraceptive-related information through newspaper and popular magazines. And for those who oppose or are sensitive to contraception, BFRP tries to correct misinformation and adverse publicity through the use of press releases.^ieng

Safety of abortion and tubal sterilization performed separately versus concurrently.

Concurrent abortion and sterilization are preferred by many women to avoid a second hospitalization, operation, and, in some instances, general anesthesia. Several authors have shown concern, however, that the two procedures carry a higher risk of morbidity when performed concurrently versus separately. To determine whether the concurrent performance of sterilization and induced abortion is as safe as the two procedures performed separately, we selected women undergoing these procedures from two separate multicenter, prospective, national United States studies: the Joint Program for the Study of Abortion and the Collaborative Review of Sterilization. Using standard definitions of major morbidity, we calculated the crude rate of one or more major complications to be 0.9% for the abortion-only group, 1.7% for the group concurrent abortion and tubal sterilization. Thus our data suggest that performing concurrent abortion and sterilization is as safe as performing those procedures separately.

PIP: Concurrent abortion and sterilization are preferred by many women to avoid a 2nd hospitalization, operation, and, in some instances, general anesthesia. Several authors have shown concern, however, that the 2 procedures carry a higher risk of morbidity when performed concurrently versus separately. To determine whether the concurrent performance of sterilization and induced abortion is as safe as the 2 procedures performed separately, women undergoing these procedures from 2 separate multicenter, prospective, national US studies were selected: the Joint Program fro the Study of Abortion and the Collaborative Review of Sterilization. Using standard definitions of major morbidity, the crude rate of 1 or more major complications was calculated to be 0.9% for the abortion only group, 1.7% for the group concurrent abortion and tubal sterilization. Thus the authors' data suggest that performing concurrent abortion and sterilization is as safe as performing those procedures separately.

Menstrual regulation and contraception in Bangladesh: competing or complementary?

To examine the relationship between menstrual regulation (MR) and subsequent use of contraception in Bangladesh, we studied the birth control practices of a 6-month cohort of 4359 family-planning acceptors in a family-planning clinic in Dacca. We compared their use of birth control measures before and after MR. We attempted to examine the subsequent pregnancy and induced-abortion rates of 1671 of these women through a 3-year non-concurrent prospective study. Of those 1172 made their first visit to the clinic to obtain an MR and the remaining 499 women, who served as a comparison group, made their first visit to obtain contraceptive services not associated with MR. Three years' followup data were available for 558 women in the MR group and 228 women in the comparison group. Based on these data, the 3-year pregnancy rate for the MR group was 37.6/100 women and the induced abortion rate was 4.3/100 women. The 3-year pregnancy rate for the comparison group was 39/100 women and the induced abortion rate was 3.5/100 pregnancies. Thus, during a 3-year period women in the MR group did not obtain abortions significantly more often than women in the comparison group.

Continuation of contraception following menstrual regulation--a Bangladesh experience.

PIP: The study compares the 3 years of birth control practice of 1172 women who underwent early menstrual regulation (MR) and 499 others who accepted contraceptives only (nonMR) from an urban clinic in Bangladesh. About 60% of the women in the sample were followed-up and their all-method continuation rate was analyzed by life-table technique. The 3-year overall continuation rate in the MR group (64%) did not differ from that of the nonMR group (62%). In the age groups 25 and over, the continuation rate was higher in the MR group. Among the women who did not desire any more children, the continuation rate in the MR group was significantly higher than that of the nonMR group (80% versus 68%, P0.05). Of women with parity greater than 2, the MR group had significantly higher continuation rates than the nonMR group. The MR group had higher extended use-effectiveness for IUDs, conventional contraceptives (condom and foam), injectables, and oral contraceptives than the nonMR group. These findings indicated effective contraceptive practice following MR for this urban population. Easy availability of a multimethod service after MR seemed to be important in promoting effective contraception.^ieng

Weighing risks against benefits in contraceptive safety.

PIP: The safety or health benefit of family planning needs to be weighed against the risks associated with unintended pregnancy and birth. It is the responsibility of family planning providers to consider these relative benefits and to inform contraceptive users of them. The risks related to childbearing and contraception differ greatly, varying with age, parity, race, nutritional status, geographic area, amount and type of medical care, contraceptive method, and availability of legal abortion. The prevention of pregnancy in less developed countries has a larger public health impact than in developed nations. A significant proportion of maternity related mortality and morbidity could be reduced by increasing the interval between pregnancies and by limiting the number of births. Contraception is 5-10 times safer than childbearing in developing countries, but data on contraceptive risks are inadequate so it is difficult to weigh the risks and benefits of a specific contraceptive method for a specific population. The information presented on contraceptive methods has been drawn mainly from studies conducted in the more developed countries. More than 150 million women around the world are using oral contraceptives (OCs). Even in a developed country such as England, deaths caused by strokes associated with OC use are only 1/8 the number of deaths due to pregnancy. In less developed countries, the incidence of these diseases is even lower than in developed countries. For OC users in a developing country, the diagnosis of complications and adequate treatment are not always readily available and so mortality from these complications may be higher. Yet, there are many advantages in addition to the OC's contraceptive effect, such as reduced rates of iron deficiency anemia and benign breast disease. There appears to be an increased risk of spontaneous abortion and ectopic pregnancy among IUD users, but careful selection of women for IUD insertion can minimize these risks. Young women with no children particularly should be informed of the increased risks to health and fertility, but the public health impact may be limited in developing countries where most women who practice family planning have had several children. Considering the risk benefit ratio, the advantages of sterilization far outweigh any adverse effects and contribute significantly to the improvement and promotion of family health. Despite the known side effects of long-acting progestogens such as Depo-Provera, they have proven to be an important contraceptive method for many countries. They are particularly appropriate for women who have completed their desired family size and are awaiting permanent sterilization. The US Food and Drug Administration has not yet approved its use as a contraceptive in the US. Barrier methods cause no known illness, disease, or mortality, and they offer some protection against sexually transmitted diseases and are highly effective when used by motivated persons.^ieng