A generalized right truncated bivariate Poisson regression model with applications to health data.

A generalized right truncated bivariate Poisson regression model is proposed in this paper. Estimation and tests for goodness of fit and over or under dispersion are illustrated for both untruncated and right truncated bivariate Poisson regression models using marginal-conditional approach. Estimation and test procedures are illustrated for bivariate Poisson regression models with applications to Health and Retirement Study data on number of health conditions and the number of health care services utilized. The proposed test statistics are easy to compute and it is evident from the results that the models fit the data very well. A comparison between the right truncated and untruncated bivariate Poisson regression models using the test for nonnested models clearly shows that the truncated model performs significantly better than the untruncated model.

Delivery complications and healthcare-seeking behaviour: the Bangladesh Demographic Health Survey, 1999-2000.

Maternal health services have a potentially critical role in the improvement of reproductive health. The use of health services is related to the availability, quality and cost of the services, as well as to social structure, health beliefs and the personal characteristics of the users. The present paper examined the factors that influence the use of maternal health services for some selected pregnancy-related complications (e.g. prolonged labour, excessive bleeding, high fever/discharge and convulsions) in Bangladesh by using data from the Bangladesh Demographic Health Survey, 1999-2000. It was found that younger mothers were significantly less likely to seek professional healthcare at the time of birth. The odds for rural women seeking healthcare services from a doctor, nurse and/or midwife were half those of urban women. The strong influence of the mothers' education and parity on the utilisation of healthcare services is consistent with findings from other studies. The possession of assets emerged as an important predictor of seeking care from health professionals at the time of birth. Another factor, i.e. a husband's concern about pregnancy complications, showed a significant and positive impact on the utilisation of healthcare services, which is very important for rural women when they are dependent on their spouses. It was observed that the respondents living in urban areas, who had higher levels of education and lower parity, and more assets (used as a proxy for income), visited trained healthcare providers more often and were more likely to use healthcare facilities provided by trained personnel at the time of delivery. This is a reflection of the fact that, irrespective of their needs, only people from higher economic or educational groups can afford to seek healthcare from trained personnel in Bangladesh. In other words, predisposing and enabling factors appear to have a strong association with women's healthcare utilisation during pregnancy.

Determinants of antenatal morbidity: a multivariate analysis.

OBJECTIVES: The aim of this paper was to investigate the potential risk factors for developing complications and their magnitude during the antenatal period. METHODOLOGY: The data used in this paper came from a prospective survey in rural areas of Bangladesh conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT) between November 1992 and December 1993. The differential patterns were analyzed for respondents' selected characteristics, and multivariate analysis was performed employing logistic regression and proportional hazards models for life-threatening and high-risk complications during pregnancy. RESULTS: For life-threatening complications during pregnancy, several factors emerged as potential risk factors, such as number of the pregnancy, age at marriage, duration of pregnancy, economic status and history of anemia prior to the index pregnancy. The last two covariates were associated only in the proportional hazards. Potential risk factors for high-risk complications during pregnancy were level of education, age at marriage, wanted pregnancy, duration of pregnancy and economic status. CONCLUSIONS: Health planners and policy makers in developing countries are trying to facilitate health services at the doorsteps of rural people. Our findings will help them understand the magnitude and underlying determinants of maternal morbidities and help their health planning process to reduce both life-threatening and high-risk complications during the antenatal period. Early age at marriage needs to be prevented through encouragement of girls' education as well as through increased social awareness programs. An effective quick referral mechanism should be developed to provide emergency services to high risk-groups. Finally, the importance of additional food supplements needs to be promoted during antenatal care visits as well as through mass media in order to reach people living in remote areas of rural Bangladesh.

Complications during pregnancy, delivery, and postnatal stages and place of delivery in rural Bangladesh.

The utilization of safe motherhood services including maternity care in Bangladesh is very poor. Only a very small proportion of deliveries takes place in a hospital/clinic. This study is based on data from a follow-up study on maternal morbidity in rural Bangladesh. Analysis is performed on the nature of complications by place of delivery. Most of the deliveries have taken place in the women's own or her mother's home. In addition, home deliveries are mostly assisted either by an untrained birth attendant or by relatives or others. Education, economic status, whether pregnancy was wanted or not, regular visits for antenatal care, past history of breathing problems and liver diseases, and palpitation during pregnancy appear to have significant association with place of delivery in rural Bangladesh. The utilization of a hospital/clinic instead of birth at home is higher among women with secondary or higher level of education, who desired the pregnancy, and who made regular visits for antenatal care. Delivery at a mother's home appears to be positively associated with higher economic status, desired pregnancy, gainful employment, and visits for antenatal care. If the respondents suffer from diseases/symptoms, then it is more likely that the delivery would take place in the mother's home.

Statistical methods for analysis of repeated measures on maternal morbidity.

OBJECTIVES: This paper applies statistical methods to identify factors associated with pregnancy-related complications in rural Bangladesh. The results are examined in order to identify the factors that can help formulate policy for reducing pregnancy-related morbidity. METHODS: Two statistical methods are used in this study to analyse the repeated-measures data on pregnancy-related complications in rural Bangladesh. One method is based on the application of linear logistic regression at each follow up, and the results are compared to identify the potential risk factors. Then the generalised estimating equation (GEE) approach is used, and the results based on each follow up are compared with those obtained from the application of the GEE approach. The maternal morbidity data collected by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies are used in this paper. RESULTS: Economic status, visit for antenatal care, and histories of sexually transmitted disease, hypertension, heart disease and breathing problem are positively associated with the complications during pregnancy, while wanted pregnancy, household type, primary and secondary schooling, and five or more pregnancies are associated negatively with the response variable. Involvement with gainful employment shows a negative association by the first technique. The GEE approach failed to identify some important factors such as history of anaemia, previous pregnancy and gainful employment. However, duration of pregnancy appears to have an association with pregnancy complications, which was not found from the conditional model based on each follow up. CONCLUSION: It appears that unwanted pregnancies need to be reduced through a well-organised and targeted family planning campaign for potential mothers of all ages in rural Bangladesh. Nutritional anaemia may cause various complications, and suggestions are given for reducing anaemia among pregnant women. In the rural areas of Bangladesh, first births usually occur at teenage. The first-birth pregnancy among teenagers can be a source of severe complications. There can be special programs to address the need for delay in the first pregnancy of those who marry at an early age.

A computer program to estimate the parameters of covariate dependent higher order Markov model.

This paper presents a computer program developed in S-plus to estimate the parameters of covariate dependent higher order Markov Chain and related tests. The program can be applied for two states Markov Chain with any order and any number of covariates depending on the PC capabilities. The program provides the maximum likelihood estimates of the parameters, together with their estimated standard error, t-value and significance level. It also produces the test results for likelihood ratio and model chi-square. To illustrate the program we have used a longitudinal data set on maternal morbidity of rural women in Bangladesh. The occurrences of haemorrhage, convulsion, or fits at different follow-ups were used as outcome variable. Economic status, wanted pregnancy, ages at marriage, and education of women were used as covariates.

Fertility transition in Bangladesh: understanding the role of the proximate determinants.

Bangladesh has been passing through a crucial phase of fertility transition. The level of fertility declined dramatically during the early 1990s without any remarkable improvement in socioeconomic and health status, and then remained constant at a high level of 3.3, despite the increased use of contraception. Such fertility transition can be traced to variations in one or more of the proximate or direct determinants of fertility. This paper critically analyses the fertility levels in Bangladesh with a view to exploring the possible explanations of fertility decline in the 1990s and then its stabilization. The main focus of the study is to examine the role of the major proximate determinants of fertility in bringing about the change in fertility level in Bangladesh. The data for the study come from a series of nationally representative surveys over the period of 1975 to 1999-2000. The analysis indicates that fertility has temporarily ceased to decline in recent years due to the 'tempo' effect of high past fertility, but in general a declining trend in fertility is underway. The analysis suggests that the fall in fertility is consistent with the underlying trends in most important proximate determinants of fertility. In recent years contraception has emerged as the highest fertility reducing factor in Bangladesh and its effect is greatest in middle and older age groups. Although until the early 1990s postpartum lactational infecundability was the most important and strongest fertility reducing factor in Bangladesh, in recent years its fertility inhibiting effect has gradually decreasing owing to the declining trend in the lactational infecundability period. The analysis reveals that although the fertility reducing effect of the marriage pattern is increasing, its effect is offset by the declining trend in the lactational infecundability period. A review of these two variables suggests that their effect cannot be raised much for prevailing socioeconomic and cultural reasons, and any future reduction in fertility in Bangladesh may be largely dependent on increased use of effective birth control methods.

A multistage model for maternal morbidity during antenatal, delivery and postpartum periods.

There is acute dearth of information regarding factors affecting complications during different stages of childbearing in Bangladesh. This study employs a multistage model that involves transitions at different stages to complications. The proposed model appears to display more meaningful explanation concerning the impact of different factors on the incidence of complications taking into account types of transitions. Two alternative models are also presented in this paper in order to demonstrate possible simplifications of the proposed model. This study uses data from a prospective survey on Maternal Morbidity in Bangladesh. The survey was conducted during the period 11 1992-12 1993. A total of 1020 pregnant women were followed during pregnancy, delivery and 90 days after delivery. This study reveals some very important findings regarding the potential impact of antenatal visits, economic status, whether the index pregnancy was desired or not and number of pregnancies prior to the index pregnancy. It is observed that slightly more than 50 per cent of the women suffer from at least one of the major complications (haemorrhage, excessive vomiting, oedema and fits/convulsion) during pregnancy. It is noteworthy that if a woman suffers from one or more of the major complications during pregnancy, then it is more likely that she will suffer from complications during delivery. This study reveals that the women who suffer from one or more of the major complications during pregnancy are expected to have a substantially higher risk of suffering from complications during postpartum period, irrespective of no complications or complications during delivery. Generally speaking, higher economic status can reduce the complications at the postpartum stage, although women belonging to higher economic status may suffer from complications during pregnancy and delivery at a higher rate. It is surprising that antenatal visit is positively associated with incidence of complications during pregnancy and delivery, but antenatal visit reduces complications at the postpartum stage.

Determinants of the use of maternal health services in rural Bangladesh.

Utilization of health services is a complex behavioral phenomenon. Empirical studies of preventive and curative services have often found that use of health services is related to the availability, quality and cost of services, as well as to social structure, health beliefs and personal characteristics of the users. In this paper an attempt is made to examine the factors associated with the use of maternal health care services in Bangladesh on the basis of data from a survey of maternal morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT). The results from both the bivariate and multivariate analyses confirmed the importance of mother's education in explaining the utilization of health care services. Female education retains a net effect on maternal health service use, independent of other women's background characteristics, household's socioeconomic status and access to healthcare services. The strong influence of mother's education on the utilization of health care services is consistent with findings from other studies. Women whose husbands are involved in business/services also positively influenced the utilization of modern health care services. However, the study results are inconclusive with respect to the influence of other predisposing and enabling factors, such as women's age, number of previous pregnancies and access to health facilities. Multivariate logistic regression estimates do not show any significant impact of these factors on the use of maternal health care. The influence of severity of disease condition in explaining the utilization of maternal health care appears to be significant. Multivariate analysis indicate that women having had a life-threatening condition are little over two times more likely to seek care from a doctor or nurse to treat their maternal morbidities.

Analysis of ante-partum maternal morbidity in rural Bangladesh.

This paper presents the results of a prospective study of maternal morbidity during the ante-partum period in rural areas of Bangladesh. The data came from a survey of Maternal Morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT) during the period from November 1992 to December 1993. Since then no such national level survey has been conducted in Bangladesh. This paper employs multiple-decrement life table technique, a convenient way of analysing the risks of different types of disease conditions that women experience during the antenatal period for different age categories. The high-risk complications such as ante-partum haemorrhage, excessive vomiting, fits/convulsion and oedema were considered in this study. In this study a cause specific model was applied to explore the differences in the risks exerted at different ages of reproductive life attributable to some selected complications of pregnancy. The results of this study indicate that women of age 25-29 years are less susceptible to most of the selected life-threatening and high-risk complications during pregnancy such as haemorrhage, fits/convulsion and oedema. However, younger women (age < 25 years) are more likely to have excessive vomiting during pregnancy, and older women (age > or = 30 years) are at greater risk of haemorrhage, fits/convulsion and oedema.

Utilisation of postnatal care in Bangladesh: evidence from a longitudinal study.

Utilisation of health services is a complex behavioural phenomenon. Empirical studies of preventive and curative services in Bangladesh have often showed that the use of health services is related to the availability, quality and cost of services, as well as to social structure, health beliefs and personal characteristics of the users. The present paper attempts to examine factors associated with the utilisation of healthcare services during the postnatal period in Bangladesh by using prospective data from a survey on maternal morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERT). Both bivariate and multivariate analyses of the data confirmed that the mother's age at marriage had a significant and positive impact on the utilisation of quality healthcare services. The husband's occupation also showed a strong impact on healthcare utilisation, indicating higher use of quality care for postpartum morbidity by wives of business and service workers. The bivariate analysis showed that the number of pregnancies prior to the index pregnancy and desired pregnancies are significantly associated with the utilisation of postpartum healthcare. However, the results of this study were inconclusive on the influence of other predisposing and enabling factors, such as maternal education, the number of previous pregnancies, the occupation of the husband, antenatal care visits during pregnancy and access to health facilities. Multivariate logistic regression estimates did not show any significant impact of these factors on the use of maternal healthcare.

Inconsistent use of oral contraceptives in rural Bangladesh.

The purpose of this study is to explore predictors of inconsistent use of oral contraceptives (OCs) in rural Bangladesh. A total of 801 rural OC users were included in the study, about half of them (49%) missed one or more active pill(s) during the 6 months before the survey.Multivariate analysis revealed that Muslim women were 60% more likely to be inconsistent OC users compared to their non-Muslim counterparts. Women who lacked knowledge about contraindications were 60% more likely to take the pill inconsistently than were women who had the knowledge. Women who were not visited by family planning workers or did not have access to mass media were 40% more likely to be inconsistent OC users.OC users need increased information about correct OC use, which could be provided via improved access to mass media with specific messages on how to use OCs properly. Better access to the community clinics could improve the pill-taking behaviors of rural Bangladeshi women.