Health System and Skilled Birth Attendants: A Bangladesh Study

This report delves into the critical role of skilled birth attendants (SBAs) in Bangladesh, addressing the persistent challenge of maternal mortality. It begins with an acknowledgement and table of contents, followed by an abstract that highlights the study's focus on the health system's 'architecture' and its impact on women's access to SBAs. The report then explores the background of the study, reviewing existing literature and defining key terminology. It emphasizes the significance of SBAs in reducing maternal deaths and improving newborn survival. The methodology section details the data sources, sampling techniques, and statistical methods used to analyze the determinants of SBA utilization. The results and discussion chapter presents socio-demographic, household, and economic characteristics of respondents, along with an analysis of skilled birth attendance during delivery. The report concludes with a summary of the study's findings and recommendations for policy and programmatic interventions to improve maternal health outcomes in Bangladesh, with a particular focus on strengthening the health system to increase access to SBAs and reduce maternal mortality.

Dedicated
To
Almighty Allah
1

At first, I do express my whole-hearted gratitude to almighty Allah for giving me strength,
patience and ability to perform this project work completely.
I would like to express my best regards, profound thankfulness, indebtedness and deep
appreciation to my honorable and beloved supervisor for his constant supervision, inspiring
guidance, enthusiastic encouragement, wise advice and an affectionate surveillance though the
entire period of my research work.
I really owe to him so much for giving me such an opportunity to work in close association with
him, without his effort and guidance it have not been possible to complete this project task.
I also express my deepest gratitude to all of my respectable teachers for their kind help. I am also
helped by some of elder brother in my department, I am grateful to them. The respondents who
provided data willingly, I am heartily grateful to them.
I convey my heartiest thanks to all of my friends and well wishers for their encouragement,
stimulation and co-operation that inspired me to complete my project task.
Especially I am very grateful to my honorable parents for their regular financial support and
encouragement to finish this dissertation. In fine, I am alone responsible for the errors and
shortcomings in this study if there be any, I am sorry for that.
The Author
2
Acknowledgement

Table of Contents
Chapter Title Page Number
Dedication 1
Acknowledgment 2
Contents 3,4
List of table 4
Abstract 5
Chapter One Research Perspective
1.1 Background of the study 6,7
1.2 Review of literature 7,8
1.3 Concept of terminology 9
1.4 importance of the study 9
1.5Objective of the study 10
1.6 Organization of the study 10
1.7 Limitation of the study 10,11
Chapter Two Data source and Methodology
2.1 Introduction 12
2.2 Selection of the project title 12
2.3 Selection of study area 12
2.4 Preparation of questionnaire 13
2.5 Pre-Testing 13
2.6 Sampling design and sampling technique 13
2.7 Selection of respondents 14
2.8 Data collection 14
2.9 Time of data collection 14
2.10 Data processing 14
2.10.1 Editing 14
2.10.2 Coding 15
2.10.3 Tabulation 15
2.10.4 Computerization 15
2.11 Selection of variables 15
2.11.1 Dependent variables 15
2.11.2 Independent variables 15
2.12 Statistical methodology 16
2.12.1 Frequency Analysis 16
2.12.2 Graphical representation 16
2.12.3 Bivariate analysis 16, 17
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Chapter Three Result and Discussion
3.1 Introduction 17
3.2 Socio-demographic characteristics of the
respondents
17,18
3.3 House-hold characteristics of the respondents 19
3,4 Economic characteristics of the respondents 20,21
3.5 Skilled birth attendants during delivery 22-26
Chapter Four Summary and conclusion
4.1 Summary of the study 27
4.2 Conclusion 27
Reference 27-29
List of Tables
Table number Table Name Page Number
Table one Distribution of the respondents by socio-demographic
characteristics
18,19
Table Two Distribution of the respondent by household characteristics 19,20
Table three Distribution of the respondent by Economic characteristics 20,21
Table Four Distribution of the respondent by Demographic
characteristics
22-24
Table Five Skilled Birth attendants during Delivery 24,25
Table six Association between skilled and unskilled birth attendance 25
Table seven Assistance during delivery by different socio-economic
and demographic characteristics
25,26
Abstract
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Despite some visible progress in some areas of health sectors, Bangladesh is still struggling to
sustain efforts towards decreasing Maternal Mortality Rate (MMR). Evidence shows that there is
lower access to skilled birth attendant in Bangladesh. Access to skilled birth attendants (SBAs)
during delivery has been identified as an effective mechanism to significantly reducing MMR.
Previous studies have focused on socio-demographic characteristics of women including cultural
and religious dynamics with communities with limited attention to the health system. Using the
World Health Organisation’s health system strengthening framework, this paper analyses how
health system ‘architecture’ playing role in create fragile platform for the women to access
skilled birth attendants. It draws emphasis on governance and policy, financing, health
information, workforce, service delivery, medicines and commodities including infrastructure.
As governance is the dominant factor and plays critical role in determining success of all facets
of the health system, this paper further proposes a systematic strategy that seeks to mitigate the
identified challenges. Lessons from this study are relevant to guiding policy makers in
Bangladesh as well as in other resource-constrained settings in making evidence based decisions
regarding strengthening the health system to access a skill birth attendant to make birth safer for
both mothers and newborns.
Keywords: Millennium Development Goal, Skilled birth attendant, traditional
(conventional/untrained) birth attendants, Community-based Skilled Birth Attendant, trained
traditional birth attendants, institutional delivery.
Chapter one
Research Perspective
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1.1 Background of the study
Maternal deaths across the globe have been estimated to be approximately 289,000 in 2013,
while the death toll of newborn within the first 4 weeks of birth has reached at 3.6 million. Most
of the complications related to pregnancy and childbirth are unpredictable, and take place around
the time of delivery and postpartum period. This is why, access to Skilled Birth Attendants
(SBAs) is strongly recommended for all the pregnant women so as to make sure a normal
delivery is conducted well, related complications are recognized early and referred immediately
to the appropriate healthcare facilities. Birth attendance by SBAs is considered as the “single
most important factor in preventing maternal deaths”. Delivery attendance by SBAs is also very
important in preventing stillbirths and improving newborn survival. The proportion of births
attended by SBAs is one of the two indicators of the progress toward achieving Millennium
Development Goal (MDG)-5.
The utilization of SBAs at birth is quite low in Bangladesh. About one in every five deliveries is
attended by SBAs; the proportion is even lower in slum and tribal areas. Home delivery assisted
mainly by Traditional Birth Attendants (TBAs) is as high as 71% in Bangladesh. Government of
Bangladesh initiated the Community-based Skilled Birth Attendant (CSBA) program to increase
accessibility to skilled delivery at home in 2003 with the target to train 13,500 government field
staff as CSBAs. As of June 2014, nearly 9,000 government CSBAs have been trained. Besides,
some of the development partners have also been supporting the CSBA training to the private
candidates, especially to cover the hard-to-reach areas. Recent evaluation of the CSBA program
indicates that even though CSBAs are available in the rural areas, their utilization is low in the
community. It is, therefore, imperative to examine the determinants of delivery by SBAs so as to
understand well the areas that require further policy reform and programmatic interventions in
line with progress toward MDG-5. Determinants of delivery by SBAs identified in previous
studies have been inconsistent, and there is paucity of information in Bangladeshi context.
Current paper aims at identifying the determinants of delivery by SBAs in rural Bangladesh.
Despite an attempt to enhance maternal health services, the maternal mortality ratio of mothers is
a global concern, and it remains high in the majority of the developing countries. Globally, the
daily maternal mortality rate associated with pregnancy and delivery complications is 830.
303,000 women in 2015 died during pregnancy and childbirth, with 302,000 (99%) of such death
occurring in the rural areas of developing countries with low income .Globally, the proportion of
maternal death is 216 per 105 live births, where Bangladesh has a rate of 176 per 105 live births
important factor in preventing maternal deaths”. With the wide disparity in maternal mortality
rates of developing and developed countries in 2015 (239:12 per 105 live births), subsequently, a
new goal of the United Nations named Sustainable Development Goal (SDG) was developed,
which aimed at reducing the death rate below 70 per 105 by the year of 2030. Notwithstanding
global improvement in the health sector, only 52% (42% medically trained personnel and trained
traditional birth attendants assisted in 10 % of deliveries) of the birth was performed by skilled
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birth attendants in Bangladesh which excludes the traditional birth attendants (TBAs), as they are
recognized as the health professionals to oversee pregnancy, childbirth and postnatal care. Safe
delivery is one of the four foundations of safe motherhood. Having accurate knowledge of
delivery can decrease the risk of complexity or infections, which may lead to fatal. Delivery in
unhealthy environments without protective equipment creates many troubles that can lead to high
morbidity and maternal mortality. Hence, it is important to increase the survival rate of mother
and child during delivery through the utilization of clean and befitting delivery rooms (whether
the local type of rooms, which are mostly used by Traditional Birth Attendants (TBAs) or the
standard delivery rooms, which is obtainable in well-equipped hospitals). Poor use of SBA is
often considered the cause of life or death for both mother and child by tribal and non-tribal
women. This is notably worse in rural areas. There is the dearth of literature on the presence of
SBA during birth among tribal women of Bangladesh at the health care centers. A study found
that TBA (Traditional Birth Attendant) is the first option for pregnant women to give birth to a
baby at home. The most commonly cited reason for choosing TBA home delivery is "poverty."
Another study showed that the beliefs and practices of indigenous women in Bangladesh are
significant factors influencing the selection of child deliveries at home . According to another
Bangladesh study on nursing mothers in 2013, 80% of respondents stated that they delivered
their babies at home. Out of these, about 71% of them expressed that home delivery was smooth,
while about 29% of them stated that they were bound to deliver at home because of family
decision and financial constraint.
Thus, this study aims at emphasizing the importance of skilled birth attendant’s services and the
factors militating against the access to SBAs among rural women of Bangladesh. Finding from
this study will help to formulate policies to promote the services of SBAs among rural women in
Bangladesh during birth. This study will instigate the government in setting policies that will
prompt and compel SBAs utilization during childbirth by rural women of Bangladesh.
1.2 Review of literature
There are many studies that have been carried out the importance of skill birth attendance and its
determinants despite-socio economical condition. A number of studies have also been done
which is related to the present study. Some of the relevant literature in the context of the present
study is reviewed in the following.
Islam et al., (2014) in a study of reproductive health he found that, Maternal occupation, parity,
complications during pregnancy and antenatal checkup by SBAs were the significant
determinants of delivery by SBAs. Promotion of quality antenatal care in the community may
improve the delivery by skilled providers in rural areas of Bangladesh.
Naser and Karim (2020) in a study they found the indigenous people are socially, linguistically,
and scientifically diverse. A global trend leads us to the notion that primitive women are
somewhat less privileged than non-tribal mothers around the world. This problem also sounds
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true in the context of Bangladesh. A competent birth attendant at birth is the most important
intervention for pregnant women.
Abul (2012) observed that the use of skilled attendants at delivery was very low in Bangladesh.
Parental education and birth order were strong predictors for the use of skilled assistance at
delivery. Rural women and women from Muslim religion were at greater disadvantage in the use
of skilled assistance at delivery.
Soleiman (2018) observed that The lack of availability and access to basic and obstetric
emergency care is a major cause of the high levels of maternal mortality and morbidity in
Somalia. Barriers to accessing skilled birth attendant services are many as reflected, in Somalia
only one out of 6 women receive the appropriate care.
Mulunesh and Mekonnen (2015) found on a study that, utilization of skilled birth attendant is
still very low with a high number of deliveries being attended by unqualified persons at home.
There are still women who deliver by themselves. Women’s higher education, urban residence
type, higher frequency of antenatal care visits, proximity of living to a health center, and
encountering complications during current labour were found to be positively correlated with
skilled birth attendant utilization.
Ahsan (2022) found on a study that Lessons from Bangladesh’s maternal and child health
services delivery and service utilization during the last two decades have important implications
for policymakers and public health researchers in low- and middle-income countries. The
empirical evidence presented in the dissertation provides insight into what can be replicated in
similar low- and lower-middle-income countries to better understand maternal health equity.
Yuva(2014) observed on his study that The use of skilled birth attendants is low in those
countries where maternal mortality rates are high and most of these deaths could be prevented if
skilled birth attendant services were available. Only 36 percent of women use skilled birth
attendants in Nepal.
1.3 Concept and Terminology
Skilled Birth attendance:
Skilled birth attendance (SBA) is a key strategy for averting maternal mortality ratio (MMR).
The lifetime risk of maternal death is high in countries with low SBA. With the presence of a
skilled birth attendant, the possibility of death owing to intra partum-related complications or
stillbirth can be reduced by 20%. Elevating SBA rates for women can, therefore, contribute
substantially toward the realization of the Sustainable Development Goal (SDG). SDG three
inter alia envisages the reduction of maternal mortality to 70 per 100, 000 maternal mortality by
2030. To achieve this, SBA, which is delivery assisted by a skilled birth attendant, has been
recognized as a protective mechanism for saving maternal and newborn lives. A skilled birth
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attendant is “an accredited health professional such as a midwife, doctor, or nurse who has been
educated and trained to proficiency in the skills needed to manage normal (uncomplicated)
pregnancies, childbirth, and the immediate postnatal period, and in the identification,
management, and referral of complications in women and newborns”..
1.4 Importance of the study
The presence of a skilled birth attendant at delivery is important in averting maternal and
neonatal mortality and morbidity. It has now shown that even trained traditional birth attendants
(TBAs) cannot, in most cases, save women's lives effectively because they are unable to treat
complications, and are often unable to refer. Qualified midwives and doctors are often not
available in the rural areas and community settings where most women in developing countries
deliver. Defining the minimum competency level necessary to meet the definition of skilled birth
attendant is important, particularly in countries such as Bangladesh with limited availability of
facility-based emergency obstetric care. Maternal and child health workers are local women aged
18-35 who completed a 15-week course in maternal and child health. As the role of MCHWs has
expanded to meet the country's needs for skilled attendance, a 6-week "refresher" course in
midwifery skills is offered. The results of this clinical skills assessment of 104 randomly selected
MCHWs from 15 districts across Nepal supports the premise that MCHWs with appropriate
training have an acceptable level of knowledge and skill, demonstrated in a practice situation, to
meet the definition of community level skilled birth attendants. Yet, competency alone will not
necessarily improve the situation. To affect maternal mortality in Nepal, MCHWs must be
widely available, they must be allowed to do what they are trained to do, and they must have
logistical and policy support.
1.5 Objective of the study
To accomplish every study, the researcher has to undertake a plan preparation with one or more
objectives. The main objectives of this research should be specifically mentioned. Actually
scopes and objectives of a research vary from area to area, time to time and phenomenon to
phenomenon. The main objectives of this research are:
(i) To explore the background characteristics of married women of Trishal, Mymensingh
Bangladesh.
(ii) To explore different socio-economic and demographic variables according to presence
of skilled birth attendant during delivery in Trishal, Mymensingh, Bangladesh
1.6 Organization of the Study
The study has been organized into four chapters. The first chapter is the introduction that deals
with background of study, review of literature, concept and terminology, objectives of the study,
importance of the study and limitation of the study.
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Chapter two contains data and methodology. This chapter is included as introduction, selection
of project title, selection of the study area, preparation of the questionnaire, pretesting, sampling
design and sampling technique, selection of respondent, data collection, time of data collection,
data processing, selection of the variables dependent variables, independent variables, statistical
methodology and bivariate analysis..
Chapter three contains results and discussions of the present study and chapter four contains
summary and conclusion.
1.7 Limitations of the Study
The main objectives of the research are to find out the hidden aspects what has not been
discovered yet. But due to lack of necessary knowledge and experience in the fieldwork, some
problems arise in the time of collecting data. Generally primary data collection is a difficult task.
The data have been collected from married women who are living in rural areas is was not
always easy to reach them .They also provide information on various demographic and socio-
economic variables of her head of family. The whole data collection process is very systematic
and methodological. But even then, there are limitation because of the illiterate and ignorance of
the people. Some of the limitations are as follows.
(i) The time and cost were not sufficient for the study, there may have some
nonsampling errors in this study.
(ii) In some cases the respondents failed to give accurate age, monthly income, age
at marriage etc. in such cases we got appropriate answer indirectly.
(iii) Many religious minded women are not interested to respond and some times
they raise some questions and some these questions are irrelevant as difficult to
the researcher.
(iv) The respondents are afraid of their husband and other members of the family to
interview.
(v) Data has been fixed within 540 respondents due to lack of time and financial
problem.
CHAPTER TWO
Data and Methodology
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2.1 Introduction
Data source, Quality, and Methodology are important part for obtain accurate findings and lastly
comment on these findings for any research. Research methodology is the philosophy of
researcher to systematically solve the problem. It is necessary for the researcher to understand
not only the research methodology but also consider the logic behind the methods which is used
in the context of the research study and explain the research is conducted. The present chapter is
confined to indicate a description of the study area; selected population, sample size, sampling
technique, preparation of the questionnaire, study period and all other related issues of the study.
In addition, data editing, data coding, data analysis and limitation of the study has also included
this chapter.
2.2 Selection of Project Title
The Department of Population Science at jatiya kabi kazi nazrul islam university approves a
system, where every students of fourth year have to carry out a project work on different project
title. For this purpose several groups are formed and assigned to different teachers. After
formation of groups, I met wth my honorable supervisor and discussed about various problems.
Among various issues, we have selected the most important area of research. Besides, I have a
keen interest to do research work on this phenomenon: “Maternal and child health”. So after
along discussion with my Supervisor, I have selected my project title as “A cross sectional study
of Delivery by Skilled Birth Attendant in Trishal, Mymensingh, Bangladesh”
2.3 Selection of Study Area
For collecting the primary data of research, the researcher is to select the study area properly for
successful end. For conducting the project work I have selected Trishal Union, Boilor Union,
Dhanikhula Union and Shakua Union, under Trishal Upazila, Mymensingh District with discuss
my honorable supervisor. Basically it’s a rural area where maternal service still un-adequate and
unreachable in many cases like skilled birth attendance during delivery.
2.4 Preparation of questionnaire
Question is essential for collecting primary data of any research. Often a questionnaire is
considered as the heart of survey operation. The questionnaire consists of a set of question for
information. It is designed in such a way that maximum information can be obtained within a
short time by covering our object of the study. Language of the questionnaire should be simple
and easy to understand which the keystone of the survey is. Every question is relevant to the
concerned of this study. The questionnaire was designed keeping the following points in mind:
1. Number of question of the questionnaire should be limited.
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2. A respondents should adequately be assumed that his identify will not be reveled and the
information will not be used against his interest.
3. Set some question in the questionnaire to check on the validity of other question
4. Avoid long confusion question and formulate simple short and validity of other question.
5. Start the easy question then slowly put the difficult question but maintain its sequence
following in essential to the questionnaire for any research work.
At first a draft questionnaire was prepared and then the same was thoroughly discussed. On the
entire question, the draft questionnaire was finalized at the end.
2.5 Pre- Testing
In order to check the ratability and validity of the draft interviewing schedule it was pre– testing
in a purposively selected area. As a result of presenting some question were deleted, added,
modified or changed to their logical; place in the formal of the interviewing schedule.
2.6 Sampling Design and Sampling Technique
Sampling is essential and parts of statistical survey. Because the Researcher would not get
economical facilities from any sources and the time is very limited. And it is assume that
purposive sampling will save both time and money. A variety of sampling techniques are now
being used in statistical practice but in this study, simple random sampling technique is used. A
simple random sampling is one in which each unit of population has an equal and independent
chance of being included in it.
To evaluate the sample size, Cochran's equation was used (Eq. 1 & 2).
N= Z2 pq ÷d^2………………….. (1)
Where; z = level of confidence (95% or 1.92 )
P= Estimated proportion of the population's attribute
n= ( 1.95 ×1.95 ×0.05 × 0.05 ) ÷ (0.05× 0.05)=384……………… (2) With an additional 41%,
(384+136), the sample size is 540 or ample representation. Of this number, only 540 households
were surveyed from the 07 words of trishal union under trishal Upazila.
2.7 Selection of Respondents
In this research work 540 female respondents were taken from the study area that were migrated
to the study area from different district and other region due to marriage or other causes.
2.8 Data Collection
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