Maternal mortality is defined as death of women from pregnancy- related complications occurring throughout pregnancy, labor, childbirth and in the postpartum period (up to the 42nd days after birth (WHR, 2005). Maternal mortality is one of the major public health concerns in the world. Death during postnatal period is playing an important role in increasing maternal mortality and morbidity ratio (BMMMR, 2010).
Postnatal period (or called postpartum) is defined by the WHO as the period beginning one hour after the delivery of the placenta and continuing until six weeks (42 days) after the birth of an infant. The first hours, days and weeks after childbirth are a dangerous time for both mother and newborn baby. In this period, the physical examination of the mother and proper counselling by skilled health service provider is very essential to prevent the health complications. The WHO has recommended postnatal visit for at least three times. The first visit within 24 hours, second visit within 2-3 days and the fourth visit in the seventh day is the normal schedule for postnatal visit. These visits help to find out the health problems in time.
Antenatal care (ANC) and postnatal care (PNC) are the key indicators to measure the maternal health, particularly safe motherhood. Antenatal care is a very good predictor of safe delivery and provides health information and services that can improve the health of women and infants (Bloom, Lippeveld & Wypij, 1999; WHO & UNICEF, 2003).The primary aim of antenatal care is to achieve, at the end of pregnancy, a healthy mother and a healthy baby. In addition, antenatal care has a positive impact on the utilization of postnatal health care service (Chakraborty, Islam, Chowdhury & Bari, 2002). Postnatal care and intra-partum care significantly reduces maternal mortality and morbidity because most maternal deaths occur in the first week after delivery (Campbell & Graham, 2006; Hurt et all, 2008).
Despite improvements, pregnancy – related complications remains the leading cause of death and disability among women and of child bearing age disproportionately among different rural-urban dwellers, poor-rich groups, cultural groups and indigenous non indigenous groups (Gill & Ahmed, 2004; BDHS, 2007).
The present situation indicates an improvement in the global maternal deaths ratio (Hawkins, 2005). Globally 47 % maternal deaths decline in 2010 from 1990 (WHO, UNICEF, UNFPA & The World Bank estimates, 2010). However, progress towards the Millennium Development Goals (MDG) has been very slow in many countries (Bhutta, 2010).
Bangladesh has strengthened its emergency obstetric care (EmOC) under the Directorate General of Health services through national and international collaborations (Islam, Haque, Waxman, & Bhuiyan, 2006).The United Nations Population Fund (UNFPA) commenced support of government improvement of 64 maternal and child welfare centres for EmOC in 1993 (Gill & Ahmed, 2004). In addition, the Obstetrical and Gynaecological Society of Bangladesh with the support of UNICEF improved EmOC in 11 district hospitals on a pilot basis in the period 1994-1998, with subsequent expansion to other districts (Chakraborty, et. al, 2002). As a result ANC and PNC visits increased substantially in Bangladesh from 1999-2000 to 2007. However, pregnancy related complications remains the leading cause of death and disability among women.
Global urbanization has become a vital issue in recent years. The urban population is expected to increase by 84%, from 3.4 billion in 2009 to 6.3 billion in 2050 (United Nation, 2010). Bangladesh along with other Asian countries, has experienced rapid urban growth in the recent decades (NIPORT, 2008 & Uzma et all, 2004) This rapid urbanization in Bangladesh, increased with the growth of urban slums, is likely to have profound implications on its health profile, especially on maternal and child health (NIPORT, 2008). Maternal and child health is strongly related with beliefs and practices around pregnancy and childbirth which has implications for the health of the child and mother after the birth (Choudhury et, all, 2012).
The maternal mortality ratio (MMR) in Bangladesh was 320 per 100,000 live births in 2001 which decreased to 194 per 100,000 live births in 2010 (BMMMS, 2010). Bangladesh is presently on track to achieve the primary target of Millennium Development Goal (MDG) -5 with a goal to reduce the maternal mortality. Despite this achievement the condition in urban slums is worse compared to urban non slum areas with respect to antenatal care by medically trained provider (62% vs. 85%), delivery at a health facility ( 12% vs. 46%) and skilled assistance at delivery (18% vs. 56% ) respectively (NIPORT, 2008). This makes urban health issues, especially of the slum dwellers a high priority. It is therefore crucial to address maternal health of the urban slum dwellers in Bangladesh. Usually in urban slums, the maternal health services are offered at home or in static service delivery sites operated by nongovernmental organization (NGO) field workers. In some instance, services are available at clinics or dispensaries managed by NGOs, the government or the private sectors (NIPPORT, 2008).
Pregnancy and childbirth are the important event of life. However, the women are more vulnerable to complications and the deaths in this period. Therefore, the proper care and support is needed from the pregnancy to postnatal period. As in the world, there are so many different communities and religious groups, the way of care and support is different in pregnancy, childbirth and postnatal period. Some of the community applies their cultural practices during childbirth and postnatal care. The study shows that believe in the supernatural things like evil eye and spirits are still rooted in some communities. In spite of religion, class, urban and rural origins, the majority of Bangladeshi people believe in the existences of a supernatural world (Afsana & Rasid, 2000). The health care seeking behaviour during pregnancy and child birth are linked to women’s social and cultural interpretation of illness and well being and any complications in birth are often attributed to supernatural causes (Afsana & Rasid, 2000).
Food taboo is also the strong in the people especially during pregnancy and postnatal period. It depends upon the people’s beliefs. A study done by (Choudhury, et. al, 2012) shows that the mothers are allowed to take only dry food which was cooked without water, and rice with mashed potato and black cumin seed because these foods are believed to keep stomach of a women cool and initiate the production of breast milk. Another study also shows that there were various dietary restrictions imposed on the mothers which deprived them of proper nutrition intake. Commonly, the mothers were not allowed to have food during the first day after delivery to allow healing of the birth passage (Choudhury & Ahmed, 2011).
In some cultures, the mother should stay in isolation for few days after delivery. During that period mothers stay in a separate room. According to a study, the mother should stay in inner kimma (a private room) for 7-9 days. During this time, women sit by the fire, drink hot water, eat burning salt with rice and place searing materials on their lower back (Islam, 2011). Another study also showed that the women have to stay in isolation for the first 5-9 days after delivery because women are considered to be impure during this time. They are not allowed to touch any food for preparing meals (Choudhury & Ahmed, 2011).
To improve the maternal and child health of slum dwellers, many INGOs and NGOs are working in this area. BRAC is also implementing the project called “MANOSHI” with the same aim in all slums of Dhaka city. As the result, the maternal and child health is improving gradually.
1.2 Rationale / Justification
Maternal mortality is the major health problem in developing countries like Bangladesh. Together with the improvement in knowledge and awareness level of community and the various intervention implemented by government, the maternal health care service utilization is increasing. However, the extent of service utilization is still low particularly natal and postnatal care services. More than 29 out of 100 deliveries take place at home and only 27% seek postnatal care from health service provider (BDHS, 2011). Postnatal care is still a neglected issue because it is not as emphasized as antenatal care.
The maternal mortality and morbidity survey shows that majority of deaths occurred due to postnatal complications. Around 31% of total maternal deaths occurred due to haemorrhage. As a result, postpartum deaths now comprise a higher proportion of maternal deaths (73%) up from 67% in 2001(BMMMS, 2010). It indicates that postnatal care interventions should be given more priority. The government and other stakeholders should take account of PNC when implementing the maternal health programs.
Millennium development goal (MDG 5) is achievable in Bangladesh because of intervention by the government. However, people living in the rural and urban slums are not utilizing the maternal health services adequately. Socio cultural factors are the most important factor that can play important role in changing the health seeking behaviour. The behaviour cannot be changed unless recognizing the socio-cultural norms in the society.
This study aimed to explore the potential factors that can affect utilization of postnatal care services. Findings from this study will give a reflection of maternal health status as well as extent of post natal care service utilization which can be used to improve the utilization of post natal care in urban slums.
1.3 Operational definition
Postnatal period: The period beginning one hour after the delivery of the placenta and continuing until six weeks (42 days) after the birth of an infant. It is the most critical period for mother because most of the maternal deaths occur in this period.
Postnatal care: All the cares provided by family members, traditional birth attendance or health care service providers during postnatal period. It includes care in home or in health facility.
Cultural practice: The practice performed according to traditional norms and cultural beliefs by slum dwellers. It includes food intake practice, place of delivery, isolation, untouchability etc.
Food taboos: The prohibition on certain food intake to mother during postnatal period thinking harmful for health. It depends on the peoples’ perceptions and beliefs.
Family support: It included support in physical work and psychosocial support to the mother by family members during postnatal period.
Danger signs: The signs of physical or mental abnormalities that appear during postnatal period, which includes fever, severe, lower abdominal pain, hypertension and sepsis during postnatal period.
PNC visit: The standard scheduled visits to health care service providers for health check up during postnatal period. Health service providers conduct the physical examination of mother, appropriate counselling of mother and the newborn baby, supplementation of iron and vitamin A during these visits.
Personal hygiene: Those activities that are carried out to keep the mother clean during delivery and postnatal care.
Health seeking behaviour: It is the behaviour where the mothers go for health seeking during postnatal care. It includes formal and informal care.
Cultural beliefs: It includes the beliefs of mothers regarding postnatal care. It includes beliefs on food taboos, evil eye, untouchability etc.
1.4 Objectives of the study
General objective:
To understand the perceptions of women, their family members and health care providers on postnatal care in a Dhaka slum of Bangladesh
Specific objectives:
To explore cultural beliefs and norms regarding post-natal care
To explore the cultural practices of postnatal care among women in urban slums
To explore the barriers women face in seeking post natal care from health care centres in slum areas
Chapter II
Methodology
2.1 Study design
The study used the qualitative exploratory research design to explore the stated objective as enumerated because it is a sensitive issue and related to socio cultural behaviour. The aim of this study approach is to use multiple sources of data to explore the same phenomena from different angles. Qualitative research provides in-depth and contextual information that cannot be obtained from quantitative research alone. Therefore a lot of in- depth interviews and focus group discussion were conducted to understand the perception and practices towards postnatal care.
2.2 Study site
The study site was Sattar- Molla slum, Mirpur, Dhaka where BRAC is implementing Manoshi program to improve maternal and child health. This slum was chosen for the study because slums are neglected area by the government. There is no any governmental health facility for slum dwellers.
2.3 Study population
The study population were slum dweller mothers who have 6 weeks to 1 year children. Six weeks after birth is postnatal period so the respondent were taken from the mothers who had completed the postnatal period and the mothers who had less than 1 year child because there is less chance of memory or reporting bias. Besides them, their mother in laws and their husbands were also used as the source of information because mother in laws and husbands are the main decision makers in most of the families. In addition, Shasthya Sebika (SS), Shasthya Kormi (SK) and Urban Birth Attendent (UBA) who are involved in that field were included as key informants.
2.4 Sampling method and technique
Purposive sampling method will be employed in this study because only particular women who had experienced on postnatal period and having one year child were interviewed.
2.5 Data collection methods
The study employed the use of multiple qualitative methods to triangulate the data.
Key Informant Interview (KII)
Key Informant Interviews were conducted with SS, UBA and SK of BRAC health program because they were involved in the maternal and child health program and had close relation with mothers. A total of 3 KIIs, each from SS, SK and UBA were conducted. The KII gave the researcher a better understanding of the situation of the selected slums regarding postnatal care or related interventions in this area. According to Patton (2002), key informants are useful in helping the researcher to understand what is happening and why it is happening. Using key informants is a good option for the researcher to understand the cultural context regarding postnatal care practices. A semi structured key informant interview guideline was used as a tool for interview.
In-Depth Interview (IDI)
In-Depth Interviews were conducted for this particular study because it allows participants to tell their experiences and their stories in detail about phenomenon on an individual basis. Fifteen IDIs were carried out with mothers having 6 weeks to 1 year child. In-depth interviews involve conducting intensive individual interviews with a small number of participants to explore their perspectives on a particular idea, program, or situation. An in- depth interview guideline was used for interview.
Focus Group Discussion (FGD)
Focus group discussions were conducted with mother in laws and husbands of women separately. Two FGDs – one with mother in laws and one with husbands were carried out. According to Mack et all (2005), FGD provides a large number of information over a short period of time and is also effective for accessing a broad range of views on a specific topic as opposed to achieving group consensus. Focus group discussion guideline was used for information collection.
2.6 Data analysis technique
The qualitative data have no limited words like quantitative data. These data are words rather than numbers. Therefore the data were collected by using the voice recorders as well as taking notes. A Bangladeshi research assistant was used for data collection who also performed translation of the information from Bengali to English. The translated data were manually analyzed in the framework of content and thematic qualitative data analysis.
The collected data were transcribed verbatim and all the information were recorded and noted from field note, memo and audio record. The data were familiarized through multiple readings of each individual and focus group discussion interview transcript. This helped me to understand and start thinking about the structuring and organization of it into meaningful parts. Coding was performed and then emerging patterns and categories were identified. The data coded on broad categories were further sorted out with specific coding and analysis was done.
Data were displayed by using the data display matrices. Matrices included quotes, repeated verbatims, major ideas, themes and memos. Conclusions and verifications were further drawn from the display matrices especially with the emerging themes. Reflective codes were used to draw conclusions especially with the information drawn from different themes.
2.7 Research team
The researcher and one Research Assistant (RA) collected the data. Before collecting the data, all research instruments (IDI, KII, FGD guidelines) were translated from English to Bengali with the help of RA to minimize the errors. After data collection, data were again translated from Bengali to English for further analysis.
2.8 Ethical consideration
Ethical approval was obtained from the Ethical Review Committee of James P.Grant School of Public Health and the researcher followed all guidelines. Informed verbal consent was taken from the prospective participants before collecting the data. All participants were then informed about the nature and purpose of the study, right to withdrawal, and option to refuse to answer any question. Anonymity and confidentiality of information were maintained at every stage of the study. No name of any respondent was used during the final write up of the thesis. Permission for taking photographs and for recording their voice was taken before conducting each interview and focus group discussion.
Chapter III
Findings
The findings of this study are divided and presented in three different sections based on the specific objectives of the study, previously set concepts and responses from the participants. The first section describes perception on PNC and cultural beliefs on postnatal care based on the responses from the participants. The second section describes cultural practices performed during the last postnatal period. And the third section describes about some of the barriers and difficulties faced by the participants on seeking postnatal care service from health facilities.
3.1 Socio demographic characteristics of the participants
Table : Socio demographic characteristics of the participants
Age
Average age 22.8 years ( 15-30 years in range )
Educational level
Primary education-9, Secondary education-4
and no education-2
Occupation
All housewife
Husband’s occupation
Garment workers-6, Businessman (small shop )-3 Building constructer (Rajmistri)-3, CNG Driver-3
Monthly family income
Average 8100 Tk. (3000-15000 Tk.)
Number of children
Having one child-9, Having two children-3,
Having three child and more-3
Number of family member
Average 6 member (3-14) members
Religion
All Muslim
Place of delivery during last child
BRAC birthing hut-12, Dhaka medical college 2 and Arman medical college -1
All participants of the study were mothers having infants from 6 weeks to 1 year of age. Fifteen mothers were interviewed in depth. The average age of participant was 23 years. However some mothers were very young, even under 18 years. The youngest mother was 15 years old and the oldest participant was 30 years of age. Nine of the participants had attended primary education, four had attended secondary education but not completed and two of the participants had never attended any formal education. All the participants were housewives; none of them was engaged in income earning activities outside their homes. The study found that majority (9) of their husbands were garment workers, while some had small shops and some were CNG driver and building constructor (Rajmistri). Their monthly income ranged from 3,000-15,000 taka with an average of 8,100 taka. Nine of the participants had only one child, 3 had two children and 3 had more than two (3-4) children. The family size ranged from 3-15 members with an average of six members. All the participants were Muslim. As there was a birthing centre of BRAC, most of the participants gave birth to their child at that birthing hut. Only three deliveries occurred at the medical college hospital.
3.2 Perception regarding postnatal period
Perception of women
In-depth interview with participants revealed that women perceive the postnatal period as critical period because in this period many health problem especially fever and hypertension can occur. Most of the participants thought that they should take rest at least 45 days after delivery. Family members should support them on household works. They also said that they need to take nutritious food like meat, fruits and vegetables as well as maintain hygiene otherwise their baby will get sick. They also said that their health should be checked time to time by health service providers. However, they did not have very good knowledge on postnatal complications. Some important findings regarding PNC are described as below:
-Most of the women knew the exact duration of postnatal period
Majority of the respondents were aware about the duration of postnatal period. Ten out of 15 participants reported that the exact duration of postnatal period was 45 days. However, some mothers did not know about the exact duration of PNC. Some of the mothers replied that the postnatal duration of PNC is 2 years and some of the mothers said 1 month. However, the participants had good idea about taking rest during postnatal period. They thought a mother should take rest as much as she can. Some mothers also had idea about this period being a critical period so they should not have sex. A participant said that:
“I think a mother should take care of herself minimum about 45 days, we should not have sex, should be aware.” IDI-14
– Little knowledge on danger sign/complications
From the interview with participants, it was found that very few had the knowledge regarding danger signs during PNC. None of them could say all the five danger signs. Only 1 out of 15 respondents could say at least two danger signs (heavy blood loss and hypertension) during PNC. Very few respondents (3 out of 15) reported fever as a danger sign of PNC, only four out of 15 respondents said that hypertension is a danger sign. Rest of all had no idea on danger signs during postnatal period. During the interview, the participants said that:
“As far as I remember heavy blood flow, body shaking and pressure is bad thing etc.”
IDI -14
“If I face any problem then that is bad for baby, if we face a serious disease then go otherwise don’t. If we face cold we eat Tulshi juice” IDI- 13
“High pressure is bad for me and my baby, because I will be in serious condition.” IDI -3
Except these the participants have good attitude on PNC period.
Perception of family member:
The perception of family member regarding PNC was same as the perception of mothers. They also think mother should take rest up to 3-4 months after delivery. Mother should not do heavy work in this period. But they did not know the exact duration of PNC period. They also thought the family member should support and give them nutritious food like green vegetable and fruits. They were not very much aware about complication but they think if the mother has fever and hypertension then they should go to the doctor, Only very few mother-in-laws said that fever and headache were the bad things during postnatal period. As the same way husbands also had no idea about it they also couldn’t say any danger signs/complications of PNC except fever and hypertension. Some findings are as flow:
-Family members do not know the exact period of PNC
The family members also did not have idea about exact period of postnatal. They believed that the mother should take rest minimum 2-3 months and some of the members said that the mother should take rest about one year. None of the mother in laws and husbands knew the exact period of postnatal period. However they were aware about that the mother should take care of herself and her family member like sister in laws, mother in laws or mothers or and others should support the recently delivered women. They should not do heavy work at that time. Almost all members were agreed about this perception on the discussion. One of the members from focus group discussion said that:
“A mother should take care of herself and baby up to 1 year at least. She should not put herself into more work. Only can do few light work and easy work. She is not allowed to do heavy work and to carry heavy things. Other family members like mother in law or sister in law or mother or sister they can help to do this kind of heavy work.” (FGD- 2 Husband)
The family members also did not know about all five danger signs of postnatal period. Only very few mother -in- laws said that fever and headache were the dangerous during postnatal period. As the same way husbands also had no idea about it they also couldn’t say anything except fever and hypertension. They did not take it very seriously because they did not face these kinds of problem till date.
Perception of Health service provider
The perception of health service provider was positive towards postnatal care. They thought the health condition of mother should be checked frequently because it was very critical period. If any complication appears, they should go to the hospital. She can do light work but should not do heavy work. The family members also should support them during this time. The mother should take rest up to when she feels good.
– No exact period for PNC
Two out of 3 service providers thought that there was no exact period for postnatal care. However, one health care provider said the exact postnatal period was 45 days after delivery. They thought mother should take care up to when she feels good or ready for work. They thought mother can start light work within a few days but she should not do heavy works up to at least six months. One of the service providers expresses that:
“A mother should take rest at least for 1 to 6 months. It is important to take care of mothers health, she should avoid cold otherwise the baby will suffer with cold. She should not carry heavy things in this time; she will be in trouble if she does in this period.” (KII-1 provider)
-Good knowledge on danger signs:
The health providers working under the BRAC birthing hut, were trained on maternal and child heath. They had confidence on their role and responsibility. They said easily about the five danger signs of PNC. All of the health providers had good knowledge on that. Here is the statement of one respondent:
“If we find any mother who will deliver her baby within 24 hours, we measure her blood, ask the condition of her menstruation whether its heavy or not or coming out with bad smell, does she facing any pain in abdomen, does she have any fever (if then measure the temperature)”KII- Provider
3.3 Cultural beliefs
In this section the cultural beliefs related to postnatal care is explained. Basically this section talks about existing superstitions in the study area. It includes beliefs in Tabij, Food taboos, mobility and untouchability/ isolation during PNC.
Beliefs in Tabij
-Women and their mother- in- laws belief in tabij
Everybody had the belief that they must use tabij for the protection of baby and themselves from the evil eye and ghost. If they did not use this, they had to face many problems. This was found to be the most common belief prevailing in the community. The mothers especially wear these in their neck but for the baby they use both neck and waist. They did that as per the suggestion from their elderly. One of the participants stated:
“Yes me and my baby use tabij for our safety and to protect us from evil eyes. The navel, hair, nail, dirt of ear and body are kept those inside a small pieces of cloth and tied up with tabij. It is done to avoid black majic.. When my baby will be 18 months, I will throw it in water. I have also pierced my baby boy’s ear because my grandmother suggested to do that because he was born in “Bhadro”( one of the Bengali month). Though my husband was telling not to do that because otherwise his son will not be able to give Azan (call for prayer) in Mosque” (IDI -7, Line No. 91-98)
Another mother said that:
Yes, my dad gave me Tabij for my baby and me. If I would not use the Tabij I used to see so many weird things. I also become afraid to allow others to come to my house because there were so many people who have sex at night but don’t take shower early in the morning. It’s dangerous; it causes bad sign for a new mother and baby. People suggest me not to allow other lady to carry my baby if they have mince. We tell people to make the hand hot over fire to avoid ghost. We always do this and keep fire outside our room door. We must do this while entering home otherwise baby starts to cry. (IDI -1)
The perception on wearing tabij of mothers was same with the perception of the family member specially the elderly people such as mother in laws in the family. Almost the entire mother in laws reported that they suggested wearing tabij to their daughter in laws to avoid the evil eyes and ghost. They did so because they strongly believed on tabij and they were influenced from their traditional thoughts. They also reported that they used Tabij at their time especially in postnatal period as per the suggestion of their mother in laws and elderly people. Therefore, this was an ongoing process because these things were rooted in their community strongly. Everybody said that if someone did not believe it, he or she will face many problems especially health problems. A mother in law stated during group discussion:
“We believe in tabij because it is traditional thoughts. Our mother-in-laws used it, we used it and also we suggest using it to our daughter in laws. We don’t know who have evil eyes in the society but we know there may be so many bad eyes. So we should protect ourselves by wearing such kinds of things so that one’s bad eyes can’t effect on our body.” (FGD-1 L.N.-20)
-But male participants and providers did not believed in Tabij
The perception regarding wearing tabij was a little bit different among male participants. The same discussion with husbands of recently delivered women was found that they did not believed that much as female participants reported. They thought this was only the people’s beliefs because their elderly people used it and still using it but it had no any scientific evidence that it reduced health problems or any kind of problems. They did not believe on evil eyes or anything
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