Access to maternal healthcare services among Indigenous women in the Chittagong Hill Tracts, Bangladesh: A cross-sectional study

Sociocultural practices and beliefs during pregnancy, childbirth, and postpartum among indigenous pastoralist women of reproductive age in Manyara, Tanzania: a descriptive qualitative study

BACKGROUND

Despite interventions improving maternal and newborn morbidity and mortality, progress has been sluggish, especially in hard-to-reach indigenous communities. Sociocultural beliefs in these communities more often influence the adoption of particular behaviors throughout pregnancy, childbirth, and postpartum. Therefore, this study identified sociocultural beliefs and practices during pregnancy, childbirth, and postpartum among indigenous pastoralist women of reproductive age in the Manyara region, Tanzania.

METHODS

The study was a descriptive qualitative design. We used purposive sampling to select twelve participants among community members who were indigenous women of Manyara who had ever experienced pregnancy. In-depth interviews were audio-recorded and transcribed verbatim, and organized manually. We used manual coding and inductive-deductive thematic analysis.

RESULTS

The study's findings showed that sociocultural beliefs and practices are widespread, covering antenatal through childbirth to the postnatal period. Both harmful and harmless practices were identified. For example, the use of herbal preparations to augment labor was reported. Previously, most women preferred home delivery; however, the practice is changing because of increased knowledge of home delivery complications and the accessibility of the facilities. Nevertheless, women still practice hazardous behaviors like applying strange things in the birth canal after delivery, increasing the risk of puerperal infection.

CONCLUSIONS

Sociocultural practices are predominant and widely applied throughout the peripartum period. These beliefs encourage adopting specific behaviors, most harmful to both mother and fetus. These sociocultural practices tend to affect the utilization of some essential maternal and child health practices. Eliminating unsafe peripartum practices will increase the use of medical services and ultimately improve outcomes for both mothers and their newborns. Public health interventions must recognize the cultural context informing these cultural practices in marginalized indigenous communities. Healthcare providers should routinely take the history of commonly traditional practices during the peripartum period to guide them in providing quality care to women by correcting all harmful practices.

Uptake of antepartum care services in a matrilineal-matrilocal society: a study of Garo indigenous women in Bangladesh

BACKGROUND

The indigenous Garo is a close-knit matrilineal-matrilocal community. This community's expectant mothers receive less antepartum biomedical care, making them prone to maternal mortality. This study developed a conceptual framework to explore how the external environment, personal predispositions, enabling components and perceived antepartum care needs influence and generate a gap in antepartum biomedical care uptake.

METHODS

The author used qualitative data from the study area. The data were collected through conducting 24 semi-structured interviews with purposively selected Garo women. After transcribing the data, the author generated the themes, grouped them into two broader domains, and analyzed them using the grounded theory approach.

RESULTS

The emergent themes suggest adding the external environment (i.e., healthcare facilities' availability and services and culturally relevant healthcare services) to Anderson's behavioral model to understand indigenous women's antepartum care uptake disparity. Antepartum care uptake disparities arise when Andersen's behavioral model's other three drivers-personal predisposition, enabling components, and needs components-interact with the external environment. The interplay between enabling resources and the external environment is the conduit by which their predispositions and perceived needs are shaped and, thus, generate a disparity in antepartum care uptake. The data demonstrate that enabling resources include gendered power dynamics in families, home composition and income, men's spousal role, community practices of maternal health, and mother groups' and husbands' knowledge. Birth order, past treatment, late pregnancy, and healthcare knowledge are predispositions. According to data, social support, home-based care, mental health well-being, cultural norms and rituals, doctors' friendliness, affordable care, and transportation costs are perceived needs.

CONCLUSIONS

Garo family members (mothers/in-laws and male husbands) should be included in health intervention initiatives to address the problem with effective health education, highlighting the advantages of biomedical antepartum care. Health policymakers should ensure the availability of nearby and culturally appropriate pregnancy care services.

Community perspectives of barriers indigenous women face in accessing maternal health care services in the Chittagong Hill Tracts, Bangladesh

OBJECTIVES

Bangladesh has achieved notable success in improving maternal health by increasing women's access to good quality and low-cost maternal health care (MHC) services. However, the health system of Bangladesh has earned criticism for not ensuring equitable MHC access for all women, particularly for Indigenous women in the Chittagong Hill Tracts (CHT). Little is known about Indigenous communities' perspectives on these inequalities in MHC service access in the CHT. Therefore, this study aimed to explore Indigenous communities' perspectives on challenges and opportunities for improving MHC service access in the CHT.

DESIGN

This qualitative descriptive study was conducted in two sub-districts of Khagrachhari between September 2017 and February 2018. Eight Indigenous key informants from three Indigenous communities (Chakma, Marma and Tripura) were recruited via snowballing and purposive techniques and participated in face-to-face, semi-structured interviews. Key informants comprised community leaders and health care providers. Data were analysed thematically using Nvivo12 software.

RESULTS

Findings suggest that distance, poor availability of resources and infrastructure, lack of community engagement in the design of health interventions, Indigenous cultural beliefs, misconceptions about MHC services, and maltreatment from health care providers were the key barriers to accessing MHC services; all are interconnected. Indigenous women faced humiliation and maltreatment from MHC staff. Failure to provide a culturally-safe environment suggests a lack of cultural competency among health staff, including Indigenous staff.

CONCLUSION

Findings suggest that cultural competency training for all health care providers is needed to improve cultural appropriateness and accessibility of services. Refresher training and undisrupted supply of basic MHC services for front-line care providers will benefit the entire community and will likely be cost-effective for the government. Designing health programmes through extensive community consultation is essential.

Relationship between maternal healthcare utilisation and empowerment among women in Bangladesh: evidence from a nationally representative cross-sectional study

OBJECTIVE

To examine the relationship between women's empowerment and maternal healthcare utilisation in Bangladesh.

DESIGN

This cross-sectional study uses data from the most recent nationally representative Bangladesh Demographic and Health Survey, 2017-2018.

SETTING

Bangladesh.

PARTICIPANTS

Married women aged 15-49 years who had a live birth within the 3 years preceding the survey (n=4767).

PRIMARY AND SECONDARY OUTCOME MEASURES

Women's empowerment was measured using the recently developed and validated survey-based Women's emPowERment (SWPER) index. The index includes three domains: social independence, decision-making and attitude to violence. Outcomes included utilisation of at least one antenatal care from skilled providers (ANC1), at least four antenatal care visits (≥4 ANC), delivery assisted by a skilled birth attendant (SBA) and a postnatal visit within 2 days of delivery (PNC). Logistic regression analyses were used to assess the identified relationships.

RESULTS

Among participants, 83% received ANC1, 46.3% received ≥4 ANC, 51.9% reported SBA and 50.9% sought PNC. Women with high levels of social empowerment relative to those with low levels were more likely to use ANC1 (adjusted OR (AOR) 1.85; 95% CI 1.40 to 2.45), ≥4 ANC (AOR 1.55; 95% CI 1.27 to 1.90), SBA (AOR 2.12; 95% CI 1.71 to 2.62) and PNC (AOR 1.95; 95% CI 1.56 to 2.44). Compared with women with low levels of decision-making empowerment, women with high levels were more likely to use SBA (AOR 1.49; 95% CI 1.21 to 1.83) and PNC (AOR 1.47; 95% CI 1.19 to 1.81). Additionally, significant inequality was observed among women moving from low to high empowerment in all domains of the empowerment index.

CONCLUSIONS

Higher empowerment levels were positively associated with maternal healthcare utilisation in Bangladesh. Our findings suggest the need to address women's empowerment in policies aiming to expand health service utilisation.

Prevalence and factors associated with antenatal care service access among Indigenous women in the Chittagong Hill Tracts, Bangladesh: A cross-sectional study

Background

Prevalence of accessing antenatal care (ANC) services among Indigenous women in the Chittagong Hill Tracts (CHT) is unknown. This study aims to estimate the prevalence of accessing ANC services by Indigenous women in the CHT and identify factors associated with knowledge of, and attendance at, ANC services.

Methods

Using a cross-sectional design three Indigenous groups in Khagrachari district, CHT, Bangladesh were surveyed between September 2017 and February 2018. Indigenous women within 36 months of delivery were asked about attending ANC services and the number who attended was used to estimate prevalence. Socio-demographic and obstetric characteristics were used to determine factors associated with knowledge and attendance using multivariable logistic regression techniques adjusted for clustering by village; results are presented as odds ratios (OR), adjusted OR, and 95% confidence intervals (CI).

Results

Of 494 indigenous women who met the inclusion criteria in two upazilas, 438 participated (89% response rate) in the study, 75% were aged 16–29 years. Sixty-nine percent were aware of ANC services and the prevalence of attending ANC services was 53% (n = 232, 95%CI 0.48–0.58). Half (52%; n = 121) attended private facilities. Independent factors associated with knowledge about ANC were age ≥30 years (OR 2.2, 95%CI 1.1–4.6), monthly household income greater than 20,000 Bangladeshi Taka (OR 3.4, 95%CI 1.4–8.6); knowledge of pregnancy-related complications (OR 3.6, 95%CI 1.6–8.1), knowledge about nearest health facilities (OR 4.3, 95%CI 2.1–8.8); and attending secondary school or above (OR 4.8, 95%CI 2.1–11). Independent factors associated with attending ANC services were having prior knowledge of ANC benefits (OR 7.7, 95%CI 3.6–16), Indigenous women residing in Khagrachhari Sadar subdistrict (OR 6.5, 95%CI 1.7–25); and monthly household income of 20,000 Bangladeshi Taka or above (OR 2.8, 95%CI 1.1–7.4).

Conclusion

Approximately half of Indigenous women from Chittagong Hill Tracts Bangladesh attended ANC services at least once. Better awareness and education may improve ANC attendance for Indigenous women. Cultural factors influencing attendance need to be explored.

Wide range of G6PD activities found among ethnic groups of the Chittagong Hill Tracts, Bangladesh

The proportion of Plasmodium vivax malaria among all malarias is increasing worldwide. Treatment with 8-aminoquinolines remain the only radical cure. However, 8-aminoquinolines can cause severe hemolysis in glucose-6-phosphate dehydrogenase (G6PD) deficient patients. The population of the multi-ethnic Chittagong Hill Tracts (CHT) carry the highest malaria burden within Bangladesh. As in many countries the national treatment guidelines recommend 8-aminoquinoline based radical cure without routine G6PD deficiency (G6PDd) testing to guide treatment. Aim of this study was to determine the need for routine testing within a multi-ethnic population by assessing the prevalence of G6PDd among the local population. Participants from 11 ethnicities were randomly selected and malaria status was assessed by microscopy, rapid diagnostic test (RDT) and polymerase chain reaction (PCR). G6PD status was determined by spectrophotometry and G6PD genotyping. The adjusted male median (AMM) was defined as 100% G6PD activity, participants were categorized as G6PD deficient (<30% activity), G6PD intermediate (30% to 70% activity) or G6PD normal (>70% activity). Median G6PD activities between ethnicities were compared and the association between G6PD activity and malaria status was assessed. 1002 participants were enrolled and tested for malaria. G6PD activity was measured by spectrophotometry in 999 participants and host G6PD genotyping undertaken in 323 participants. Seven participants (0.7%) had peripheral parasitaemia detected by microscopy or RDT and 42 by PCR (4.2%). Among 106 participants (32.8%) with confirmed genotype, 99 (93.4%) had the Mahidol variant. The AMM was 7.03U/gHb with 90 (9.0%) G6PD deficient participants and 133 (13.3%) with intermediate G6PD activity. Median G6PD activity differed significantly between ethnicities (p<0.001), proportions of G6PD deficient individuals ranged from 2% to 26% but did not differ between participants with and without malaria. The high G6PDd prevalence and significant variation between ethnicities suggest routine G6PDd testing to guide 8-aminoquinoline based radical in the CHT and comparable settings.

Barriers to accessing maternal health care services in the Chittagong Hill Tracts, Bangladesh: A qualitative descriptive study of Indigenous women's experiences

BACKGROUND

Increased maternal health care (MHC) service utilisation in Bangladesh over the past decades has contributed to improvements in maternal health outcomes nationally, yet there is little understanding of Indigenous women's experiences of accessing MHC services in Bangladesh.

METHODS

Face-to-face semi-structured qualitative interviews with 21 Indigenous women (aged 15-49 years) within 36 months of delivery from three ethnic groups (Chakma, Marma and Tripura) were conducted between September 2017 and February 2018 in Khagrachhari district. Purposive sampling was used to recruit women representative of the population distribution in terms of age, ethnic community and service use experience. All interviews were conducted in Bangla language and audio-recorded with consent. Interviews were transcribed directly into English before being coded. Data were analysed thematically using a qualitative descriptive approach aided by NVivo12 software.

RESULTS

Of the 21 women interviewed, 14 had accessed at least one MHC service during their last pregnancy or childbirth and were categorised as the User group. The remaining seven participants were categorised as 'Non-users' as they had not access antenatal care, facility delivery or postnatal care services. Women reported that they wanted culturally relevant, respectful, home-based and affordable care, and generally perceived formal MHC services as being only for complications and emergencies. Barriers to accessing MHC services included low levels of understanding about the importance of MHC services, concerns about service costs, limited transport and fears of intrusive practices. Experiences within health services that deterred women from accessing future MHC services included demands for unofficial payments and abusive treatment by public facility staff.

CONCLUSION

Improving access to MHC services for the CHT Indigenous women requires improved understandings of cultural values, priorities and concerns. Multifaceted reform is needed at individual, community and health systems levels to offer culturally appropriate health education and flexible service delivery options.