Risk factors for pregnancy related complications among urban slum and non-slum women in Bangladesh

Factors influencing delivery-related complications and their consequences in hard-to-reach areas of Bangladesh

BACKGROUND AND OBJECTIVES

Bangladesh's high maternal mortality ratio is exacerbated by delivery-related complications, particularly in hard-to-reach (HtR) areas with limited healthcare access. Despite this, few studies have explored delivery-related complications and factors contributing to these complications among the disadvantaged population. This study aimed to investigate the factors contributing to delivery-related complications and their consequences among the mothers residing in the HtR areas of Bangladesh.

METHODS

Data were collected using a cross-sectional study design from 13 HtR sub-districts of Bangladesh between September 2019 and October 2019. Data from 1,290 recently delivered mothers were analysed.

RESULTS

Around 32% (95% CI: 29.7-34.8) of the mothers reported at least one delivery-related complication. Prolonged labour pain (21%) was the highest reported complication during the delivery, followed by obstructive labour (20%), fever (14%), severe headache (14%). Mothers with higher education, a higher number of antenatal care (ANC) visits, complications during ANC, employed, and first-time mothers had higher odds of reporting delivery-related complications. More than one-half (51%) of these mothers had normal vaginal delivery. Nearly one-fifth (20%) of mothers who reported delivery-related complications were delivered by unskilled health workers at homes. On the other hand, about one-fifth (19%) of the mothers without any complications during delivery had a caesarean delivery. Nine out of ten of these caesarean deliveries were done at the private facilities.

CONCLUSION

Delivery-related complications are significantly related to a woman's reproductive history and other background characteristics. Unnecessary caesarean delivery is prominent at private facilities.

Rule-based expert system for the diagnosis of maternal complications during pregnancy: For low resource settings

Objectives

Maternal complications are health challenges linked to pregnancy, encompassing conditions like gestational diabetes, maternal sepsis, sexually transmitted diseases, obesity, anemia, urinary tract infections, hypertension, and heart disease. The diagnosis of common pregnancy complications is challenging due to the similarity in signs and symptoms with general pregnancy indicators, especially in settings with scarce resources where access to healthcare professionals, diagnostic tools, and patient record management is limited. This paper presents a rule-based expert system tailored for diagnosing three prevalent maternal complications: preeclampsia, gestational diabetes mellitus (GDM), and maternal sepsis.

Methods

The risk factors associated with each disease were identified from various sources, including local health facilities and literature reviews. Attributes and rules were then formulated for diagnosing the disease, with a Mamdani-style fuzzy inference system serving as the inference engine. To enhance usability and accessibility, a web-based user interface has been also developed for the expert system. This interface allows users to interact with the system seamlessly, making it easy for them to input relevant information and obtain accurate disease diagnose.

Results

The proposed expert system demonstrated a 94% accuracy rate in identifying the three maternal complications (preeclampsia, GDM, and maternal sepsis) using a set of risk factors. The system was deployed to a custom-designed web-based user interface to improve ease of use.

Conclusions

With the potential to support health services provided during antenatal care visits and improve pregnant women's health outcomes, this system can be a significant advancement in low-resource setting maternal healthcare.

Spatial distribution of caesarean deliveries and their determinants in Bangladesh: evidence from linked data of population and health facility survey

Background

Health facility-level factors play a crucial role in women's access to and use of caesarean section (CS) services, but lacks relevant evidence. The study aimed to understand the effects of health facility-level factors on CS delivery in Bangladesh.

Methods

The 2017-18 Bangladesh Demographic and Health Survey (2017-18 BDHS) and the 2017 Bangladesh Health Facility Survey (2017 BHFS) were linked and analysed in this study. The sample comprised of 4954 women gave at least one live birth within three years preceding the survey. The outcome variable was delivery through CS (yes, no) and the explanatory variables were health facility-level, individual-level, household-level, and community-level factors. Moran's I and Getis-Ord General G statistic were used to identify the hotspots of delivery through CS. Mixed-effect multilevel logistic regression was used to examine the association of the outcome variable with explanatory variables.

Findings

Around 33% of women in Bangladesh underwent CS in their most recent pregnancies. The hotspots of delivery through CS are located primarily in Rajshahi, Dhaka, and Khulna divisions. The likelihood of delivered through CS increased with the rising scores of the management (Adjusted Odds Ratio (AOR), 1.83; 95% CI 1.04-2.07) and infrastructure (AOR, 3.14; 95% CI 1.40-5.12) of the nearest health facility. The readiness of health facilities to provide comprehensive obstetric care was significantly associated with an increased likelihood of delivery through CS (AOR, 2.18; 95% CI 1.15-3.28). These relationships were strong for private than non-government and government health facilities.

Interpretation

The proximity of comprehensive obstetric care facilities to women's residences and their readiness to provide services play critical roles in the access to and use of CS in Bangladesh. The findings highlight the importance of necessary healthcare personnel, including midwives, availability of government hospitals where undue CS are avoided, and awareness-building programmes about the adverse effects of CS delivery.

Funding

None.

Complication experience during pregnancy and place of delivery among pregnant women: a cross-sectional study

BACKGROUND

Unlike other causes such as abortion, obstetric complications like hemorrhage, and hypertensive disorders of pregnancy, which are difficult to resolve for women who give birth out of health facilities are persisted or increased to be the cause of maternal mortality in Ethiopia. Direct obstetric complications resulted in the crude direct obstetric case fatality rate in this country. This study aimed to assess the relationship between Complication Experience during Pregnancy and Place of Delivery among Pregnant Women.

METHOD

A community-based cross-sectional study was conducted to assess the baseline information as a part of a randomized control trial study. The sample size that was calculated for the cohort study with the assumptions to detect an increase in a minimum acceptable diet from 11 to 31%, with 95% CIs and 80% power, an intra-cluster correlation coefficient of 0·2 for a cluster size of 10 was used for this study. Statistical analysis was done using SPSS version 22.

RESULT

The prevalence of self-reported pregnancy-related complications and home delivery were 79(15.9%, CI; 12.7-19.1) and 46.90% (95%CI; 42.5-51.1) respectively. Women who did not face vaginal bleeding were five times AOR 5.28(95% CI: 1.79-15.56) more like to give birth at home than those who faced this problem. Women who did not face severe headache were nearly three AOR 2.45(95%CI:1.01-5.97) times more like to give birth at home.

CONCLUSION

This study concluded that home delivery was high among the study participants whereas pregnancy-related complications such as vaginal bleeding and severe headache were identified as protective factors for facility delivery. Hence, the researchers recommended the incorporation of "storytelling" into the existing health extension program packages to improve facility delivery which shall be applied after the approval of its effectiveness by further research.

Maternal and newborn health for the urban poor: the need for a new mental model and implementation strategies to accelerate progress

Background

Urbanization challenges the assumptions that have traditionally influenced maternal and newborn health (MNH) programs. This landscaping outlines how current mental models for MNH programs have fallen short for urban slum populations and identifies implications for the global community. We employed a three-pronged approach, including a literature review, key informant interviews with global- and national-level experts, and a case study in Bangladesh.

Main body

Our findings highlight that the current mental model for MNH is inadequate to address the needs of the urban poor. Implementation challenges have arisen from using traditional methods that are not well adapted to traits inherent in slum settings. A re-thinking of implementation strategies will also need to consider a paucity of available routine data, lack of formal coordination between stakeholders and providers, and challenging municipal government structures. Innovative approaches, including with communications, outreach, and technology, will be necessary to move beyond traditional rural-centric approaches to MNH. As populations continue to urbanize, common slum dynamics will challenge conventional strategies for health service delivery. In addition, the COVID-19 pandemic has exposed weaknesses in a system that requires intersectoral collaborations to deliver quality care.

Conclusion

Programs will need to be iterative and adaptive, reflective of sociodemographic features. Integrating the social determinants of health into evaluations, using participatory human-centered design processes, and innovative public-private partnerships may prove beneficial in slum settings. But a willingness to rethink the roles of all actors within the delivery system overall may be needed most.

A systematic review of the health of internal migrants in Bangladesh

Internal migrants are more disadvantaged than non-migrants in terms of their health. However, the extent of this difference is unclear. Following the PRISMA guideline, we conducted a systematic review to explore the existing evidence on the health of internal migrants of Bangladesh. We searched Pubmed, Web of Science and Google Scholar to identify peer-reviewed literature on health related issues of the internal migrant population and identified 29 papers for inclusion. Included studies reported health issues or risk factors relating to water, sanitisation and hygiene access and practice, risky sexual behaviour and sexually transmitted infection, mental health status, occupational health status, general healthcare availability, healthcare service utilisation and healthcare seeking behaviour. This systematic review reveals that research on health issues of internal migrants of Bangladesh is limited for common communicable and noncommunicable diseases like waterborne and skin disease, tuberculosis, hypertension and diabetes. Further, despite that many of these migrants are labourers, occupational health related issues like work place accidents, musculoskeletal disorders are insufficiently explored. Barriers to healthcare accessibility in this population are poor socioeconomic status, illiteracy and low general health knowledge. For improved development and implementation of health policies targeting this important population, future studies should focus on understudied diseases and disease prevalence and be designed to elicit from the perspectives of internal migrants, their key health needs around risk factors and health services accessibility.

Perceived Barriers in Accessing Health Care and the Risk of Pregnancy Complications in Indonesia

Background

Accessing immediate health care during pregnancy is key to preventing and treating pregnancy-related complications, which are the leading cause of maternal morbidity and mortality. As the largest archipelago country in the world, Indonesia faces the challenges of disparity in access to healthcare services across geographical regions and socioeconomic groups.

Objective

This study aims to assess the relationship between perceived barriers to accessing health care and the risk of pregnancy-related complications among women of reproductive age in Indonesia.

Methods

Data from a nationally representative sample of 15,021 last births within 5 years preceding the 2017 Indonesia Demographic and Health Survey were analyzed to examine barriers in accessing health care and the risk of having complications during pregnancy. The statistical model of logistic regression was used to investigate the effect of barriers on the risk of pregnancy complications, and results were presented as odds ratios (ORs) with 95% confidence intervals (CIs).

Results

The majority of women in Sumatra and Maluku-Papua regions encountered physical, cultural, and financial barriers to accessing health care. The results indicate significantly higher odds of having complications in mothers who had distance barriers (OR: 1.46, 95% CI: 1.20-1.77), relative to mothers who reported no barriers, after adjusting for women's characteristics.

Conclusion

The findings suggest that it is necessary to tackle specific physical barriers by providing more developed health-care systems in rural and geographically isolated areas, to bring health services closer to home.

Quality of Care in Family Planning Services: Differences Between Formal and Informal Settlements of Kira Municipality, Uganda

Background: Quality of care (QoC) of family planning (FP) affects contraceptive use, and it varies across types of urban settlement. This study assesses the difference in service delivery point (SDP) structural and process factors between formal and informal urban settlements, and the opinion of the client on the QoC in informal settlements. This is useful in creating an evidence base to advocate for better quality services for the most vulnerable in society. Methods: This was a cross-sectional survey that included SDPs of Kira municipality in Wakiso district, Uganda. Data were collected from all the service points in Kira municipality with the caretakers consented. In addition, using multi-stage sampling, 626 women of reproductive age (15-49 years) who lived in the informal settlements of Kira municipality were interviewed. Data were collected using structured questionnaires, descriptive analysis was carried out in Stata version 14.0, and Chi-square and t-tests were used to compare the informal with the formal settlements. Results: Formal settlements generally had more higher-level SDPs compared to informal settlements (value of p < 0.001). SDPs in the formal settlements provided more FP methods and had more community health workers (CHW) to support their work. Also, SDPs in the formal settlements were more likely to have long-term FP methods available and more likely to have trained personnel to insert and remove implants and IUDs compared to those in informal settlements. Additionally, more SDPs in the formal settlements provided counseling for permanent, long-term, and short-term FP methods. Of the 626 interviewed women, most of the women (68.6%) reported that they would not return to the previous FP provider or refer a friend to the same provider (72.7%). Conclusions: There is a lower quality FP services in the informal settlements with a commensurable effect on the client satisfaction with the services. Therefore, improving the quality of FP services in informal settlements should be a top priority. Improved quality of services could act as a motivation to increase the uptake of modern contraceptives in such settings.

An assessment of the role of socio-economic, maternal and service utilization factors in increasing self-reported maternal complications in India

Background

Self-reported maternal complications are associated with maternal morbidity, deliveries by C-section, postpartum depression, and maternal death. Thus, it is necessary to examine the contribution of socio-demographic and maternal characteristics, as well as service utilization in the rising self-reporting of maternal complications (difficulty with daylight vision, convulsions, swelling of the legs, body or face, heavy vaginal bleeding or high fever) in India. The study aimed at examining the factors that have influenced the increasing prevalence of maternal complications between 2005–06 and 2015–16 in India.

Methods

Data from the two most recent rounds of the National Family Health Survey, which covered a sample of 36,850 and 190,898 women respectively who delivered in the last five years preceding the survey has been used. Logistic regression analysis was performed to carve out the factors which significantly contributed to maternal complications among women aged 15 – 49 years in India. With the help of the Fairlie decomposition technique, the study quantified the contribution of factors which influenced the changes in maternal complications in the period from 2005–06 to 2015–16.

Results

A significant increase was seen in the prevalence of maternal complications — from 43.6% to 53.7% between the years 2005–06 and 2015–16. About 21% of the increase could be explained by certain maternal, households level factors, service utilization and birth outcomes. For example, service utilization, in which 13% was attributed to the place of delivery and 6% to postnatal care, was the major contributor to the increase in maternal complications from 2005–06 to 2015–16). This was followed by individual-level factors like education (2%), body mass index (4%) and tobacco use,. It was also found that household-level factors like standard of living (-3.7%) and region (-1.4%), and birth weight contributed to the reduction of complications during the period.

Conclusion

The increase in the prevalence of maternal complications in India could be attributed mainly attributed to increase in reporting behavior, an outcome of increased utilization of maternal healthcare services, and increase in BMI. However, reduced prevalence of maternal complications can be attributed to the decrease in the prevalence of low-birth-weight babies and tobacco use among women in India.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03997-x.

Women's Perception of Male Involvement in Antenatal, Childbirth and Postnatal Care in Urban Slum Areas in Bangladesh: A Community-Based Cross-Sectional Study

Male participation in reproductive health issues has been considered to be an effective and promising strategy to address the women’s reproductive health problems since the 1990s. Under this background, we aim to explore the women’s perception of men’s involvement in antenatal care (ANC), delivery and postnatal care (PNC) in the slum community of Bangladesh where various sexual and reproductive health problems exist. A community-based cross-sectional study was conducted among women and their husbands living in 12 slums of Chattogram city. Cross-tabulation with chi-square tests and multivariate logistic regression analyses were performed to examine the predictors of husbands’ support in wives’ antenatal, delivery and postnatal care. The study demonstrates that the education and economic level of most women and their husbands were very low although husbands seemed to have a better status than wives in these aspects. Almost all men (~90%) had never accessed services related to reproductive and maternal health. Only 10% of respondents gave birth to their last baby in government hospitals or private clinics. In addition, 60% of the husbands took care of their wives during pregnancy with 44% during childbirth and about 30% providing help in receiving postpartum care. Moreover, husbands’ discussions with a health worker regarding maternal and reproductive health were the most important predictors for support of their wives during pregnancy, childbirth and postpartum care (p < 0.05). Study participants’ perception of a satisfying spousal relationship also appeared to be a significant factor for husbands’ responsible role regarding wives’ antenatal care, delivery and postnatal care (p < 0.05). This study found that pregnant women living in slums received poorer health-related services when there was a low involvement of men; specifically, the husbands of pregnant women. In addition, men’s involvement was influenced by many aspects, particularly awareness-related factors (e.g., knowledge, communication and access to reproductive health services). Therefore, awareness creation is important for active involvement in antenatal, delivery and postnatal care. Strategies should be designed to provide men living in the slums with adequate information, education and communication to gain their interest and support about reproductive and maternal health.

Birth Patterns and Delayed Breastfeeding Initiation in Indonesia

Objectives

This study was conducted to examine the association between birth patterns (defined in terms of birth order and interval) with delayed breastfeeding initiation in Indonesia.

Methods

A cross-sectional study was carried out using data from the Indonesian Demographic and Health Survey 2017. The weighted number of respondents was 5693 women aged 15-49 years whose youngest living child was less than 2 years old. Multivariable logistic regression was conducted to evaluate associations between birth patterns and delayed breastfeeding initiation after adjusting for other covariates.

Results

This study found that 40.2% of newborns in Indonesia did not receive timely breastfeeding initiation. Birth patterns were significantly associated with delayed breastfeeding initiation. Firstborn children had 77% higher odds of experiencing delayed breastfeeding initiation (adjusted odds ratio, 1.77; 95% confidence interval, 1.02 to 3.04; p<0.05) than children with a birth order of 4 or higher and a birth interval ≤ 2 years after adjusting for other variables.

Conclusions

Firstborn children had higher odds of experiencing delayed breastfeeding initiation. Steps to provide a robust support system for mothers, especially first-time mothers, such as sufficient access to breastfeeding information, support from family and healthcare providers, and national policy enforcement, will be effective strategies to ensure better practices regarding breastfeeding initiation.

Pregnancy-related emergencies: Profile and outcome

Background:

National efforts to reduce maternal mortality with respect to community services have primarily focused on upgrading transportation infrastructure and formalizing training for care providers. There is, however, a paucity of baseline data on the profile and outcomes of pregnant women presenting to the Emergency Department (ED) in India.

Methods:

This retrospective study enrolled all pregnant women presenting to a large tertiary medical care center in India, between November 2016 and November 2017.

Results:

There were 696 ED visits by pregnant women during the study period. The mean age was 26.85 (SD: 4.88) years. Pregnant women in the first trimester contributed to 50.8% of all visits, and 54% being multigravida. The most common presenting complaints were bleeding/spotting per vaginum (PV) (38.2%) and abdominal pain (37.6%) followed by fever (21.6%) and vomiting (21.5%). Obstetric causes contributed to 53.2% of the ED visits, while nonobstetric causes amounted to 43.2%. Over a third (39.7%) required hospital admission. Of these patients, 73% delivered in CMC with live births amounting to 62.3% while 3.5% ended in fetal deaths. The miscarriages rate was as high as 28%. More than half (51.1%) of the deliveries were by normal vaginal delivery. There were no maternal deaths during the time of admission.

Conclusions:

Our study sheds new light on the profile of emergency visits among pregnant patients and their relationship to the outcome of pregnancy. First trimester visits were most common with complaints of bleeding PV and abdominal pain. This could explain the high rate of miscarriages among this population.

Modelling zero-truncated overdispersed antenatal health care count data of women in Bangladesh

Overdispersion in count data analysis is very common in many practical fields of health sciences. Ignorance of the presence of overdispersion in such data analysis may cause misleading inferences and thus lead to incorrect interpretations of the results. Researchers should account for the consequences of overdispersion and need to select the correct choice of models for the analysis of such data. In this paper, Generalized Linear Models (GLMs) are applied in modelling and analysis of antenatal care (ANC) count data extracted from the Bangladesh Demographic and Health Survey (BDHS) 2014. Pearson chi-square and different score tests are used to investigate the effect of overdispersion in the analysis. Overdispersion is found to be significant in the antenatal health care count data and so appropriate modelling is used to produce valid inferences for the regression parameters. The zero-truncated negative binomial regression (0-NBR) is found to be the best choice for analysing such data while excluding zero counts. Study findings reveal that place of residence, order of birth, exposure to mass media, wealth index and education of mother have significant impacts on the ANC status of women during pregnancy in Bangladesh.