Inequity in Health Services in Different Areas under the Essential Healthcare Programme of BRAC

Transcription

1 Inequity in Health Services in Different Areas under the Essential Healthcare Programme of BRAC Saira Parveen Jolly Anita Sharif Chowdhury Tridib Roy Chowdhury Ariful Alam Soheli Rahman Mahfuzar Rahman August 2016 Research Monograph Series No. 67 1

2 Inequity in Health Services in Different Areas under the EHP of BRAC Copyright 2016 BRAC August 2016 Printing and publication Altamas Pasha Cover design Sajedur Rahman Layout design Md Abdur Razzaque ISSN Published by BRAC Research and Evaluation Division BRAC Centre 75 Mohakhali Dhaka 1212, Bangladesh Tel: (88-02) , , Fax: (88-02) Web: BRAC/RED publishes research reports, scientific papers, monographs, working papers, research compendium in Bangla (Nirjash), proceedings, manuals and other publications on subjects relating to poverty, social development and human rights, health and nutrition, education, gender, environment and governance Printed by Zaman Printing and Packaging Islampur Road, Dhaka

3 CONTENTS Acknowledgements Abbreviation Abstract 01 Chapter 1. Background 02 Objectives 05 Chapter 2. Methodology 05 Study design 05 Sample size and sampling technique 06 Tool development 08 Data collection 08 Data analysis 09 Chapter 3. Maternal health services 09 Socio-demographic characteristics 09 Family planning 14 Antenatal care (ANC) 15 Delivery care 19 Postnatal care (PNC) 23 Chapter 4. Under-two childrens health 23 Infant and young child feeding practice 27 Micronutrient Powder (MNP) 30 Vaccination of children 31 Management of Diarrhoea 32 Management of AR 34 Knowledge on Hygiene and Sanitation 37 Chapter 5. Discussion 43 Chapter 6 Recommendations 45 References 49 Annexures 3

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5 ACKNOWLEDGEMENTS We also thankful to Dr Kaosar Asana, Director BRAC Health, Nutrition and Population Programme (HNPP), for her continuous support during study period. We are also grateful to Mr Suaib Ahmed and his team for logistic and management support. We are very much thankful to the respondents for supporting and providing us information on maternal and child health for this study. All the research assistants who worked hard during data collection in the field are highly acknowledged with gratitude. Special thanks to Mr Iftekhar Ahmed Chaudhury, former Coordinator, Editing and Publications for editing the report. Mr Altamas Pasha and Mr Md Abdur Razzaque deserve thanks for copy editing and layout design. 5

6 Inequity in Health Services in Different Areas under the EHP of BRAC ABBREVIATION ADP Adolescent Development Programme ANC Antenatal Care ARI Acute Respiratory Infection BCG BacilleCalmette Guérin BDHS Bangladesh Demographic Health Survey CF Complementary Food CHW Community Health Worker CSBA Community Skilled Birth Attendant DPT Diphtheria, Pertussis and Tetanus EHC Essential Health Care FP Family Planning FWV Family Welfare Visitor IYCF Infant and Young Child Feeding MDG Millennium Development Goals MNCH Maternal, Neonatal and Child Health MNP Micronutrient Powder MTP Medically Trained Provider NHW Newborn Health Worker PNC Postnatal Care PO Programme Organiser SBA Skilled Birth Attendant SD Standard Deviation SDG Sustainable Development Goals SK Shasthya Kormi SS Shasthya Shebika TBA Traditional Birth Attendant TTBA Trained Traditional Birth Attendant WHO World Health Organization 6

7 ABSTRACT The Essential Health Care (EHC) programme, one of the key development efforts of BRAC, provides an integrated package of preventive and basic curative services through community health workers (CHWs). The programme aims to improve health and nutrition of women and under-five children in rural Bangladesh. However, impression about regional variation and inequity in use of services from both public and private sectors is needed to identify the gap and further intensify the programme. A community-based cross-sectional study was conducted in 30 upazilas (sub-districts )in rural Bangladesh during March This covers seven working regions (Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur and Sylhet) of the EHC programme. A total of 1,200 married women with a child aged 1-2 years were interviewed. Data on socio-demographic characteristics; maternal health service indicators, such as family planning (FP), antenatal care (ANC), delivery care, postnatal care (PNC); newborn care; infant and young child feeding (IYCF) practices; immunisation; management of morbidities of children; and knowledge on hygiene and sanitation were collected through a pre-structured questionnaire. A score was used to identify women who received continuous care between pregnancy and postnatal period from a medically trained provider (MTP) including doctor, nurse, FWV, midwife and paramedic. With respect to this score a very low proportion of women in Rajshahi were using all the services from an MTP. Use of maternal health services from MTPs was in general associated positively with household income-expenditure level and maternal literacy; while compared to Dhaka, other areas were associated negatively. Even in Rajshahi IYCF practice was worse than other comparing regions. IYCF indicators were also associated positively with income and literacy. In addition, regular home visits by CHWs significantly improved micronutrient powder intake by the under-two children. Although, only half of the families with a child who suffered from diarrhoea sought treatment from an MTP, for ARI they sought treatment from a non-medical professional. Findings of this study suggest that the gaps in maternal and under-five child health services among the poor and illiterate give the room for implementing door to-door services of EHC programme through the CHWs. In addition, it needs to be ensured that the target people may get all the services consistently, especially in Rajshahi. 7

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9 Chapter 1 Background CHAPTER 1 BACKGROUND Bangladesh has achieved massive success in improving coverage in family planning, reducing maternal, infant and child mortality; vaccination, tuberculosis and malaria control (EL Arifeen et al. 2013; Huda et al. 2014). The country has also extraordinary uptake of oral rehydration therapy for diarrhoea compared to other countries in this region (EL Arifeen et al. 2013). Three major strategies have been identified to have contributed to the success, which are development of innovative ideas, communitybased approach of health service delivery through community health workers (CHWs) and adaptation of new technologies (EL Arifeen et al. 2013). The government of Bangladesh realising the limitations in the healthcare system, adapted a strategy to partner with non-government organisations (NGO), the private sector, and communities to ensure increased coverage. Community-based approach of health service delivery became successful due to the ardent efforts of CHWs (EL Arifeen et al. 2013). Bangladesh was one of the first countries to develop national-scale cadres of CHWs in 1960s followed by BRAC in 1970s. As of now, BRAC covers about half of the country s CHWs (EL Arifeen et al. 2013). Despite all these efforts the risk of inequity in maternal and under-five child health still exists over about two decades (Adams et al. 2013). Substantial inequity between the highest and lowest asset quintiles is observed in child mortality, antenatal care (ANC), skilled birth attendant (SBA), complete immunisation and treatment for acute respiratory infection (ARI) (Adams et al. 2013). Rapid urbanisation, chronic disease outbreaks, and varying climate changes are apparently emerging as new challenges in Bangladesh for reducing gap in health equity. Hard-to-reach areas such as Chittagong Hill Tracts, the coastal belt, and the Haor wetland areas are under-privileged in terms of health service coverage. For enhancing equity in health service utilisation existing gaps need to be identified before implementing intervention and adopting a wide reaching system for maintaining sustainable changes (Victoria et al. 2003). However, Bangladesh has been able to reduce the gap between the highest and lowest quintile in use of oral rehydration therapy (ORT) and modern family planning methods (Adams et al. 2013). In this regard, a continuous and sustained effort of CHWs is the key behind this success. The BRAC health programme has a community based approach to reach the vulnerable groups through CHWs and contribute to increasing provision of health services and reducing the bulging inequity (Arifeen et al. 2013). One of BRAC s major 1

10 Inequity in Health Services in Different Areas under the EHP of BRAC development efforts is called the Essential Health Care (EHC) programme. It is an integrated package of preventive and basic curative services at a minimum cost to improve health and nutrition of the poor people especially women of reproductive age and under-five children. In order to achieve equity and proper accessibility of services, BRAC ensured delivery of EHC services at the doorsteps of the underprivileged and neglected people primarily through CHWs. The BRAC CHWs counsel caregivers about the various danger signs of ARI. They also refer children to skilled providers if the children exhibit any of the danger signs. Moreover, CHWs also provide primary treatment to the children with ARI. The first line of CHWs are the Shasthya sebikas (SSs) and the second line of health workers are named as Shasthya kormis (SKs). EHC started the third phase of the programme since January 2011 with 16 service components. The components are for example, health and nutrition, education: safe water, sanitation and hygiene promotion; immunization; family planning; pregnancyrelated care: pre-natal and post-natal care; promotion of safe delivery practices; basic curative care; community-based management of ARI; community-based management of diarrhoeal diseases; tuberculosis control; malaria control; prevention and control of non-communicable diseases (NCDs); essential newborn care; child healthcare; eye care; and oral hygiene promotion. The marginalised people in Bangladesh do not receive services from medically trained providers (MTPs), such as doctor, nurse, Family Welfare Visitor (FWV) and midwife. There are many factors behind this, such as social and cultural barrier, distance of facility from locality or sometimes unaffordable treatment cost. Shortage of physicians or other trained professionals led to the awareness in BRAC that a group of CHWs can play a major role in community mobilisation and deliver a range of commodities. It may be mentioned here that the World Health Organization (WHO) has provided a definition of CHWs which akin to the CHWs in BRAC, Bangladesh (Bhutta et al. 2010). Unlike professionals they have shorter training on health care. They deliver some of the basic initial health services including antenatal and postnatal care (PNC) check-ups, identifying the emergency cases, referring patients and motivating the community for overcoming various cultural and social barriers. It is hypothesised that utilisation of CHWs where MTP services are acutely absent would be a sustainable strategy and help expedite universal health coverage. Therefore, it was urgent to identify the service gap of MTPs in different regions of EHC and its hindering factors that programme may intensify service coverage to achieve its goal. OBJECTIVES The major objective of the study is to investigate the regional variation and inequity in EHC indicators across seven working areas of BRAC. The specific objectives are: 2 To explore the status of reproductive and maternal healthcare services (family planning, antenatal care, delivery care and postnatal care) from MTPs and BRAC s CHWs among women in different BRAC regions. To explore the newborn care practice (cord cutting), child healthcare

11 Chapter 1 Background practice (immunisation), infant and young child feeding (IYCF) practices (including complementary feeding and micronutrient powder (MNP) feeding), management of diarrhoea and ARI by MTP in the community of different BRAC regions. To explore the knowledge on hygiene and sanitation and disease of undertwo children among women in different BRAC regions. To identify the inequity in maternal and child healthcare services from an MTP. 3

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13 Chapter 2 Methodology CHAPTER 2 METHODOLOGY STUDY DESIGN This was a cross-sectional study conducted in 30 sub-districts (upazilas) of rural Bangladesh during March to April, 2013 (Fig 2.1). Fig 2.1 Map of study areas SAMPLE SIZE AND SAMPLING TECHNIQUE Baliadanga Thakurgaon Sadar Haripur Kazipur Raiganj Tarash Kamarkanda Ullah ra pa Daulatpur GiorM anikganj Shibal aya N Legend District Upazila Kulaura Sreemangal Kamalganj Parshuram Chhagalnaya Feni Sadar Sonagaji A total of 1,200 women with a child aged months were interviewed. Considering 5% level of significance and 80% power, the calculated sample size was 400 married women with an under-two child for estimating maternal health service and under-two child healthcare service indicators. This was later multiplied by three for reducing the design effect from random selection of upazila or subdistricts and villages. Thus, the total sample size was 1,200. Since our target was to explore the status of both maternal and child health components of EHC programme a mother with an under-two child assumed to cover requirement of this study. 5

14 Inequity in Health Services in Different Areas under the EHP of BRAC Earlier EHC was working in 363 upazilas of 47 districts of Bangladesh. Of these 363 upazilas, 30 were selected using Probability Proportion to Size (PPS), i.e. more upazilas would come from larger districts (Fig. 2.2). Data collection covered the seven BRAC EHC working regions (Annexure1). Five villages were selected randomly from each upazila. A list of households having children aged one-two years were prepared from each village. Finally, eight women from eight households from each village were selected randomly for interview. Fig 2.2 Sampling technique 47 districts (363 upazilas) 30 upazilas Five villages/ upazilas Eight households/ village Selected by Probability Proportion to Size (PPS) Household listing Selected randomly 1200 women with a child aged months 40 women/ upazilas 8 women/ village TOOL DEVELOPMENT A pre-tested questionnaire was developed including structured and semi-structured questions to collect information on socio-demographic characteristics, family planning, ANC, delivery and PNC, infant and child feeding practice, child health, hygiene and sanitation. The questionnaire was pretested in field before finalisation. During data collection following definitions were followed: Current use of contraception is defined as the proportion of currently married women who reported that they were using a family planning (FP) method at the time of the survey. An ANC visit refers check-up by a health care provider during pregnancy. A PNC is defined as care of the mother after childbirth up to six weeks. A medically trained provider (MTP) includes either a qualified doctor, nurse, FWV or paramedic. 6

15 Chapter 2 Methodology Diarrhoea was defined as the passage of three or more loose or liquid stools per day while dysentery defined as severe diarrhoea with the presence of blood and mucus in the feces. Acute respiratory infection (ARI) was defined as infection, which hampers normal breathing and characterized by a viral infection that affects the nose, trachea, or lungs. The overall prevalence of ARI was estimated with the associated symptoms of cold, cough, fast breathing, and chest in-drawing during the last two weeks of interview (Mamun et al. 2012). In an earlier study, prevalence of ARI was estimated by incidence of both common cough and cold or pneumonia during the last two weeks of interview (BDHS, 2011). However, in the current study the prevalence of ARI was estimated by recalling the data during the last one-month of interview. Complete vaccination and being fully immunised is a state when a child receives one dose of vaccine against tuberculosis (BCG), three doses of vaccine against diphtheria, pertussis and tetanus (DPT), three doses of polio vaccine (excluding polio vaccine at birth), and one dose of measles vaccine. Infant and young child feeding (IYCF) practice Four components of IYCF practices exist in the EHC programme. Those are, initiation of breastfeeding within one hour after birth, colostrum feeding, exclusive breastfeeding up to six months, and timely initiation of complementary feeding along with micronutrient powder (MNP). Early initiation of breastfeeding refers to initiation of breast milk within an hour after birth. Regarding colostrum feeding the enumerators explained to the mother about the color and consistency of the colostrum. Colostrum is the first milk secreted at the time of parturition, differencing from the milk secreted later, by containing more lactalbumin and lactoprotein and also being rich in antibodies that confer passive immunity to the newborn. Colostrum secrets until 72 hours after parturition. It is not necessary starting breastfeeding within one hour, if the mother starts later but within 72 hours which confirms that the child has fed colostrum. Exclusive breastfeeding that is the infant receives only breast milk until six months of age (180 days) without any additional food or drink, not even water. Timely initiation of complementary feeding (CF) refers infants will receive age appropriate quality and quantity of food from their age of 181 days along with breastfeeding. In addition they will also receive MNP for two months with an interval of four months and again two months for prevention of micronutrient deficiency. 7

16 Inequity in Health Services in Different Areas under the EHP of BRAC DATA COLLECTION Skilled interviewers (science graduates having survey experience) were recruited for data collection. A five-day intensive training was organised which included lectures, mock interviews, role play, and field practice at the community level. A training manual was developed to guide the interviewers in the field. Five teams were formed for data collection each consisting of one supervisor and four interviewers. The respondents were informed earlier about the purpose of the survey, data collection process, ensured about their anonymity, and sought their cooperation in completing the survey. DATA ANALYSIS The status of all the EHC indicators is shown here. A chi-square test was performed. One-way ANOVA was performed for comparing the normally distributed variables and data were shown as mean (SD). Kruskal-Wallis one-way analysis of variance by rank - tests were performed for the skewed variables and data were shown as median (range). The association between indicators and predictors was analysed using the multivariate logistic regression analysis and the data expressed as odds ratio (OR) with 95% confidence interval (CI). The OR was adjusted for explanatory variables like age of the women, literacy, perceived income-expenditure condition, frequency of household visit by BRAC SS, BRAC EHC regions, ANC from an MTP, and institutional delivery. A database of dichotomous variables was constructed for this analysis. The value 1 was given for woman receiving any of the maternal health service indicators; otherwise the value of 0 was used. In the case of the predictor variables, the upper segment was given a value of 1 otherwise 0. With respect to investigating the regional variation, Dhaka was taken as reference in the analysis which was given a value of 0, otherwise other areas were given a value of 1. This analysis was performed using STATA software (version 12). Significance was taken at p<0.05. Composite score for continuum of care of maternal health A composite score for the maternal health service indicators was prepared to estimate the proportion of respondents who had received continuum of care between pregnancy and postnatal period. The maternal healthcare services namely four or more ANC check-ups from MTPs, skilled assisted delivery, PNC check-up from MTPs within 48 hours, and use of safe tools for cord cutting were compiled together. The respondents who received above-mentioned services together they scored four. Later, these cases were coded as 1 to a new variable and cases who scored 0 to 3 they were coded as 0. 8

17 Chapter 3 Maternal Health Services CHAPTER 3 MATERNAL HEALTH SERVICES SOCIO-DEMOGRAPHIC CHARACTERISTICS Table 3.1 shows the socio-demographic characteristics of women in different BRAC regions. Their average age ranged from years with highest literacy in Barisal (80%) and lowest in Rajshahi (57%). Most of the women were housewives and Muslims. Their monthly family income was higher in Dhaka, however, perceived household income status in the previous year was better in Chittagong. In Barisal the monthly visit of the BRAC SS was better than the other areas. FAMILY PLANNING The highest proportion of couples using contraceptive method was in Rangpur district (85.6%) (Fig 3.1). However, use of modern Family Planning method was highest in Fig 3.1 Type of modern FP method, used by married couples by BRAC region Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Percentage of using different modern FP methods Pill Condom Permanent method Injection Long-term method Traditional method 9

18 Inequity in Health Services in Different Areas under the EHP of BRAC Dhaka district (79.4%), with Sylhet (53.8%) being the lowest. Women tended to use FP methods more than their husbands, as the pill was the most widely used method followed by injection in all districts (Fig 3.1). Even the use of permanent methods was limited only to 1-5%. The sources of pill and condom were categorised into four groups, BRAC SS, government health worker, drug seller, and others in order to assess their contribution for the supply of different FP methods. In Sylhet and Chittagong, the government health workers contribution seemed lower than other areas, while in these two areas BRAC SSs contribution were higher than other comparing areas (Fig 3.2). Across all areas drug sellers played a major role for supplying FP material to the couples. Fig 3.2 Source of FP method suppliers (pill or condom) as reported by respondents by BRAC region Proportion of using pill or condom BRAC SS Govt. Health Worker Drug Seller Others (a) a. Includes NGO workers and relative Barisal Chittagong Dhaka Rajshahi Rangpur Sylhet Khulna The major reason for not using FP method was the absence of menstruation after delivery, followed by being divorced (Annexure 2). In Rangpur, another reason for not using the contraceptive method was pregnancy (22%). On the other hand, in Barisal and Khulna 17% of women were not using any contraceptive method as their husbands were not staying with them. 10

19 Chapter 3 Maternal Health Services Table 3.1 Household characteristics of the respondents by BRAC region Study variables Age categories % (n)* Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet P-value N=120 N=160 N=160 N=240 N=200 N=160 N= 160 <25 years 39.2 (47) 56.3 (90) 46.3 (74) 48.8 (117) 42.5 (85) 58.1 (93) 43.1 (69) years 60.8 (73) 43.8 (70) 53.8 (86) 51.3 (123) 57.5 (115) 41.6 (67) 56.9 (91) Age Mean (±SD) 24.6 (45) 26.3 (44) 24.8 (42) 24.7 (48) 25.7 (53) 24.2 (49) 26.0 (51) Can read and write % (n)* 80 (96) 75 (120) 73.1 (117) 75.4 (181) 57.5 (115) 62.5 (100) 62.5 (100) Years of schooling % (n)* None 5.38 (7) 10 (16) 11.3 (18) 7.9 (19) 22 (44) 17.5 (28) 17.5 (28) years 40.8 (49) 21.3 (35) 30 (48) 30.4 (73) 36.5 (73) 23.8 (38) 41.9 (67) 6-10 years 45 (54) 61.3 (98) 50 (80) 55 (132) 37.5 (75) 53.8 (86) 40 (64) (10) 6.9 (11) 8.8 (14) 6.7 (16) 4 (8) 5 (8) 0.6 (1) Occupation % (n)* Housewife 98.3 (118) 98.8 (158) 95 (152) 97.1 (233) 99.5 (199) 95.6 (153) 96.9 (155) 0.09 Others 1.7 (2) 1.3 (2) 5 (4) 2.9 (7) 0.5 (1) 4.4 (7) 3.1 (5) Marital Status % (n)* Married 99.2 (119) 98.1 (157) 100 (160) 99.6 (239) 99.5 (199) 98.8 (158) 96.3 (154) 0.02 Others a 0.8 (1) 1.9 (3) (1) 0.5 (1) 1.2 (2) 3.7 (6) Religion % (n)* Muslim 98.3 (118) 94.4 (151) 83.8 (134) 88.3 (212) 91.5 (183) 91.9 (147) 80.6(129) Hindu 1.7 (2) 5.6 (9) 16.3 (26) 11.7 (28) 8.5 (17) 8.1 (13) 19.4 (31) 11

20 Inequity in Health Services in Different Areas under the EHP of BRAC Study variables HH income in thousand/ month (BDT), Median (range) Perceived HH income status in the previous year, % (n)* Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet N=120 N=160 N=160 N=240 N=200 N=160 N= 160 P-value 9 (3-100) 10 (2-100) 12 (2.5-50) 6 (3-100) 8 (2-32) 6 (2.5-40) 9 (1.2-60) Surplus 33.3 ( 40) 55.6 (89) 29.3 (47) 28.8 (69) 24.5 (49) 29.4 (47) 29.4 (47) Equal 42.5 (51) 26.9 (43) 41.3 (66) 38.3 (92) 44.5 (89) 38.8 (62) 33.8 (54) Deficit 24.2 (29) 17.5 (28) 29.4 (47) 32.9 (79) 31 (62) 31.9 (51) 36.9 (59) Frequency of home visit by SS, % (n)* Regular 53.3 (64) 32.5 (52) 36.3 (58) 42.1 (101) 24 (48) 18.1 (29) 32.5 (52) Often 17.5 (21) 37.5 (60) 42.5 (68) 28.8 (69) 46 (92) 61.9 (99) 45 (72) Never 29.2 (35) 30 (48) 21.3 (34) 29.2 (70) 30 (60) 20 (32) 22.5 (36) One-way ANOVA; Kruskal-Wallis rank test; *Chi-square test; ; a Includes divorced, widow and destitute 12

21 Chapter 3 Maternal Health Services Includes NGO workers and relative Compared to Dhaka other areas were less likely to use modern FP methods. The respondents in Sylhet and Chittagong had about 70% less use of FP methods compared to Dhaka [adjusted OR % CI ( ); adjusted OR % CI ( )] (Table 3.2). The respondents who had equal income-expenditure condition had 38% higher chance of using modern FP methods than those who were in deficit income-expenditure category [adjusted OR % CI ( )]. FP was noticed to be lowest in Sylhet and Chittagong compared to Dhaka (Table 3.1). But FP practice was not associated with all the explanatory variables. However, women with similar income-expenditure condition had a significantly higher tendency of using FP methods. Table 3.2 Predictors of using modern FP methods (Multivariate logistic regression) Predictor Proportion of using modern FP method, % (n) Adjusted Odds Ratio 95% CI Age <25 years (=0) 1 25 years (=1) 69.6(435) Can read & write No (=0) 1 Yes (=1) 71.3(591) Perceived income-expenditure condition Deficit (=0) 1 Surplus (=1) 68.0(264) Equal (=1) 75.3(344) * Regular household visited by SS No (=0) 1 Yes (=1) 70.8(627) Region Dhaka (=0) 1 Barisal (=1) 71.7(86) Chittagong (=1) 58.8(94) * Khulna (=1) 75(180) Rajshahi (=1) 75.5(151) Rangpur (=1) 78.8(125) Sylhet (=1) 53.8(86) * *p <0.05 (n=1200); 0 = Reference category; 1 = Exposure category MTP = Medically Trained providers which includes MBBS doctor, nurse, FWV, midwife and paramedics 13

22 Inequity in Health Services in Different Areas under the EHP of BRAC ANTENATAL CARE (ANC) Receiving four or more ANCs from an MTP was less than 10% among women in Rajshahi, Rangpur, Chittagong, and Sylhet (Fig 3.3). However, 4+ ANC services received from BRAC SK was higher in Rangpur than other regions. Again, in Dhaka and Khulna, more than 20% of the women received ANC from MTPs. When it is combined with BRAC effort of ANC check-ups through CHWs, this indicator did not reach the desired optimal level (national target is 100%). This trend was similar in other regions among which Rajshahi had the worst situation (23%). Fig 3.3 Four or more ANC received from different providers by the respondents during last pregnancy by BRAC region Percentage Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Medically trained provider (a) Trained provider (b) BRAC SK a. Includes MBBS doctor, nurse, FWV, paramedic and midwife b. Includes MTP and BRAC SK Four or more ANCs received from MTPs was positively associated with having adequate maternal literacy and a higher socioeconomic status. However, compared to Dhaka, women of other regions had lesser tendency of using ANC services from MTPs. Apparently, ANC services from MTPs was associated negatively with the visit of BRAC SS. It revealed that with the visit of the BRAC SS services from SK increased which in turn reduces the use of services from the MTPs. We found that the visit of BRAC SK was correlated positively with the ANC visit of BRAC SK (Annexure 6). On the other hand, it was correlated negatively with the ANC visits of MTPs. 14

23 Chapter 3 Maternal Health Services Table 3.3 Predictors of 4+ ANCs from MTP (Multivariate logistic regression) Predictors Age Proportion of receiving 4+ ANC from MTP, %(n) Odds Ratio 95% CI <25 years (=0) 1 25 years (=1) 12.6(79) Can read and write No (=0) 1 Yes (=1) 15(124) * Perceived income-expenditure condition Deficit (=0) 1 Surplus(=1) 19.3(75) * Equal (=1) 8.8(40) HH visited by SS 1 No (=0) Yes (=1) 10.4(92) * Region Dhaka (=0) 1 Barisal (=1) 12.5(15) * Chittagong (=1) 6.3(10) * Khulna (=1) 20.4(49) Rajshahi (=1) 4(8) * Rangpur (=1) 5.6(9) * Sylhet (=1) 8.1(13) * *p<0.05 (n=1200); 0 = Reference category; 1 = Exposure category MTP = Medically Trained Providers which includes MBBS doctor, nurse, FWV, midwife and paramedics DELIVERY CARE Institutional delivery varied with different regions. In the Dhaka region around half of the deliveries took place at facility (Fig 3.4). In Khulna and Rangpur more than 40% deliveries took place at facility. However, in Barisal, Chittagong, Rajshahi, and Sylhet less than one-fourth of the deliveries were conducted at facility. Fig 3.4 Practice of institutional delivery among the respondents by BRAC regions Percentage Barisal 23.1 Chittagong 47.4 Dhaka 42.1 Khulna 25.5 Rajshahi 43.8 Rangpur 25.6 Sylhet 15

24 Inequity in Health Services in Different Areas under the EHP of BRAC Fig 3.5 Types of birth attendant during last pregnancy of the respondents by BRAC regions Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet MTP (a) TTBA/TBA/NHW Others (b) a. Includes MBBS doctor, nurse, FWV, paramedic and midwife b. Includes village doctors and relative Obstetric care received from a SBA or an MTP such as MBBS doctor, nurse, midwife, FWV, or paramedic varied across different regions. It seemed that in Dhaka the national target of SBA of 50% (BDHS, 2009) was achieved through institutional delivery (Fig 3.5). The proportion of C-section delivery was also highest here compared to other regions (33%) (Fig 3.6). Rajshahi and Chittagong regions had the worst condition in using MTP during delivery. More than 60% of the births preceding one year of interview were assisted by trained traditional birth attendants (TTBA) or traditional birth attendants (TBA) in Rajshahi (63%) and Chittagong (62%). Fig 3.6 Types of delivery reported by the respondents by BRAC regions Percentage Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Normal C-section Episiotomy 16

25 Chapter 3 Maternal Health Services Although, Dhaka had better use of MTP, however, in case of home delivery this proportion was less than 5% (Fig 3.7). Alike, Dhaka, Rajshahi (1.3) and Rangpur (3.3) had similar situation. For ensuring safe and hygienic cord cutting the BRAC SS sells delivery kit in the community. We found that in the case of home delivery, use of delivery kit for cord cutting was lowest in Dhaka region (11%) while the highest being in Barisal (39%). Fig 3.7 Proportion of home delivery assisted by MTPs and use of delivery kit during last pregnancy by BRAC region Percentage of home delivery Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Delivery assisted by MTP (a) Use of delivery kit a. Includes MBBS doctor, nurse, FWV, paramedic and midwife SBA assistance during delivery was associated significantly with factors such as literacy of women, higher income, and receiving four or more ANC from MTPs (Table 3.4). In addition, women in Barisal, Chittagong and Rajshahi tended to use less MTPs compared to Dhaka region. We found that, the contribution of BRAC CHWs about safe delivery was noteworthy in all regions except Dhaka where most of the women were informed about it from MBBS doctors (56%) (Fig 3.8). 17

26 Inequity in Health Services in Different Areas under the EHP of BRAC Table 3.4 Predictors of using MTP during delivery (Multivariate logistic regression) Predictor Proportion delivery assisted by MTP, % (n) Odds Ratio 95% CI Age, <25 years (=0) 1 25 years (=1) 37.8 (236) Can read & write No (=0) 1 Yes (=1) 46.4 (385) * Perceived income-expenditure condition Deficit (=0) 1 Surplus (=1) 51.5 (200) * Equal (=1) 36.1 (165) Regular household visited by SS No (=0) 1 Yes (=1) 40.2 (356) Received ANC from MTPs 0-3 (=0) 1 4+ (=1) 79.4 (112) * Region Dhaka (=0) 1 Barisal (=1) 35 (42) * Chittagong (=1) 32.5 (53) * Khulna (=1) 79.2 (118) Rajshahi (=1) 26.5 (53) * Rangpur (=1) 45 (72) Sylhet (=1) 38.1 (61) *P<0.05 (n = 1200); 0 = Reference category; 1 = Exposure category MTP = Medically Trained Providers which includes MBBS doctor, nurse, FWV, midwife and paramedics 18

27 Chapter 3 Maternal Health Services Fig 3.8 Source of information regarding delivery to women by BRAC region Percentage BRAC SS BRAC SK MBBS doctor Nurse 1.4 Barisal Chittagong Rajshahi Dhaka Rangpur Khulna Sylhet POSTNATAL CARE (PNC) Regarding PNC the respondents were asked about health check-up of her or her baby within 42 days of delivery. Rajshahi region was the worst in receiving PNC (26.5%) (Fig 3.9). Even PNC from MTP was least in this region (Fig 3.9). PNC from an MTP was associated with certain background variables such as literacy of the women, having higher household income, and four or more ANC check-ups from MTPs (Table 3.5). The OR also varied by different regions. Results revealed that women residing in Rajshahi (OR: 0.54) and Barisal (OR: 0.58) had less tendency of receiving PNC from an MTP after childbirth compared to Dhaka. Fig 3.9 Providers of PNC services by BRAC regions (Multiple responses) Percentage of PNC received BRAC SK MTP (a) Others providers (b) Barisal Chittagong Rajshahi Dhaka Rangpur Khulna Sylhet a. Includes MBBS doctor, nurse, FWV, paramedic and midwife b. Includes NGO worker, village doctors, traditional healer 19

28 Inequity in Health Services in Different Areas under the EHP of BRAC Table 3.5 Predictors of receiving PNC from MTP after delivery (Multivariate logistic regression) Predictors Proportion of receiving PNC from MTP, % (n) Odds Ratio 95% CI Age <25 years (=0) 1 25 years (=1) 31.5(197) Can read & write No (=0) Yes (=1) 36.8(305) * Perceived income-expenditure condition Deficit (=0) 1 Surplus (=1) 42(163) * Equal (=1) 28.2(129) Regular HH visited by SS No (=0) 1 Yes (=1) 32.7(289) Received ANC from MTPs 0-3 (=0) 1 4+ (=1) 63.1(89) * Region Dhaka (=0) 1 Barisal (=1) 29.2(35) * Chittagong (=1) 31.3(50) Khulna (=1) 32.9(79) Rajshahi (=1) 22(44) * Rangpur (=1) 33.1(53) Sylhet (=1) 31.3(50) *p<0.05; 0 = Reference category; 1 = Exposure category MTP = Medically Trained providers which includes MBBS doctor, nurse, FWV, midwife and paramedics All the maternal health service indicators had been compiled together for getting a composite variable which indicated those mothers who had received continuous care during their pregnancy, delivery, and postnatal period. Results revealed that more women in Dhaka received all the health services (16%) compared to other regions (Fig 3.10). In contrast, women in Rajshahi tended to use less services (1.5%). 20

29 Chapter 3 Maternal Health Services Fig 3.10 All the health service indicators received by the respondents by BRAC regions Percentage Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet ANCs from MTP Delivery assisted by MTP Use of safe tools for cord sutting PNC from MTP All maternal health service related indicators *MTP includes doctor, nurse, FWV, paramedic, midwife 21

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31 Chapter 4 Under-two Children s Health CHAPTER 4 UNDER-TWO CHILDREN S HEALTH INFANT AND YOUNG CHILD FEEDING PRACTICE Early initiation of breastfeeding, colostrum feeding, exclusive breastfeeding (EBF) and complementary feeding (CF) are very much important and crucial for ensuring proper child growth and development. The BRAC SK counsels women about feeding practice of under-five children in the local community. It was found that overall colostrum feeding was satisfactory and >90% of the newborns were fed colostrum after birth (Fig 4.1). However, initiation of breastfeeding within an hour after birth ranged from 72-82% of the cases. In Rajshahi, 80% of the newborns were initiated breastfeeding within an hour after birth. Nevertheless, the proportion of EBF was the least in Rajshahi (48.5%) compared to other regions. In addition, the proportion of EBF was 50% in Sylhet. Regarding breastfeeding indicators, Barisal had a better proportion than other comparing regions. Fig 4.1 Breastfeeding practice among the under-two children by BRAC regions Sylhet Rangpur Rajshahi Khulna Initiation of breast feeding within one hour Colostrum Feeding Exclusive breast feeding Dhaka Chittagong Barisal Percentage 23

32 Inequity in Health Services in Different Areas under the EHP of BRAC Results revealed that colostrum feeding and EBF was not strongly associated with the explanatory variables (Annexures 11 and 12). However, we found initiation of breastfeeding within an hour was associated positively with several factors such as literacy of the women, high income of the family, and negatively with institutional delivery (Table 4.1). This indicator varied with regions and in reference to Dhaka it was positively associated with Barisal, Chittagong, Rangpur and Sylhet. Table 4.1 Predictors of initiation of breastfeeding within an hour after birth (Multivariate logistic regression) Predictor Proportion of newborn initiated breast milk within one-hr, % (n) Odds Ratio 95% CI Age 25 yrs (=0) 1 25 yrs (=1) 89.4 (559) Can read & write No (=0) 1 Yes (1) 90.7 (752) * Perceived income-expenditure condition Deficit (=0) 1 Surplus (1) 90.7 (352) Equal (1) 91.5 (418) * Regular HH visited by SS No (=0) 1 Yes (1) 90.1 (797) Region Dhaka (=0) 1 Barisal (=1) 92.5 (111) * Chittagong (=1) 97.5 (156) * Khulna (=1) 88.3 (212) Rajshahi (=1) 84.5 (169) Rangpur (=1) 90.6 (145) * Sylhet (=1) 95 (152) * Institutional delivery No (=0) 1 Yes (1) 81.2(199) * *p<0.05; 0 = Reference category; 1 = Exposure category Introduction of solid or semi-solid food within the age of 181 days varied across the regions (Fig 4.2). Rajshahi had the worst condition in this indicator (53.5%). In contrast, in Barisal 90% of the infants were introduced complementary feeding at the age of 181 days. In Khulna and Sylhet about 60% of infants were introduced CF at a desirable age. 24

33 Chapter 4 Under-two Children s Health Fig 4.2 Complementary feeding practice among the under-two children by BRAC regions Propotion of children started complementary feeding at the age of 181 days Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Table 4.2 Predictors of starting complementary feeding by the age of 181 days (Multivariate logistic regression) Predictor Proportion of infants started CF by 181 days, % (n) Odds Ratio 95% CI Age <25 yrs 1 25 yrs 69.6 (435) Can read & write No (=0) 1 Yes (1) 71.3(591) Perceived income-expenditure condition Deficit (=0) 1 Surplus (=1) 74.0 (287) Equal (=1) 69.1 (316) Households visited by SS No (=0) 1 Yes (1) 68.9(610) Region Dhaka (=0) 1 Barisal (=1) 90.0 (108) * Chittagong (=1) 88.8(142) * Khulna (=1) 61.3(147) * Rajshahi (=1) 53.6(107) * Rangpur (=1) 71.3(114) Sylhet (=1) 62.5(100) * *p<0.05 (n = 1200); 0 = Reference category; 1 = Exposure category 25

34 Inequity in Health Services in Different Areas under the EHP of BRAC Table 4.3 Reason for not practicing IYCF by the respondents by BRAC regions Study variables Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet N Reason for not feeding colostrums, % (n)* Mother was sick 55.6 (5) 0 (0) 31.0 (9) 57.1 (16) 16.1 (5) 6.7 (1) 0 (0) Delay in breast milk secretion 44.4 (4) 25 (1) 58.6 (17) 25 (7) 61.3 (19) 20 (3) 62.5 (5) Baby was sick 0 (0) 50 (2) 0 (0) 3.6 (1) 0 (0) 6.7 (1) 12.5 (1) Others a 0 (0) 25.0 (1) 10.3 (3) 14.3 (4) 22.6 (7) 66.7 (10) 25 (2) N Reason for not practicing exclusive breastfeeding, % (n)* Insufficient milk 95.7 (22) 35.7 (15) 96.8 (61) 88.6 (70) 84.7 (83) 91.3 (42) 63.5 (47) Mother was sick 4.3 (1) 9.5 (4) 0 (0) 1.3 (1) 4.1 (4) 0 (0) 1.4 (1) Satisfy baby s thirst 0 (0) 11.9 (5) 0 (0) 1.3 (1) 0 (0) 0 (0) 25.7 (19) Others b 0 (0) 42.9 (18) 3.2 (2) 8.9 (7) 11.2 (11) 8.7 (4) 9.5 (7) N Reasons for not introducing family food after six months, % (n)* Hindu belief 0 (0) 37.5 (3) 26.1 (6) 11.9 (5) 13.2 (5) 8.3 (1) 63.6 (28) Baby got sufficient milk 100 (1) 25 (2) 17.4 (4) 35.7 (15) 18.4 (7) 0 (0) 11.4 (5) Baby did not want to eat 0 (0) 12.5 (1) 26.1 (6) 26.1 (11) 52.6 (20) 50 (6) 11.4 (5) Others c 0 (0) 25 (2) 30.4 (7) 26.2 (11) 15.8 (6) 41.7 (5) 13.6 (6) a Includes to satisfy baby s thirst, did not know about colostrum, social belief, baby had cough, doctor suggested for formula feeding b Includes baby formula is better than breast milk, baby formula is good for health, baby was unwilling to take breast milk, water is good for health c Includes did not feel necessity, baby was sick, formula milk was sufficient, food was not digested and vomiting 26

35 Chapter 4 Under-two Children s Health Beginning complementary food at the age of 181 days varied with different regions even after adjusting for different background variables (Table 4.2). With reference to Dhaka, women of Barisal and Chittagong had higher tendency of introducing family food by the age of 181 days, while women of Khulna, Rajshahi and Sylhet had lower tendency to do such. It was revealed that in Sylhet due to Hindu beliefs most mothers did not introduce complementary feeding (Table 4.3). On the other hand, in Rajshahi mothers did not have much patience to feed their child as 52% mothers stated that reluctance of babies to eat solid or semi-solid food as a reason. In Khulna mothers had misconception and lack of knowledge on the importance of complementary feeding as they mentioned that till the age of 6 months, formula milk was sufficient for the baby. Although women were informed about IYCF practices from various sources, data revealed that BRAC CHWs had a significant role in this regard (Fig 4.3). About 34-65% of women from different regions were informed by the BRAC CHW. Fig 4.3 Source of information regarding IYCF practices to the mothers by BRAC regions (Multiple responses) Percentage BRAC SS/SK Qualified doctor Nurse TV/Radio/News paper Others (a) Barisal l Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet a. Includes village doctor, CNO/CNP, relatives, self, NGO worker, FWA, FWV, neighbor, paramedics, family member, text book MICRONUTRIENT POWDER Figure 4.4 shows the proportion of children across different regions who were fed MNP during the previous six months of interview. The highest proportion of children fed MNP was in Barisal (38%). In contrast, 17% of women in Rajshahi fed MNP to their children. In other places this proportion was less than 25%. 27

36 Inequity in Health Services in Different Areas under the EHP of BRAC Among children who were fed MNP Fig 4.4 neither all of them started at the age of six months nor they completed the 60 days cycle (Fig 4.5). With respect to initiation and compliance the Sylhet region was better compared to other 20 regions. In Chittagong and Dhaka none of the infants started feeding MNP by 10 the sixth month age. In all regions most 0 of the women got MNP from BRAC SS (Fig 4.6). In Chittagong a significant proportion of MNP was purchased from drug shop (22%) while in Barisal other NGOs were the principal source of supplying MNP to women (38%). Proportion of children aged <6 months Proportion of children who fed micronutrient powder (MNP) Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Fig 4.5 Proper age of starting MNP and its compliance as reported by mothers by different regions Percentage of children who Fed MNP MNP initiated at age of 6th month Completed a 60 days cycle of MNP feeding Barisal l Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Consumption of MNP by the infants was associated significantly with maternal literacy and households visited by the BRAC SSs (Table 4.4). We found regional variation in MNP feeding. Children of Barisal and Chittagong had more MNP compared to Dhaka. 28

37 Chapter 4 Under-two Children s Health Fig 4.6 Source of MNP supply by different regions Sylhet Rangpur Rajshahi Khulna Dhaka Chittagong Barisal BRAC lss Drug shop Others Table 4.4 Predictors of feeding MNP by the children (Multivariate logistic regression) Predictor Proportion of children who fed MNP % (n) Odds Ratio 95% CI Age 25 years <25 yrs (=0) 1 25 yrs(1) 22.4(140) Can read and write No (=0) 1 Yes (1) 27(224) * Perceived income-expenditure condition Deficit (=0) 1 Surplus (1) 25.8(100) Equal (1) 24.1(110) Households visited by SSs No (=0) 1 Yes (1) 28.2(250) * Region Dhaka (=0) 1 Barisal (=1) 37.5(45) * Chittagong (=1) 31.9(51) * Khulna (=1) 19.6(47) Rajshahi (=1) 17(34) Rangpur (=1) 25.6(41) Sylhet (=1) 20(32) *p<0.05 (n = 1200); 0 = Reference category; 1 = Exposure category 29

38 Inequity in Health Services in Different Areas under the EHP of BRAC VACCINATION OF CHILDREN The Expanded Programme on Immunisation (EPI) is a priority programme of the government of Bangladesh. It follows international guidelines recommended by the WHO. According to the Bangladesh guidelines, children are considered fully immunised when they have received one dose of the vaccine against tuberculosis (BCG), three doses of the vaccine against DPT or pentavalent vaccine, three doses of polio vaccine (excluding polio vaccine given at birth), and one dose of measles vaccine. WHO recommends giving children all the vaccines before their first birthday and recording the vaccination information on a vaccination card provided to parents. In this study analyses on vaccination was conducted only with the children who had a vaccination card. According to the vaccination card, vaccination coverage was almost 100%; fully vaccinated children ranged from 85-97% (Fig 4.7). The lowest proportion of children who got fully immunised was in Sylhet. Fig 4.7 Complete vaccination coverage by nine months of age among children by BRAC region Percentage of children Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet a. Included 1 dose of BCG, 3 doses of Polio, 3 doses of Penta and 1 dose of Measles vaccine We found that the BRAC SSs are working more on immunisation. Nearly 47% of the respondents stated that during vaccination BRAC SSs were present at the EPI centre and this proportion was the highest in Sylhet compared to other regions (Annexure 15). When immunisation was computed with the background variables we found that complete vaccination was associated positively with maternal literacy (Annexure 14). 30