Women & Health
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Utilization of maternal health care services among indigenous women in Bangladesh: A study on the Mru tribe Rakibul M. Islam MPhil, MPH To cite this article: Rakibul M. Islam MPhil, MPH (2016): Utilization of maternal health care services among indigenous women in Bangladesh: A study on the Mru tribe, Women & Health, DOI: 10.1080/03630242.2016.1153020 To link to this article: http://dx.doi.org/10.1080/03630242.2016.1153020
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Date: 15 April 2016, At: 23:59
WOMEN & HEALTH http://dx.doi.org/10.1080/03630242.2016.1153020
Utilization of maternal health care services among indigenous women in Bangladesh: A study on the Mru tribe Rakibul M. Islam, MPhil, MPHa,b
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a Women’s Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; bDepartment of Population Sciences, University of Dhaka, Dhaka, Bangladesh
ABSTRACT
ARTICLE HISTORY
Despite startling developments in maternal health care services, use of these services has been disproportionately distributed among different minority groups in Bangladesh. This study aimed to explore the factors associated with the use of these services among the Mru indigenous women in Bangladesh. A total of 374 currently married Mru women were interviewed using convenience sampling from three administrative sub-districts of the Bandarban district from June to August of 2009. Associations were assessed using Chi-square tests, and a binary logistic regression model was employed to explore factors associated with the use of maternal health care services. Among the women surveyed, 30% had ever visited maternal health care services in the Mru community, a very low proportion compared with mainstream society. Multivariable logistic regression analyses revealed that place of residence, religion, school attendance, place of service provided, distance to the service center, and exposure to mass media were factors significantly associated with the use of maternal health care services among Mru women. Considering indigenous socio-cultural beliefs and practices, comprehensive community-based outreach health programs are recommended in the community with a special emphasis on awareness through maternal health education and training packages for the Mru adolescents.
Received 27 June 2015 Revised 1 September 2015 Accepted 7 September 2015 KEYWORDS
Bangladesh; health care services; logistic regression; the Mru; utilization
Introduction Use of maternal health care services (MHCS) improves the survival and quality of life of mothers and children; however, it is often underutilized by those mothers and children who are in greatest need (Options Consultancy Services/Evidence for Action, Cambridge Economic Policy Associates, and the Partnership for Maternal, Newborn & Child Health 2013). It is a complex behavioral phenomenon. Empirical studies of preventive and curative CONTACT Rakibul M. Islam, MPhil, MPH [email protected] Women’s Health Research Program, School of Public Health and Preventive Medicine, Monash University, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia. © 2016 Taylor & Francis
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services have revealed that the use of health services is related to the availability, quality, cost, continuity, and comprehensiveness of services, as well as to the social structure, health beliefs, and personal characteristics of the users (Andersen and Newman 2005). Numerous studies also have demonstrated that women’s current age, level of education, parity, income, physical proximity of health care services, and exposure to mass media play a significant role in the utilization of MHCS (Ahmed et al. 2010; Islam and Odland 2011). Moreover, considerable unequal access to and use of good quality of care remains in both developed and developing countries, in different regions, races, and ethnicities (Mahabub-Ul-Anwar, Rob, and Talukder 2006). A review on health care access and use among indigenous people in North America, Australia, and New Zealand found that access to and use of health care services were significantly lower among the indigenous population compared with non-indigenous population (Marrone 2007). Although health care facilities in Bangladesh have undergone remarkable developments since her independence in 1971, the benefits are unequally spread among different socio-economic, ethnic/minority, and indigenous groups. Use of modern health care facilities remains extremely poor in lower socio-economic groups as well as in some parts of Bangladesh, especially in hilly areas, which are physically difficult to access and in which a high proportion of indigenous population live (Karim, Rafi, and Begum 2005; Mahabub-Ul-Anwar et al. 2006). Consequently, health outcomes are extremely poor in the indigenous people compared with mainstream people (Adnan and Dastidar 2011; Mahabub-Ul-Anwar et al. 2006). However, a systematic study has not yet been conducted among the indigenous people in Bangladesh to find the factors associated with their use of MHCS. The main objective of this study was to explore factors associated with MHCS utilization among the Mru women, the most disadvantaged indigenous community in Bangladesh. The Mru and their reproductive health
The Mru are the most underprivileged indigenous people in Bangladesh, living on the hilltops, ravines, cliffs, and deep forest areas of the Bandarban district (Islam and Odland 2011). They live in 356 villages in the Bandarban district, comprising 5,398 households (Rafi 2006). According to the census conducted by the Mru Social Culture in 1995, the total Mru population was estimated at 59,748 (Rafi 2006). Along with Buddhism and Christianity, Mru people also believe in a new religion, Crama, which was created by Man Ley Mru in 1985 and is discussed in detail elsewhere (Islam and Thorvaldsen 2012). The male-female ratio of literacy among the Mru is 2.6:1.6, and 93% of villages are more than one mile away from a primary school (Rafi 2006). A literate person in Bangladesh is one who can read, write, calculate, and be
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socially aware. A recent study showed that nutrition uptake among mothers after childbirth is heavily restricted in Mru society. After delivery, a mother is given only salted rice and sits beside the fire from 9 to 30 days, depending on their clan practices. The prevalence and frequency of their antenatal and postnatal care visits are very low compared with mainstream society due to cultural issues, distance, road infrastructure, and socioeconomic status. Furthermore, they mostly depend on village healers and traditional midwives rather than seeking modern medical care (Islam and Odland 2011).
Methods
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Study sample
This cross-sectional study was conducted in the Bandarban District in the remote southeastern part of Bangladesh where the Mru people live. The Bandarban District has seven upazilas (administrative sub-districts), three of which were Alikadam, Lama, and Thanchi, which were selected purposively for this study. The rationale for selecting these three sites was that the majority of the Mru people live in Alikadam, followed by Thanchi and Lama. Geographically, Thanchi’s terrain is the most remote and hilly, followed by Alikadam and Lama. These regions have a diversity of religions, for instance, Animism/Buddhism, Christianity, and Crama. Finally, socio-economic situations differ with people living in Lama being better off followed by Alikadam and Thanchi upazilas. The total number of households (HHs) under 12 union councils (the smallest rural administrative and local government units in Bangladesh) in the three selected upazilas was 5,398 ranging from 27 to 939 HHs per union council (Rafi 2006). Of the 12 union councils, two from each upazila were selected randomly, including 1,487 HHs from six union councils under the three study upazilas. Finally, 391 HHs, some of which were deep in the bushes, were approached by one local indigenous person as well as the study guide who was an indigenous college student using convenience sampling, and 374 women agreed to participate, comprising 133 from Alikadam, 170 from Lama, and 71 from Thanchi, with a participation rate of 95.6%. To be eligible for the study, women were required to: (1) live in the study locations during the survey; and (2) have at least one child aged 5 years or younger or have had children who died after delivery or/and were delivered as a stillbirth. Only one woman from each HH was interviewed if more than one eligible woman were found. If an eligible woman was not found in a HH, an adjacent HH was approached. Although selected conveniently, the study attempted to get a sample from different religions, socio-economic conditions, and distance from homes to service centers. However, difficulties in obtaining a representative sample based on the above mentioned criteria included the remote locations of the
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Mru villages, transportation problems, and lack of educated Mru female interviewers.
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Data collection
A survey questionnaire comprising both closed and open-ended questions was used for data collection. This is a part of the standard survey questionnaire of Bangladesh Demographic and Health Survey with the intention of making comparisons to the national data (National Institute of Population Research and Training 2013). The questionnaire was developed in English and translated in Bangla and verified by a process of back-translation. Because the Mru have a distinct language, seven bilingual female interviewers having 9 to 12 years of schooling from the Mru community were recruited to conduct the face-to-face interview survey. Of seven, three interviewers were working as health workers in non-government organizations (NGOs). Specifically, one took formal training as a midwife from a private medical college hospital, two interviewers were students, and the others were housewives. A pilot survey was conducted, and the final data collection took place from June to August 2009. Informed consent was taken verbally from participants before starting face-to-face interviewing because most of them could not read or write. Moreover, indigenous people are suspicious of signed documents due to the ongoing land acquisition practices by mainstream people (Adnan and Dastidar 2011). Cultural sensitivities in remote villages were addressed by engaging indigenous leaders. Outcome measures
The outcome variable used in this study was use of MHCS, including antenatal, postnatal, and delivery care visits. “Use” was defined as at least one visit in the last 3 years preceding the survey. Women who visited the upazila health complex (UHC), family welfare center (FWC), the satellite clinic (SC), and village/local doctors were coded as using MHCS. Covariates
Demographic, socioeconomic, and spatial factors of the respondents were considered as covariates. Thus, the variables for bi-variate and multivariable analyses were place of residence, age, religion, income, education and occupation of the respondents, education and occupation of the respondents’ husbands, parity, place of health service provided in the community, distance to the health service centers, and exposure to mass media.
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Statistical analysis
The Statistical Package for Social Sciences software (version 20.0; SPSS Inc., Chicago, IL, USA) was employed for data analyses. Bi-variate analyses were performed based on cross tabulations using chi-square tests, and multivariable analyses were conducted using binary logistic regression analysis. Only variables found significant (p < .05) in bivariate analyses were entered into the multivariable logistic regression model, and adjusted odds ratio (ORs) were reported. Women’s occupation and husbands’ occupation were excluded in the final regression model because they were concentrated in one category of independent variables. Associations were viewed as significant if the OR had a p value of ≤.05 and were reported with 95% confidence intervals. Analyses did not reveal any interactions between the variables. Collinearity between place of service provided and distance in kilometers was examined using the variance inflation factor and found not to be significant. The area under the receiver operating characterisric curve (ROC) and the Hosmer and Lemeshow test were used to assess the model’s discrimination and to test goodness-of-fit, respectively. This research was approved by the Faculty of Humanities, Social Sciences and Education, University of Tromso, Norway and district government officials, Bandarban, Bangladesh. Results Background characteristics of respondents
Of the 374 women surveyed, 45.5% were from Lama, 48.1% were from the 25 to 29 years of age group, and 96.5% had not attended school. The respondents belonged to different religions, 57.2% of whom believed in Buddhism, followed by Crama (25.1%) and Christianity (17.6%). Some people also believed in Animism, although they liked to introduce themselves as Buddhist. Mru women simultaneously (98.7%) engaged in swidden/jum cultivation and household activities. Their main sources of drinking water were rivers (53.5%), followed by streams (23%), and wells (3.7%). A majority of women (57.2%) had no toilet facilities, using the bush and open fields, and 36.9% used an open latrine. Less than one-third (30.7%) of the study women visited MCHS, regardless of service providers in the community. More than half of the women (55.1%) reported that service was provided in the locality by the UHC, followed by the FWC (28.3%). Some women also visited the SC (4.3%), village/local doctors (4.0%). Use of maternal health care services
In this study, use of MHCS was assessed in relation to different demographic and socio-economic characteristics of the women who had a live birth in the
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Table 1. Association between the use of maternal health care services and socio-economic and demographic characteristics. Ever visit health care services n (%)
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Characteristics Place of residence (p < .001) Alikadam Lama Thanchi Religion (p = .011) Christianity Crama Buddhism Monthly income in BDTa (p = .370) 7,000 Age in years (p = .456) 35 School attendanceb (p = .001) Yes No Occupationb (p = .033) Agriculture and housewife Service Husband’s school attendance (p < .001) Yes No Husband’s occupation* (p < .001) Agriculture Other Place of service provided (p < .001) Upazila health complex Family welfare center Otherc Distance in kilometers (p = .011) 16 Mass media exposureb (p < .001) Access to any media No access to any media
N
Yes
No
133 170 71
10 (7.5) 91 (53.5) 14 (19.7)
123 (92.5) 79 (46.5) 57 (80.3)
66 94 214
12 (18.2) 38 (40.4) 65 (30.4)
54 (81.8) 56 (59.6) 149 (69.6)
112 240 22
30 (26.8) 76 (31.7) 9 (40.9)
82 (73.2) 164 (68.3) 13 (59.1)
159 180 35
53 (33.3) 54 (30.0) 8 (22.9)
106 (66.7) 126 (70.0) 27 (77.1)
13 361
10 (76.9) 105 (29.1)
3 (23.1) 256 (70.9)
369 5
111 (30.1) 4 (80.0)
258 (69.9) 1 (20.0)
26 348
21 (80.8) 94 (27.0)
5 (19.2) 254 (73.0)
355 19
102 (28.7) 13 (68.4)
253 (71.3) 6 (31.6)
206 106 62
24 (11.7) 55 (51.9) 36 (58.1)
182 (88.3) 51 (48.1) 26 (41.9)
54 78 136 106
26 25 32 32
28 53 104 74
19 355
(48.1) (32.1) (23.5) (30.2)
14 (73.7) 101 (28.5)
(51.9) (67.9) (76.5) (69.8)
5 (26.3) 254 (71.5)
a
1 USD = 80 BDT at the time of survey (approximately). Fisher’s exact test has been used for school attendance, occupation, husband’s occupation, and mass media variables. c Other includes both satellite clinic and local doctors. Note: N denotes number of frequency. b
3 years preceding the survey. Bivariate analyses (Table 1) showed that place of residence, religion, women’s school attendance and occupation, husbands’ school attendance and occupation, place of service provided, distance to the service center, and exposure to mass media were positively associated with ever visiting MHCS. More than half (53.5%) of the women from Lama visited MHCS, while 7.5% and 19.7% respondents from Alikadam and Thanchi ever
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visited MHCS, respectively. Ever visiting MHCS was higher among women who belonged to Crama religion (40.4%) compared with women who belonged to Buddhism (30.4%) and Christianity (18.2%). Only 23.1% of respondents who had attended school did not ever visit MHCS, while the corresponding percentage was 70.9% among those who never attended school. Employed women were more (80.0%) likely to visit a MHCS compared with women who were agriculturalists and housewives (30.1%). Husband’s school attendance and occupation were also associated with ever visiting MHCS. Most of the women (80.8%) who ever visited MHCS had husbands who attended school, while the corresponding value was 27% for women whose husbands had not attended school. Women whose husbands were involved in business and employed visited MHCS more often than women whose husbands were involved in agriculture and other works, such as day labor, fishermen, etc. Distance from the home to the service centers was associated with ever use of MHCS. Women who lived less than 3 kilometers from service centers were more likely to visit MHCS compared with women who lived more than 3 kilometers. About three-fourths of the women (73.7%) who had exposure to any mass media (radio, television, or newspaper) ever visited MHCS, while 28.5% of women visited MHCS who had no exposure to any mass media. A multivariable logistic regression model was fitted to explore factors related to MHCS utilization among Mru women (Table 2). Place of residence, religion, women’s school attendance, service provided in the locality, distance from home to the service centers, and exposure to mass media were significantly associated with MHCS use. Table 2. Results of multiple logistic regression for the relation of socio-economic and demographic characteristics to the use of maternal health care services. Independent variables Place of residence (referent = Alikadam) Thanchi Lama Religion (referent = Christianity) Crama Buddhism School attendance (referent = No) Yes Place of service provided (referent = Upazila health complex) Family welfare center Other Distance in kilometers (referent = 16 Access to mass media (referent = No access to any media) Access to any media Constant
Odds ratio
95% CI
4.30 20.35
1.44–12.24 6.92–49.74
3.05 1.96
1.44–6.46 0.98–3.91
10.68
1.18–62.66
7.33 3.48
2.76–19.44 1.35–9.02
0.66 0.21 0.42
0.23–1.91 0.08–0.57 0.13–1.34
8.73 0.08
1.82–41.82
Note. CI denotes confidence interval. The area under the receiver operating characteristic curve and the Hosmer and Lemeshow p value for use of maternal health care services were 0.859 and 0.063, respectively.
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Multivariable logistic regression analyses suggested that women from Lama (adjusted odds ratio (OR) = 4.30, 95% CI 1.44–12.24) and Thanchi (OR = 20.35, 95% CI 6.92–49.74) were significantly more likely to use MHCS compared with women from Alikadam. Women who belonged to Crama (OR = 3.05, 95% CI 1.44–6.46) religion were significantly more likely to use MHCS compared with Christian women. Analyses also suggested that women who attended school (OR = 10.68, 95% CI 1.18–62.66) were more likely to use MHCS. Women who visited FWCs (OR = 7.33, 95% CI 2.76– 19.44) and other service centers, such as SC and village doctors (OR = 3.48, 95% CI 1.35–9.02) were significantly more likely to use MHCS compared with women who visited UHCs. Analyses further suggested that women who lived more than 3 kilometers from the service center (OR = 0.66, 95% CI 0.23–1.91) were significantly less likely to visit MHCS compared with women who resided less than 3 kilometers from the service center. Women who had exposure to any mass media (OR = 8.73, 95% CI 1.82–41.82) were about nine times more likely to use MHCS compared with women who had no access to any media. Discussion The findings of this study revealed that the prevalence of MHCS use was low (30.7%) among the Mru women, which might be an important reason for their poor maternal health outcomes in the community (Islam and Odland 2011; Islam and Thorvaldsen 2012). Place of residence was an important factor associated with the use of MHCS because “door-step awareness programs” conducted by NGOs, especially in Lama, were absent in Alikadam. Therefore, this kind of awareness and maternal health education programs might improve maternal health care use in other places in the community, as well as in other underprivileged indigenous communities in Bangladesh. The association between distance to the service center from the place of residence and the use of MHCS could be explained by the geographic proximity and feasibility of transportation in the Mru community. Such that women were more likely to visit FWC than UHC because FWC was more community-based, designed especially for maternal and child health services and close to their households. On the contrary, UHC is far from most of the Mru villages and provides general health care services including MHCS. Lack of road infrastructure was an important structural barrier for low use of MHCS because no vehicles, either modern or traditional, could be used for local transportation in the Mru villages. However, the current study did not collect information on how long it took study participants to reach these service centers from the Mru villages. Better MHCS use by women who belonged to Crama religion could be explained by the fact that this religion first evolved near the urban area and gradually spread into rural areas resulting in a majority of the followers living relatively near to the urban areas. Consequently, they were also reasonably
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near to service centers, which might be the reason for their slightly higher use of MHCS. Women’s education was another important factor associated with the use of MHCS, which is in line with other studies (Ahmed et al. 2010; Birmeta, Dibaba, and Woldeyohannes 2013; Koch et al. 2012). The results found that women’s education has a net effect on MHCS irrespective of other background characteristics, household, and socio-economic status. Both women and their husbands who were educated and involved either in business or service, had greater use of MHCS compared with those who were involved in agriculture and household work that could be explained by their better socio-economic status. Studies found that poor economic conditions were significantly associated with women’s use of MHCS (Ahmed et al. 2010; Filippi et al. 2006). Thus, the income of poor families in the Mru households might be an important factor for their low use of MHCS because they could not afford the high transportation and maternity costs, although the present study did not show statistically significant associations with income. Lack of exposure to mass media was another significant factor related to low use of MHCS in this study, which is in agreement with numerous studies across the world (Birmeta, Dibaba, and Woldeyohannes 2013; de Fossard and Lande 2008; Islam, Islam, and Banowary 2009a; Wakefield, Loken, and Hornik 2010). Limitations The main limitation of this study was use of a convenience sampling. Thus, it was not possible to make inferences or generalization of the results for the whole community or other indigenous communities in Bangladesh. Secondly, the temporal relationship between outcome and exposures could not be assessed and might not be causal due to the cross-sectional nature of the study. Finally, few educated Mru women were found in the community to conduct the interview. Of seven interviewers, three were involved in NGOs as health workers, which might have affected their viewpoint or skewed their portrayal of the health situation of the study area in unknown ways. Conclusions and recommendations In conclusion, practical issues, for instance, availability of health care facilities, distance to the service centers, and exposure to mass media, were more related than socio-economic factors to use of MHCS among the Mru indigenous women in Bangladesh. Consistent with this, previous study conducted among Garo indigenous people in Bangladesh showed that socioeconomic conditions were not associated with maternal health outcomes. The socio-economic condition of Garo people was not better than mainstream people; however, their maternal health status was much better than the national level due to their better maternal health care services provided
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by the missionary hospital (Islam, Islam, and Banowary 2009a, 2009b). Thus, maternal health service programs should receive greater emphasis for the Mru community along with socio-economic development. Because Mru women do not leave their villages when they are sick, government and NGO health workers should bring MHCS to the community. In addition, comprehensive outreach programs should be provided in the community with maternal health education and training among Mru girls so that they can take up community responsibilities considering their socio-cultural beliefs and practices. Community-based collaborative strategies might be another noteworthy approach to improve the MHCS uptake. A study conducted among indigenous women in the Townsville of Australia found significant development of sustainable antenatal care services through this approach (Panaretto et al. 2007). The Mru women work hard and are very busy in their daily work in the Jhum field because of their traditional and cultural practices, which might impede them to seek MHCS and treatment. Thus, further in-depth studies are needed to explore health care seeking behavior among indigenous people in Bangladesh. Acknowledgments The author of this study would like to thank the Center for Sámi Studies, the Norwegian Higher Education Grant Program, and the Department of Indigenous Studies, University of Tromsø, which made this study possible. The author is also grateful to Dr. John Oldroyd for reviewing and editing the manuscript. Finally, the author wishes to thank the Mru women who participated in this study.
Funding Rakibul M. Islam is supported by the Norwegian Higher Education Grant Program, and the fieldwork of this study is supported by the Centre for Sámi Studies, University of Tromsø, Norway.
References Adnan, S., and R. Dastidar. 2011. Alienation of the lands of indigenous peoples: In the Chittagong Hill Tracts of Bangladesh. Dhaka, Bangladesh: Chittagong Hill Tracts Commission and International Work Group for Indigenous Affairs. Ahmed, S., A. A. Creanga, D. G. Gillespie, and A. O. Tsui. 2010. Economic status, education and empowerment: Implications for maternal health service utilization in developing countries. Plos One 5 (6):e11190. doi:10.1371/journal.pone.0011190. Andersen, R., and J. F. Newman. 2005. Societal and individual determinants of medical care utilization in the United States. Milbank Quarterly 83 (4). doi:10.1111/j.14680009.2005.00428.x. Birmeta, K., Y. Dibaba, and D. Woldeyohannes. 2013. Determinants of maternal health care utilization in Holeta town, central Ethiopia. BMC Health Services Research 13 (1):256. doi:10.1186/1472-6963-13-256.
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de Fossard, E., and R. Lande. 2008. Entertainment-education for better health. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs, Information and Knowledge for Optimal Health. Filippi, V., C. Ronsmans, O. M. R. Campbell, W. J. Graham, A. Mills, J. Borghi, M. Koblinsky, and D. Osrin. 2006. Maternal health in poor countries: The broader context and a call for action. The Lancet 368 (9546):1535–41. doi:10.1016/S0140-6736(06)69384-7. Islam, M. A., M. R. Islam, and B. Banowary. 2009b. Sex preference as a determinant of contraceptive use in matrilineal societies: A study on the Garo of Bangladesh. The European Journal of Contraception & Reproductive Health Care 14 (4):301–6. doi:10.1080/13625180903033460. Islam, M. R., M. A. Islam, and B. Banowary. 2009a. Determinants of exposure to mass media family planning messages among indigenous people in Bangladesh: A study on the Garo. Journal of Biosocial Science 41 (2):221–31. doi:10.1017/S0021932008003088. Islam, M. R., and J. O. Odland. 2011. Determinants of antenatal and postnatal care visits among Indigenous people in Bangladesh: A study of the Mru community. Rural and Remote Health 11 (2):1672. Islam, M. R., and G. Thorvaldsen. 2012. Family planning knowledge and current use of contraception among the Mru indigenous women in Bangladesh: A multivariate analysis. Open Access Journal of Contraception 3:9–16. Karim, F., M. Rafi, and S. A. Begum. 2005. Inequitable access to immunization and vitamin A capsule services: A case of ethnic minorities in three hill districts of Bangladesh. Public Health 119 (8):743–46. doi:10.1016/j.puhe.2004.10.013. Koch, E., J. Thorp, M. Bravo, S. Gatica, C. X. Romero, H. Aguilera, and I. Ahlers. 2012. Women’s education level, maternal health facilities, abortion legislation and maternal deaths: A natural experiment in Chile from 1957 to 2007. Plos One 7 (5):e36613. doi:10.1371/journal.pone.0036613. Mahabub-Ul-Anwar, M., U. Rob, and M. N. Talukder. 2006. Inequalities in maternal health care utilization in rural Bangladesh. International Quarterly of Community Health Education 27 (4):281–97. doi:10.2190/IQ.27.4.b. Marrone, S. 2007. Understanding barriers to health care: A review of disparities in health care services among indigenous populations. International Journal of Circumpolar Health 66:3. doi:10.3402/ijch.v66i3.18254. National Institute of Population Research and Training, Mitra and Associates, and ICF International. 2013. Bangladesh Demographic and Health Survey 2011. Dhaka, Bangladesh and Calverton, MD: Authors. Options Consultancy Services/Evidence for Action, Cambridge Economic Policy Associates, and the Partnership for Maternal, Newborn & Child Health. 2013. Success factors for women’s and children’s health: Country specific review of data and literature on 10 fasttrack countries’ progress towards MDGs 4 and 5. http://www.who.int/pmnch/knowledge/ publications/country_data_review.pdf?ua=1&ua=1 (accessed June 10, 2015). Panaretto, K. S., M. R. Mitchell, L. Anderson, S. L. Larkins, V. Manessis, P. G. Buettner, and D. Watson. 2007. Sustainable antenatal care services in an urban Indigenous community: The Townsville experience. Medical Journal of Australia 187:18–22. Rafi, M. 2006. Small ethnic groups of Bangladesh: A mapping exercise. Dhaka, Bangladesh: Panjeree Publications. Wakefield, M. A., B. Loken, and R. C. Hornik. 2010. Use of mass media campaigns to change health behaviour. The Lancet 376 (9748):1261–71. doi:10.1016/S0140-6736(10)60809-4.
ISSN: 0363-0242 (Print) 1541-0331 (Online) Journal homepage: http://www.tandfonline.com/loi/wwah20
Utilization of maternal health care services among indigenous women in Bangladesh: A study on the Mru tribe Rakibul M. Islam MPhil, MPH To cite this article: Rakibul M. Islam MPhil, MPH (2016): Utilization of maternal health care services among indigenous women in Bangladesh: A study on the Mru tribe, Women & Health, DOI: 10.1080/03630242.2016.1153020 To link to this article: http://dx.doi.org/10.1080/03630242.2016.1153020
Accepted author version posted online: 16 Feb 2016. Published online: 16 Feb 2016. Submit your article to this journal
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Date: 15 April 2016, At: 23:59
WOMEN & HEALTH http://dx.doi.org/10.1080/03630242.2016.1153020
Utilization of maternal health care services among indigenous women in Bangladesh: A study on the Mru tribe Rakibul M. Islam, MPhil, MPHa,b
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a Women’s Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; bDepartment of Population Sciences, University of Dhaka, Dhaka, Bangladesh
ABSTRACT
ARTICLE HISTORY
Despite startling developments in maternal health care services, use of these services has been disproportionately distributed among different minority groups in Bangladesh. This study aimed to explore the factors associated with the use of these services among the Mru indigenous women in Bangladesh. A total of 374 currently married Mru women were interviewed using convenience sampling from three administrative sub-districts of the Bandarban district from June to August of 2009. Associations were assessed using Chi-square tests, and a binary logistic regression model was employed to explore factors associated with the use of maternal health care services. Among the women surveyed, 30% had ever visited maternal health care services in the Mru community, a very low proportion compared with mainstream society. Multivariable logistic regression analyses revealed that place of residence, religion, school attendance, place of service provided, distance to the service center, and exposure to mass media were factors significantly associated with the use of maternal health care services among Mru women. Considering indigenous socio-cultural beliefs and practices, comprehensive community-based outreach health programs are recommended in the community with a special emphasis on awareness through maternal health education and training packages for the Mru adolescents.
Received 27 June 2015 Revised 1 September 2015 Accepted 7 September 2015 KEYWORDS
Bangladesh; health care services; logistic regression; the Mru; utilization
Introduction Use of maternal health care services (MHCS) improves the survival and quality of life of mothers and children; however, it is often underutilized by those mothers and children who are in greatest need (Options Consultancy Services/Evidence for Action, Cambridge Economic Policy Associates, and the Partnership for Maternal, Newborn & Child Health 2013). It is a complex behavioral phenomenon. Empirical studies of preventive and curative CONTACT Rakibul M. Islam, MPhil, MPH [email protected] Women’s Health Research Program, School of Public Health and Preventive Medicine, Monash University, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia. © 2016 Taylor & Francis
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services have revealed that the use of health services is related to the availability, quality, cost, continuity, and comprehensiveness of services, as well as to the social structure, health beliefs, and personal characteristics of the users (Andersen and Newman 2005). Numerous studies also have demonstrated that women’s current age, level of education, parity, income, physical proximity of health care services, and exposure to mass media play a significant role in the utilization of MHCS (Ahmed et al. 2010; Islam and Odland 2011). Moreover, considerable unequal access to and use of good quality of care remains in both developed and developing countries, in different regions, races, and ethnicities (Mahabub-Ul-Anwar, Rob, and Talukder 2006). A review on health care access and use among indigenous people in North America, Australia, and New Zealand found that access to and use of health care services were significantly lower among the indigenous population compared with non-indigenous population (Marrone 2007). Although health care facilities in Bangladesh have undergone remarkable developments since her independence in 1971, the benefits are unequally spread among different socio-economic, ethnic/minority, and indigenous groups. Use of modern health care facilities remains extremely poor in lower socio-economic groups as well as in some parts of Bangladesh, especially in hilly areas, which are physically difficult to access and in which a high proportion of indigenous population live (Karim, Rafi, and Begum 2005; Mahabub-Ul-Anwar et al. 2006). Consequently, health outcomes are extremely poor in the indigenous people compared with mainstream people (Adnan and Dastidar 2011; Mahabub-Ul-Anwar et al. 2006). However, a systematic study has not yet been conducted among the indigenous people in Bangladesh to find the factors associated with their use of MHCS. The main objective of this study was to explore factors associated with MHCS utilization among the Mru women, the most disadvantaged indigenous community in Bangladesh. The Mru and their reproductive health
The Mru are the most underprivileged indigenous people in Bangladesh, living on the hilltops, ravines, cliffs, and deep forest areas of the Bandarban district (Islam and Odland 2011). They live in 356 villages in the Bandarban district, comprising 5,398 households (Rafi 2006). According to the census conducted by the Mru Social Culture in 1995, the total Mru population was estimated at 59,748 (Rafi 2006). Along with Buddhism and Christianity, Mru people also believe in a new religion, Crama, which was created by Man Ley Mru in 1985 and is discussed in detail elsewhere (Islam and Thorvaldsen 2012). The male-female ratio of literacy among the Mru is 2.6:1.6, and 93% of villages are more than one mile away from a primary school (Rafi 2006). A literate person in Bangladesh is one who can read, write, calculate, and be
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socially aware. A recent study showed that nutrition uptake among mothers after childbirth is heavily restricted in Mru society. After delivery, a mother is given only salted rice and sits beside the fire from 9 to 30 days, depending on their clan practices. The prevalence and frequency of their antenatal and postnatal care visits are very low compared with mainstream society due to cultural issues, distance, road infrastructure, and socioeconomic status. Furthermore, they mostly depend on village healers and traditional midwives rather than seeking modern medical care (Islam and Odland 2011).
Methods
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Study sample
This cross-sectional study was conducted in the Bandarban District in the remote southeastern part of Bangladesh where the Mru people live. The Bandarban District has seven upazilas (administrative sub-districts), three of which were Alikadam, Lama, and Thanchi, which were selected purposively for this study. The rationale for selecting these three sites was that the majority of the Mru people live in Alikadam, followed by Thanchi and Lama. Geographically, Thanchi’s terrain is the most remote and hilly, followed by Alikadam and Lama. These regions have a diversity of religions, for instance, Animism/Buddhism, Christianity, and Crama. Finally, socio-economic situations differ with people living in Lama being better off followed by Alikadam and Thanchi upazilas. The total number of households (HHs) under 12 union councils (the smallest rural administrative and local government units in Bangladesh) in the three selected upazilas was 5,398 ranging from 27 to 939 HHs per union council (Rafi 2006). Of the 12 union councils, two from each upazila were selected randomly, including 1,487 HHs from six union councils under the three study upazilas. Finally, 391 HHs, some of which were deep in the bushes, were approached by one local indigenous person as well as the study guide who was an indigenous college student using convenience sampling, and 374 women agreed to participate, comprising 133 from Alikadam, 170 from Lama, and 71 from Thanchi, with a participation rate of 95.6%. To be eligible for the study, women were required to: (1) live in the study locations during the survey; and (2) have at least one child aged 5 years or younger or have had children who died after delivery or/and were delivered as a stillbirth. Only one woman from each HH was interviewed if more than one eligible woman were found. If an eligible woman was not found in a HH, an adjacent HH was approached. Although selected conveniently, the study attempted to get a sample from different religions, socio-economic conditions, and distance from homes to service centers. However, difficulties in obtaining a representative sample based on the above mentioned criteria included the remote locations of the
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Mru villages, transportation problems, and lack of educated Mru female interviewers.
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Data collection
A survey questionnaire comprising both closed and open-ended questions was used for data collection. This is a part of the standard survey questionnaire of Bangladesh Demographic and Health Survey with the intention of making comparisons to the national data (National Institute of Population Research and Training 2013). The questionnaire was developed in English and translated in Bangla and verified by a process of back-translation. Because the Mru have a distinct language, seven bilingual female interviewers having 9 to 12 years of schooling from the Mru community were recruited to conduct the face-to-face interview survey. Of seven, three interviewers were working as health workers in non-government organizations (NGOs). Specifically, one took formal training as a midwife from a private medical college hospital, two interviewers were students, and the others were housewives. A pilot survey was conducted, and the final data collection took place from June to August 2009. Informed consent was taken verbally from participants before starting face-to-face interviewing because most of them could not read or write. Moreover, indigenous people are suspicious of signed documents due to the ongoing land acquisition practices by mainstream people (Adnan and Dastidar 2011). Cultural sensitivities in remote villages were addressed by engaging indigenous leaders. Outcome measures
The outcome variable used in this study was use of MHCS, including antenatal, postnatal, and delivery care visits. “Use” was defined as at least one visit in the last 3 years preceding the survey. Women who visited the upazila health complex (UHC), family welfare center (FWC), the satellite clinic (SC), and village/local doctors were coded as using MHCS. Covariates
Demographic, socioeconomic, and spatial factors of the respondents were considered as covariates. Thus, the variables for bi-variate and multivariable analyses were place of residence, age, religion, income, education and occupation of the respondents, education and occupation of the respondents’ husbands, parity, place of health service provided in the community, distance to the health service centers, and exposure to mass media.
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Statistical analysis
The Statistical Package for Social Sciences software (version 20.0; SPSS Inc., Chicago, IL, USA) was employed for data analyses. Bi-variate analyses were performed based on cross tabulations using chi-square tests, and multivariable analyses were conducted using binary logistic regression analysis. Only variables found significant (p < .05) in bivariate analyses were entered into the multivariable logistic regression model, and adjusted odds ratio (ORs) were reported. Women’s occupation and husbands’ occupation were excluded in the final regression model because they were concentrated in one category of independent variables. Associations were viewed as significant if the OR had a p value of ≤.05 and were reported with 95% confidence intervals. Analyses did not reveal any interactions between the variables. Collinearity between place of service provided and distance in kilometers was examined using the variance inflation factor and found not to be significant. The area under the receiver operating characterisric curve (ROC) and the Hosmer and Lemeshow test were used to assess the model’s discrimination and to test goodness-of-fit, respectively. This research was approved by the Faculty of Humanities, Social Sciences and Education, University of Tromso, Norway and district government officials, Bandarban, Bangladesh. Results Background characteristics of respondents
Of the 374 women surveyed, 45.5% were from Lama, 48.1% were from the 25 to 29 years of age group, and 96.5% had not attended school. The respondents belonged to different religions, 57.2% of whom believed in Buddhism, followed by Crama (25.1%) and Christianity (17.6%). Some people also believed in Animism, although they liked to introduce themselves as Buddhist. Mru women simultaneously (98.7%) engaged in swidden/jum cultivation and household activities. Their main sources of drinking water were rivers (53.5%), followed by streams (23%), and wells (3.7%). A majority of women (57.2%) had no toilet facilities, using the bush and open fields, and 36.9% used an open latrine. Less than one-third (30.7%) of the study women visited MCHS, regardless of service providers in the community. More than half of the women (55.1%) reported that service was provided in the locality by the UHC, followed by the FWC (28.3%). Some women also visited the SC (4.3%), village/local doctors (4.0%). Use of maternal health care services
In this study, use of MHCS was assessed in relation to different demographic and socio-economic characteristics of the women who had a live birth in the
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Table 1. Association between the use of maternal health care services and socio-economic and demographic characteristics. Ever visit health care services n (%)
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Characteristics Place of residence (p < .001) Alikadam Lama Thanchi Religion (p = .011) Christianity Crama Buddhism Monthly income in BDTa (p = .370) 7,000 Age in years (p = .456) 35 School attendanceb (p = .001) Yes No Occupationb (p = .033) Agriculture and housewife Service Husband’s school attendance (p < .001) Yes No Husband’s occupation* (p < .001) Agriculture Other Place of service provided (p < .001) Upazila health complex Family welfare center Otherc Distance in kilometers (p = .011) 16 Mass media exposureb (p < .001) Access to any media No access to any media
N
Yes
No
133 170 71
10 (7.5) 91 (53.5) 14 (19.7)
123 (92.5) 79 (46.5) 57 (80.3)
66 94 214
12 (18.2) 38 (40.4) 65 (30.4)
54 (81.8) 56 (59.6) 149 (69.6)
112 240 22
30 (26.8) 76 (31.7) 9 (40.9)
82 (73.2) 164 (68.3) 13 (59.1)
159 180 35
53 (33.3) 54 (30.0) 8 (22.9)
106 (66.7) 126 (70.0) 27 (77.1)
13 361
10 (76.9) 105 (29.1)
3 (23.1) 256 (70.9)
369 5
111 (30.1) 4 (80.0)
258 (69.9) 1 (20.0)
26 348
21 (80.8) 94 (27.0)
5 (19.2) 254 (73.0)
355 19
102 (28.7) 13 (68.4)
253 (71.3) 6 (31.6)
206 106 62
24 (11.7) 55 (51.9) 36 (58.1)
182 (88.3) 51 (48.1) 26 (41.9)
54 78 136 106
26 25 32 32
28 53 104 74
19 355
(48.1) (32.1) (23.5) (30.2)
14 (73.7) 101 (28.5)
(51.9) (67.9) (76.5) (69.8)
5 (26.3) 254 (71.5)
a
1 USD = 80 BDT at the time of survey (approximately). Fisher’s exact test has been used for school attendance, occupation, husband’s occupation, and mass media variables. c Other includes both satellite clinic and local doctors. Note: N denotes number of frequency. b
3 years preceding the survey. Bivariate analyses (Table 1) showed that place of residence, religion, women’s school attendance and occupation, husbands’ school attendance and occupation, place of service provided, distance to the service center, and exposure to mass media were positively associated with ever visiting MHCS. More than half (53.5%) of the women from Lama visited MHCS, while 7.5% and 19.7% respondents from Alikadam and Thanchi ever
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visited MHCS, respectively. Ever visiting MHCS was higher among women who belonged to Crama religion (40.4%) compared with women who belonged to Buddhism (30.4%) and Christianity (18.2%). Only 23.1% of respondents who had attended school did not ever visit MHCS, while the corresponding percentage was 70.9% among those who never attended school. Employed women were more (80.0%) likely to visit a MHCS compared with women who were agriculturalists and housewives (30.1%). Husband’s school attendance and occupation were also associated with ever visiting MHCS. Most of the women (80.8%) who ever visited MHCS had husbands who attended school, while the corresponding value was 27% for women whose husbands had not attended school. Women whose husbands were involved in business and employed visited MHCS more often than women whose husbands were involved in agriculture and other works, such as day labor, fishermen, etc. Distance from the home to the service centers was associated with ever use of MHCS. Women who lived less than 3 kilometers from service centers were more likely to visit MHCS compared with women who lived more than 3 kilometers. About three-fourths of the women (73.7%) who had exposure to any mass media (radio, television, or newspaper) ever visited MHCS, while 28.5% of women visited MHCS who had no exposure to any mass media. A multivariable logistic regression model was fitted to explore factors related to MHCS utilization among Mru women (Table 2). Place of residence, religion, women’s school attendance, service provided in the locality, distance from home to the service centers, and exposure to mass media were significantly associated with MHCS use. Table 2. Results of multiple logistic regression for the relation of socio-economic and demographic characteristics to the use of maternal health care services. Independent variables Place of residence (referent = Alikadam) Thanchi Lama Religion (referent = Christianity) Crama Buddhism School attendance (referent = No) Yes Place of service provided (referent = Upazila health complex) Family welfare center Other Distance in kilometers (referent = 16 Access to mass media (referent = No access to any media) Access to any media Constant
Odds ratio
95% CI
4.30 20.35
1.44–12.24 6.92–49.74
3.05 1.96
1.44–6.46 0.98–3.91
10.68
1.18–62.66
7.33 3.48
2.76–19.44 1.35–9.02
0.66 0.21 0.42
0.23–1.91 0.08–0.57 0.13–1.34
8.73 0.08
1.82–41.82
Note. CI denotes confidence interval. The area under the receiver operating characteristic curve and the Hosmer and Lemeshow p value for use of maternal health care services were 0.859 and 0.063, respectively.
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Multivariable logistic regression analyses suggested that women from Lama (adjusted odds ratio (OR) = 4.30, 95% CI 1.44–12.24) and Thanchi (OR = 20.35, 95% CI 6.92–49.74) were significantly more likely to use MHCS compared with women from Alikadam. Women who belonged to Crama (OR = 3.05, 95% CI 1.44–6.46) religion were significantly more likely to use MHCS compared with Christian women. Analyses also suggested that women who attended school (OR = 10.68, 95% CI 1.18–62.66) were more likely to use MHCS. Women who visited FWCs (OR = 7.33, 95% CI 2.76– 19.44) and other service centers, such as SC and village doctors (OR = 3.48, 95% CI 1.35–9.02) were significantly more likely to use MHCS compared with women who visited UHCs. Analyses further suggested that women who lived more than 3 kilometers from the service center (OR = 0.66, 95% CI 0.23–1.91) were significantly less likely to visit MHCS compared with women who resided less than 3 kilometers from the service center. Women who had exposure to any mass media (OR = 8.73, 95% CI 1.82–41.82) were about nine times more likely to use MHCS compared with women who had no access to any media. Discussion The findings of this study revealed that the prevalence of MHCS use was low (30.7%) among the Mru women, which might be an important reason for their poor maternal health outcomes in the community (Islam and Odland 2011; Islam and Thorvaldsen 2012). Place of residence was an important factor associated with the use of MHCS because “door-step awareness programs” conducted by NGOs, especially in Lama, were absent in Alikadam. Therefore, this kind of awareness and maternal health education programs might improve maternal health care use in other places in the community, as well as in other underprivileged indigenous communities in Bangladesh. The association between distance to the service center from the place of residence and the use of MHCS could be explained by the geographic proximity and feasibility of transportation in the Mru community. Such that women were more likely to visit FWC than UHC because FWC was more community-based, designed especially for maternal and child health services and close to their households. On the contrary, UHC is far from most of the Mru villages and provides general health care services including MHCS. Lack of road infrastructure was an important structural barrier for low use of MHCS because no vehicles, either modern or traditional, could be used for local transportation in the Mru villages. However, the current study did not collect information on how long it took study participants to reach these service centers from the Mru villages. Better MHCS use by women who belonged to Crama religion could be explained by the fact that this religion first evolved near the urban area and gradually spread into rural areas resulting in a majority of the followers living relatively near to the urban areas. Consequently, they were also reasonably
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near to service centers, which might be the reason for their slightly higher use of MHCS. Women’s education was another important factor associated with the use of MHCS, which is in line with other studies (Ahmed et al. 2010; Birmeta, Dibaba, and Woldeyohannes 2013; Koch et al. 2012). The results found that women’s education has a net effect on MHCS irrespective of other background characteristics, household, and socio-economic status. Both women and their husbands who were educated and involved either in business or service, had greater use of MHCS compared with those who were involved in agriculture and household work that could be explained by their better socio-economic status. Studies found that poor economic conditions were significantly associated with women’s use of MHCS (Ahmed et al. 2010; Filippi et al. 2006). Thus, the income of poor families in the Mru households might be an important factor for their low use of MHCS because they could not afford the high transportation and maternity costs, although the present study did not show statistically significant associations with income. Lack of exposure to mass media was another significant factor related to low use of MHCS in this study, which is in agreement with numerous studies across the world (Birmeta, Dibaba, and Woldeyohannes 2013; de Fossard and Lande 2008; Islam, Islam, and Banowary 2009a; Wakefield, Loken, and Hornik 2010). Limitations The main limitation of this study was use of a convenience sampling. Thus, it was not possible to make inferences or generalization of the results for the whole community or other indigenous communities in Bangladesh. Secondly, the temporal relationship between outcome and exposures could not be assessed and might not be causal due to the cross-sectional nature of the study. Finally, few educated Mru women were found in the community to conduct the interview. Of seven interviewers, three were involved in NGOs as health workers, which might have affected their viewpoint or skewed their portrayal of the health situation of the study area in unknown ways. Conclusions and recommendations In conclusion, practical issues, for instance, availability of health care facilities, distance to the service centers, and exposure to mass media, were more related than socio-economic factors to use of MHCS among the Mru indigenous women in Bangladesh. Consistent with this, previous study conducted among Garo indigenous people in Bangladesh showed that socioeconomic conditions were not associated with maternal health outcomes. The socio-economic condition of Garo people was not better than mainstream people; however, their maternal health status was much better than the national level due to their better maternal health care services provided
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by the missionary hospital (Islam, Islam, and Banowary 2009a, 2009b). Thus, maternal health service programs should receive greater emphasis for the Mru community along with socio-economic development. Because Mru women do not leave their villages when they are sick, government and NGO health workers should bring MHCS to the community. In addition, comprehensive outreach programs should be provided in the community with maternal health education and training among Mru girls so that they can take up community responsibilities considering their socio-cultural beliefs and practices. Community-based collaborative strategies might be another noteworthy approach to improve the MHCS uptake. A study conducted among indigenous women in the Townsville of Australia found significant development of sustainable antenatal care services through this approach (Panaretto et al. 2007). The Mru women work hard and are very busy in their daily work in the Jhum field because of their traditional and cultural practices, which might impede them to seek MHCS and treatment. Thus, further in-depth studies are needed to explore health care seeking behavior among indigenous people in Bangladesh. Acknowledgments The author of this study would like to thank the Center for Sámi Studies, the Norwegian Higher Education Grant Program, and the Department of Indigenous Studies, University of Tromsø, which made this study possible. The author is also grateful to Dr. John Oldroyd for reviewing and editing the manuscript. Finally, the author wishes to thank the Mru women who participated in this study.
Funding Rakibul M. Islam is supported by the Norwegian Higher Education Grant Program, and the fieldwork of this study is supported by the Centre for Sámi Studies, University of Tromsø, Norway.
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