This thesis entitled “Maternal Health and Maternal Mortality: A Study of Four Selected Districts of Assam” submitted for the degree of Doctor of Philosophy has not previously been submitted for any other degree of this or any other university and is my original work. This is to certify that Miss Pranti Dutta has prepared the thesis entitled "Maternal Health and Maternal Mortality: A Study of Four Selected Districts of Assam" for the degree of Doctor of Philosophy at the Indian Institute of Technology Guwahati.
Barriers to Maternal Health Seeking Behavior
Summery of Findings and Policy Suggestions
Abstract
In addition, maternal health-seeking behavior is shaped by organizational factors such as unavailability of ambulance and unavailability of female health care providers; cultural factors such as ignorance and hesitation; socio-economic factors such as long queues at facilities, lack of access to people at home to care for pregnant women and heavy workloads. Health promotion measures must encourage people to seek medical care and ensure the availability of physical infrastructure and female health care providers.
INTRODUCTION
- Background of the Study
- Women’s Health and Maternal Mortality
- Statement of the Problem
- Objectives of the Study
- Data Sources and Methodology
- Layout of the Chapters
In addition, to identify barriers to maternal health seeking behavior (Chapter 6), we use a Bayesian logistic regression to fit the data. Therefore, this chapter provides the background of maternal health as well as maternal mortality to identify the scope for further research in Assam.
Appendix
Maternal Health in Perspective
Issues of Maternal Health
- Definitions
- Measuring Maternal Mortality
- Magnitudes of Maternal Deaths in India
- Maternal Mortality: Getting Priority in Healthcare Sector
The conventional definition of maternal mortality ratio (MMR) is the ratio of the number of maternal deaths in a given period per 1,00,000 live births, while maternal mortality is the number of maternal deaths in a given period per 1,00,000 women of reproductive age (WHO, 2010). The World Health Organization (WHO) report of 1990 (published in 1996) has developed the worldwide concern for the issues of maternal mortality and also women's and children's health.
Factors Behind Maternal Mortality: A Brief Review 1. Production of Health
- Review on Factors Influencing Maternal Mortality
Critical determinants of maternal mortality are (1) availability and use of maternal care services from a health perspective; (2) economic development and accumulation of material resources according to the wealth perspective; and (3) the position of women in society according to the perspective of empowerment. In this context, family planning services are one of the ways proposed to reduce maternal mortality (Rosenfield & Maine, 1985).
Conclusions
Another study conducted by Das et al. 2012) in the tea gardens of Assam, identified anemia as a major problem among female tea garden workers. Moreover, female kindergarten workers continue to engage in hard work even during pregnancy and the postpartum period, which cause harm to both the mother and the newborn (Borah, 2013).
Maternal Health Scenario of Assam
- Background Characteristics: Assam
- Location, Demography and State Economy
- Current Healthcare System- Structure and Scenario of Assam
- Trend of Maternal Deaths and Maternal Illness in Assam
- Operational Schemes on Maternal Health
- Maternal Healthcare in Assam: A District Level Analysis
- Trend and Socio-Demographic Factors of MMR
Data from the National Family Health Survey (NFHS I to IV) reports show that child vaccination has increased over the period (1992-93 to 2015-16), but the proportion of children receiving all vaccines in Assam ( 47.1 percent) is much less than at the national level (62.0 percent). According to Sample Registration System (SRS), Registrar General of India (RGI-SRS Maternal Mortality Ratio (MMR) in Assam is 300 per 1,00,000 live births, which is the highest in India (all statistics of India is 167 deaths).14 Table 3.1.A provides a comparative observation on maternal health outcome indicator performance based on the National Family Health Survey (NFHS) III report between Assam and India.15 In Assam, maternal health performance indicators such as receipt of antenatal care (70.7 percent) and postnatal care (16 percent) are lower than the national level (76.4 and 41.2 percent respectively). The table reveals that about 60.2 percent of of Assam women had faced complications during their pregnancy (compared to the national level of 61 percent).
Further, according to DLHS III, nearly 67.8 percent of women in Assam have suffered from at least one birth complication (compared to 35 percent nationally).
Districts
The trend of maternal mortality for Assam at the district level during 2011-12 to 2013-14 reveals that MFR has increased over the years (Figure 3.4).
Trend of MMR in Assam
- Sources of Data
- Spearman’s Rank Correlation Analysis of Socioeconomic Variables
- Cluster Analysis
- n=10) Mean (SD)
- n=8) Mean (SD)
- n=8) Mean (SD)
- n=1) Mean (SD)
- Discussion
- Availability of Maternal Care Facilities at District Level
- Conclusions
The detailed status of district-wise number of PHCs with maternal care facilities and percentage shortage of PHCs with maternal care facilities for the year 2007 and 2014 are presented in Table 3.21.A to Table 3.27.A. However, Table 3.30 indicates that district-wise percentage distribution of PHCs without maternal care facilities is the same, except for 24 hour delivery services (z=0.000) and ANMs (z=0.005). Most recent data on district level ASHA workers for the year 2015-16 is presented in Table 3.31.A.
Number of clusters is presented in Table 3.37, which shows that five-group solutions are the most distinct from this hierarchical cluster analysis.
Appendix Tables
MMR For estimation of district wise MMR, district wise live births were collected from NRHM, Guwahati, Assam and number of maternal deaths were collected from maternal death reporting system available on official website of NRHM Assam. PCI Per Capita Income Human Development Report, Assam Age at Marriage District Level Household Survey of AoM Assam (III) 2007-08.
Primary Health Centre
Sub centre
Field Description and Sample Profile
- Purpose of Field Study
- Selection of the Area for the Field Study
- Data Collection
- Broad Profile of the Sample Villages
- Barbaruah BPHC
- Chhaygaon BPHC
- Biswanath BPHC
- Sonai BPHC
- Geography and Demography of the Sample Villages
- Maternal Health Status of the Sample Villages
- Profile of Maternal Status
- Status of Pregnancy Outcome
- Use of Contraceptives
- Coverage of Full Antenatal Care
- Place of Delivery
This section focuses on the brief profile of the sample villages, including the location maps of the study areas. The minimum age at marriage for the respondents in the sample is found to be 12 years, and the maximum age is 28 years. The details of the availability of safe drinking water and sanitation facilities are shown in Table 4.14.
The broad profile of the sample respondents presented in this chapter provides the necessary background information.
Map-4.1: Location of Study Areas and Sample Villages
Determinants of Maternal Anemia at Disaggregated Level
Profile of Maternal Death Cases
- Perspective of Maternal Anemia
- Maternal Anemia in Studied Sample
Thus, this study discusses lower hemoglobin levels as a proxy for anemia (Gibson, R. S., 2005), and subsequent sections will discuss maternal anemia. Based on the WHO criterion of hemoglobin value, the prevalence of anemia among the studied sample is presented in table 5.4.46 In our sample, more than 90 percent are women. It is also observed that the prevalence of anemia is higher among the population of the Tea tribe compared to the rest.
The distribution of the population according to the health effects of anemia shows that more than 50 percent of women suffer from loss of energy, dizziness and headaches.
Iron Bioavailability and Dietary Concern in the Studied Areas
- Observation from Field
Lack of sufficient food puts people at risk of developing iron deficiency (ibid). The population in tea garden areas has less access to a diversified diet due to land and geographical bottlenecks. They do not have home-grown food products and have limited access to daily micronutrient intake, either due to their lack of awareness about the importance of nutritional habits or due to a lack of financial resources.
Due to low economic status, women have to work hard for their livelihood with poor nutritional diversification.
Socio–Economic Causes of Maternal Anemia in the Studied Areas
- Functional Form of the Model
- Results
- Discussions
The assumption is that the higher the female literacy, the higher the hemoglobin concentration. The literacy coefficient shows that compared to illiterate respondents, the concentration of hemoglobin level is 7% higher in literate respondents. At the same time, compared to households without land ownership, hemoglobin concentration in households with land is 5% higher.
Thus, the Oaxaca-Blinder decomposition based on the concentration of hemoglobin level helps to understand the difference in hemoglobin level in terms of endowment and coefficient effects.
Conclusions
Therefore, the gap between the average outcomes, Ya and Yb (here a and b are two groups) is equal to. The gap between a and b on the outcome variable is due to (a) a gap in the endowments (that is, to a different distribution of Xs) (E) or (b) a gap in the coefficients (β) or ( c) a gap arising from the interaction of endowments and coefficients (CE) (Saikia, Moradhvaj, & Bora, 2016). In the above equation, Xa and illiterate groups and also for and tea garden/non-tea garden population respectively.
Barriers to Maternal Health Seeking Behavior
Conceptual Framework of MHSB
Osubor et al., (2006) showed that agents in Nigeria are more likely to prefer traditional birth attendants (TBAs) because of greater accessibility, lower cost and more convenience. Agarwal et al., (2007) investigated the utilization pattern of maternal care in an urban slum in Delhi. Srivastava et al., (2014) showed that in Rohilkhand region of Uttar Pradesh that mother's education and husband's occupation are the strong predictors of utilization of maternal health care services.
Similarly, Tiwari et al. (2014) showed that accessibility and availability of maternal care services increased utilization of health facilities in Madhya Pradesh.
Health Seeking Behavior in Sample
The available literature provides insights into the different explanatory variables for assessing the low utilization of maternal care services. The following sections discuss the MHSB among the population of the studied areas and detail the factors that influence shaping health-seeking behavior at a disaggregated level. The study of health-seeking behavior makes it possible to identify the reasons for the use and non-use of available health care services and the population's perceptions towards the health care system of a particular social setting (Kroeger, 1983).
Socio-economic Social structure and economic cost Drug cost CoD Transport cost CoT.
Methodology
- Rationale for Model Selection: Bayesian Analysis
- Conceptual Framework of Bayesian Approach
- Description of Likelihood and Priors
- Bayesian Binary Logistic Model
- Computational Methods
Bayesian analysis is a statistical methodology that forms a posterior distribution using a combination of prior knowledge about the model parameters and evidence from an observed sample of data. The credible interval is the interval from the domain of the marginal posterior distribution of this parameter. The following section provides a description of key components of the Bayesian approach, such as the likelihood function and prior distribution for this model.
The right side of the equation is the probability of event A divided by event A.
Results for Health Seeking Behavior
The HPD level of both models shows that the effects of organizational parameters such as non-availability of female health care providers; cultural determinants such as hesitation and ignorance; and socioeconomic Table 6.7: Posterior distribution for binary logistic regression model in response to health-seeking behavior in surveyed villages, (Not seeking care=1 , Seeking care=0) (Base model). The difference in results in Tables 6.8 and 6.9 indicates that the prior information regarding the parameter's mean value and standard deviation is important for the estimates. The model with informative advance thus shows that the lack of availability of female health care providers and ambulance facilities increases the probability of not seeking care for maternal health.
In addition, long queues, lack of availability of a person at home and heavy workload are significant barriers for MHSB.
Discussion
Other factors such as a long queue, the unavailability of someone at home and a high workload appear to be important barriers. Pregnant women no longer want to stay in healthcare facilities after delivery (required for a minimum period of 48 hours after delivery), due to the unavailability of attendants in hospitals, the costs of accommodation and food of the attendants and the unavailability of person at home to take care of his family. Yiran et al., (2015) examined the challenges migrant women face in seeking maternal health care in Ghana.
They found that long queues and waiting times at health facilities are one of the factors affecting access to maternal health care services.
Conclusion
We propose that road perception, distance perception, ambulance unavailability and transport cost are likely to be related to each other. Similarly, perceptions about the organization, such as the unavailability of female health providers, unresponsive physicians, are likely to be related to each other. The result shows that the husband's limitation is significantly related to the unavailability of female health providers and unresponsive doctors.
Similarly, unavailability of a person at home, long queues and high workload are probably related.
Summary of Findings, Conclusions and Policy Suggestions
- Summary of the Findings
- Conclusions and Contributions
- Policy Implications
- Future Scope of the Research
Why the study of maternal health is important for the public health system (especially in Assam). What are the associations between maternal complications, health seeking, and improved maternal health outcomes? The initial chapters are devoted to the current state of maternal health care and an analysis of the factors that determine poor maternal health care.
Furthermore, the result of this model-based analysis provides a suggestion for future studies to include more explanatory variables of maternal health for a higher level of generalizability.
Bibliography
Emerging causes and determinants of maternal mortality in India: Based on large-scale survey since the 1990s. Emerging causes and determinants of maternal mortality in India: Based on large-scale survey since the 1990s. An analysis of levels and trends in maternal health and maternal mortality ratio in India.
Onttrek op 16 Maart 2013 van Advocates for Youth: Rights, Respect, responsibility: http://www.advocatesforyouth.org/component/content/article/436- adolescent-maternal-mortality-an-overlooked-crisis.
