The Antenatal Care And Postnatal Care Health Essay

Maternal mortality is defined as death of women from pregnancy- related complications occurring throughout pregnancy, labor, childbirth and in the postpartum period (up to the 42nd days after birth (WHR, 2005). Maternal mortality is one of the major public health concerns in the world. Death during postnatal period is playing an important role in increasing maternal mortality and morbidity ratio (BMMMR, 2010).

Postnatal period (or called postpartum) is defined by the WHO as the period beginning one hour after the delivery of the placenta and continuing until six weeks (42 days) after the birth of an infant. The first hours, days and weeks after childbirth are a dangerous time for both mother and newborn baby. In this period, the physical examination of the mother and proper counselling by skilled health service provider is very essential to prevent the health complications. The WHO has recommended postnatal visit for at least three times. The first visit within 24 hours, second visit within 2-3 days and the fourth visit in the seventh day is the normal schedule for postnatal visit. These visits help to find out the health problems in time.

Antenatal care (ANC) and postnatal care (PNC) are the key indicators to measure the maternal health, particularly safe motherhood. Antenatal care is a very good predictor of safe delivery and provides health information and services that can improve the health of women and infants (Bloom, Lippeveld & Wypij, 1999; WHO & UNICEF, 2003).The primary aim of antenatal care is to achieve, at the end of pregnancy, a healthy mother and a healthy baby. In addition, antenatal care has a positive impact on the utilization of postnatal health care service (Chakraborty, Islam, Chowdhury & Bari, 2002). Postnatal care and intra-partum care significantly reduces maternal mortality and morbidity because most maternal deaths occur in the first week after delivery (Campbell & Graham, 2006; Hurt et all, 2008).

Despite improvements, pregnancy – related complications remains the leading cause of death and disability among women and of child bearing age disproportionately among different rural-urban dwellers, poor-rich groups, cultural groups and indigenous non indigenous groups (Gill & Ahmed, 2004; BDHS, 2007).

The present situation indicates an improvement in the global maternal deaths ratio (Hawkins, 2005). Globally 47 % maternal deaths decline in 2010 from 1990 (WHO, UNICEF, UNFPA & The World Bank estimates, 2010). However, progress towards the Millennium Development Goals (MDG) has been very slow in many countries (Bhutta, 2010).

Bangladesh has strengthened its emergency obstetric care (EmOC) under the Directorate General of Health services through national and international collaborations (Islam, Haque, Waxman, & Bhuiyan, 2006).The United Nations Population Fund (UNFPA) commenced support of government improvement of 64 maternal and child welfare centres for EmOC in 1993 (Gill & Ahmed, 2004). In addition, the Obstetrical and Gynaecological Society of Bangladesh with the support of UNICEF improved EmOC in 11 district hospitals on a pilot basis in the period 1994-1998, with subsequent expansion to other districts (Chakraborty, et. al, 2002). As a result ANC and PNC visits increased substantially in Bangladesh from 1999-2000 to 2007. However, pregnancy related complications remains the leading cause of death and disability among women.

Global urbanization has become a vital issue in recent years. The urban population is expected to increase by 84%, from 3.4 billion in 2009 to 6.3 billion in 2050 (United Nation, 2010). Bangladesh along with other Asian countries, has experienced rapid urban growth in the recent decades (NIPORT, 2008 & Uzma et all, 2004) This rapid urbanization in Bangladesh, increased with the growth of urban slums, is likely to have profound implications on its health profile, especially on maternal and child health (NIPORT, 2008). Maternal and child health is strongly related with beliefs and practices around pregnancy and childbirth which has implications for the health of the child and mother after the birth (Choudhury et, all, 2012).

The maternal mortality ratio (MMR) in Bangladesh was 320 per 100,000 live births in 2001 which decreased to 194 per 100,000 live births in 2010 (BMMMS, 2010). Bangladesh is presently on track to achieve the primary target of Millennium Development Goal (MDG) -5 with a goal to reduce the maternal mortality. Despite this achievement the condition in urban slums is worse compared to urban non slum areas with respect to antenatal care by medically trained provider (62% vs. 85%), delivery at a health facility ( 12% vs. 46%) and skilled assistance at delivery (18% vs. 56% ) respectively (NIPORT, 2008). This makes urban health issues, especially of the slum dwellers a high priority. It is therefore crucial to address maternal health of the urban slum dwellers in Bangladesh. Usually in urban slums, the maternal health services are offered at home or in static service delivery sites operated by nongovernmental organization (NGO) field workers. In some instance, services are available at clinics or dispensaries managed by NGOs, the government or the private sectors (NIPPORT, 2008).

Pregnancy and childbirth are the important event of life. However, the women are more vulnerable to complications and the deaths in this period. Therefore, the proper care and support is needed from the pregnancy to postnatal period. As in the world, there are so many different communities and religious groups, the way of care and support is different in pregnancy, childbirth and postnatal period. Some of the community applies their cultural practices during childbirth and postnatal care. The study shows that believe in the supernatural things like evil eye and spirits are still rooted in some communities. In spite of religion, class, urban and rural origins, the majority of Bangladeshi people believe in the existences of a supernatural world (Afsana & Rasid, 2000). The health care seeking behaviour during pregnancy and child birth are linked to women’s social and cultural interpretation of illness and well being and any complications in birth are often attributed to supernatural causes (Afsana & Rasid, 2000).

Food taboo is also the strong in the people especially during pregnancy and postnatal period. It depends upon the people’s beliefs. A study done by (Choudhury, et. al, 2012) shows that the mothers are allowed to take only dry food which was cooked without water, and rice with mashed potato and black cumin seed because these foods are believed to keep stomach of a women cool and initiate the production of breast milk. Another study also shows that there were various dietary restrictions imposed on the mothers which deprived them of proper nutrition intake. Commonly, the mothers were not allowed to have food during the first day after delivery to allow healing of the birth passage (Choudhury & Ahmed, 2011).

In some cultures, the mother should stay in isolation for few days after delivery. During that period mothers stay in a separate room. According to a study, the mother should stay in inner kimma (a private room) for 7-9 days. During this time, women sit by the fire, drink hot water, eat burning salt with rice and place searing materials on their lower back (Islam, 2011). Another study also showed that the women have to stay in isolation for the first 5-9 days after delivery because women are considered to be impure during this time. They are not allowed to touch any food for preparing meals (Choudhury & Ahmed, 2011).

To improve the maternal and child health of slum dwellers, many INGOs and NGOs are working in this area. BRAC is also implementing the project called “MANOSHI” with the same aim in all slums of Dhaka city. As the result, the maternal and child health is improving gradually.

1.2 Rationale / Justification

Maternal mortality is the major health problem in developing countries like Bangladesh. Together with the improvement in knowledge and awareness level of community and the various intervention implemented by government, the maternal health care service utilization is increasing. However, the extent of service utilization is still low particularly natal and postnatal care services. More than 29 out of 100 deliveries take place at home and only 27% seek postnatal care from health service provider (BDHS, 2011). Postnatal care is still a neglected issue because it is not as emphasized as antenatal care.

The maternal mortality and morbidity survey shows that majority of deaths occurred due to postnatal complications. Around 31% of total maternal deaths occurred due to haemorrhage. As a result, postpartum deaths now comprise a higher proportion of maternal deaths (73%) up from 67% in 2001(BMMMS, 2010). It indicates that postnatal care interventions should be given more priority. The government and other stakeholders should take account of PNC when implementing the maternal health programs.

Millennium development goal (MDG 5) is achievable in Bangladesh because of intervention by the government. However, people living in the rural and urban slums are not utilizing the maternal health services adequately. Socio cultural factors are the most important factor that can play important role in changing the health seeking behaviour. The behaviour cannot be changed unless recognizing the socio-cultural norms in the society.

This study aimed to explore the potential factors that can affect utilization of postnatal care services. Findings from this study will give a reflection of maternal health status as well as extent of post natal care service utilization which can be used to improve the utilization of post natal care in urban slums.

1.3 Operational definition

Postnatal period: The period beginning one hour after the delivery of the placenta and continuing until six weeks (42 days) after the birth of an infant. It is the most critical period for mother because most of the maternal deaths occur in this period.

Postnatal care: All the cares provided by family members, traditional birth attendance or health care service providers during postnatal period. It includes care in home or in health facility.

Cultural practice: The practice performed according to traditional norms and cultural beliefs by slum dwellers. It includes food intake practice, place of delivery, isolation, untouchability etc.

Food taboos: The prohibition on certain food intake to mother during postnatal period thinking harmful for health. It depends on the peoples’ perceptions and beliefs.

Family support: It included support in physical work and psychosocial support to the mother by family members during postnatal period.

Danger signs: The signs of physical or mental abnormalities that appear during postnatal period, which includes fever, severe, lower abdominal pain, hypertension and sepsis during postnatal period.

PNC visit: The standard scheduled visits to health care service providers for health check up during postnatal period. Health service providers conduct the physical examination of mother, appropriate counselling of mother and the newborn baby, supplementation of iron and vitamin A during these visits.

Personal hygiene: Those activities that are carried out to keep the mother clean during delivery and postnatal care.

Health seeking behaviour: It is the behaviour where the mothers go for health seeking during postnatal care. It includes formal and informal care.

Cultural beliefs: It includes the beliefs of mothers regarding postnatal care. It includes beliefs on food taboos, evil eye, untouchability etc.

1.4 Objectives of the study

General objective:

To understand the perceptions of women, their family members and health care providers on postnatal care in a Dhaka slum of Bangladesh

Specific objectives:

To explore cultural beliefs and norms regarding post-natal care

To explore the cultural practices of postnatal care among women in urban slums

To explore the barriers women face in seeking post natal care from health care centres in slum areas

Chapter II

Methodology

2.1 Study design

The study used the qualitative exploratory research design to explore the stated objective as enumerated because it is a sensitive issue and related to socio cultural behaviour. The aim of this study approach is to use multiple sources of data to explore the same phenomena from different angles. Qualitative research provides in-depth and contextual information that cannot be obtained from quantitative research alone. Therefore a lot of in- depth interviews and focus group discussion were conducted to understand the perception and practices towards postnatal care.

2.2 Study site

The study site was Sattar- Molla slum, Mirpur, Dhaka where BRAC is implementing Manoshi program to improve maternal and child health. This slum was chosen for the study because slums are neglected area by the government. There is no any governmental health facility for slum dwellers.

2.3 Study population

The study population were slum dweller mothers who have 6 weeks to 1 year children. Six weeks after birth is postnatal period so the respondent were taken from the mothers who had completed the postnatal period and the mothers who had less than 1 year child because there is less chance of memory or reporting bias. Besides them, their mother in laws and their husbands were also used as the source of information because mother in laws and husbands are the main decision makers in most of the families. In addition, Shasthya Sebika (SS), Shasthya Kormi (SK) and Urban Birth Attendent (UBA) who are involved in that field were included as key informants.

2.4 Sampling method and technique

Purposive sampling method will be employed in this study because only particular women who had experienced on postnatal period and having one year child were interviewed.

2.5 Data collection methods

The study employed the use of multiple qualitative methods to triangulate the data.

Key Informant Interview (KII)

Key Informant Interviews were conducted with SS, UBA and SK of BRAC health program because they were involved in the maternal and child health program and had close relation with mothers. A total of 3 KIIs, each from SS, SK and UBA were conducted. The KII gave the researcher a better understanding of the situation of the selected slums regarding postnatal care or related interventions in this area. According to Patton (2002), key informants are useful in helping the researcher to understand what is happening and why it is happening. Using key informants is a good option for the researcher to understand the cultural context regarding postnatal care practices. A semi structured key informant interview guideline was used as a tool for interview.

In-Depth Interview (IDI)

In-Depth Interviews were conducted for this particular study because it allows participants to tell their experiences and their stories in detail about phenomenon on an individual basis. Fifteen IDIs were carried out with mothers having 6 weeks to 1 year child. In-depth interviews involve conducting intensive individual interviews with a small number of participants to explore their perspectives on a particular idea, program, or situation. An in- depth interview guideline was used for interview.

Focus Group Discussion (FGD)

Focus group discussions were conducted with mother in laws and husbands of women separately. Two FGDs – one with mother in laws and one with husbands were carried out. According to Mack et all (2005), FGD provides a large number of information over a short period of time and is also effective for accessing a broad range of views on a specific topic as opposed to achieving group consensus. Focus group discussion guideline was used for information collection.

2.6 Data analysis technique

The qualitative data have no limited words like quantitative data. These data are words rather than numbers. Therefore the data were collected by using the voice recorders as well as taking notes. A Bangladeshi research assistant was used for data collection who also performed translation of the information from Bengali to English. The translated data were manually analyzed in the framework of content and thematic qualitative data analysis.

The collected data were transcribed verbatim and all the information were recorded and noted from field note, memo and audio record. The data were familiarized through multiple readings of each individual and focus group discussion interview transcript. This helped me to understand and start thinking about the structuring and organization of it into meaningful parts. Coding was performed and then emerging patterns and categories were identified. The data coded on broad categories were further sorted out with specific coding and analysis was done.

Data were displayed by using the data display matrices. Matrices included quotes, repeated verbatims, major ideas, themes and memos. Conclusions and verifications were further drawn from the display matrices especially with the emerging themes. Reflective codes were used to draw conclusions especially with the information drawn from different themes.

2.7 Research team

The researcher and one Research Assistant (RA) collected the data. Before collecting the data, all research instruments (IDI, KII, FGD guidelines) were translated from English to Bengali with the help of RA to minimize the errors. After data collection, data were again translated from Bengali to English for further analysis.

2.8 Ethical consideration

Ethical approval was obtained from the Ethical Review Committee of James P.Grant School of Public Health and the researcher followed all guidelines. Informed verbal consent was taken from the prospective participants before collecting the data. All participants were then informed about the nature and purpose of the study, right to withdrawal, and option to refuse to answer any question. Anonymity and confidentiality of information were maintained at every stage of the study. No name of any respondent was used during the final write up of the thesis. Permission for taking photographs and for recording their voice was taken before conducting each interview and focus group discussion.

Chapter III

Findings

The findings of this study are divided and presented in three different sections based on the specific objectives of the study, previously set concepts and responses from the participants. The first section describes perception on PNC and cultural beliefs on postnatal care based on the responses from the participants. The second section describes cultural practices performed during the last postnatal period. And the third section describes about some of the barriers and difficulties faced by the participants on seeking postnatal care service from health facilities.

3.1 Socio demographic characteristics of the participants

Table : Socio demographic characteristics of the participants

Age

Average age 22.8 years ( 15-30 years in range )

Educational level

Primary education-9, Secondary education-4

and no education-2

Occupation

All housewife

Husband’s occupation

Garment workers-6, Businessman (small shop )-3 Building constructer (Rajmistri)-3, CNG Driver-3

Monthly family income

Average 8100 Tk. (3000-15000 Tk.)

Number of children

Having one child-9, Having two children-3,

Having three child and more-3

Number of family member

Average 6 member (3-14) members

Religion

All Muslim

Place of delivery during last child

BRAC birthing hut-12, Dhaka medical college 2 and Arman medical college -1

All participants of the study were mothers having infants from 6 weeks to 1 year of age. Fifteen mothers were interviewed in depth. The average age of participant was 23 years. However some mothers were very young, even under 18 years. The youngest mother was 15 years old and the oldest participant was 30 years of age. Nine of the participants had attended primary education, four had attended secondary education but not completed and two of the participants had never attended any formal education. All the participants were housewives; none of them was engaged in income earning activities outside their homes. The study found that majority (9) of their husbands were garment workers, while some had small shops and some were CNG driver and building constructor (Rajmistri). Their monthly income ranged from 3,000-15,000 taka with an average of 8,100 taka. Nine of the participants had only one child, 3 had two children and 3 had more than two (3-4) children. The family size ranged from 3-15 members with an average of six members. All the participants were Muslim. As there was a birthing centre of BRAC, most of the participants gave birth to their child at that birthing hut. Only three deliveries occurred at the medical college hospital.

3.2 Perception regarding postnatal period

Perception of women

In-depth interview with participants revealed that women perceive the postnatal period as critical period because in this period many health problem especially fever and hypertension can occur. Most of the participants thought that they should take rest at least 45 days after delivery. Family members should support them on household works. They also said that they need to take nutritious food like meat, fruits and vegetables as well as maintain hygiene otherwise their baby will get sick. They also said that their health should be checked time to time by health service providers. However, they did not have very good knowledge on postnatal complications. Some important findings regarding PNC are described as below:

-Most of the women knew the exact duration of postnatal period

Majority of the respondents were aware about the duration of postnatal period. Ten out of 15 participants reported that the exact duration of postnatal period was 45 days. However, some mothers did not know about the exact duration of PNC. Some of the mothers replied that the postnatal duration of PNC is 2 years and some of the mothers said 1 month. However, the participants had good idea about taking rest during postnatal period. They thought a mother should take rest as much as she can. Some mothers also had idea about this period being a critical period so they should not have sex. A participant said that:

“I think a mother should take care of herself minimum about 45 days, we should not have sex, should be aware.” IDI-14

– Little knowledge on danger sign/complications

From the interview with participants, it was found that very few had the knowledge regarding danger signs during PNC. None of them could say all the five danger signs. Only 1 out of 15 respondents could say at least two danger signs (heavy blood loss and hypertension) during PNC. Very few respondents (3 out of 15) reported fever as a danger sign of PNC, only four out of 15 respondents said that hypertension is a danger sign. Rest of all had no idea on danger signs during postnatal period. During the interview, the participants said that:

“As far as I remember heavy blood flow, body shaking and pressure is bad thing etc.”

IDI -14

“If I face any problem then that is bad for baby, if we face a serious disease then go otherwise don’t. If we face cold we eat Tulshi juice” IDI- 13

“High pressure is bad for me and my baby, because I will be in serious condition.” IDI -3

Except these the participants have good attitude on PNC period.

Perception of family member:

The perception of family member regarding PNC was same as the perception of mothers. They also think mother should take rest up to 3-4 months after delivery. Mother should not do heavy work in this period. But they did not know the exact duration of PNC period. They also thought the family member should support and give them nutritious food like green vegetable and fruits. They were not very much aware about complication but they think if the mother has fever and hypertension then they should go to the doctor, Only very few mother-in-laws said that fever and headache were the bad things during postnatal period. As the same way husbands also had no idea about it they also couldn’t say any danger signs/complications of PNC except fever and hypertension. Some findings are as flow:

-Family members do not know the exact period of PNC

The family members also did not have idea about exact period of postnatal. They believed that the mother should take rest minimum 2-3 months and some of the members said that the mother should take rest about one year. None of the mother in laws and husbands knew the exact period of postnatal period. However they were aware about that the mother should take care of herself and her family member like sister in laws, mother in laws or mothers or and others should support the recently delivered women. They should not do heavy work at that time. Almost all members were agreed about this perception on the discussion. One of the members from focus group discussion said that:

“A mother should take care of herself and baby up to 1 year at least. She should not put herself into more work. Only can do few light work and easy work. She is not allowed to do heavy work and to carry heavy things. Other family members like mother in law or sister in law or mother or sister they can help to do this kind of heavy work.” (FGD- 2 Husband)

The family members also did not know about all five danger signs of postnatal period. Only very few mother -in- laws said that fever and headache were the dangerous during postnatal period. As the same way husbands also had no idea about it they also couldn’t say anything except fever and hypertension. They did not take it very seriously because they did not face these kinds of problem till date.

Perception of Health service provider

The perception of health service provider was positive towards postnatal care. They thought the health condition of mother should be checked frequently because it was very critical period. If any complication appears, they should go to the hospital. She can do light work but should not do heavy work. The family members also should support them during this time. The mother should take rest up to when she feels good.

– No exact period for PNC

Two out of 3 service providers thought that there was no exact period for postnatal care. However, one health care provider said the exact postnatal period was 45 days after delivery. They thought mother should take care up to when she feels good or ready for work. They thought mother can start light work within a few days but she should not do heavy works up to at least six months. One of the service providers expresses that:

“A mother should take rest at least for 1 to 6 months. It is important to take care of mothers health, she should avoid cold otherwise the baby will suffer with cold. She should not carry heavy things in this time; she will be in trouble if she does in this period.” (KII-1 provider)

-Good knowledge on danger signs:

The health providers working under the BRAC birthing hut, were trained on maternal and child heath. They had confidence on their role and responsibility. They said easily about the five danger signs of PNC. All of the health providers had good knowledge on that. Here is the statement of one respondent:

“If we find any mother who will deliver her baby within 24 hours, we measure her blood, ask the condition of her menstruation whether its heavy or not or coming out with bad smell, does she facing any pain in abdomen, does she have any fever (if then measure the temperature)”KII- Provider

3.3 Cultural beliefs

In this section the cultural beliefs related to postnatal care is explained. Basically this section talks about existing superstitions in the study area. It includes beliefs in Tabij, Food taboos, mobility and untouchability/ isolation during PNC.

Beliefs in Tabij

-Women and their mother- in- laws belief in tabij

Everybody had the belief that they must use tabij for the protection of baby and themselves from the evil eye and ghost. If they did not use this, they had to face many problems. This was found to be the most common belief prevailing in the community. The mothers especially wear these in their neck but for the baby they use both neck and waist. They did that as per the suggestion from their elderly. One of the participants stated:

“Yes me and my baby use tabij for our safety and to protect us from evil eyes. The navel, hair, nail, dirt of ear and body are kept those inside a small pieces of cloth and tied up with tabij. It is done to avoid black majic.. When my baby will be 18 months, I will throw it in water. I have also pierced my baby boy’s ear because my grandmother suggested to do that because he was born in “Bhadro”( one of the Bengali month). Though my husband was telling not to do that because otherwise his son will not be able to give Azan (call for prayer) in Mosque” (IDI -7, Line No. 91-98)

Another mother said that:

Yes, my dad gave me Tabij for my baby and me. If I would not use the Tabij I used to see so many weird things. I also become afraid to allow others to come to my house because there were so many people who have sex at night but don’t take shower early in the morning. It’s dangerous; it causes bad sign for a new mother and baby. People suggest me not to allow other lady to carry my baby if they have mince. We tell people to make the hand hot over fire to avoid ghost. We always do this and keep fire outside our room door. We must do this while entering home otherwise baby starts to cry. (IDI -1)

The perception on wearing tabij of mothers was same with the perception of the family member specially the elderly people such as mother in laws in the family. Almost the entire mother in laws reported that they suggested wearing tabij to their daughter in laws to avoid the evil eyes and ghost. They did so because they strongly believed on tabij and they were influenced from their traditional thoughts. They also reported that they used Tabij at their time especially in postnatal period as per the suggestion of their mother in laws and elderly people. Therefore, this was an ongoing process because these things were rooted in their community strongly. Everybody said that if someone did not believe it, he or she will face many problems especially health problems. A mother in law stated during group discussion:

“We believe in tabij because it is traditional thoughts. Our mother-in-laws used it, we used it and also we suggest using it to our daughter in laws. We don’t know who have evil eyes in the society but we know there may be so many bad eyes. So we should protect ourselves by wearing such kinds of things so that one’s bad eyes can’t effect on our body.” (FGD-1 L.N.-20)

-But male participants and providers did not believed in Tabij

The perception regarding wearing tabij was a little bit different among male participants. The same discussion with husbands of recently delivered women was found that they did not believed that much as female participants reported. They thought this was only the people’s beliefs because their elderly people used it and still using it but it had no any scientific evidence that it reduced health problems or any kind of problems. They did not believe on evil eyes or anything of bad insight (kalar dristi). They thought the people who had no enough education, believed more in these kinds of things. They did not think that was a good practice but if their wives wanted to wear the tabij, they did not stop them; they allowed them to wear it. One of the respondents from group said:

“We don’t think it is very good practice to protect from evil eyes. Because we do not know what is evil eye? How is it? So these are all nonsense things. It is traditional things our elderly used it that is why people still believe it but it has no any scientific evidence that it creates health problems or any kind of problems. This is due to lack of education, lake of awareness in the community.” (FGD-2 Husband)

-Service provider don’t believe in Tabij

The same discussion was done with service providers from BRAC birthing hut of that community and it was found that they did not think wearing tabij was a good practice for seeking care. They thought this was a kind of superstitions. It was strongly believed because it was being used since very beginning. So it could not be stopped within one night. However, gradually these kinds of practice ware decreasing. One participant said:

“It is just superstitions because it is traditionally being used by many peoples even the educated people strongly believe it. But we, as service provider don’t suggest wearing tabij. However we can’t stop to do this if somebody wants to do.” (KII- provider)

The service providers personally did not believe wearing tabij but they did not say that this was bad thing directly.

Belief in food taboos

Women’s perspective

– Taboos on some kinds of fishes, vegetables, liquid food and beef

Although the mothers were aware on taking nutritious food during PNC period, still they believed on food taboos. They believed that if they take telapiya, Hilsha, bowal, shoil (Name of Fish) fish, the jinn will attack to mother or baby. They also thought if they take some kinds of vegetable like Kochu shak ,pui shak, (leafy veg.) spinach, brinjal, Shim (bean) Mishti Kumra, they had to face stomach problem like loose motion, pain etc. They had also the belief that they should avoid liquid food like dal (Pulse), soup of vegetable etc because they thought the naval of baby would not become dry and it will take more time to be separate and also there might be the chance of infection if a mother take such kinds of food. Some of the mother also thought the beef was bad thing for PNC. If they take beef within few days after delivery, their breast milk will be dry because beef observes a lot of fluid of the body.

Family member’s perspective

-The family members believe in some food taboos

Family members also believed on restriction of some kinds of food as mothers think. They thought that they should not bring fishes in the house in pray time because it was bad. The mother -in -laws do not allow having fish to their daughter in laws because they think the vaginal discharge will become bad smell. They also thought if the mother takes Mirka fish, she will shake without any region. Therefore, they thought it was better to avoid that kind of fish. The family members also avoided taking spicy and sour food as well as foods from outside like ice cream etc.

Service provider’s perspective

-The service provider also believe in some food taboos

Although the health care providers claimed that they suggested to take any kings of food which contained vitamin, protein, iron, calcium, somehow they also believed on food taboos. One of the health provider said that they suggested not taking beef, shrimp, hilsha fishes etc if the mother had scissoring delivery. If the mothers took those foods, there will be chance of infection. One health care provider also suggested not to take liquid foods like dal because the naval of baby would not be dry and separate soon. They also suggested not to take old bacteria affected food and spicy and sour foods during PNC.

Mobility

Women’s Perspective

Generally, women of that area went shopping near to their home to purchase the daily-required things like vegetables and rice. However, some women during postnatal period were not allowed to go out from their surroundings. Because some women believed on evil eye, so they did not go out for the protection of their baby and herself. However, some did not go out because of weakness.

Family member’s Perspective

The family members thought that it was not good to go outside from home before 3-4 months after delivery because the mother should take rest in home. Few participants also said that they do not allow the mothers to go outside during pray time (Azan) because it’s not good.

“We don’t allow a mother to go outside while Azan (prayer) is going on. Especially at noon and evening prayer time we don’t allow going out. We try to maintain the tradition of our elderly people.” (FGD-2 Husband)

Health service provider’s Perspective

The health service providers also thought it was good to be stay at home during PNC but if needed there should be no any restriction to go outside. They also thought that the mother should not believe on evil eyes.

Untouchability (Isolation)

Mother’s perspective

The participants reported that there was no any practice to keep the mother in separate place during PNC. However, the women with menstruation phase were not allowed to touch newborns because they thought that they were dirty. Mother in postnatal period were allowed to touch everybody but the women with menstruation or having any kind of disease were not allowed to touch the baby. If they wanted to take the baby, they had to dry their hands over the fire. They kept the fire in there room for few days after delivery to make the room warm. One of the participants said:

“No I don’t allow to touch my baby those people who have menstruation and who are sick people are allowed to come in the morning after taking shower, I asked them first whether she has menstruation phase or not, also tell them to make their hand hot over fire. Even my sisters and relatives don’t come to touch me and my son if she has menstruation. I have to maintain theses rules up to 18 months .and still we have to maintain this kind of ritual to save my son and myself. Because our elderly people told us and I also strongly believe this things” IDI-7

Family members perspective

The family members also think that there is not any practice to keep the mothers in separate place. However, they did not touch directly to the baby. Before touching, they died their hands over the fire to get rid of evil eyes. However, there was no any restriction to touch the mother.

“We use fire while entering home to make our hand hot and to become free from evil eyes. We do this because we cross so dirty area. Even when we go to the washroom at night we again use the fire to get rid of evil eyes and Jinn. Fire helps to prevent all bad air around us.” (FGD -1 Mother- in- laws)

Health service provider’s perspective

The health service providers thought that it was good practice to avoid the contamination of dirt things especially for the baby. Before touching the newborn baby, everybody should clean their hands and make warm. However, it was not good to avoid every women with menstruation phase because they also could make their hands clean.

3.4 Context of delivery

Place of delivery

Every mother said that they gave birth to their child in heath facility except one mother because she was in village in her home district during that time. There was no any health facility near by her house so she delivered at her home.

Most of the mothers, (14 out of 15) prefer to deliver in health facility because of safety and privacy. They consider the BRAC birthing hut was very good place for delivery. Because they get support from health providers and also hygiene and privacy was maintained there. They thought the place of delivery should be clean so that there would be no chance of infection

3.5 Cultural practice

Hygiene

Most of the participants maintained their personal hygiene by taking shower after few hours of delivery mainly they cleaned the lower part of the body and washed their own and their baby’s clothes with soap and detergent power. Most of the participants expressed their sincerity on personal hygiene during PNC. Some findings on hygiene were:

-Majority of women dry their cloth pieces inside the room:

In terms of menstrual hygiene (hygiene during vaginal discharge in PNC period) they used to take shower after giving birth to a child to clean the bloody parts however they mentioned that they did not take shower daily and also some participants said that they did not wash their hair due to cold. To maintain the vaginal discharge, most of the participants (11 out of 15) used old cloth pieces during PNC period. After using them they washed with soap and dried inside the room. They did not dry outside the room with sunlight because of shame. They thought it was not good to show these things to other people. There were also some beliefs in the community that they had to hide the menstruation related clothes from the evil eye. One participant said that:

“I use cloth piece during PNC period and wash it with soap and dry it inside the room and keep it another safe place.” IDI-8

-Very few participants use sanitary pad

Only 4 out of 15 participants used sanitary pad during PNC period. They used that pad because they had bothered of washing the cloth pieces as they had to avoid touching cold water at that time. They also used these because it was easy and comfortable. One of the respondents said that:

“I used pad and wrapped with paper and through it to dust bin. Sometimes people wash the pad and wrap it and through it dust bin, to get rid of evil eyes ( Kaler drishti)” IDI-6

-Most of the participants pay attention to keep the room clean

It is necessary to keep clean the place (room) where the recently delivered women live with her baby. Most of participants have the knowledge to keep the room neat and clean as possible as they can. The mothers replied that they maintain the hygiene by wiping the place using dettol (antiseptic liquid) and detergent power time-to-time and changing the bed sheet. One participant said that:

“I always clean my room and wipe the floor properly every day, wash my clothes with soap, wash my bed sheet after every week. The place must be neat and clean otherwise it will become harmful for a mother and baby. I always use hot water and mixed dettol to wash my baby, then use soap to wash him properly.” IDI-1

However, the few mothers (2 out of 15) replied that they do not have enough time to maintain hygiene and they sweep the room only with water. Some of them had difficulties to clean the room properly as they had so many people in a single small room. One of the participants expressed her view that:

“Room was small we used mat over the bed because there were so many people in that room so we couldn’t clean the room properly” IDI-7

Food Intake practice

There were some beliefs that women in postnatal period should not take some kinds of fishes, vegetable (shak) and liquid food because it might cause harmful for baby and mothers. The IDI with participants revealed that there was no that much restriction on food intake. The mother could take any type of food except sour and spicy food. They were given nutritious food like food fruits, leafy vegetables and meat.

-Majority of mother took additional food like fruits, milk and meat, fish etc.

Most of the mothers reported that they took nutritious food in that period. One of the participants said that:

“Ate many kinds of foods, especially had fishes as I was at village, my brother collects them from our pond. Had Taki, koi, bheda, shrimp fish, tengra, and puti fish. I had eaten pui shak, lau shak, Dherosh and only orange as a fruit.”IDI-13

However, there was a restriction on taking certain kinds of food:

-Women did not take liquid food in PNC period.

Some of the participant reported that they were not allowed to take liquid foods specially dal in first few days after giving birth to a child. Because their mother in laws and elderly people suggested them to take, only dry food. If they took liquid food, the baby’s navel would not be dry and separate soon.

-Also did not take beef and some kinds of fishes

One of the participant also said that she was not allowed to take beef in recent days after delivery because beef absorbs more water and decrease the amount of breast milk that creates problem for baby and also the mother.

“No I was allowed to eat everything  but I was not allowed to take beef as it absorbs more water so it dries up breast milk and I will have lost motion” IDI-13

The mother in laws also reported that they do not allow their daughter in laws to have fishes that much because it makes bad smell during postnatal menstruation. The mothers also did not allow taking Mirka (a name of fish) fish because it causes shaking without any reason.

-Mothers do not take sour and spicy food

Majority of the participants reported that they did not take spicy and sour food during PNC period because it affects on mothers and baby’s health. Some of the participant reported that they were not allowed to take some kinds of vegetable particularly leafy vegetable like shak. Because they thought if they take shak they will suffer from diarrhoea and sometimes cold.

“Not allowed to take open foods from outside market, spicy foods, ice-cream, and doctor suggested that if I face infection then don’t eat sour food. Ya, Mirka fish I always avoid because it causes shaking”

Support from family

Most of the participants said that they got support from their family members in household work during postnatal period. Especially mother in laws and mother supported them for cooking, cleaning the room and washing the cloths etc. Therefore, many of the participants got chance for taking rest for at least one month. However, a participant had to work within few days after delivery because she had no one with her except her husband. Her family members lived in another place. Therefore, at that time they could not manage the time to come her home. Normally everybody has the perception that mother should be helped by her family member during that period. One of the participants said that:

“It would be good to take rest while PNC period but its not possible for those who live alone. I also have noone to take care of me and my baby. I need to do every household chores by myself and need to take care of my baby. I think a mother should take rest for atleast 3-4 moths but we are living here only husband and wife and my elderly people couldnt manage to come to take care of us. So my husband take care fo my baby from 9 to 11 am in the morning , then I do cooking and when he left i take care of my child.” IDI-4 L.N. 54-58

The family members and service providers also thought that they should help the mother in postnatal period because in this period a mother should take rest. One of the family members said that

“We as a mother in law do all the work, we allow our daughter in laws to take rest at least for 3 months. We do not give any work to our daughter in laws at this period. Even do not allow to walk on bear foot. We suggest staying careful. BRAC sisters always suggest us and do check up of the mother and baby in the PNC period. To avoid severe cold, we do not let her to do anything. In addition, because if a mother does any work and become sick, baby may face problem.” (FGD-1 Mother-in-laws)

PNC visit

The IDIs with participants revealed that all mothers received PNC care from BRAC. However, in case of frequency and timing of PNC, the mothers did not know the actual routine (standard schedule recommend by WHO) for PNC visit because service providers came to their house. Basically SS visited frequently, almost every 2-3 days, door to door to see the condition whether the baby and mother have any problem or not and SK visits for PNC. During PNC visit, the SK checked the blood pressure, took baby’s weight and provided counselling for newborn care. One of the participants said:

“Yes, BRAC sisters almost come every week. They come to measure my pressure and baby’s weight. they always told me to stay clean and wash cloths with detol and also suggest me to wash properly my cloths which I used for mince period, also to keep baby in clean place, also to use clean dresses.” IDI 8

3.6 Barriers faced in accessing PNC

As BRAC was working in that area, there was no any problem regarding delivery and postnatal visit at that time. The health service providers provided postnatal care to mother in their home. A birthing hut was established within their slum. There were 3 Urban Birth Attendant in the birthing hut. They provided 24 hours delivery service to the mother. They conduct normal delivery; if they found any complication, they referred that case to hospital. There was a SK under this birthing hut; she provided antenatal care and postnatal care as well as health education to mother in their home. As the same way there were 12 SS under this birthing hut. They frequently visited homes, found the new pregnant mother and gave health messages in the community. All basic service of maternal and neonatal health were providing from the birthing hut. Therefore, there were no any difficulties for seeking basic maternal care in the community. All participants including family members said that they had no any difficulties regarding it. They are happy to get home based service without any cost.

However if they had a complication, they had to go another place and paid big cost for the treatment. One of the participant said that she had a problem with her vaginal tear during delivery at birthing hut then she had to go another hospital for the stitch. For that treatment, she had to pay 500 TK. One participant also shared the problem. She also had to admitted in hospital for suture and pay 1000 Tk.

3.7 Summary of the findings

The study explored the perceptions regarding postnatal care among mothers their family members and health service providers in the slum area. The study also explored the cultural belief practices and the barriers in accessing PNC. The findings are presented in three different parts.

Perception on PNC

The findings shows that almost mother consider the PNP as a critical time for the mothers. Most of the participants as well as their family members and health service provider knew that the mother should take rest at least 45 days after delivery. Family members should support them on household works. They also know that they need to take nutritious food like meat, fruits and vegetables as well as maintain hygiene otherwise their baby will get sick. They also aware that their health should be checked time to time by health service providers. They do not have very good knowledge on postnatal complications. However the mothers. However there was some knowledge on danger signs/ complications of PNP among mothers and their family members. They were not very much aware about 5 danger signs of PNP. However, health service providers were well aware on it.

Cultural beliefs:

Beliefs in Tabij: There are many beliefs in that area. Wearing tabij to get rid of evil eyes is the most common belief. Women believe in tabij more than man and health service provider.

Food taboos: There is also a belief on food taboos. It was found that the mothers avoid some food like some kinds of leafy vegetable (shak), certain fishes, beef, and liquid foods like dal (pulse) in PNP. There is a belief that if they take such kind of food, they might be in trouble. Family members and the women have same beliefs on food taboos. The health service providers also not fully out from the beliefs on food taboos. They also believe that the mother should avoid the liquid food like dal and vegetable soup.

Isolation: The mothers and family member’s belief that the mother should not be isolated or kept in separate room but there are some restriction on touching the newborn baby. The women with menstruation are not allowed to touch the baby directly. If they want to take baby they should dry their hands over the fire to get rid from evil eyes. But the health service providers think that it is good to dry the hands before caring the baby in terms of infection prevention but not evil eye.

Mobility: Generally, the women go outside surrounding their home. But they don’t think good to go far from their house before 2-3 months after delivery. Only few mothers reported that they do not go outside due to fear of evil eye. Their mothers in law also suggest them not to go out before 3 months after delivery. In addition, they are not allowed to go outside during pray time.

Cultural practice:

Hygiene: Most of the mothers replied that they maintained hygiene by taking shower or washing their lower part of body after few hours of delivery. Most of them used cloth pieces during menstrual phase in PNC. They wash the cloth pieces with soap and dry inside the room. Only 4 out of 15 use sanitary pad during PNC. They wash the cloths with soap. They also clean the room (living place of mother) with dettol and water. They pay attention to keep everything clean and hygienic.

Food intake practice: All Participants reported that they use to have everything what they wish. They take nutritious food like meat, green vegetables etc. According to them, they are aware about taking good foods during PNC. However, they have some restriction on food intake. Three out of 15 said that they didn’t take liquid food especially dal (pulse) and soup of vegetables because the baby’s naval would not be dry due to such kinds of food. One participant out of 15 also said that she was not allowed to have beef because it absorbs water from the body and makes breast milk dry.

PNC visit: The entire participants reported that they received postnatal care by BRAC sister (SK) at their home. However, they do not know when and minimum how many times should check the health condition during PNC. Blood pressure measurement and weight of baby were taken during PNC visit.

Barriers faced in accessing PNC care

All the participants as well as family members said that they do not have any barriers for accessing PNC care because BRAC sisters come almost every 2-3 days to see the health condition. Therefore, they do not realize any difficulties.

However if they have any complications during PNC, there is no any provision of treatment. They have to go beyond that birthing hut then they have to pay big cost for the treatment. Two out of 15 participants said that they had a problem with vaginal tear during delivery at birthing hut then they did not get treatment from there then they had to go another hospital for the stitch and treatment. For that treatment, they had to pay money.

Chapter IV

Discussion

The study explored the perception of women, their family member and service providers regarding postnatal care in urban slum of Dhaka Bangladesh. The cultural beliefs and practices during postnatal period were explored in this qualitative study. The study also attempted to understand the barriers of seeking postnatal care in slum dwellers. In-depth interview, focus group discussions and key informant interviews were used to collect relevant data for the study. Findings revealed strong belief on tabij for the protection of baby and mothers from evil eye and ghost. Women and their mother in laws believed more than the male participants and service providers. Although the mothers take some nutritious food during PNC, there are some restrictions. The mothers do not take liquid food, beef and some kinds of fishes and shak (leafy vegetable) which directly effects on health of recently delivered women and her baby. There is still some restriction of mobility during PNC. However, the mothers get good support from family member. The study also found the knowledge gaps on timing of post natal period and danger signs of postnatal car because the information provided by SK and SS are more focused on ANC rather than PNC. However, the PNC visit coverage is high in that area. As the BRAC has very good mechanism for providing the MNH service, the community people are very happy with these service and they do not have any difficulties for seeking MNH services.

4.1 Perception of PNC

Knowledge gap

Postnatal period is most critical period for childbearing mother. The literature also shows the majority of maternal deaths occur in this period. Therefore, anybody especially the mothers should be aware about the danger signs / complications that can appear during postnatal period so that they can take action in time for live saving. According to WHO’s recommendation, there are five danger sings need to be recognized immediately. These are: 1.Heavy vaginal blood loss, 2.Fever 3.Bad smelling vaginal discharge 4.Severe headache (sign of hypertension) and 5.Fainting. Among these sings, if any one of them appears, mother should consult a doctor otherwise it may become very dangerous even can occur the death.

Although there is very good home based PNC service providing by BRAC, there is some knowledge gaps on PNC especially danger signs/complication during PNP. Noon of the mothers as well as family members know the 5 danger signs except fever and hypertension. However, health providers have good knowledge in this regards. They have health information card (Antenatal card) which they use to give the mother in antenatal period. There are some messages clearly mentioned regarding danger signs during antenatal period and neonatal care but the messages regarding 5 danger signs/complication of PNC are missing in that chard and also they don’t have other IEC materials focusing these things to spread health message. It seems more focus on ANC than PNC. Due to lack of awareness on danger sign, it can lead the delay in treatment and even the death of mother.

4.2 Cultural beliefs

As this is the urban area, and due to exposure of NGOs, there is not that much traditional beliefs and practices related to PNC. However, this study revealed some beliefs and practices such as restrictions on food intake, wearing tabij, restriction on outside mobility and untouchablity/isolation etc. Believing in evil eye is the most common belief in the community. Almost all mothers and family member except some male participant believe in tabij. It is not directly harmful practice for health but it can affect on health care seeking behaviour that can cause the delay on treatment (Afsana & Rasid, 2000).

Belief in food taboo also exists there which can directly effect on the health. The belief in people is that the mothers in PNP, allow to take only a dry food which can makes the mothers stomach cool (Choudhaury et all, 2011). This study also found the same things and some additional belief on food intake. The mothers avoid liquid food such as dal and soup of vegetable because the naval of baby would not be dry and separate soon. They also avoid some kinds of leafy vegetables because the stomach of mother will be pained and loose motion. Certain kinds of fishes will shake the body if mother have it within few days after delivery. Some of the mothers believe that beef soak up body fluid and make less production of breast milk. These are the harmful practices because it can affect on the nutritional status of the mother and her baby as well (Choudhury et all, 2011).

In south Asia, Including Bangladesh, the mother and the baby are usually isolated immediately after delivery due to belief about impurity and pollution related to the delivery process. In this period, the mother and baby are also considered to be in a vulnerable condition (Goodbum et all, 1995). Isolation was believed to protect from exposure to disease and evil sprit. The women in this study were found that they did not stay at separate due to space constrains. However, they avoided to touch their baby from those women who had in menstruation phase without drying their hands over fire. It is good practice to prevent the infection.

Beliefs influence the practice or behaviour of people therefore these kinds of harmful belief should be reduced by proper health information.

4.3 Cultural practices

The findings of the study showed that the behavour and the practices of the mother were similar as they believed. The mothers were also forced by elderly people to perform such kinds of practices. The main issue was found that the mothers still believed on food taboos and didn’t take some very nutritious foods. The other issue is that very few women used sanitary pad and most of mothers used cloth piece and dried inside room after washing it. The mothers were not aware about that they had to dry in sun light and they had belief to hide those cloths from evil eye.

The other study showed very poor PNC service utilization in slums compared to non slum area (Bangladesh Urban Health Survey, 2006) but the postnatal visit seems very good in this slum because every mother were received PNC by BRAC health care providers more than four times. It is due to home visit service by BRAC staff. However, they were not aware about the timing of postnatal visit. It seems the mothers are dependent on service providers. In addition, it might be that the providers were more focused on physical examination rather than health education. It is good to know the time schedule of PNC visit for the mothers because sometimes mother can go herself for check up.

4.5 Barriers in accessing care

Many study shows that there are many barriers to access the postnatal care in Bangladesh but in this slum there are no any barriers found to be faced by slum dwellers on accessing the postnatal care. It is due to home visit service provided by BRAC. However they have the problems of treatment of complications of PNC. The mothers had to go and pay big cost to the private clinic even for the very simple treatments. If there is a provision for treatment of basic complication, it would be good for poor slum dwellers.

Strengths and limitations

While conducting this study, all the basic procedures were performed to increase the strengths of the study. Data collecting tools were developed after review of literature and shared with supervisor, faculty members, experts of qualitative research and pairs and incorporated their opinion. Before going to the field for data collection, Research Assistant (RA) was oriented adequately about using the tools and its content in depth. The researcher involved herself throughout the duration of data collection and provided the guidance and supervision. All the study participants were informed clearly about purpose of interview or discussion and have taken verbal consent.

The limitation of the study was that the study site was served by BRAC. Therefore, the third objective of this study, which was, to explore the barriers for seeking health care service, was not met. Because there was, no any barriers found to access PNC service due to home visit service and establishment of birthing hut near by the community. The findings are based on self-reported maternal care practices, and may therefore differ from actual practices. However, every effort was made to motivate the participants to provide true and valid information. This study covered only a small part of urban slam in Dhaka and thus may not represent the situation of all slum area in the country. However, it gives an idea about the perceptions, cultural beliefs and practice of slum dwellers regarding PNC.

Conclusion

…However, the knowledge regarding danger sign/ complication was poor. Despite increasing awareness on PNC, some cultural beliefs and practice