Maternal, Neonatal and Child Health in Northern Districts of Rural ...

Maternal, Neonatal and Child
Health in Northern Districts
of Rural Bangladesh
– Profiling the changes during 2008-2010
Md. Mahfuz Al Mamun, Masuma Billah, Sabuj Kanti Mistry,
Peter Nicholls, Brendan Dineen and Hashima-E-Nasreen
May 2012

Maternal, Neonatal and Child
Health in Northern Districts
of Rural Bangladesh
− Profiling the changes during 2008-2010
Md. Mahfuz Al Mamun 1 , Masuma Billah 2 , Sabuj Kanti Mistry 3
Peter Nicholls 4 , Brendan Dineen 5 , Hashima-E-Nasreen 6
May 2012
1
Research Associate, 2 Senior Research Associate, 3 Research Associate, BRAC, Bangladesh, 4 Senior Research Fellow,
University of Southampton, UK, 5 Research Fellow, University of Aberdeen, UK, 6 Research Coordinator, BRAC, Bangladesh

Copyright © 2012 BRAC
May 2012
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Changes of MNCH during 2008-2010
CONTENTS
Abbreviation
Acknowledgements
Executive summary
Page No.
viii
ix
x
Chapter 1 Introduction 1
Chapter 2 Methodology 5
2.1 Study design 5
2.1.1 Study setting 5
2.2 Study population 8
2.3 Sampling 9
2.4 The survey and survey tools 10
2.5 Study variables 10
2.5.1 Wealth index 12
2.6 Data processing and statistical analysis 12
2.7 Ethical approval 12
Chapter 3 Comparison of socio-demographic status 13
3.1 Characteristics of the survey respondents 13
3.2 Social and demographic characteristics of respondents’ husbands 15
3.3 Household characteristics of the respondents 15
3.4 Wealth index 17
Chapter 4 Maternal health 19
4.1 Reproductive history 19
4.1.1 History of abortion 20
4.1.1.1 Complication during abortion and its management 20
4.1.2 History of menstrual regulation 21
4.2 Family planning practices 21
4.2.1 Source of family planning methods 22
4.3 Pregnancy identification 23
4.4 Antenatal care (ANC) 23
4.4.1 Knowledge on ANC 23
4.4.2 Antenatal care practices 24
4.5 Birth preparedness 25
4.5.1 Knowledge on birth preparedness 25
4.5.2 Practices of birth planning 26
4.6 Delivery care 27
4.7 Postnatal care 28
4.8 Maternal danger signs 29
4.9 Treatment-seeking behavior for maternal complications 31
4.9.1 Complications and treatment-seeking behavior during
antenatal period 31
4.9.2 Complications and treatment-seeking behavior during
delivery period 31

Contents
4.9.3 Complications and treatment-seeking behavior during
postnatal period 31
4.10 Referral information for maternal complications 33
Chapter 5 Neonatal health 35
5.1 Essential newborn care 35
5.1.1 Knowledge of neonatal care 35
5.1.2 Practices followed for essential newborn care 37
5.2 Feeding of the newborn and infant 38
5.2.1 Knowledge of feeding children aged up to 12 months 38
5.2.2 Practice of feeding children aged up to 12 months 38
5.3 Birth weight 39
5.3.1 Birth weight of newborn 39
5.4 Thermal care for normal and low birth weight baby 40
5.5 Newborn illnesses 41
5.6 Neonatal danger signs 43
Chapter 6 Child health 45
6.1 Immunization of children 45
6.1.1 Vaccination coverage 45
6.2 Acute respiratory infection (ARI) 47
6.2.1 Prevalence of ARI 47
6.2.2 Management of ARI 48
6.3 Childhood diarrhoea 49
6.3.1 Prevalence and feeding during diarrhoea 50
6.3.2 Treatment of diarrhoea 51
6.4 Prevalence and management of Illnesses other than ARI and diarrhoea 51
Chapter 7 Factors associated with outcomes 53
7.1 Factors selected for analysis 53
7.1.1 Receiving four or more ANC actions from trained providers 53
7.1.2 Safe delivery (delivery by trained birth attendant) 54
7.1.3 Receiving PNC from trained providers 55
7.1.4 Treatment-seeking from medically trained providers for delivery
complication(s) 56
7.1.5 Use of modern family planning methods 57
7.1.6 Use of modern family planning methods among married
adolescent girls 58
7.1.7 Having all birth plans 59
7.1.8 Received all essential newborn care actions 59
7.1.9 Management of birth asphyxia by trained providers 60
7.1.10 Management of neonatal sepsis by qualified doctors 61
7.1.11 Management of ARI by medically trained providers 61
7.1.12 Management of diarrhoea by trained providers 62
Chapter 8 Discussion 63
8.1 Maternal health 63
8.1.1 Family planning 63
8.1.2 Adolescent motherhood 63
8.1.3 Abortion and menstrual regulation 64
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Changes of MNCH during 2008-2010
8.1.4 Antenatal care 64
8.1.5 Birth preparedness 65
8.1.6 Delivery care 65
8.1.7 Postnatal care 66
8.1.8 Maternal danger signs, complications and management 66
8.1.9 Inequity in maternity care 67
8.2 Newborn care 67
8.2.1 Essential newborn care 68
8.2.2 Thermal care 68
8.2.3 Newborn feeding 69
8.2.4 Neonatal danger signs and illnesses 69
8.3 Health of children under-5 years of age 69
8.3.1 Vaccination of the under-5 children 70
8.3.2 Acute respiratory infection 70
8.3.3 Diarrhoea prevalence and management 71
8.3.4 Management of other illnesses among under-5 children 71
8.4 Methodological considerations 71
8.5 Conclusion and programmatic implications 72
References 75
Annexures 79
LIST OF TABLES
Table 2.5.1 List of variables 11
Table 3.1.1 Social and demographic characteristics of the respondents 14
Table 3.2.1 Social and demographic characteristics of respondents’ husband 15
Table 3.3.1 Household characteristics of the respondents 16
Table 4.1.1 Summary statistics for reproductive history 19
Table 4.2.1 Family planning practices 22
Table 4.3.1 Pregnancy identification 23
Table 4.4.1 Antenatal care practices 24
Table 4.5.1 Birth planning practices 26
Table 4.6.1 Delivery care practices 27
Table 4.7.1 Postnatal care practices 28
Table 4.8.1 Information on maternal danger signs of the respondents (percentages) 30
Table 4.9.1 Maternal complications faced and treatment-seeking behaviour for such
complications 32
Table 5.1.1 Knowledge of essential neonatal care actions 36
Table 5.1.2 Essential neonatal care received at last delivery 37
Table 5.2.1 Feeding practices of the newborn and infants 29
Table 5.3.1 Measuring birth weight of newborn 40
Table 5.4.1 Thermal care for normal and LBW babies 41
Table 5.5.1 Prevalence and management of birth asphyxia and
neonatal sepsis (percentages) 42
Table 5.6.1 Knowledge on neonatal danger signs 43
Table 6.1.1 Vaccination, vitamin A supplementation and De-worming information 46
Table 6.2.1 Prevalence of ARI among children aged 0-59 months 48
Table 6.3.1 Information on treatment of diarrhoea 51
Table 6.4.1 Prevalence of other illnesses among children aged 0-59 months 52
Table 7.1.1 Multivariate logistic regression results for receiving 4+ ANCs from trained
provider 54
Table 7.1.2 Multivariate logistic regression results for safe delivery 55
v

Contents
Table 7.1.3 Multivariate logistic regression results for receiving PNC from
trained providers 56
Table 7.1.4 Multivariate logistic regression results for treatment-seeking from medically
trained providers for delivery complication(s) 57
Table 7.1.5 Multivariate logistic regression results for the use of modern FP methods 58
Table 7.1.6 Multivariate logistic regression results for the use of modern contraceptives
among married adolescent girls 58
Table 7.1.7 Multivariate logistic regression results for having all birth plans 59
Table 7.1.8 Multivariate logistic regression results for the practices of ENC 60
Table 7.1.9 Multivariate logistic regression results for the management of birth asphyxia
by trained providers 60
Table 7.1.10 Multivariate logistic regression results for the management of neonatal
sepsis by qualified doctors 61
Table 7.1.11 Multivariate logistic regression results for the management of ARI by
medically trained providers 62
Table 7.1.12 Multivariate logistic regression results for the management of diarrhoea by
trained providers 62
LIST OF FIGURES
Figure 2.1 District profile of survey areas 5
Figure 2.2 Map of survey areas 6
Figure 2.3 Study population 8
Figure 3.1 Wealth index 17
Figure 4.1 Ever had abortion 20
Figure 4.2 Percentage distribution of abortion, by type in three survey areas 20
Figure 4.3 Ever had MR 21
Figure 4.4 Sources of modern FP methods 23
Figure 4.5 Providers of ANC (trained and medically trained) 25
Figure 4.6 Percentage of having all major birth plans
(place, attendant and saved money) 26
Figure 4.7 Facility delivery(Public/Private) 27
Figure 4.8 Received at least one PNC from BRAC SK 29
Figure 4.9 Referred for maternal complication(s) 33
Figure 5.1 Knowledge of LBW baby management 36
Figure 5.2 Percentage of LBW babies 39
Figure 5.3 Prevalence of birth asphyxia 42
Figure 6.1 Complete vaccination for children aged less than five years 46
Figure 6.2 Prevalence of pneumonia (aged 2-59 months) 47
Figure 6.3 Prevalence of severe pneumonia (aged 2-59 months) 47
Figure 6.4 Management of pneumonia (aged 2-59 months) 49
Figure 6.5 Management of severe pneumonia (aged 2-59 months) 49
Figure 6.6 Feeding ORS during diarrhoea 50
Figure 6.7 Breast feeding during diarrhoea 50
Figure 6.8 Management of other illnesses by qualified doctors 52
LIST OF ANNEXURES
Annex 1 Revised logical framework 79
Annex 2 Profiling the changes over time (2008-2010) 82
Annex 2.1 Socioeconomic characteristics 82
Annex 2.1a Distribution of wealth index by district (Nilphamari, Rangpur and
Gaibandha) 82
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Changes of MNCH during 2008-2010
Annex 2.1b Distribution of wealth index by district (Mymensingh,
Naogaon and Netrokona) 82
Annex 2.2 Maternal health 82
Annex 2.2.1 History of abortion 82
Annex 2.2.2 Complication during abortion and its management 83
Annex 2.2.3 History of MR 84
Annex 2.2.4 Knowledge on antenatal care 85
Annex 2.2.5 Knowledge on birth preparedness 85
Annex 2.2.6 Respondents faced complications during antenatal period 86
Annex 2.2.7 Treatment-seeking behaviour for antenatal complications 87
Annex 2.2.8 Complications faced during delivery period 88
Annex 2.2.9 Treatment-seeking behaviour for delivery complications 89
Annex 2.2.10 Respondents faced complications during postnatal period 90
Annex 2.2.11 Treatment-seeking behaviour for postnatal complications 90
Annex 2.2.12 Referrals for maternal complications 92
Annex 2.3 Neonatal health 93
Annex 2.3.1 Knowledge of feeding children aged up to 12 months 93
Annex 2.3.2 Feeding practices of the newborn and infants 93
Annex 2.3.3 Experiencing neonatal danger signs and its management 94
Annex 2.4 Child health 95
Annex 2.4.1 Management of ARI among children aged 0-59 months 95
Annex 2.4.2 Prevalence of diarrhoea and related feeding practices 95
Annex 2.4.3 Treatment of other illnesses among children aged 0-59 months 96
Annex 3 Univariate analysis for identifying factors 97
Annex 3.1 Identification of factors predictive of receiving 4+ANCs 97
Annex 3.2 Identification of factors predictive of safe delivery 98
Annex 3.3 Identification of factors predictive of PNC from trained providers 99
Annex 3.4 Identification of factors predictive of treatment-seeking for delivery
complications 100
Annex 3.5 Association of different socioeconomic factors with the use of
modern FP methods 101
Annex 3.6 Association of different socioeconomic factors with the use of
modern FP among married adolescent girls 102
Annex 3.7 Association of different socioeconomic factors with having all
birth plans 103
Annex 3.8 Association of different socioeconomic and maternal factors with
receiving all essential newborn care 104
Annex 3.9 Association of different socioeconomic and maternal factors with
birth asphyxia managed by trained providers 105
Annex 3.10 Association of different socioeconomic and maternal factors with
neonatal sepsis managed by qualified doctors 106
Annex 3.11 Association of different socioeconomic and maternal factor with
management of ARI by medically trained providers 107
Annex 3.12 Association of different socioeconomic and maternal factor with
management of diarrhoea by trained providers 108
vii

Abbreviation
ABBREVIATION
ANC
ARI
BCG
BDHS
BFS
BHP
BMRC
CPR
CSBA
DPT
EmOC
ENC
FP
FWA
FWC
FWV
HNPSP
IEC
IGA
IGVGD
IMNCS
IUD
LBW
LDC
MA
MCWC
MDG
MMR
MNCH
MR
NGO
NHPSP
PCA
PNC
RED
SACMO
SD
SK
SPSS
SS
SWAP
TBA
TT
TTBA
TUP
UHC
WHO
WI
Antenatal Care
Acute Respiratory Infection
Bacillus Calmette-Guerin
Bangladesh Demographic and Health Survey
Bangladesh Fertility Survey
BRAC Health Programme
Bangladesh Medical Research Council
Contraceptive Prevalence Rate
Community Skilled Birth Attendant
Diphtheria Polio Tetanus
Emergency Obstetric Care
Essential Newborn Care
Family Planning
Family Welfare Assistant
Family Welfare Center
Family Welfare Visitor
Health, Nutrition and Population Sector Programme
Information, Education and Communication
Income Generating Activities
Income Generation for the Vulnerable Group Development
Improving Maternal Neonatal and Child Survival
Intra-Uterine Death
Low Birth Weight
Least Developed Countries
Medical Assistant
Maternal and Child Welfare Center
Millennium Development Goal
Maternal Mortality Ratio
Maternal, Neonatal & Child Health
Menstrual Regulation
Non-governmental Organization
National Health and Population Sector Programme
Principal Components Analysis
Post-natal Care
Research and Evaluation Division
Sub-assistant Clinical Medical Officer
Standard Deviation
Shasthya Kormi
Statistical Package for Social Sciences
Shasthya Shebika
Sector Wide Approach
Traditional Birth Attendant
Tetanus Toxoid
Trained Traditional Birth Attendant
Targeting the Ultra Poor
Upazila Health Complex
World Health Organization
Wealth Index
viii

Changes of MNCH during 2008-2010
ACKNOWLEDGEMENTS
We would like to acknowledge the immense support and extensive co-operation of Dr. Mahabub
Hossain, Executive Director, BRAC and Dr. WMH Jaim, Director, Research and Evaluation Division
(RED), BRAC to accomplish the study. Deepest gratitude to Dr. Kaosar Afsana, Director, BRAC
Health Programme (BHP), who helped us immensely. We are thankful to Dr. Syed Masud Ahmed,
Senior Research Coordinator, BRAC RED for reviewing the report. Sincere thanks to Dr. Peter
Byass, Professor of Epidemiology, University of Aberdeen and Umeå International School of Public
Health for his substantial help in designing the survey. Thanks are due to Mr. Hasan Shareef Ahmed
for editing the manuscript. We are also indebted to Mr. Syed Suaib Ahmed for logistic and
management support. Special thanks to all donors for their financial support. Sincere homage goes
to all of the study respondents for their assistance and valuable time to provide information for the
study.
RED is supported by BRAC's core fund and funds from donor agencies, organizations and
governments worldwide. Current donors of BRAC and RED include Aga Khan Foundation Canada,
AusAID, Australian High Commission, Bill and Melinda Gates Foundation, Canadian International
Development Agency, CARE-Bangladesh, Department for International Development (DFID) of UK,
European Commission, Euro consult Mott Mac Donald, Global Development Network Inc (GDN),
The Global Fund, GTZ (GTZ is now GIZ) (Germany), Government of Bangladesh, The Hospital for
Sick Children, Institute of Development Studies (Sussex, UK), Inter-cooperation Bangladesh,
International Labour Office (ILO), IRRI, Liverpool School of Tropical Medicine, Manusher Jonno
Foundation, Micro-Nutrient Initiative, NOVIB, Plan Bangladesh Embassy of the Kingdom of the
Netherlands, Swiss Development Cooperation, UN Women, UNHCR, UNICEF, Unilever-UK,
University of Leeds, World Bank, World Food Programme, World Fish, Winrock International USA,
Save the Children USA, Save the Children UK, Safer World, Rockefeller Foundation, BRAC UK,
BRAC USA, Oxford University, Karolinska University, International Union for Conservation of Nature
and Natural Resources (IUCN), Emory University, Agricultural Innovation in Dryland Africa Project
(AIDA), AED ARTS, United Nations Development Program, United Nations Democracy Fund, Family
Health International, The Global Alliance for Improved Nutrition (GAIN), Sight Saver (UK), Engender
Health (USA), International Food Policy Research Institute (IFPRI) and Yale/Stanford University.
ix

Executive summary
EXECUTIVE SUMMARY
INTRODUCTION
In late 2008, BRAC initiated a comprehensive five-year maternal neonatal and child health (MNCH)
programme named ‘Improving maternal, neonatal and child survival (IMNCS)’ to promote maternal,
neonatal and child health in three selected northern districts of Bangladesh - Rangpur, Gaibandha
and Mymensingh. These interventions are in addition to the three core BRAC programmes carried
out in all districts of Bangladesh, namely microfinance, health and education. The design of these
new interventions has been guided by experience gained through a pilot phase of the research
which began in 2006 in Nilphamari district.
The baseline survey of 2008 was carried out before launching the IMNCS interventions in six districts
– four interventions and two controls. In control districts – Naogaon and Netrokona, no MNCH
interventions were in place. Based upon pilot and scaling-up experiences, in 2010, BRAC Health
Programme took a decision to further scale up its MNCH interventions in six additional districts of
Bangladesh – Faridpur, Madaripur, Rajbari, Magura (central), and Kurigram and Lalmonirhat
(northern). To elucidate the type and degree of impact of the BRAC IMNCS project intervention, a
follow-up survey has been undertaken in these 13 districts in 2010, including the similar six districts
of 2008. The survey of 2010 considered Jhenaidah as a control district. Hence, survey of 2010 has
been acted as midline for the older districts and baseline for the new districts. This report compares
baseline (2008) and follow-up data (2010) to record the benchmark changes made in various
aspects of MNCH as a result of BRAC-IMNCS programme in four intervention and two control
districts in northern part of Bangladesh. Nilphamari has been considered as the index district for
assessing changes in performance of ‘objectively verifiable indicators’ of the logical framework
developed for the BRAC IMNCS programme.
METHODOLOGY
This quasi-experimental study was carried out in 13 rural districts of Bangladesh, where BRAC
operates its core development initiatives i.e. microfinance, education, community empowerment,
human rights and legal services (HRLS), water, sanitation and hygiene (WASH) and health. In
addition, BRAC health programne (BHP) operates IMNCS programme in 10 of the aforementioned
13 districts. The components of BRAC IMNCS intervention include improving awareness of family
planning, identification of pregnancy, providing antenatal, delivery and postnatal care, essential
newborn care, management of newborn and child illnesses, referral for complications and improving
clinical management in health facilities. Naogaon, Netrokona and Jhenaidah were however, devoid
of IMNCS activities and termed as control areas.
A multi-stage cluster random sampling procedure was employed, involving random selection at four
levels: households within villages, villages within unions, unions within upazilas and upazilas within
districts; and the selection of intervention and control settings was purposive. In 2010, the same
villages that were included in the 2008 survey were selected for the midline follow-up survey. In this
light the sampling strategy for this research was characterized by a panel data approach.
Two groups of mothers having the following criteria were selected for interview:
• Group 1: Mothers who have had any pregnancy outcome within the past one year at the time of
survey (mother of under-1 live child; or mother of under-1 child died in the past year; or mother
who experienced any abortion or MR or stillbirth or IUD in the last one year).
• Group 2: Mothers of live child aged 12-59 months.
Data were collected using a structured questionnaire adopted from that used in the recent
demographic and health survey (DHS) of Bangladesh, and included socio-demographic
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Changes of MNCH during 2008-2010
characteristics of the household, and the respondent’s knowledge and practice of family planning,
maternal, neonatal and under-5 child healthcare.
Information on ante-partum, child-birth, post-partum and newborn care was obtained from mothers
belonging to the group of respondents with a pregnancy outcome in the last 12 months. Mothers
who have had menstrual regulation (MR), abortion, intra-uterine death (IUD) or whose baby had died
were not asked about neonatal or child care. Mothers of children aged 12-59 months were asked
several questions regarding their youngest child in that age range, as it was possible that a given
mother may have more than one child of these ages. The questions focused on key illnesses (acute
respiratory infection, diarrhoea) and their management as well as related health issues such as
immunization status and vitamin A intake.
The sample size was determined considering the changes over time of log-frame indicators, 80%
statistical power, 1% level of significance and a design effect of 1.5. The final sample size was 720
mothers per district, 420 from Group 1 and 300 from Group 2. Accordingly, the 2010 survey was
carried out on 9,360 respondents in 13 districts. The survey encompassed 780 villages in 156
unions within 72 upazilas of 13 districts. A sub-total of 5,460 mothers belonged to Group 1 and
3,900 to Group 2.
The 2008 baseline data were merged with 2010 data, and we considered only the same six districts
of 2008 baseline survey. Then the total six districts were split into three strata according to the
length of intervention: Nilphamari (intervention began in 2006), Rangpur, Gaibandha and
Mymensingh (intervention began in 2008), and Naogaon and Netrokona (control districts, from
2008). In each case, the attention had been given on the comparison between 2008 and 2010 data
focusing on the project’s log frame indicators on the variables of knowledge and practice of
antenatal, safe delivery, post-natal, neonatal and child healthcare. Chi-square test, independent t-
test and Mann-Whitney U test had been used to assess the statistical significance of differences, if
any. Multiple logistic regression analyses were also performed to assess the simultaneous effects of
other variables on the project’s main outcome indicators i.e utilization of 4+ ANC, PNC from trained
provider, delivery by trained birth attendants, and health-seeking from medically trained providers in
the case of childhood illnesses.
FINDINGS
Socioeconomic profile of the respondents
The mean age of respondents was 24 years in Nilphamari and 25 years in the rest of the study
areas. Literacy rate was 53% in Nilphamari and 55% elsewhere with average years of schooling of 4
everywhere. The respondents were mostly housewives though their involvement with some income
generating activities had significantly been increased in Nilphamari, but the percentage remained low
(11%) in other three intervention districts. The proportion of landless people was increased
substantially across everywhere in the course of time, with the highest land ownership in control
areas. Somewhat decreasing trend was found in BRAC membership; most of the member of BRAC
was involved with Dabi ∗ which was highest in Nilphamari (81%). The percentage of households
eligible for BRAC membership had increased 10% everywhere in the study areas.
More than 98% of the households were headed by men and the average household size was 5 in all
study areas. Around 6 out of 10 families were nuclear. Less than 1% respondent collected water
from any source other than tubewell for both drinking and cooking purposes. The use of sanitary
toilet (water seal and septic tank) decreased in Nilphamari (27% to 16%) but remained almost similar
in elsewhere. In Nilphamari and in control areas, the use of soap for hand washing after defecation
∗ Dabi- Poverty alleviation for poor landless women
xi

Executive summary
had decreased (56% in 2008 to 46% in 2010 and 50% to 41% respectively); however it remained
unchanged in Rangpur, Gaibandha and Mymensingh.
Wealth index
The wealth index was calculated using a weighted sum of household assets. The resulting scores
were then ranked and the sample was divided into quintiles from one (poorest) to five (richest). The
distribution of wealth index in all the six study districts was analyzed separately. Very little changes
observed over the two year period. In Gaibandha and Naogaon, a slightly higher percentage of
people belonged to poor quintiles in 2010 compared to the baseline. Across Nilphamari however,
around 17% people were in the fourth quintile at baseline which reached to 21% by 2010 and in
Rangpur, a slight increase had been noticed. Conversely, poverty was found to be intensified in
Netrokona over time and appeared as the poorest district (34% in the poorest quintile) in 2010.
Reproductive history
Respondent’s median age of marriage was 15 years and first conception was 17 years in all
intervention areas, and the median age of first marriage was 16 years and first conception was 17
years in control districts. In Nilphamari, 16% of the respondents experienced one or more under-5
child death, 18% in other three intervention districts, and 15% in the control districts. Three-quarters
of the under-5 deaths occurred during the neonatal period.
Abortion and menstrual regulation
In Nilphamari, 9% of the respondents experienced abortion in their lifetime compared to 14% in
other three intervention and 16% in the control districts. Excessive bleeding and abdominal pain
were the frequently reported abortion complications. In the event of complications, more than half
sought treatment from qualified doctors in Nilphamari, 33% in other three intervention and 36% in
control districts. Four percent of the mothers in Nilphamari experienced MR in their lifetime that was
slightly increased everywhere. In Nilphamari, 60% of MR-related complications were managed by
qualified doctors, which were gone down from 50% to 18% during 2008 - 2010 in other intervention
districts.
Antenatal care
Receiving at least four antenatal cares from trained providers was found to be increased significantly
across all the three study areas during 2008 and 2010, with the highest achievement in Nilphamari
increasing from 76% to 92%. The percentage of pregnant women who received at least one ANC
from a trained provider was >90% in all the intervention districts, far greater than that for the control
districts (59%). The most common provider of ANC in the intervention districts were BRAC workers,
namely Shasthya Kormi (SK) (94% in Nilphamari and 83% in other intervention districts).
Birth preparedness
The respondents in Nilphamari were more likely to determine places (100% in Nilphamari, 92% in
other three intervention, and 84% in control districts), attendants (96% in Nilphamari, 86% in other
three intervention, and 71% in control districts) and save money (79% in Nilphamari, 65% in other
three intervention districts, and 40% in control districts) for emergency preparations compared to
other intervention and control districts.
Delivery care
Facility delivery was more likely to take place in Nilphamari (26%) compared to other study districts
(19% in Rangpur, Gaibandha and Mymensingh, and 23% in control). Delivery with assistance of
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Changes of MNCH during 2008-2010
trained providers increased everywhere during 2008-2010 (52% to 74% in Nilphamari, 33% to 54%
in other three intervention districts and 43% to 55% in control districts), with highest achievement in
Nilphamari. Nilphamari had achieved the universal level in cord tying and cutting using sterile
instrument (97% and 99% respectively); the percentages were also high in other study areas.
Postnatal care
Receiving PNC from trained provider increased significantly in intervention areas (72% to 92% in
Nilphamari and 17% to 65% in other three intervention districts). For home deliveries, 75% of the
mothers in Nilphamari were provided with at least one PNC by BRAC SKs within 48 hours of
delivery, whereas, it was 40% in other three intervention districts. On the other hand, 61% of the
respondents in control districts received no PNC compared to 30% in Rangpur, Gaibandha and
Mymensingh, and 5% in Nilphamari.
Maternal danger signs, complications and management
More women (47%) retained knowledge of three or more (maximum five) primary danger signs in
Nilphamari compared to other areas (25% in Rangpur, Gaibandha and Mymensingh, and 24% in
control districts). Six out of every 10 women facing maternal danger signs sought treatment from
public or private health facilities in Nilphamari, which was little lower in other study areas (43% in
other three intervention and 50% in control districts).
The reported maternal complications during antenatal, delivery and postnatal period were found to
be higher in control districts compared to intervention districts. Though the prevalence of
complications increased over the two-year period, the percentage of women seeking treatment from
medically trained provider and health facility (hospital/clinic) for such complications had also been
increased in all intervention areas. The identified prime factors for not seeking treatment for such
complications included respondent’s perception of treatment was not necessary and lack of money.
Care of the newborn
Almost universal level of achievement was observed in Nilphamari and other intervention districts in
the case of wiping practice, whereas in control areas it was 88%. Among the normal weight babies,
bathing practice on or after three days decreased significantly (from 86% to 76%) in Nilphamari, but
slightly improved (from 61% to 65%) in other three intervention districts, whereas in control areas the
percentage declined from 80% to 70%. However, among the low birth weight (LBW) babies, bathing
practice after seven days was increased in every intervention areas (51% to 60% in Nilphamari and
35% to 44% in other three intervention settings), but in control districts it decreased from 67% to
46%.
Newborn feeding
In Nilphamari, 88% of the mother instantiated breastfeeding within one hour of birth in 2008 which
was remained unchanged. A positive trend was also visible in other three intervention areas where it
increased from 74% to 83%. In control, however the percentage remained unchanged (83%). A
significant increase was observed in breastfeeding exclusively up to six months in Nilphamari from
42% in 2008 to 62% in 2010. However, a downward trend in exclusive breastfeeding was noticed in
Rangpur, Gaibandha and Mymensingh (29% in 2008 and 26% in 2010) and remained unchanged in
control districts.
Neonatal illness
The percentage of neonates faced breathing difficulties (birth asphyxia) remained similar in
Nilphamari (9.8% in 2008 and 9.4% in 2010) and in other three districts (10.4% in 2008 and 10.6%
xiii

Executive summary
in 2010) over the two year period. One-fifth of the neonates faced neonatal sepsis in Nilphamari
which remained same (20.2% in 2008 and 21.1% in 2010). In Rangpur, Gaibandha and
Mymensingh, significant progress was observed (19% to 10%) in reducing the prevalence of sepsis.
But the reported prevalence increased from 22% to 25% in control districts.
Immunization coverage of under-5 children
Nilphamari achieved the highest level of completed childhood immunization (89%) followed by
control (82%) and Rangpur, Gaibandha and Mymensingh districts (81%). Over the two-year period,
significant increase in Vitamin A coverage was observed, reaching around 90% in all study areas.
Acute respiratory infection (ARI) in under-5 children
The prevalence of pneumonia of children aged 2-59 months decreased significantly to 1.6% from
9.4% in Nilphamari, 6.0% from 12.9% in Rangpur, Gaibandha and Mymensingh, and 10.0% from
17.0% in the control setting. Likewise, a significant reduction in the prevalence of severe pneumonia
was also identified in all the intervention settings (3.1% from 12.3% in Nilphamari and 4.3% from
10.2% in the other three intervention districts), though not in control districts. The majority of
pneumonia cases were managed by non-formal health providers. Management of pneumonia by
medically trained providers was shown to be increased in all intervention areas but not in control.
The percentage of children with severe pneumonia managed by medically trained providers was
found to be greater than that for pneumonia, across all the surveyed areas, though non-formal
healthcare providers dominated in the provision of care for severe pneumonia cases.
Childhood diarrhoea
Prevalence of diarrhoea was found to be unchanged over two years in Nilphamari, although
decreased (12% from 15%) in other three intervention districts, and the highest prevalence in control
districts (15%). Greater than 80% of the children in intervention districts were rehydrated with oral
rehydration solution (ORS), whereas less than three-quarters of children in control districts received
ORS. Breastfeeding during diarrhoeal episodes remained high in all survey areas.
Other childhood illnesses and health-seeking behaviour of under-5 children
The prevalence of other conditions like skin disease, dysentery, mouth ulcer, worm infestation, and
ear and eye infections were reduced both in intervention and the control districts. Fever was found
to be the most commonly reported symptoms in all study areas.
Factors associated with selected outcome variables
Carrying out multivariate logistic regression, wealth index was not found to be associated with any
outcome variable in the intervention districts. In control areas, it was significantly associated with
receiving 4+ ANCs from trained provider, PNC from trained provider and treatment seeking from
medically trained provider for delivery complication. No covariate was found to be significantly
associated with management of birth asphyxia by trained provider and neonatal sepsis by qualified
doctor in the intervention areas. Parity was found to be associated with birth asphyxia management.
Husband’s education and age at first marriage were associated with the management of neonatal
sepsis in control areas. Husband’s education in intervention districts, and mother’s literacy and
wealth index in control areas were found to be associated with the management of ARI among
under-5 children by medically trained provider.
xiv

Changes of MNCH during 2008-2010
CONCLUSION
Differences were observed within the study areas over time. A notable improvement was observed in
Rangpur, Gaibandha and Mymensingh. The highest achievement was found in Nilphamari in
receiving ANC and PNC from trained providers, birth plan, delivery by medically trained birth
attendant, receiving all essential newborn care, initiation of breastfeeding within one hour of birth,
and care for LBW babies. This evidenced the effect of the length of intervention on knowledge and
practice regarding MNCH issues.
Though a positive trend was observed regarding delivery by medically trained provider, mothers
receiving PNC from medically trained providers and management of birth asphyxia by trained
providers in Rangpur, Gaibandha and Mymensingh districts, these percentages are lower than that
of the control districts. Programme need to pay more attention on these issues.
More intensive analysis of the data may draw conclusive findings and would also highlight the actual
contribution of MNCH intervention.
xv

Changes of MNCH during 2008-2010
Chapter
1
Introduction
At least one pregnant woman dies every minute globally, leading to an estimated 358,000 maternal
deaths annually due to pregnancy-related complications (WHO 2010). Estimate also indicates that
approximately 10 million under-5 child deaths are likely to occur annually given the present trends
(World Vision Australia and Nossal Institute for Global Health 2008). Notably women living in least
developed countries (LDC) are 300 times more vulnerable to die in similar situation with the highest
rates of maternal mortality existing in sub-Saharan and South Asia including Bangladesh (Richards
2009).
The overall scenario of maternal and neonatal health of Bangladesh is characterized by relatively high
levels of morbidity and mortality. The country is densely populated and approximately 3.5 million
births take place each year, the great majority of which (76%) take place at home without medical
assistance (BMMS 2010). Furthermore, 54% of expectant mothers receive antenatal care (ANC)
from medically trained providers whilst even far fewer women (23%) are cared for post-natally by a
qualified person (BMMS 2010). As of 2009, it was estimated that the lifetime risk of maternal death
in Bangladesh was very high, i.e. the probability that a 15-year old female will die eventually due to a
maternal cause was one in 21 (approximately 5%). It merits highlighting that favourable progress on
maternal, neonatal and child health (MNCH) status has been achieved in recent years. The maternal
mortality rate (MMR) has declined from 320 live births in 2001 to 194 per 100,000 live births in 2010
(BMMS 2010). It remains high particularly amongst adolescent mothers (Dawson et al. 2010) and
among those who are living in rural areas, where 75% of the total population live and almost 80% of
maternal deaths occur (IRIN 2010). Effective measures need to be taken to lower the MMR to
143/100,000 live births by 2015, the millennium development goals (MDG) target for Bangladesh.
Given the present estimated MMR nationally, achieving this target poses particular challenges (WHO
2010).
A progress has been achieved in child mortality between 2004 and 2007 having fallen from 88/1,000
live births to 65/1,000 live births (BDHS 2007). The neonatal mortality is still high in the country that
accounts for more than half of all under-five deaths and more than two-thirds of all infant deaths
(BDHS 2007). The proportion of neonatal deaths to infant mortality has increased during 2002 to
2006, due to the lack of progress in preventing neonatal deaths through appropriate antenatal and
delivery care. Evidence indicates that in Bangladesh, nearly 80% of all newborn babies do not
receive postnatal care (PNC) from trained providers within six days of birth (UNICEF 2009).
It is reported that the major newborn killer is neonatal sepsis (52%) followed by birth asphyxia
(inability to breathe at birth 21%). LBW (11%) also contribute substantially to the burden of poor
neonatal outcomes. Women and children who survive, complications during childbirth have an
increased risk of further health problems e.g. disabilities in children (UNICEF 2009).
1

Introduction
Evidence indicates that maternal death carries negative impact on the likelihood of survival of the
newborn child. Those children whose mother succumbed to a maternal-related cause are 10 times
more likely to die within two years of their mother’s death (WHO 2010a). The estimated lifetime risk
of dying from pregnancy and childbirth-related causes in Bangladesh is around 100 times higher
than that of high-income countries. About 75% of the babies born to those women also die within
the first week of their birth (WHO 2004).
Evidence shows that 74% of all maternal deaths could be averted if all women had access to the
interventions for preventing or treating pregnancy and birth complications (Hunt and Mesquita 2010).
The United Nations calls for achieving the MDGs by 2015 with special attention to the reinforcement
of safe motherhood initiatives and child survival programmes (United Nations 2010). In this light
MDG 5 emphasizes the need to reduce by 2015, e.g. MMR by three-quarters from that of 1990.
Likewise, MDG 4 calls for a reduction in child mortality by two-thirds of the under-five mortality rate
from 1990 by 2015.
By following the steps of the global community, the government of Bangladesh has established its
own goal to improve reproductive health as per the MDG provision by 2015. In response, the
country has taken a sector wide approach (SWAP) together with poverty reduction strategies to
focus on maternal and child health, for attaining the MDGs (MoHFW 2003). Keeping pace with the
MDG targets and the national strategies, different governmental and non-governmental
organizations (NGO), bilateral agencies and donors have been implementing health interventions −
individually or in partnership with government − to reduce maternal, neonatal and child mortality,
particularly amongst the poor. In 2001, the country also launched the National Strategy for Maternal
Health, aiming at reducing MMR by focusing on improving provision of emergency obstetric care
(EmOC).
BRAC, the largest NGO in the world, has nearly 40 years of experience in implementing communitybased
health interventions through the BRAC Health Programme (BHP), within both rural and more
recently urban settings. In 2008, BRAC has launched a comprehensive five-year MNCH Programme
in rural areas. Intensifying awareness of MNCH issues and the provision of essential medication are
the key components of the MNCH programme. Through this programme, special attention is placed
on ANC, delivery care and PNC. Likewise, BRAC delivers infant and child health services particularly
for acute respiratory infections (ARI), including pneumonia and management of diarrhoea. These
essential healthcare interventions are provided through an extensive network of local resident
women who have been trained as maternal-child primary healthcare workers called the Shasthya
Shebika (SS), amongst others involved in delivering care throughout the villages and wider
community.
The pilot intervention of this rural MNCH project began in Nilphamari district in August 2005. The
Research and Evaluation Division (RED) of BRAC carried out a pilot study in Nilphamari in 2006
(Nasreen and Rafi 2007) which provided key insights regarding MNCH conditions in the district. The
findings of this study were used to develop the strategies and approaches of intervention to be
implemented. This study revealed the existence of shallow knowledge of pregnancy-related risks,
and awareness about essential pregnancy, delivery and neonatal care. Likewise inadequate were
health-related practices for MNCH-related practices, e.g. treatment for common childhood illnesses.
While the level of immunization coverage and vitamin A intake were satisfactory, many MNCH
indicators are deficient.
In 2008 the project was expanded to three further districts of northern Bangladesh – Rangpur,
Gaibandha and Mymensingh, and in 2010 to six more districts - Faridpur, Madaripur, Rajbari,
Magura, Kurigram and Lalmonirhat. Two more districts where no MNCH interventions are planned
were also identified as control districts in 2008, namely Naogaon and Netrokona and one more
district in southern part of the country was also selected as control district in 2010 named
2

Changes of MNCH during 2008-2010
Jhenaidah. The baseline survey in all six districts – four interventions and two controls - was
completed in December 2008.
In the following two years, a comprehensive MNCH intervention has been implemented in the four
intervention districts. To elucidate the type and degree of impact of the BRAC MNCH programme
intervention, a re-survey has been undertaken of the same six districts in September 2010. This
survey has served as a baseline for six new intervention districts where Jhenaidah district has been
considered as control. This second survey has focused on key maternal, newborn and child
outcomes and the possible changes that have occurred over two years of the implemented MNCH
programme.
The core aim of this impact evaluation is to analyze the situation of MNCH in the intervention districts
at different stages of project implementation compared with the control districts by comparing
results for key MNCH indicators from the 2008 and 2010 surveys in old four intervention and two
control districts. The specific objectives are to:
• Identify the level of women’s knowledge and types of practices regarding maternal health
(pregnancy identification, ante-, intra-, and post-partum care), and the health status and healthrelated
practices for neonates and under-5 children
• Assess the prevalence of maternal complications as well as that for the major illnesses in
neonates and under-5 children
• Examine healthcare utilization for maternal, neonatal and under-five child care complications and
sicknesses
• Identify the profile of abortion (induced/spontaneous), its management and potential
complications
• Identify the profile of MR, potential complications and its management
• Profile the current referral networks including transport contingencies for essential MNCH
services
3

Changes of MNCH during 2008-2010
Chapter
2
Methodology
2.1 STUDY DESIGN
This quasi-experimental study focused on the impact of MNCH interventions that had been
implemented through BRAC rural MNCH programme. This comprehensive health programme has
been carried out in a number of selected ‘intervention’ districts in addition to BRAC’s core
development initiatives i.e. microfinance, education, community empowerment, human rights and
legal services (HRLS), water, sanitation and hygiene (WASH) and health. Alternatively, in the ‘control’
districts, the BRAC MNCH programme was not being implemented during the course of the study
though all other programmes were present. This study design, therefore, compared the health
indicators between the intervention
and control districts over two years
(2008 to 2010). Furthermore, withindistrict
Figure 2.1. District profile of survey areas
changes in terms of the key
health indicators had also been
assessed based on the 2008
baseline data compared with the
2010 midline survey results.
2006
Nilphamari
2008
Nilphamari
Rangpur
2010
Nilphamari
Rangpur
2.1.1 Study setting
Gaibandha
Gaibandha
This study was conducted in 2010 in
several districts in northern and
central region of Bangladesh. The
areas surveyed include four old and
six new intervention districts of the
IMNCS programme of BRAC and
three control districts where the
programme was not implemented
(Fig. 2.1).
Intervention
Mymensingh
Mymensingh
Faridpur
Madaripur
Rajbari
Magura
Kurigram
The intervention districts are:
Lalmonirhat
• Nilphamari in which a pilot
MNCH intervention commenced
in 2005 and served as the basis
for further implementation in
other districts of the MNCH
actions.
Control
Naogaon
Netrokona
Naogaon
Netrokona
Jhenaidah
5

Methodology
• Rangpur, Gaibandha and Mymensingh, where the MNCH intervention was introduced in 2008
as part of ‘Improving Maternal, Neonatal and Child Survival (IMNCS)’ project following the initial
implementation of the BRAC MNCH programme in Nilphamari.
• Based upon experiences, in 2010, the programme was scaled up in two northern and four
central districts − Kurigram, Lalmonirhat Faridpur, Madaripur, Rajbari, and Magura.
Figure 2.2. Map of survey areas
Intervention since 2005
Intervention since 2008
Intervention since 2010
Control districts
6

Changes of MNCH during 2008-2010
The control districts for this study are Naogaon, Netrokona and Jhenaidah. These settings served as
the comparison districts. Geographically, all of the afore-mentioned districts are located in the north,
north-western or central regions of Bangladesh. The study participants, predominantly resident in
rural communities, are mostly involved in agricultural activities.
The MNCH programme was initiated along with other regular health interventions in Nilphamari
district in 2006. This was undertaken as a pilot intervention. In 2008, the IMNCS project was built
upon the model developed in the pilot programme in four districts namely Rangpur, Gaibandha,
Mymensingh, and Nilphamari, and in 2010 in Faridpur, Madaripur, Rajbari, Magura, Kurigram and
Lalmonirhat. In the same time, the control districts of Naogaon, Netrokona and Jhenaidah were
selected on the basis that the BRAC IMNCS programme was not implemented in those districts (Fig.
2.2).
BRAC’s IMNCS intervention comprises a number of components aiming to reduce maternal,
neonatal and child mortality and morbidity, particularly among the poor and socially excluded
population. The components include improving awareness on family planning, identification of
pregnancy, providing ANC, delivery care and PNC, birth planning, essential newborn care,
management of newborn illnesses, management of acute respiratory infection and diarrhoea among
children aged

Methodology
2.2 STUDY POPULATION
The sample size for the 2010 survey in 13 old and new districts was 9,360 women and for this
report 4,320 women of reproductive ages (15 to 49 years) living in the six districts being assessed at
this stage in the IMNCS project evaluation (Fig. 2.3). Inclusion of the women was contingent upon
having been married and who were identified as being or having been a mother (in the case of a
child death). Two groups having the following criteria were selected for the survey.
Figure 2.3. Study population
Study population
Nilphamari
Rangpur, Gaibandha
and Mymensingh
Naogaon & Netrokona
(Control)
Total
1 district 3 districts 2 districts 6 districts
1 × 6 = 6 upazilas
(6 upazilas/district)
3 × 6 = 18 upazilas
(6 upazila/district)
2× 6 = 12 upazilas
(6 upazilas/district)
36 upazilas
6× 2 = 12 unions
(2 unions/upazila)
18 × 2 = 36
(2 unions/upazila)
12 × 2 = 24 unions
(2 unions/upazila)
72 unions
12 × 5 = 6 0 villages
(5 villages/union)
36 × 5 = 180 villages
(5 villages/union)
24 × 5= 120 villages
(5 villages/union)
360 villages
60×12=720
respondents (12
respondents/village)
180 × 12 = 2160
respondents (12
respondents/village)
120 × 12 = 1440
respondents (12
respondents/village)
4320 respondents
Group 1. Mothers who have had any pregnancy outcome within the study time period from
06/October/2009 to 05/October/2010:
• Mother of live child aged

Changes of MNCH during 2008-2010
Group 2. Mothers of live children aged 12-59 months; these mothers did not have any pregnancy
outcome in the mentioned study period
2.3 SAMPLING
For the determination of sample size of this midline survey the following information was considered
as background outline:
• Indicators those were included in the revised logical framework (Annex 1)
• Assessment of change over time from the baseline survey results to this midline assessment of
the key MNCH indicators
A simple comparison of change over time was adjusted with baseline results through a single
sample test to determine the level of difference, if any, between the 2010 results in the intervention
and control districts from the 2008 baseline findings. Based on 80% power, 1% statistical
significance and a design effect of 1.5, to detect a 12.5% increase above a 20% baseline, a sample
size of at least 300 subjects for each of the two groups of mothers was determined. Based on these
parameters, a provisional total of 600 subjects from each district were calculated. However, to
account for the approximate level of menstrual regulation (MR) and abortion that are estimated to
occur during a given year, the final sample size per district was increased to 720 mothers per
district, 420 from Group 1 and 300 from Group 2.
As stated previously, six districts had been surveyed in 2008 for the baseline survey, consisting of
Nilphamari as the singular intervention district having started in 2006; Rangpur, Gaibandha and
Mymensingh from 2008; Naogaon and Netrokona which were identified as the control districts from
2008.
In 2008, a multi-stage cluster random sampling procedure was employed consisting of districts,
upazilas, unions and villages as the population strata. The selection of which districts would be the
intervention and control settings was purposive in nature. However, at each successive stratum,
random sampling was done for site selection. For instance, within each district six upazilas were
selected randomly. As such, in each upazila two unions were then selected randomly and,
subsequently five villages in each union were randomly identified. In each village, complete
enumeration of households was undertaken by the interviewer to develop a sampling frame from
which a sample of 12 households was randomly selected.
Eligibility of the mothers to be interviewed followed the inclusion criteria for the aforementioned
Groups 1 and 2 criteria. Twelve mothers (seven from Group 1 and five from Group 2) were randomly
selected as the respondents from each sampled village.
In 2010, the same villages that were included in the 2008 were selected for the midline follow-up
survey. The sampling strategy for this research was characterized by a panel data approach. It
merits pointing out that women who was surveyed in 2008 were not recruited for the 2010 study.
Accordingly, the 2010 survey was carried out on 4,320 respondents in six districts. The survey
encompassed 360 villages in 72 unions within 36 upazilas of the six districts. A sub-total of 2,520
mothers was Group 1 respondents and 1,800 corresponded to Group 2.
If any randomly selected respondent was found unavailable following three visits to the household,
that subject was replaced by another randomly selected respondent within the same village. This
initiative was taken to avoid non-response error.
9

Methodology
2.4 THE SURVEY AND SURVEY TOOLS
The survey instrument was a structured questionnaire addressing the indicators of project’s logframe.
For comparison with other population-based survey data from Bangladesh, the survey
questionnaire took into account elements of data reporting from other national studies e.g. the
Bangladesh Demographic and Health Survey 2007 (BDHS 2007). Further refinement and
development of the survey instrument accrued from a series of meetings between Ipact (University of
Aberdeen) and the BRAC IMNCS programme personnel. The questionnaire was used to collect
information on the following topics:
• Background characteristics including age, education, occupation, religion, NGO involvement,
husband’s background characteristics
• Household characteristics including main material for floor, roof, walls, household assets
• Sanitation and drinking water facility
• Reproductive history including age at marriage and conception, number of birth, child deaths
and age at death
• Use of family planning methods
• Maternity care including ANC, delivery care and PNC
• Antenatal, delivery, postnatal complications and treatment-seeking behaviour
• Newborn care, complications and their treatment-seeking behaviour
• Vaccinations and childhood illnesses and treatment-seeking behaviour
Information on ante-partum, child-birth, post-partum and newborn care was obtained from mothers
belonging to the group of respondents with a pregnancy outcome in the last 12 months. Mothers
who have had MR, abortions, IUDs or whose baby had died were not asked about neonatal or child
care.
Mothers of children aged 12-59 months were asked several questions regarding their youngest child
in that age range, as it was possible that a given mother may have more than one child of these
ages. The questions focused on key illnesses (acute respiratory illness, diarrhoea) and their
management as well as related health issues, e.g. immunization status.
The questionnaire was pre-tested in Gazipur district in September 2010, followed by review and
revision of its content whereby feedback and observations generated from pilot study were
incorporated into the final version of the questionnaire. Following appropriate modification of the
survey instrument, data collection was conducted from October 2010 to January 2011.
Seventy eight female interviewers were recruited for data collection. Female interviewers were
selected to ensure maximum participation of the respondents and optimal data collection. Selection
of the interviewers was based on prior experience in health survey data collection and suitability to
work in rural setting. The interviewers were divided into 13 groups, each headed by a male team
leader to organize the logistics involved with the rural field work as well as supervising data collection
and the data quality. All the interviewers and team leaders were trained by experienced researchers.
2.5 STUDY VARIABLES
The key variables and measuring indicators are summarized in Table 2.5.1.
10

Changes of MNCH during 2008-2010
Table 2.5.1 List of variables
Demographic and
socioeconomic status
Name of variable
• Age
• Literacy of respondent and her husband
• Years of completed schooling of respondent and her husband
• Wealth status
• Involvement in income generating activities
• NGO involvement
• Land ownership of the household
Reproductive history • Age at first marriage
• Age at first conception
• Number of pregnancy
• Number of live births
• Number of child deaths
• Age of child at death
• Number of abortion/MR/IUD
• Complication during abortion/MR
• Complication management generated from MR/abortion
Family Planning (FP) • Current use of FP
• Source of FP methods
• Side effects and management
• Reason for absenteeism
Pregnancy identification • Month of pregnancy identification
• Person identified the pregnancy
Antenatal Care (ANC) • Number and timing of ANC visits
• Source of ANC services
• Birth preparedness
• Complication faced, management, and referral
Delivery care • Place of delivery
• Attendant at delivery
• Delivery outcome
• Cord cutting practices
• Complications and management during delivery
Postnatal Care (PNC) • Number and timing of PNC visits
• Source of PNC services
• Complications, management and referral during PNC period
Maternal danger sign • Knowledge on maternal danger sign
• Occurrence and management of maternal danger signs
Neonatal danger sign • Knowledge on neonatal danger sign
• Occurrence and management of neonatal danger signs
Newborn care • Essential newborn care
• Birth weight
• Management of low birth weight babies
• Initiation of breastfeeding
• Newborn feeding practices
• Birth asphyxia and its management
• Neonatal sepsis and its management
Under-5 child care • Knowledge and practices regarding ARI
• Knowledge and practices regarding Diarrhoea
• Immunization
• Vitamin A intake
11

Methodology
2.5.1 Wealth index
In line with the socioeconomic data presented in the Demographic and Health Survey (DHS) reports,
this study collected similar information on similar key variables of this type. However, information
regarding traditional economic measures such as consumption expenditure was not collected.
Rather, data on ownership of durable assets (e.g. radio, television, bicycle, cell phone etc.), and
household characteristics (e.g. material used for the floor of the dwelling, the roof material and the
nature of the toilet facilities) were collected. Access to services such as electricity supply and the
source of drinking water, domestic fuel use and the ownership of livestock were also identified.
With this set of socioeconomic data a wealth index was developed following the programme
objective to provide services to all, particularly poor. Thus, through the development of a wealth
index, analysis of MNCH indicators would take into account the socioeconomic data. Construction
of the wealth index was based on principal components analysis (PCA) of key socioeconomic
variables (Rustein and Johnson 2004). Each variable was then given a weight based on its loading in
the first general factor identified in the PCA. The resulting score for each household (HH) was
standardized with a mean ‘0’ and standard deviation ‘1’ (Gwatkin et al. 2007). Households were
then ranked and assigned a score in the range of one to five. A score equal to one was identified as
the poorest house hold (HH) and score of five identified the richest HH. The wealth index was finally
used to compare the antenatal, safe delivery and post-natal status of respondents across the five
wealth-related groups.
2.6 DATA PROCESSING AND STATISTICAL ANALYSIS
The 2010 survey data were verified, edited, coded and entered into a customized database. Data
quality was ensured by cleaning the data inconsistencies. Data were analyzed using SPSS version
17 and EPI info version 6.
The survey data was comprised of the 2008 baseline data merged with the 2010 data. Then the
total six districts were split into three strata, as follows:
• Nilphamari (intervention began in 2006)
• Rangpur, Gaibandha and Mymensingh (intervention began in 2008)
• Naogaon and Netrokona (control districts, from 2008)
Both univariate and multivariate statistical techniques were used for analyzing the 2010 survey data.
Univariate analysis was carried out to assess the relationship between key individual MNCH
indicators and specific independent variables. This statistical testing involved chi-square tests for
calculating differences of proportions between groups, independent sample t-tests for mean
differences and Mann-Whitney U test for the median differences. Multiple logistic regression
analyses were also performed to assess the relationship, if any, of selected independent variables on
single dependent variables when controlling for the simultaneous effects of other variables in the
regression model.
2.7 ETHICAL APPROVAL
The ethical clearance was obtained from the Bangladesh Medical Research Council. The purpose of
study was verbally described to the participants. Moreover, the interviews were conducted after
obtaining informed consent. The respondents were ensured of the confidentiality of information
provided.
12

Changes of MNCH during 2008-2010
Chapter
3
Comparison of socio-demographic
status
This chapter scanned the information on demographic and socioeconomic characteristics of survey
respondents and their husbands. Besides, the chapter intended to describe their household
characteristics. By using the household assets and belongings, a wealth index was constructed to
indicate the economic status of the households.
3.1 CHARACTERISTICS OF THE SURVEY RESPONDENTS
Table 3.1.1 shows the socio-demographic profile of the respondents. The mean age of the
respondents in Nilphamari was 24 and in the rest of the study areas it was 25 which are similar to
the earlier survey of 2008. One-third of the respondents came from the 20-34 years age group. The
number of respondents in the younger cluster was highest in Nilphamari (20%), in the rest it was not
more than 15%. However, in all study areas the population of this age group was found higher than
the previous year. In 2008, the age was ranged from 13 to 50, whereas in 2010 it ranged from 14 to
48 years. The population was predominantly Muslim everywhere. However, the other religion was
highest in Nilphamari and accounted for almost double than other study areas. Very few divorced,
separated and widowed were found and almost 99% of the respondents were currently married.
Literacy status improved significantly everywhere; 53% in Nilphamari and 55% elsewhere. Mean year
of schooling was 4 everywhere that gives a common picture of school attainment. On an average
not more than 7% of the respondents completed secondary or higher education.
The respondents were mostly housewife though their involvement in income generating activities
(IGA) was found to be significantly increased in Nilphamari (p= 0.006), but the percentage was
lowest (11%) in other intervention districts. The proportion of landless people increased substantially
everywhere over time; land ownership was highest in control areas. BRAC membership was found
decreasing. However, most of the BRAC members was involved with Dabi, highest being in
Nilphamari (81%). The percentage of households eligible for BRAC membership was at least 10%
increased everywhere in the study areas.
13

Comparison of socio-demographic status
Table 3.1.1. Social and demographic characteristics of the respondents
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
2008 2010 P-value 2008 2010 P-value 2008 2010 P-value
N 1200 720 3600 2158 2400 1440
Age
• ≤ 19 years 17.7 20.1 .199 13.8 15.7 .107 14.8 15.3 .558
• 20-34 years 76.0 75.0 76.9 75.7 76.8 77.3
• ≥ 35 years 6.3 4.9 9.4 8.6 8.4 7.4
Mean age (SD) 24.39 24.29 .690 25.73 25.22 .001 25.23 25.11 .541
(5.39) (5.33) (5.96) (5.08)
(5.84) (5.65)
Religion
• Muslim 75.7 78.1 .232 95.2 94.3 .118 88.9 87.9 .346
• Others 24.3 21.9 4.8 5.7 11.1 12.1
Marital status
• Married 98.9 99.7 98.9 99.3 .140 99.0 99.2 .604
• Others 1.1 0.3 1.1 0.7 1.0 0.8
Literacy
• Can read and write 47.5 53.3 .013 50.8 55.5 .001 52.4 55.7 .046
• Educational status
• No education 35.0 26.8 .001 34.5 28.9

Changes of MNCH during 2008-2010
3.2 SOCIAL AND DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS’
HUSBANDS
Husbands’ mean age was 32 years in Nilphamari and 33 years elsewhere; accounted for 7-8 years
higher than their wives’ mean age. Around 45 to 49% could read and write, and the average year of
schooling was 4. The proportion of husband’s literacy was less than their wives. Husbands were
involved with IGA; the highest proportion of them was day labourer and farmer. Many of them were
also involved with small business and pulling rickshaw/van (Table 3.2.1).
Table 3.2.1. Social and demographic characteristics of respondents’ husbands
Nilphamari Rangpur, Gaibandha and
Mymensingh
Naogaon and
Netrokona (Control)
2008 2010 P-value 2008 2010 P-value 2008 2010 P-value
N 1200 720 3600 2158 2400 1440
Husband’s Age
• ≤ 25 years 15.5 19.6 14.0 16.5 14.5 12.5
• 26- 40 years 75.4 70.2 71.8 68.8 71.6 73.6
• ≥ 41 years 9.1 10.2 14.2 14.7 13.9 13.9
Mean age (SD) 31.9
(6.53)
Literacy
• Can read and
write
31.7
(6.69)
.585 33.4
(7.35)
33.2
(7.75)
.287 33.3
(7.35)
33.2
(7.31)
.770
42.6 45.3 .252 44.8 49.0 .002 45.3 48.7 .043
Educational status
• No education 44.5 40.5 .292 47.0 42.6 .001 45.8 41.2

Comparison of socio-demographic status
Table 3.3.1. Household characteristics of the respondents
Nilphamari
Rangpur, Gaibandha and
Mymensingh
Naogaon and
Netrokona (Control)
2008 2010 P-value 2008 2010 P-value 2008 2010 P-value
N 1200 720 3600 2158 2400 1440
Sex of HH head
• Male 98.3 99.6 97.2 97.8 97.5 98.5
• Female 1.8 0.4 2.8 2.2 2.5 1.5
Mean household size 5.10 5.10 .956 4.99 4.99 .963 5.12 5.08 .524
(SD)
(2.04) (1.99)
(1.95) (1.87)
(2.03) (2.24)
Type of family
• Nuclear 67.0 66.0 .644 71.9 68.2 .003 64.1 65.3 .454
• Extended 33.0 34.0 28.1 31.8 35.9 34.7
Principal type of
drinking water
• Tube well 97.9 99.3 .018 98.5 99.3 .014 98.2 98.6 .298
• Others 2.1 0.7 1.5 0.7 1.8 1.4
Principal type of
cooking water
• Tube well 97.3 99.0 .008 97.9 98.5 .118 95.9 95.8 .900
• Others 2.8 1.0 2.1 1.5 4.1 4.2
Sanitation facility
• Sanitary (water 27.4 15.8 20.8 20.9 22.6 24.0
seal & septic
tank)
• Broken water 34.8 49.0

Changes of MNCH during 2008-2010
3.4 WEALTH INDEX
The distribution of wealth index in all the six study districts was analyzed separately. The changes
between 2008 and 2010 were measured (Fig. 3.1). Little changes were observed over the period
across the study districts. In Gaibandha and Naogaon, a slightly higher percentage of people were
found to be belonged to poor quintiles in 2010 compared to the baseline. Across Nilphamari,
however, around 17% of the people were found to be in the fourth quintile at baseline which
reached at 21% in 2010. In Rangpur, a slight increase was noticed. Conversely, poverty was found
to be intensified in Netrokona over the time and appeared as the poorest district (34% in the poorest
quintile) by 2010 (Annex 2.1a and Annex 2.1b).
Figure 3.1 Wealth index
120
100
Percentage
80
60
40
20
0
2008 2010 2008 2010 2008 2010 2008 2010 2008 2010 2008 2010
Nilphamari Rangpur Gaibandha Mymensingh Naogoan Netrokona
Poorest Second Middle Fourth Richest
17

Changes of MNCH during 2008-2010
Chapter
4
Maternal health
4.1 REPRODUCTIVE HISTORY
In Bangladesh, the legal age of marriage for women is 18 years though cultural practices persist,
which lead women of even younger ages being married. Early marriage is affiliated with a high
percentage of young women conceiving in their teenage. Though a dramatic decline has been
observed in the proportion of women marrying in their early teens, the median age at marriage (15.3
years) has essentially remained unchanged throughout the last decade (BDHS 2007).
In the study areas where the BRAC MNCH programme is being conducted, the median age at
marriage was 15 years while the median age at first conception was 17 years. In the two control
districts, the median age at first marriage was 16 years, which was higher than that for the
intervention districts as well as the national median. Age at first conception in Naogaon and
Netrokona remained the same (17 years) as in the intervention areas (Table 4.1.1).
Table 4.1.1. Summary statistics for reproductive history
Nilphamari Rangpur, Gaibandha and Naogaon and Netrokona
Mymensingh
(Control)
2008 2010 P-value 2008 2010 P-value 2008 2010 P-value
N 1200 720 3600 2158 2400 1441
Median age at first 15 15 15 15 16 16
marriage
Median age at first 17 17 17 17 17 17
conception
Average number of 2.35 2.35 .901 2.54 2.39 .001 2.42 2.33 .100
children ever born (SD) (1.43) (1.40)
(1.61) (1.49)
(1.66) (1.49)
Experienced one or more 16.8 17.1 19.3 17.9 15.1 16.0
child deaths
Experienced one or more 16.6 16.1 .787 18.7 17.6 .270 14.8 15.4 .625
under-5 child deaths
Number of children died 202 123 696 387 363 230
Age stratification of child
death
• Neonatal 74.3 75.6 .785 63.4 76.2 5 years 3.0 6.5 .128 5.6 2.8 .038 4.1 4.3 .899
19

Maternal health
In Nilphamari, 16% of the respondents reported at least one or more under-5 child deaths,
compared to 18% in the other three intervention districts; it was slightly lower (15%) in the control
districts. Moreover, three-quarters of the under-5 deaths occurred in the neonatal period (Table
4.1.1).
4.1.1 History of abortion
It was evident that 9% of
the respondents in
Nilphamari, 14% in other
intervention areas, and
16% in control areas had
abortion (Fig. 4.1). Most of
them experienced not
more than one abortion in
their life time (Annex 2.2.1).
Induced abortion is not
legal in the country unless
clinically recommended.
However, 14% in
Nilphamari, 23% in other
intervention areas, and
10% in control areas
among all abortion were
recorded as induced.
Everywhere the percentage
went downward than the
incidence happened in
2008 (Fig. 4.2).
4.1.1.1 Complication
during abortion and its
management
Figure 4.1. Ever had abortion
Percentage
18
16
14
12
10
8
6
4
2
0
2008 2010 2008 2010 2008 2010
Nilphamari
Rangpur, Gaibandha
and Mymensingh
Figure 4.2. Percentage distribution of abortion, by
type in three survey areas
Percentage
120
100
80
60
40
20
0
Control
Spontaneous
Induced
2008 2010 2008 2010 2008 2010
Complication was not an
Nilphamari Rangpur, Gaibandha Control
uncommon phenomena
and Mymensingh
created through abortion;
48% of women in Nilphamari, 44% in other intervention districts, and 70% in control areas
experienced complications due to abortion (Annex 2.2.2). More complications were occurred in the
cases of spontaneous abortion than that of induced cases. The most commonly faced abortion
complication was excessive bleeding (3 out of 4). Abdominal pain was reported in half of the
abortion cases. No action was taken in the incidence of complications for 7% in Nilphamari, 9% in
other three intervention districts, and 17% in control areas.
Increasing number of women in Nilphamari was going to qualified doctor while facing complications
due to abortion, but it was lower in other three districts and control areas. On the other hand, the
popularity of village doctor had gradually been increasing. In Nilphamari, it was evident that more
women than the previous year (5 to 19%) were going to district hospitals and UHC/MCWC/FWC (10
to 14%).
20

Changes of MNCH during 2008-2010
4.1.2 History of menstrual regulation (MR)
About 4% of the respondents acknowledged that they had undergone at least one MR in their
lifetime; however, it increased slightly everywhere (Fig. 4.3). The complication faced due to MR was
substantially increased in Nilphamari (p=0.029) (Annex 2.2.3). In a similar way of abortion-related
complications, most of the women experienced excessive bleeding and abdominal pain due to MR.
Figure 4.3. Ever had MR
Percentage
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
2008 2010 2008 2010 2008 2010
Nilphamari
Rangpur, Gaibandha and
Mymensingh
Control
In case of MR complications in Nilphamari, all the respondents sought services from the health
service providers, while it was 89% in other intervention areas. In Nilphamari, 60% of the cases were
managed by qualified doctors, while it was found to be lower in other intervention areas that gone
down from 50 to 18% during 2008 to 2010. (Annex 2.2.3)
4.2 FAMILY PLANNING PRACTICES
The contraceptive prevalence rate (CPR) was higher in Rajshahi Division (65.9%) compared to 56%
nationally (BDHS 2007). At baseline of the BRAC MNCH intervention in 2008 in Nilphamari, the CPR
was 65.8%. By 2010 the CPR had increased to nearly 70% (Table 4.2.1). In other three intervention
districts, the CPR had decreased over time to nearly 60%, a ‘borderline’ significant reduction
(p=0.052). Use of any form of family planning method had also dropped in the control districts in
2010 resulting in an intermediary CPR compared to the intervention districts.
Use of modern family planning methods in the surveyed areas was notable, as the difference
between the use of any contraceptive method and modern methods was substantially less than the
difference reported nationally. Furthermore, increases in use of modern methods had observed in all
the survey areas, especially in Nilphamari (p=0.01) since 2008 (Table 4.2.1).
Nilphamari reported the highest proportion of adolescent girls giving birth amongst the districts
surveyed. Accordingly, compared to the other districts surveyed, in 2010, girls in Nilphamari were
about 60% more likely to have given birth than their counterparts in the other intervention districts
(OR=1.64; 95% CI 1.26-2.14) as well as being nearly twice as likely to have had a delivery than
adolescents in the control districts (OR=1.9; 95% CI 1.5-2.5) (data not shown). In related manner,
Nilphamari reported the highest level of use of modern family planning methods amongst married
adolescent girls in the districts surveyed. In all the districts, more than half of married adolescent
women were using modern family planning methods (Table 4.2.1).
21

Maternal health
Table 4.2.1. Family planning practices
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 p-value 2008 2010 p-value 2008 2010 p-value
N 1200 720 3600 2158 2400 1440
Currently using any 65.8 69.9 .063 62.4 59.9 .052 65.6 63.8 .249
family planning (FP)
method
Currently using modern 61.3 67.1 .011 55.6 56.3 .581 59.8 60.0 .878
FP method 1
N 600 420 1800 1258 1200 840
Married adolescent girls 24.8 27.4 .361 19.4 19.3 .930 19.8 19.4 .847
giving birth
N 212 145 495 338 355 220
Current use of modern 50.5 56.6 .258 51.5 51.2 .925 58.0 52.7 .213
FP method 1 among
married adolescent girls
N 411 217 1352 866 826 522
Reasons for not using
any FP method*
• Not in a partnership 4.4 0.9 .003 7.9 4.3

Changes of MNCH during 2008-2010
Figure 4.4. Sources of modern FP methods
120
Percentage
100
80
60
40
20
0
2008 2010 2008 2010 2008 2010
Nilphamari
Rangpur, Gaibandha
and Mymensingh
Control
Pharmacy/shops
BRAC field
workers
NGO/Private
Satellite clinic
Public facility
Govt. field
workers
4.3 PREGNANCY IDENTIFICATION
Identification of a woman being pregnant as early as possible in the first trimester is important to
promote ANC for her. BRAC SS/SK working at community level identified more than half of the
pregnancies in Nilphamari (51%) in the first trimester. This compared favourably with the much lower
percentages of identification for other intervention (16.8%), and control districts (1.4%) (Table 4.3.1).
Table 4.3.1. Pregnancy identification
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
2008 2010 p-value 2008 2010 p-value 2008 2010 p-value
N 600 420 1800 1258 1200 840
Pregnancy identified
by SS/SK in the 1 st - 51.0 - - 16.8 - 0.0 1.4 -
trimester 1
1
Within first three months of pregnancy
4.4 ANTENATAL CARE (ANC)
The healthcare that a woman receives during her pregnancy is generally termed as antenatal care or
ANC. Study shows that ANC visit is closely associated with safe motherhood and with the wellbeing
of newborn too. As a signatory to the UN MDGs, Bangladesh is committed to reduce maternal
mortality by 75% by the year 2015, compared to its level from 1990. ANC is an essential component
for reducing the risk of maternal mortality (BDHS 2007). The World Health Organization (WHO)
recommends at least four ANC visits for all pregnant women. In the 2010 survey, women who gave
a live birth or a stillbirth in previous year were considered eligible for responding to questions
concerning the ANC they may have received during the pregnancy.
4.4.1 Knowledge on ANC
The respondents were asked initially whether they knew about the necessity of ANC visits. The 2010
study revealed that knowledge about the importance of ANC was universal. In Nilphamari, the most
23

Maternal health
commonly cited reasons for ANC were for the purposes of ensuring a safe delivery and, to a lesser
extent, to know the position of the fetus. Early recognition of possible complications with pregnancy
was also cited as a reason for ANC. However, in other districts, both intervention and control areas,
the main two reasons were inverted, i.e. know the position of the fetus was most commonly noted
and to a lesser extent for safe delivery purposes (Annex 2.2.4).
4.4.2 Antenatal care (ANC) practices
The percentage of pregnant women received at least four ANCs increased significantly in all the
three study areas between 2008 and 2010. Nilphamari achieved the highest level amongst all the
districts, increased from 76 to 92% (p=0.001) during 2008-2010. The most notable improvement
was observed in the intervention districts of Rangpur, Gaibandha and Mymensingh over the twoyear
period. At baseline, ANC was low (15%), whereas by 2010 a significant increase was observed
(p

Changes of MNCH during 2008-2010
Attending for ANC early in pregnancy, especially in the first trimester, is an important indicator of
effective maternal health programmes. The median number of months when the first ANC visit
occurred was assessed. Nilphamari was shown to have the earliest first ANC visit (within three
months) compared to other areas. Reductions in the time to the initial ANC visit were found in all the
intervention clusters over the two-year period. However, no improvement in the control districts was
noted, wherein the median first ANC visit took place at five months in 2008 and 2010.
ANC practices were found to be delivered by different cadres of trained providers including BRAC
Shasthya Kormi (SK), family welfare visitors (FWV), nurses, midwives, paramedics and qualified
doctors. The most common provider of ANC in the intervention districts was the SKs. More than
90% of the pregnant women received at least one ANC from trained provider in all the intervention
districts, which was 59% for the control districts (Table 4.4.1).
There was disparity between the intervention and control districts regarding women received at least
four ANCs from trained providers. From 2008 to 2010 in the intervention areas, a significant increase
(p=0.001) was identified in the proportion of women received at least four ANCs from trained
providers. Thus, pregnant women in Nilphamari were highly more likely to receive at least four ANCs
from trained providers than those from Naogaon and Netrokona (OR 36.4; 95% CI 24.7-53.7) as
were women from Rangpur, Gaibandha and Mymensingh compared with those from the control
districts (OR 8.6; 95% CI 6.8-10.9) (data not shown). Provision of ANC from medically qualified
persons was far less common in those districts though it was the principal source of ANC in the
control districts (Fig. 4.5).
Figure 4.5. Providers of ANC (trained and medically trained)
Percentage
100
80
60
40
20
0
2008 2010 2008 2010 2008 2010
Nilphamari
Rangpur, Gaibandha
and Mymensingh
Control
Received at least four ANCs from medically trained provider
Received at least four ANCs from trained provider
4.5 BIRTH PREPAREDNESS
BRAC MNCH programme pay importance on birth preparedness to ensure pregnant women and
their families to be prepared with a package of birth plan. In general, there are three major
preparation needs to be done for birth preparedness. For instances, determination of place and
attendant for delivery, and also to save money for immediate expenses.
4.5.1 Knowledge on birth preparedness
The respondents were ranked according to their knowledge. There was no one in Nilphamari who
did not have any knowledge regarding birth planning (Annex 2.2.5). In the other intervention areas,
more than half of the respondents had knowledge of 1-2 birth plans. The respondents were
25

Maternal health
substantially aware about deciding the place and attendant, half of them in intervention had
awareness regarding saving money.
4.5.2 Practices of birth planning
Almost three-fourth of the respondents in Nilphamari prepared themselves for delivery by
determining place and attendant and also saved money. In other intervention areas, a substantial
improvement also found (p

Changes of MNCH during 2008-2010
4.6 DELIVERY CARE
Information on delivery care was obtained from mothers who have had a live or still birth in the
preceding year. Delivery at home was found to be common practice in the study areas. A little
higher facility delivery was observed in Nilphamari and cited with increasing phenomena. One-fourth
of the deliveries in Nilphamari and one-fifth in other intervention areas took place in facility
(public/private) (Fig. 4.7). In the study areas, generally 9 out of 10 deliveries were recorded as normal
(Table 4.6.1). On the other hand, the percentage of c-section delivery had risen almost double from
4 to 8% from 2008 to 2010; while the national rate of such is 7.5% (BDHS 2007).
Figure 4.7. Facility delivery (Public/Private)
30
25
Percentage
20
15
10
5
0
2008 2010 2008 2010 2008 2010
Nilphamari
Rangpur, Gaibandha and
Mymensingh
Control
Table 4.6.1. Delivery care practices
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
2008 2010 p-value 2008 2010 p-value 2008 2010 p-value
N 544 384 1571 1104 1040 716
Place of delivery
• Home 79.2 73.7 86.1 80.3 81.7 75.6
• On the way 0.2 0.5 0.6 0.4 0.8 1.5
• Public facility 14.7 18.2 6.8 12.1 8.8 11.9
• Private facility or others 5.9 7.6 6.5 7.2 8.7 11.0
• Facility delivery
20.6 25.8 .063 13.2 19.4

Maternal health
Sterile blade was used commonly for cord cutting for almost all cases in Nilphamari, more than 93%
cases in other three intervention districts, and 85% in control districts. Tying cord with sterile thread
was also commonly practiced in Nilphamari with an increased trend. The similar trend was also
observed in other intervention districts, but not in the control districts (Table 4.6.1).
4.7 POSTNATAL CARE (PNC)
Postnatal Care (PNC) is indeed a crucial part of safe motherhood that mother receives within 42
days of delivery. Here the results of PNC are articulated from the information obtained from those
mothers who have had a live birth only.
The percentage of women received at least three PNCs has increased significantly across the three
study areas between 2008 and 2010. Nilphamari achieved the highest level amongst all the districts,
increasing from 28 to 58% (p

Changes of MNCH during 2008-2010
The BRAC MNCH programme is intended to ensure first PNC within 48 hours of delivery for home
delivery. A substantial increase was cited everywhere in programme areas having at least one PNC
from a trained provider by this time line increasing with 50 to 77% in Nilphamari and 2 to 41%
elsewhere. It is a successful endeavour of BRAC SKs who were providing PNC for almost all such
cases (Fig. 4.8).
Figure 4.8. Received at least one PNC from BRAC SKs
80
70
60
Percentage
50
40
30
20
10
0
2008 2010 2008 2010
Niphamari
Rangpur, Gaibandha and Mymensingh
In the contrary, the percentage of having no PNC was also substantially decreased in Nilphamari
and it happened only for 5% cases. In other intervention areas, the case of having no PNC was 77%
in 2008 and now it gone down at 30% in 2010 whether it was 61% in control areas (Table 4.7.1).
4.8 MATERNAL DANGER SIGNS
The signs of deadly diseases those are usually faced by a woman during the pregnancy, delivery or
after delivery are termed as maternal danger signs. Five danger signs were identified as maternal
danger signs including excessive bleeding/retained placenta, convulsion, prolonged labour/hand or
leg prolapsed, edema/severe headache/blurred vision, and high fever with foul smelling discharge.
The mothers who had a live birth or any other birth outcome (abortion/MR/still birth/IUD) in last one
year preceding the survey were asked about knowledge, prevalence and treatment-seeking
behaviour on maternal danger signs.
Since the data of maternal danger signs were not collected for 2008, only the data for 2010 were
presented in Table 4.8.1. Table 4.8.1 shows that 30% of the mothers were aware of at least three
maternal danger signs in Rangpur, Gaibandha and Mymensingh which was much higher (47%) in
Nilphamari. However, a lower percentage (24%) was reported in the control districts though the
median knowledge was identical (2) in all three study areas. A high percentage (95%) of the mothers
reported to have knowledge on going to hospital while maternal danger signs were identified in
Nilphamari compared to elsewhere. A considerable percentage (12%) of the mother also reported to
have the knowledge to call the BRAC SS/SK in Nilphamari against a very low percentage in other
study areas.
29

Maternal health
Edema, blurred vision, and severe headache were shown to be the most predominant danger signs
faced during this period in all three study areas (Table 4.8.1). Around 38% of the mothers in
Nilphamari reported to face these danger signs, whilst it was one out of five mothers in Rangpur,
Gaibandha and Mymensingh were found to face maternal danger signs; even higher percentage
(42%) observed in control areas. More than half of the mothers facing maternal danger signs sought
treatment from public or private health facility in Nilphamari which was a little bit lower in other study
areas.
Table 4.8.1. Information on maternal danger signs of the respondents (percentages)
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and
Netrokona (Control)
2008 2010 p-value 2008 2010 p-value 2008 2010 p-value
N - 383 - 1091 - 700
Knowledge on maternal danger
signs
• None (0) - 1.0 - 6.6 - 5.3
• Poor (1-2) - 52.5 - 63.7 - 61.9
• Moderate (3) - 38.1 - 25.0 - 23.8
• Good (4-5) - 8.4 - 4.7 - 2.0
Median knowledge on maternal
danger signs
- 2
(0-5)
- 2
(0-5)
- 2
(0-4)
N - 379 - 1019 - 663
Know what to do when danger
signs identified*
• Know/have BRAC referral
mobile number
3.2 9.9 2.1
• Know to go to hospital/Referral 94.5 81.8 78.9
place
• Know to call BRAC SS/SK 12.4 0.5 0.3
N 383 1091 700
Faced maternal danger signs 46.7 32.6 58.1
Individual maternal danger signs
faced*
• Excessive bleeding/Retained
placenta
- 7.3 - 10.0 - 17.3
• Convulsion - 2.1 - 1.6 - 5.3
• Prolonged labour/Hand or leg - 6.3 - 8.3 - 18.0
prolapsed
• Edema/Severe
- 38.4 - 20.7 - 42.4
headache/Blurred vision
• High fever with foul smelling - 0.8 - 3.0 - 6.7
discharge
N 179 356 407
Action taken on recognizing
maternal danger signs
• No action taken - 5.0 - 21.6 - 14.5
• Help from BRAC staff - 9.5 - 6.2 - 1.5
• Help from facility (public or
private)
• Others (Village doctor,
Homeopath, Pir/Fakir,
traditional healer,
drug seller, etc)
* Multiple response questions
- 59.8 - 43.0 - 49.9
- 25.7 - 29.2 - 34.2
30

Changes of MNCH during 2008-2010
4.9 TREATMENT-SEEKING BEHAVIOUR FOR MATERNAL COMPLICATIONS
Maternal morbidity or mortality is a consequence of a number of complications usually takes place
during antenatal, delivery or postnatal period. To control for the maternal death we must have to
concentrate on the management of these complicated disorders, the underlying causes of maternal
death. This section provides information on the prevalence and treatment-seeking behaviour of
some commonly occurred maternal complications in our study areas.
4.9.1 Complications and treatment-seeking behaviour during antenatal period
The percentage of mothers with complications during antenatal period increased over time in all
study areas. Edema, severe headache, high fever, blurred vision, lower abdominal pain and anemia
was continued to be the most frequent complications during antenatal period in 2010 with highest
percentage been reported for severe headache across all study areas (24% in Nilphamari, 18% in
Rangpur, Gaibandha and Mymensingh and 38% in the control areas of Naogaon and Netrokona)
(Annex 2.2.6).
Most of the women who faced complications during antenatal period found to seek treatment from
healthcare providers and the proportion increased over time in the intervention areas (Annex 2.2.7).
However, the percentage of women with complications sought treatment from qualified doctors,
hospital/clinics and medically trained providers was found to be increased only in Nilphamari (Table
4.9.1 and Annex 2.2.7).
4.9.2 Complications and treatment-seeking behaviour during delivery period
During the delivery period, the most prevalent complications were found to be substantial bleeding,
high fever, severe headache, and prolonged and obstructed labour which were not changed
substantially over the two-year period (Annex 2.2.8). Percentage of women received treatment from
healthcare providers for complications was found to be increased over the two-year period. In 2008,
around 83% women suffering from delivery complications in Nilphamari sought treatment from
healthcare providers which increased up to 90% in 2010; an increasing trend (75 to 83%) was also
observed in Rangpur, Gaibandha and Mymensingh (Annex 2.2.9). However, treatment-seeking for
complications during delivery period from medically trained providers remained to be unchanged in
all intervention areas whereas in control areas it was found to be declined (Table 4.9.1).
4.9.3 Complications and treatment-seeking behaviour during postnatal period
Irrespective of the study areas and time of the survey, severe headache, blurry vision, high fever and
abdominal pain were found to be the most frequently occurred complications during postnatal
period (Annex 2.2.10). At baseline, one-fourth of the mothers with postnatal complications received
treatment from medically trained providers which reached up to 29% by 2010 in Nilphamari and also
increased from the baseline (20 to 26%) in Rangpur, Gaibandha and Mymensingh. But this remained
fairly unchanged in control areas (Table 4.9.1). Receiving treatment in UHC/MCWC/FWC was found
to be increased from 11 to 15% in Nilphamari (Annex 2.2.11). Though not such big increase was
observed in Rangpur, Gaibandha and Mymensingh, the trend was positive.
31

Maternal health
Table 4.9.1. Maternal complications faced and treatment-seeking behaviour for such
complications
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 p-value 2008 2010 p-value 2008 2010 p-value
N 544 384 1571 1104 1040 716
Complication faced 37.3 52.9

Changes of MNCH during 2008-2010
4.10 REFERRAL INFORMATION FOR MATERNAL COMPLICATIONS
This section presents information on referrals for complications during antenatal, delivery and
postnatal period. The percentages of women referred for maternal complications show a slight
increase in the intervention areas, particularly in Nilphamari (Fig. 4.9). Referral to hospital for maternal
complications increased from 12% in 2008 to 17% in 2010 in Nilphamari and from 5 to 7% in other
intervention districts (Annex 2.2.12). However, no change was noted in control districts. Most of the
complicated mothers were referred to by BRAC workers (38% in 2008 and >50% in 2010) in
Nilphamari. Although village doctors were found to be the most prominent persons for referral in
Rangpur, Gaibandha and Mymensingh in 2010, referral by BRAC workers increased considerably (2
to 23%) during the two-year period. Increasingly mothers were referred to UHC/MCWC/FWC in
intervention areas and received treatment. Surgery, c-section, blood transfusion and episiotomy
rates were found to be increased over the two-year period in all study areas. Starting from 26% in
2008 the percentage was reached 40% by 2010 in Nilphamari and a relatively smaller increase (31
to 40%) was observed in Rangpur, Gaibandha and Mymensingh.
Figure 4.9. Referred for material complication(s)
20
15
Percent
10
5
0
2008 2010
Nilphamarai
Rangpur, Gaibandha & Mymensingh
Control
33

Changes of MNCH during 2008-2010
Chapter
5
Neonatal health
5.1 ESSENTIAL NEWBORN CARE (ENC)
5.1.1 Knowledge of neonatal care
Essential newborn care (ENC) comprises comprehensive strategies and preventive measures that
are intended to be administered immediately after the delivery of the newborn. According to WHO,
ENC practices include clean cord care, thermal care and initiating breastfeeding immediately or
within the first hour after birth. Aligned with WHO guidelines, BRAC MNCH programme also
identified five essential actions for ENC including hygienic cord care, thermal control (including drying
and wrapping) and early breastfeeding initiation.
Findings from the 2010 survey in Nilphamari indicate that the median number of known ENC actions
was 2 out of a maximum 5, indicating a slight decrease, from the level (three actions) that was
reported in 2008. In the intervention districts of Rangpur, Gaibandha and Mymensingh, the median
number of ENC knowledge of 2, remained unchanged over the two years of intervention. Overall
knowledge status, when considering the proportion of mothers who knew at least one ENC action
to as many as four (combining ‘poor’ and ‘medium’ knowledge levels), an increase was noted in
Nilphamari (from 88% in 2008 to 97% in 2010) (Table 5.1.1). For these combined categories, a
declining trend was noticed for the other three intervention districts as well as for the two control
clusters.
LBW baby management is one of the major challenges to ensure proper care of neonatal health and
the programme defined the proper management of LBW baby through a) frequent breastfeeding
and b) proper wrapping of neonates. The 2010 survey revealed that in Nilphamari, 4 of 10 women
had proper knowledge of both aspects of LBW baby management; reflected no overall change
from 2008 to 2010 with a surprising result of decreasing knowledge on proper wrapping. In the
other three intervention districts, this value decreased due to a significant reduction in the
percentage of women reporting knowledge of frequent breastfeeding being recommended for the
LBW infant (Fig. 5.1). This finding contrasts with the significantly increased level of knowledge about
frequent breastfeeding amongst women in Nilphamari (p=0.002) (Table 5.1.1). Overall decrease in
knowledge of the management of LBW infants was found in the control districts, reflecting large
deficits in awareness about proper care of such children.
35

Neonatal health
Figure 5.1. Knowledge of LBW baby management
80
70
60
Percentage
50
40
30
20
10
0
2008 2010 2008 2010 2008 2010
Nilphamari
Rangpur, Gaibandha and
Mymensingh
Control
Frequent breastfeeding
Proper wrapping
Table 5.1.1. Knowledge of essential neonatal care actions
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
2008 2010 P-value 2008 2010 P-value 2008 2010 P-value
N 539 383 1553 1091 1026 700
Median no. of Known 3(0-5) 2(0-5)

Changes of MNCH during 2008-2010
5.1.2 Practices followed for essential newborn care
Almost universal level of achievement was attained in Nilphamari in the case of wiping practice.
Moreover, Almost 9 out of 10 respondents used sterile blade for tying and cutting cord, and 8 out of
10 initiated breastfeeding within one hour of birth in Nilphamari. In Rangpur, Gaibandha and
Mymensingh, significant achievement was found in all five ENC actions. Three in 10 newborns
received ENC from trained providers in Nilphamari in 2008, which was found to be increased to 7.
Similar positive change had also been observed in other intervention areas though not faster like
pilot intervention in Nilphamari. ENC provided by BRAC SS in the case of home delivery covered
60% in Nilphamari and 18% elsewhere (Table 5.1.2). The level of receiving all essential newborn care
in Nilphamari remained unchanged.
In the other three intervention districts of Rangpur, Gaibandha and Mymensingh, certain
improvements were noted regarding the ENC received, e.g. initiation of breastfeeding within one
hour of birth (p

Neonatal health
5.2 FEEDING OF THE NEWBORN AND INFANT
5.2.1 Knowledge of feeding children aged up to 12 months
Initiation of breastfeeding as soon as possible after delivery, preferably within the first hour of life is
recommended. Across all the three survey areas, ≥75% of women was aware of the importance of
early breastfeeding. However, in Nilphamari, a decrease in knowledge on this issue was noted
counteracted by an increase in the belief that breastfeeding should be initiated after one hour postdelivery.
Conversely, in Rangpur, Gaibandha and Mymensingh significant progress in awareness
about early breastfeeding was noted compared to that reported in 2008 (Annex 2.3.1).
As regards children being exclusively breast-fed for six months, significant increase in knowledge on
this issue was identified in all the intervention districts in 2010, with approximately 92% of women in
Nilphamari (p=0.001) and two-thirds of those in Rangpur, Gaibandha and Mymensingh (p=0.004)
being aware of this recommendation (Annex 2.3.1). Despite the increase in knowledge in Rangpur,
Gaibandha and Mymensingh, the level of knowledge reported in those three areas was similar to
that reported in the control districts.
Similar knowledge levels were noted in 2010 across the three survey groups concerning the time to
initiate complementary food, i.e. after six months, though no significant increases were observed
from that in 2008. Once again, more than 90% of the women surveyed in Nilphamari correctly
reported that infants should commence complementary feeding once completing six months of life
(Annex 2.3.1).
5.2.2 Practices of feeding children aged up to 12 months
Table 5.2.1 presents comprehensive data regarding breastfeeding and weaning food practices of
newborn and infants. In terms of the major findings indicative of differences from 2008 to 2010, a
significant increase in the feeding of colostrums immediately after birth was observed in Rangpur,
Gaibandha and Mymensingh (p94% of the mothers in all the six districts surveyed.
Breastfeeding within the first hour of birth increased significantly in Rangpur, Gaibandha and
Mymensingh (p

Changes of MNCH during 2008-2010
Table 5.2.1. Feeding practices of the newborn and infants
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 P-value 2008 2010 P-value 2008 2010 P-value
N 539 383 1553 1091 1026 700
Fed colostrums 95.4 94.8 .849 89.1 93.6

Neonatal health
Approximately 1 in every 4 newborns had LBW in Nilphamari. This was the highest reported
prevalence amongst the three survey areas. However, due to the absence of data for large numbers
of infants in the other survey areas, caution should be exercised when interpreting this finding.
Rather than being suggestive of a disproportionately high level of LBW existing in Nilphamari, one
should consider the reported figure as a potentially valid estimation of this condition given the lack of
birth weight data in the other districts, especially in Naogaon and Netrokona (Table 5.3.1).
Table 5.3.1. Measuring birth weight of newborn
Nilphamari
Rangpur, Gaibandha and
Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 P-value 2008 2010 P-value 2008 2010 P-value
N 539 383 1153 1091 1026 700
Weight taken after
birth
• Within 48 hrs 56.8 74.7

Changes of MNCH during 2008-2010
hair of the baby after one month (p=0.004) and the use of a ‘baby jacket’ though this practice was
utilized in a very limited number of cases (Table 5.4.1).
Table 5.4.1. Thermal care for normal and LBW babies
Nilphamari Rangpur, Gaibandha and
Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 P-value 2008 2010 P-value 2008 2010 P-value
N (Normal weight 289 233 119 561 105 93
baby)
Thermal care for 54.7 59.7 .253 20.2 21.7 .703 32.4 28.0 .499
normal weight baby 1
• Wiping baby with 97.9 100.0 .027 98.3 98.2 .939 100 94.6 .016
clean dry cloth
• Bathing on or 85.5 78.1 .029 60.5 64.7 .386 80.0 69.9 .100
after 3 days
• Shaving hair after 61.6 63.1 .726 29.4 27.6 .694 38.1 34.4 .590
1 month
N (LBW baby) 74 55 17 112 12 11
Thermal care for LBW 25.7 29.1 .666 5.9 17.0 .239 8.3 9.1 .949
baby 2
• Wiping 97.3 100.0 .219 100.0 93.8 .289 100.0 81.0 .122
• Kangaroo mother 62.2 58.2 .647 58.8 72.3 .255 50.0 45.5 .827
care/ Used baby
jacket
• Bathing after 7 51.4 60.0 .329 35.3 43.8 .511 66.7 45.5 .305
days
• Shaving hair after 62.2 85.5 .004 23.5 33.0 .433 25.0 54.5 .147
1 month
Special care for LBW 89.2 83.6 .356 82.4 73.2 .421 66.7 72.7 .752
babies (Frequent
breast feeding and
proper wrapping)
• Frequent
91.9 96.4 .298 82.4 79.5 .782 91.7 90.9 .949
breastfeeding
• Proper wrapping 94.6 85.5 .077 94.1 89.3 .537 75.0 72.7 .901
1
Wiping the baby, bathing on or after 3 days, shaving hair after 1 month
2
Wiping the baby, kangaroo mother care, bathing after 7 days, shaving hair after 1 month
5.5 NEWBORN ILLNESSES
Birth asphyxia and neonatal sepsis dominate as the commonest cause of neonatal death; birth
asphyxia accounts for 45% and sepsis causes 12% of all neonatal deaths (Chowdhury et al. 2010).
The percentage of neonates facing breathing difficulties (birth asphyxia) remained similar in
Nilphamari and other three districts over the two-year period and was not higher than 10% (Fig. 5.3).
Qualified doctors were found as the most popular care provider for birth asphyxia treatment in
Nilphamari. The care-seeking from qualified doctors increased massively from 9.4% in 2008 to
58.3% in 2010 in Nilphamari (p

Neonatal health
significant in controlling sepsis (p

Changes of MNCH during 2008-2010
5.6 NEONATAL DANGER SIGNS
The mothers who had birth outcome in the preceding year interviewed for neonatal danger signs.
The eight danger signs were listed by the MNCH programme which are related to sucking milk,
hypothermia, chest in-drawing, infection in eyes, unconsciousness/lethargic status of children,
convulsion, umbilical infection, and frequent vomiting. The mothers were ranked according to their
responses; 3-5 responses were ranked as having moderate knowledge while >5 responses were
termed as good knowledge. The median number of knowledge the mothers had was 3 in
Nilphamari, 2 in Rangpur, Gaibandha and Mymensingh and 1 in control districts having maximum 4.
In Nilphamari 95% had the knowledge of going to hospital or referral places after facing those
danger signs while this awareness was found among 70% elsewhere (Table 5.6.1).
Fever and hypothermia were the mostly faced complications everywhere followed by chest indrawing.
Most of them went to public or private facility for treatment (Annex 2.3.3).
Table 5.6.1. Knowledge on neonatal danger signs
Nilphamari
Rangpur, Gaibandha and
Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 p-
value
2008 2010 p-value 2008 2010 p-
value
N - 383 - 1091 1026 700
Knowledge on neonatal
danger signs
• None - 1.8 - 11.3 - 13.0
• Poor (1-2) - 43.3 - 73.3 - 73.0
• Moderate (3-5) - 54.8 - 15.4 - 14.0
• Good (6-8) - 0.0 - 0.0 - 0.0
Median knowledge on - 3 (0-4) - 2 (0-4) - 1 (0-4)
neonatal danger signs
N - 376 - 968 609
Know what to do when
danger signs identified
• Know/have BRAC
referral mobile
number
• Know to go to
hospital/Referral
place
• Know to call BRAC
SS/SK
3.2 8.0 1.1
94.9 70.2 61.2
9.8 0.6 0.5
43

Changes of MNCH during 2008-2010
Chapter
6
Child health
6.1 IMMUNIZATION OF CHILDREN
According to WHO criteria, children are considered completely immunized if they received one dose
of BCG, three doses of DPT, three doses of polio vaccine (excluding polio vaccine given at birth),
and one dose of measles vaccine. In 2009, pentavalent, a combined vaccine dose containing DPT,
Hepatitis B and Pneumonia (Hib) vaccines was introduced; and therefore, considered accordingly
while calculating the coverage of DPT and also the complete vaccination status.
6.1.1 Vaccination coverage
Table 6.1.1 presents information on immunization status of the children aged 98%) were found to have received at least one vaccine in the three study areas
in 2010 though lower levels of complete immunization existed in all the survey areas. Although no
significant changes in complete vaccination coverage occurred within any of the districts from the
baseline to midline surveys, important differences in coverage across the survey district settings
were noted in 2010. Nilphamari had the highest level of complete childhood immunization followed
by the control and Rangpur, Gaibandha and Mymensingh districts (Fig. 6.1). Moreover, children in
Nilphamari were more likely to be fully immunized compared to those from Rangpur, Gaibandha and
Mymensingh (OR=1.9; 95% CI 1.3-2.9), and Naogaon and Netrokona (OR=1.8; 95% CI 1.2-2.8).
Coverage was similar for each of the specific vaccines across all of the districts, e.g. BCG having the
highest percentage among the five vaccines in all three survey areas. Significant increases in
Hepatitis B immunization coverage were identified for all districts, reaching 96.3% (p

Child health
Figure 6.1. Complete vaccination for children aged less than five years
percentage
90
88
86
84
82
80
78
76
Nilphamari
Rangpur,
Gaibandha and
Mymensingh
2008 2010
Control
Table 6.1.1. Vaccination, vitamin A supplementation and De-worming information
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 P-value 2008 2010 P-value 2008 2010 P-value
Number of children 600 300 1800 900 1200 600
12 –59 months
Children with at least 99.2 98.0 .133 97.9 98.0 .923 98.3 98.7 .590
one vaccination
Card available 71.8 73.0 .263 57.7 62.6 .048 62.8 65.5 .507
Children with
87.2 89.0 .429 81.7 80.9 .624 83.4 82.0 .451
complete vaccination 1
• BCG 98.2 97.7 .614 96.8 96.3 .495 96.9 97.3 .622
• Polio3 94.5 95.3 .596 89.8 91.4 .167 91.9 89.0 .042
• DPT3 94.2 95.7 .345 89.1 89.9 .567 91.3 88.5 .055
• Hepatitis–B 76.5 96.3

Changes of MNCH during 2008-2010
6.2 ACUTE RESPIRATORY INFECTION (ARI)
Interviewers asked mothers if their children suffered from acute respiratory infection (ARI) within three
months before the survey. ARI is classified according to the specific symptoms: ‘Cough and cold
only’ is classified separately, ‘cough and cold accompanied with fast breathing’ is termed as
pneumonia, while ‘cough and cold accompanied with both fast breathing and chest in-drawing’ is
termed as severe pneumonia. Symptoms such as being unable to eat, experiencing convulsions,
dizziness, breathing problems, exhibiting wheezing sounds when breathing, and having fever/
hypothermia are examples of very severe diseases.
6.2.1 Prevalence of ARI
Since ARI is even more deadly for young children, the prevalence and management were presented
separately for children aged

Child health
intervention areas (p

Changes of MNCH during 2008-2010
group, it is hard to comment on the changes that occurred over the two-year period between
surveys. However, notable increase was observed in receiving treatment from trained providers for
severe pneumonia in Rangpur, Gaibandha and Mymensingh where an increase from 33 to 84%
observed (Annex 2.4.1).
As regards the treatment of pneumonia in
older children, aged 2 to 59 months, the
majority of cases were managed by nonmedical
persons in both the intervention
and control districts (Annex 2.4.1). Medically
trained provider was found to be increased
in all the intervention areas but not in the
control areas where it was actually reduced
(Fig. 6.4). At baseline, 21% of the
pneumonia affected children was treated by
medically trained provider in Rangpur,
Gaibandha and Mymensingh, by the end of
2010 which was reached to 23%. However,
most dramatic increase was observed in the
intervention areas of Nilphamari where
baseline percentage of 18 was raised up to
30% over a 2-year period (Fig. 6.4).
Figure 6.4. Management of pneumonia
(aged 2-59 months)
Percentage
40
30
20
10
0
2008 2010
Nilphamari
Rangpur, Gaibandha and Mymensingh
Control
The percentages of children with severe pneumonia managed by medically trained providers were
found to be greater than that for pneumonia across all the surveyed areas. Despite this, nonmedically
trained persons dominate the
care for severe pneumonia cases in all the
districts (Annex 2.4.1). Being treated for
severe pneumonia by medically trained
personnel was highest in Nilphamari. As
such a child was twice as likely to be
treated by a trained person in Nilphamari
compared to other intervention districts
decreased in both the intervention areas of
Rangpur, Gaibandha and Mymensingh and
the control areas of Naogaon and
Netrokona. Nevertheless, the percentage of
children with severe pneumonia in
Nilphamari was found to be increased from
36 to 45% over the study period (Fig. 6.5).
6.3 CHILDHOOD DIARRHOEA
Figure 6.5. Management of severe
pneumonia (aged 2-59 months)
Percentage
After introducing oral rehydration solution (ORS) and recent invention of Zinc in diarrhoea treatment
throughout the country in a large scale, diarrhoea prevalence has reduced considerably in
Bangladesh. Nonetheless, approximately 5% of child deaths in Bangladesh are still attributable to
diarrhoea. This section provides information about the prevalence and management of childhood
diarrhoea.
50
40
30
20
10
0
2008 2010
Nilphamari
Rangpur, Gaibandha and Mymensingh
Control
49

Child health
6.3.1 Prevalence and feeding during diarrhoea
During the 2010 survey, the mothers were asked if their under-5 children suffered from diarrhoea in
the preceding three months. Annex 2.4.2 presents the prevalence of diarrhoea and feeding during
diarrhoea. Even if the prevalence was found to be remained unchanged over the two years in
Nilphamari, a significant decrease (p

Changes of MNCH during 2008-2010
6.3.2 Treatment of diarrhoea
An increase in the percentage of children received treatment for diarrhoea occurred between 2008
and 2010 across all study areas. The increase to 95.7% in Nilphamari was statistically significant
(p=0.04) while substantial increases in the other districts also identified. Overall, it was reported that
approximately 9 out of every 10 children with diarrhoea received treatment (Table 6.3.1).
Treatment provision from a trained provider was found to have been greater in the control districts
compared to intervention areas. One-third of young children with diarrhoea in Naogaon and
Netrokona received treatment from personnel trained in the management of diarrhoea whereas one
in every five children in the intervention districts received such treatment. A similar differential was
identified regarding treatment from a medically trained provider across the districts. Finally, very few
children with diarrhoea were treated by BRAC SS/SK in any of the settings. This is also convincing
that more people were seeking treatment from a medically trained provider over time. The
percentage of children received treatment from medically trained providers increased from 16 to
18% in Nilphamari in two years. Against a decrease in control areas, the intervention areas of
Rangpur, Gaibandha and Mymensingh experienced a little increase (Table 6.3.1).
Table 6.3.1. Information on treatment of diarrhoea
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 P-value 2008 2010 P-value 2008 2010 P-value
N 153 93 493 228 217 190
Treatment received 88.2 95.7 .047 88.8 93.0 .083 83.9 88.9 .138
during diarrhoea
Treatment received 15.6 18.0 .633 19.2 20.8 .636 27.5 26.6 .859
provider 1
from medically trained
Treatment received 25.9 20.2 .326 21.0 21.2 .948 34.1 33.1 .854
from trained provider 2
Treatment received
from BRAC SS/SK
0.7 2.2 .337 0.2 0.0 .486 0.5 0.6 .958
1
Qualified doctor, nurse
2
Qualified doctor, nurse, FWV, FWA, MA/SACMO, BRAC SS/SK
6.4 PREVALENCE AND MANAGEMENT OF ILLNESSES OTHER THAN ARI AND
DIARRHOEA
Due to the increased prevalence of fever reported in 2010, the percentage of the children

Child health
Table 6.4.1. Prevalence of other illnesses among children aged 0-59 months
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 P-value 2008 2010 P-value 2008 2010 P-value
Children aged 0-59 1111 674 3284 1946 2184 1276
months
Children suffered 37.1 80.4

Changes of MNCH during 2008-2010
Chapter
7
Factors associated with outcomes
7.1 FACTORS SELECTED FOR ANALYSIS
In this chapter, the results that are presented deal with the analysis undertaken to identify which
independent variables were associated with key indicators of maternal, newborn and under-5 care.
In the first instance the results are based on univariate analysis, conducted by means of a series of
chi-square tests for independence. The list of independent variables (reference category) that were
taken into account for the chi-square tests were:
• Literacy status of the mother (Can’t read and write)
• Literacy status of her husband (Can’t read and write)
• Educational level achieved by the mother (No education or primary incomplete)
• Educational level achieved by her husband (No education or primary incomplete)
• The amount of land owned by the family (No land)
• Wealth index status (The poorest)
• BRAC eligibility (Not eligible)
• Age of the mother at first marriage (≤ 17 years)
• Age of the mother when first conceiving (≤ 19 years)
• Parity (Primiparous)
• Having received at least four antenatal care actions from trained provider during last pregnancy
(No)
• Having one (or more) of the mother’s children die (No child death)
The aforementioned variables were analyzed for their association with twelve key outcome
indicators. The detailed results are presented in tables found in Annex 3.1 – Annex 3.12. The
narrative provided highlights the findings of the univariate analysis, showing which independent
variables are associated with the specific outcome indicators of interest. The analysis was
undertaken on a district-specific basis on the 2010 data only, so as to reflect the present day
situation and possibly impact of the maternal-child health interventions provided.
7.1.1 Receiving four or more ANC actions from trained providers
According to the findings of the univariate analyses performed, the educational level achieved by the
women was the only independent covariate to be significantly positively associated with receiving at
least four ANC services from the trained providers in Nilphamari district. The mother and her
husband being literate, the educational level achieved by each of them and one’s position on the
wealth index indicator were significantly associated with receiving four or more ANC services from a
trained provider in the other intervention districts. All accounted key indicators except age at first
53

Factors associated with outcomes
conception were found to be highly significantly associated with going for at least four antenatal
visits to a trained provider in the two control districts (Annex 3.1).
However, upon carrying out logistic regression modeling for receiving 4 or more ANCs, by district(s),
very few variables were found to be independently associated with this outcome when controlling for
other variables. In Nilphamari and three other intervention districts, a higher level of educational
achievement of the respondent’s husband was found to be the only covariate to be positively
associated with receiving 4+ ANCs. In the two control districts, the mothers who are literate and
who belong to the fourth and richest wealth quintile were found to be significantly positively
associated with receiving 4+ ANCs (Table 7.1.1).
Table 7.1.1. Multivariate logistic regression results for receiving 4+ ANCs from trained
providers
Associated factors
Mother’s Literacy
• Can read and
write
p-
value
4+ANCs received from trained providers
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
OR (95% CI ) p- OR (95% CI) p- OR (95% CI)
value
value
– – – – .000 2.52 (1.51 – 4.19)
Mother’s education
• Primary or higher .019 2.19 (1.14 – 4.21) .000 1.6 (1.23 – 2.06) – –
Wealth index
• Second – – – – .099 1.93 (.88 – 4.23)
• Middle – – – – .161 1.75 (.80 – 3.84)
• Fourth – – – – .000 3.81 (1.86 – 7.8)
• Richest – – – – .000 4.66 (2.26 – 9.58)
7.1.2 Safe delivery (delivery by trained birth attendant)
The mother and her husband being literate, the educational level achieved by each of them and the
mother having received at least four ANC sessions from a trained provider were significantly
associated with undergoing safe delivery. These findings were identified in all three of the survey
areas (Annex 3.2).
Primiparity was also shown to be associated with safe delivery, most especially in Nilphamari where
the vast majority of primiparous women (85.8%) were attended by a trained provider as compared
to approximately two-thirds of multiparous women in that district in 2010. Marriage of the mother at
18 years of age or older was also associated with a safe delivery in Nilphamari and the two control
districts. Women living in the control districts of Naogaon and Netrokona who were >19 years at first
conception were more likely to have a safe delivery compared to their younger counterparts.
However, this was not shown to be the case in the other intervention districts (Annex 3.2).
A statistically significant higher percentage of women who were not eligible for BRAC programmes
underwent a safe delivery in Rangpur, Gaibandha and Mymensingh and the two control districts
compared to those who were eligible. However, this was not the case in Nilphamari where it was
found that similar percentages of BRAC eligible (74.2%) and non-eligible (73.8%) women accessed
safe delivery. In fact, the highest level of safe delivery was reported in Nilphamari (74%) compared to
other two settings, even when compared to those who were not BRAC eligible from the other
districts surveyed (Annex 3.2).
54

Changes of MNCH during 2008-2010
Similarly, safe delivery was associated with being relatively wealthier as indicated by a) the amount of
land owned and b) one’s position on the wealth index. The link between safe delivery and greater
wealth was identified in Rangpur, Gaibandha and Mymensingh districts and the control districts
though not in Nilphamari, wherein neither the amount of land owned nor one’s wealth index position
were predictors of safe delivery, based on the univariate analyses performed.
In summary, several predictor variables were shown to be associated with delivery attended by a
trained provider in all or most of the districts, according to the findings of the univariate analyses
performed (Annex 3.2).
However, upon carrying out logistic regression for safe delivery, by district(s), very few variables were
found to be independently associated with this outcome when controlling for other variables (Table
7.1.2). In the case of Nilphamari, a higher level of educational achievement of the husband and
primiparous status of the mother were significantly associated with undergoing safe delivery. For
other three intervention districts, literacy status of the mother, educational achievement of the
husband and having received at least four ANC actions from a trained provider were associated with
safe delivery. In the two control districts, not being eligible for BRAC, being aged 18 years or older
when the woman was married and the educational achievement of the husband were independent
variables associated with being attended by a trained provider at the last delivery.
Table 7.1.2. Multivariate logistic regression results for safe delivery
Associated factors
Mother’s literacy
• Can read and
write
p-
value
Nilphamari
OR (95% CI ) p-
value
Safe delivery
Rangpur, Gaibandha
and Mymensingh
OR (95% CI) p-
value
Naogaon and Netrokona
(Control)
OR (95% CI)
– – .02 1.39 (1.06 – 1.82) – –
Mother’s education
• Primary or higher .001 2.38 (1.46 – 3.93) .009 1.43 (1.09 – 1.87) .012 1.49 (1.09 – 2.04)
BRAC eligibility
• Eligible – – – – .001 .60 (.44 - .82)
Age at first marriage
• > 17 years – – – – .011 1.63 (1.12 – 2.38)
Parity
• Multiparous .004 .420 (.24 - .76) – – – –
4+ ANCs by trained
provider
• Yes – – .000 1.78 (1.38 – 2.30) – –
7.1.3 Receiving PNC from trained providers
According to the findings of the univariate analyses performed, no covariate was found to be
significantly associated with receiving PNC from a trained provider in Nilphamari (Annex 3.3).
In the case of Rangpur, Gaibandha and Mymensingh, the husband being literate, the educational
level achieved by both the mother and her spouse and the amount of land owned were all
significantly associated with undergoing PNC from a trained provider. In the control districts, all
covariates were highly significantly associated with PNC seeking from trained provider with the
exception of receiving four or more ANC practices from a trained provider (Annex 3.3).
55

Factors associated with outcomes
Carrying out multiple logistic regression for seeking PNC, it was found that higher educational level
of the husband, multiparity, and having received at least four ANCs from trained provider were
significantly associated with seeking PNC from trained provider in Nilphamari (Table 7.1.3). In the
other three intervention districts, having received at least four ANC services from a trained provider
was the only significant covariate. In the two control districts, mother’s literacy, experiencing first
conception after the age of 19, and having four or more ANC visits from a trained provider were
significantly positively associated with receiving PNC from trained provider whereas multiparity was
negatively associated.
Table 7.1.3. Multivariate logistic regression results for receiving PNC from trained
providers
Associated factors
Mothers literacy
• Can read and
write
Husband’s
education
• Primary or
Receiving postnatal care from trained providers
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
p-value OR (95% CI ) p-value OR (95% CI) p-value OR (95% CI)
– – – – .007 1.82 (1.17 – 2.81)
.011 3.25 (1.32 – 1.03) – – – –
higher
Wealth index
• Second – – – – .055 1.82 (.99 – 3.35)
• Middle – – – – .010 2.21 (1.21 – 4.02)
• Fourth – – – – .643 1.16 (.61 – 2.22)
• Richest – – – – .000 6.52 (3.54 – 12.0)
Age at first
conception
• > 19 years – – – – .019 1.75 (1.10 – 2.80)
Parity
• Multiparous .045 2.31 (1.02 – 5.23) – – .008 .59 (.40 - .87)
4+ ANCs by
trained provider
• Yes .020 3.09 (1.19 – 8.02) .000 4.23 (3.24 – 5.53) .001 2.13 (1.35 – 3.36)
7.1.4 Treatment-seeking from medically trained providers for delivery complication(s)
According to the findings of the univariate analyses performed, receiving four or more ANCs from a
trained provider was found to be the only independent covariate to be significantly associated with
seeking care from a medically trained provider in Nilphamari (Annex 3.4). There were no differences
according to other characteristics of the mother and her husband which influenced having sought
treatment for a delivery complication in the district.
However, in the case of Rangpur, Gaibandha and Mymensingh, all the key variables, excluding any
‘child death ever’, were significantly associated with treatment-seeking behaviour for delivery
complication. Similar results were found in the two control districts though age at first conception
was found not to be associated with such treatment-seeking behaviour (Annex 3.4).
Carrying out logistic regression for treatment-seeking behaviour for delivery complications(s), it was
found in Nilphamari that being married at 18 years of age or older has a positive association with
care-seeking for a delivery complication (Table 7.1.4). Conversely, receiving four or more ANCs from
a trained provider was negatively associated with care-seeking for delivery complication in this
56

Changes of MNCH during 2008-2010
district. In the case of Rangpur, Gaibandha and Mymensingh districts, a higher level of education of
the husband, being older when the woman is married and having received at least four ANC visits by
a trained provider were statistically positively associated with care-seeking from medically trained
provider for delivery complications. In the two control districts, a higher level of education of the
mother, having relatively better economic conditions (second, middle, fourth and richest wealth
quintile status) and four or more ANC visits from a trained provider were significantly positively
associated with care-seeking from medically trained provider for delivery complications (Table 7.1.4).
Table 7.1.4. Multivariate logistic regression results for treatment-seeking from medically
trained providers for delivery complication(s)
Treatment seeking from medically trained providers for delivery complication(s)
Associated factors Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
p- OR (95% CI ) p- OR (95% CI) p-value OR (95% CI)
value
value
Mother’s education .038 1.66 (1.03 – 2.67)
• Primary or – – – –
higher
Husband’s
education
Primary or – – .014 1.69 (1.15 – 2.58) – –
higher
Wealth index
• Second – – – – .097 1.84 (0.89 – 3.76)
• Middle – – – – .041 2.08 (1.03 – 4.18)
• Fourth – – – – .034 2.2 4.63)
• Richest – – – – .000 5.58 (2.7 – 11.4)
Age at first
marriage
• > 17 years .038 2.47 (1.05 – 5.82) .013 1.80 (1.13 – 2.85) – –
4+ ANC by trained
provider
• Yes .007 0.11(.02 - .55) .040 1.55 (1.02 – 2.34) .007 2.08 (1.22 – 3.52)
7.1.5 Use of modern family planning methods
The age of respondents and wealth index were the two covariates found to be significantly
associated with using modern family planning methods in Nilphamari (Annex 3.5). In Rangpur,
Gaibandha and Mymensingh, the mothers being literate, of a higher level of education, owning more
land, not being eligible for BRAC membership, being wealthier, younger at first conception, and not
having experienced a child death were significantly associated with using modern FP methods.
Regarding the control districts, the maternal age group, the mothers being literate, the couple both
being of a higher educational level, being relatively wealthier, younger at first having conception, and
had one or more child died were significantly associated with the use of modern contraception
(Annex 3.5).
Carrying out multiple logistic regressions for using modern FP methods, we found no variable to be
associated with this outcome amongst mothers in Nilphamari (Table 7.1.5). In Rangpur, Gaibandha
and Mymensingh, being relatively older (20-34 years or 35 years or older) was positively associated
with the use of modern FP methods. Wealth status was also significantly associated as those who
were wealthier were more likely to use modern FP methods. Being younger (≤20 years), being
younger when first conceived, and having had one (or more) child died were negatively associated
with the use of modern family planning methods in these three districts. In the two control districts,
57

Factors associated with outcomes
the age group of 20-34 years and ≥35 years, BRAC eligible, and the higher wealth quintiles were
significantly positively associated with the use of modern FP methods (Table 7.1.5). Age at first
conception, multiparity, and one or more child deaths were negatively associated with the use of
modern family planning methods.
Table 7.1.5. Multivariate logistic regression results for the use of modern FP methods
Use of modern family planning methods
Associated
factors
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
p-value OR (95% CI ) p-value OR (95% CI) p-value OR (95% CI)
Age group
• 20 – 34 years – – .009 1.39 (1.09 – 1.77) .000 2.21 (1.56 – 3.13)
• ≥ 35 years – – .004 1.77 (1.21 – 2.6) .001 2.56 (1.47 – 4.48)
BRAC eligibility
• Yes – – – – .035 1.29 (1.02 – 1.65)
Wealth index
• Second – – .632 1.07 (.81 – 1.41) .030 1.44 (1.04 – 1.99)
• Middle – – .014 1.41 (1.07 – 1.86) .029 1.47 (1.04 – 2.04)
• Fourth – – .021 1.39 (1.05 – 1.83) .000 1.94 (1.37 – 2.74)
• Richest – – .000 1.90 (1.42 – 2.53) .001 1.87 (1.29 - )
Age at
conception
• > 19 – – .000 .59 (.47 - .75) .000 .48 (.36 - .65)
Parity
• Multiparous – – – – .012 .69 (.51 - .92)
Child death
• One or more – – .001 .68 (.54 - .85) .013 .68 (.50 - .92)
7.1.6 Use of modern family planning methods among married adolescent girls
In all the intervention districts, not having experienced a child death was associated with the use of
modern family planning methods among married adolescent girls (Annex 3.6). Furthermore, in
Rangpur, Gaibandha and Mymensingh, the mothers having primary or higher education and the
husband being literate were associated with the use of modern family planning methods among
married adolescent girls. However, no particular covariate was found to be related with this indicator
in the two control districts.
Carrying out multiple logistic regression for using modern FP methods among married adolescent
girls revealed that the respondents who had one or more children died were less likely to use
modern contraceptives in both intervention areas (Table 7.1.6). However, no particular variable was
found to be significant in the control districts.
Table 7.1.6. Multivariate logistic regression results for the use of modern contraceptives
among married adolescent girls
Use of modern contraceptives among married adolescent girls
Associated factors Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
p-value OR (95% CI ) p-value OR (95% CI) p-value OR (95% CI)
Child death
• One or more .010 .13 (.03 - .62) .009 .32 (.14 - .75) – –
58

Changes of MNCH during 2008-2010
7.1.7 Having all birth plans
In the intervention districts, the literacy and educational level achieved for both the mother and her
husband were significantly associated with having all three birth plans. As well lack of BRAC
eligibility, the position on the wealth index, and having four or more ANC visits from trained providers
were associated with this outcome. In Naogaon and Netrokona, maternal education and literacy
status, not being eligible for BRAC, and wealth index were related to having birth plans (Annex 3.7).
The multiple logistic regression in Nilphamari shows that a mother having a literate husband, and
received four or more ANC services from a trained provider was more likely to have made all three
birth plans before delivery (Table 7.1.7). The link between having the birth preparations in place and
greater wealth (as indicated by one’s position on the wealth index) was also identified as being
significant in Rangpur, Gaibandha and Mymensingh. Complete birth preparation was also
associated with mothers having a higher level of education, and received at least 4 ANCs from a
trained provider in these intervention areas. However, in the two control districts, mothers’ having a
higher level of education was the only covariate found to be significantly associated with birth
planning.
Table 7.1.7. Multivariate logistic regression results for having all birth plans
Associated
factors
Mother’s
education
• Primary or
higher
Husband’s
literacy
• Can read and
p-
value
Nilphamari
OR (95% CI ) p-
value
Having all birth plans
Rangpur, Gaibandha
and Mymensingh
OR (95% CI) p-
value
Naogaon and Netrokona
(Control)
OR (95% CI)
– – .003 1.54 (1.16 – 2.03) .001 1.69 (1.23 – 2.33)
.011 1.93 (1.16 – 3.23) – – – –
write
Wealth index
• Second – – .051 1.48 (1.0 – 2.18) – –
• Middle – – .054 1.50 (1.0 – 2.25) – –
• Fourth – – .000 2.74 (1.75 – 4.30) – –
• Richest – – .001 2.27 (1.40 – 3.68) – –
Received 4+ ANC
from trained
provider
• Yes .000 6.98 (3.51 – 13.91) .000 2.93 (2.25 – 3.83) – –
7.1.8 Received all essential newborn care actions
According to the findings of the univariate analyses performed, parity was the only factor associated
with receiving all five essential newborn care actions in Nilphamari (Annex 3.8). The mother and her
husband being literate, the educational level achieved by each of them, being relatively wealthier as
indicated by a) the amount of land owned and b) one’s position on the wealth index, age at first
conception, having child death, and the mother received at least four ANC sessions from a trained
provider were significantly associated with receiving all five ENC actions in Rangpur, Gaibandha and
Mymensingh. The husband being literate, the educational level achieved, and being older when first
conceived were found to be associated for the control districts.
59

Factors associated with outcomes
However, carrying out multiple logistic regressions for ENC practices revealed that being
primiparous was associated with ENC in Nilphamari (Table 7.1.8). Higher education level of the
mother, first conception after the age of 19, and receiving four or more ANCs from a trained provider
were positively associated with ENC in Rangpur, Gaibandha and Mymensingh. Having more land
was negatively associated with receiving all 5 ENCs in these districts. In the control districts, the
husband’s educational level and delayed first conception after 18 years were associated with ENC.
Table 7.1.8. Multivariate logistic regression results for the practices of ENC
Associated factors
p-
value
Received all essential newborn care actions
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and
Netrokona
OR (95% CI ) p-
value
OR (95% CI) p-
value
(Control)
OR (95% CI)
Mother’s education
• Primary or higher – – .000 1.68 (1.31 – 2.17) – –
Husband’s education
• Primary or higher – – – – .000 1.75 (1.28 – 2.39)
Amount of land
• 1- 50 decimals – – .008 .59 (.40 - .87) – –
• > 50 decimals – – .002 .49 (.31 - .77) – –
Age at first conception
• > 19 years – – .008 1.53 (1.12 – 2.09) .022 .61 (.40 - .93)
Parity
• Multiparous 0.025 .60 (.39 - .94) – – – –
Sought 4+ ANCs from
trained provider
Yes – – .000 1.73 (1.33 – 2.24) – –
7.1.9 Management of birth asphyxia by trained providers
Birth asphyxia being managed by a trained provider was not found to be significantly associated
with any independent variable in any of the intervention districts. In the two control areas, mother’s
literacy, the husband’s level of education, parity, wealth index status, and a history of child death
were significantly associated with management of birth asphyxia by trained provider (Annex 3.9).
As regards management of birth asphyxia by a trained provider, primiparous women were more
likely to have management of birth asphyxia provided by trained providers in the control areas (Table
7.1.9).
Table 7.1.9. Multivariate logistic regression results for the management of birth asphyxia
by trained providers
Associated
factors
Management of birth asphyxia by trained providers
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and
Netrokona
(Control)
p-value OR (95% CI ) p-value OR (95% CI) p-value OR (95% CI)
Parity
• Multiparous – – – – .009 .28 (.11 - .72)
60

Changes of MNCH during 2008-2010
7.1.10 Management of neonatal sepsis by qualified doctors
No covariate was found to be significantly associated with neonatal sepsis management in
Nilphamari. The husband’s level of education was the only variable associated with sepsis
management by qualified doctors in Rangpur, Gaibandha and Mymensingh. In the control districts,
literacy and higher educational achievement for both the mother and her husband were associated
with neonatal sepsis management being provided by a qualified doctor. Likewise management of
neonatal sepsis was associated with being relatively wealthier as indicated by a) the amount of land
owned and b) one’s position on the wealth index in the control districts (Annex 3.10).
No independent covariates were identified for management of neonatal sepsis by a qualified doctor
upon carrying out multiple logistic regression in the intervention areas. However, in the control
districts, optimal newborn sepsis management was more likely when the husband had higher level
of education though having an intermediate amount of land (1 to 50 decimals) was negatively
associated with obtaining this level of care in those two districts (Table 7.1.10).
Table 7.1.10. Multivariate logistic regression results for the management of neonatal
sepsis by qualified doctors
Management of neonatal sepsis by qualified doctors
Associated factors Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
p-value OR (95% CI ) p-value OR (95% CI) p-value OR (95% CI)
Husband’s education
• Primary or higher – – – – .003 4.10 (1.64 – 10.26)
Amount of land
• 1- 50 decimals – – – – .023 .12 (.02 - .74)
7.1.11 Management of ARI by medically trained providers
The educational level achieved by the respondent’s husbands was significantly associated with
treatment-seeking behaviour for the management of ARI in Nilphamari (Annex 3.11). The
respondents, whose husbands are more educated, were supposed to go for a medically trained
provider to seek treatment if her baby had faced ARI. In Rangpur, Gaibandha and Mymensingh, no
covariate was found to be independently significant with seeking treatment from medically trained
provider for the management of ARI.
The mother and her husband being literate and having higher level of education, not being eligible for
BRAC, and being relatively wealthier as indicated by a) the amount of land owned and b) one’s
position on the wealth index were found to be significantly associated with the ARI management by
medically trained provider in the two control areas (Annex 3.11).
Multiple logistic regression revealed that the respondent’s husbands being literate was associated
for the management of ARI in Nilphamari (Table 7.1.11). In the control districts, obtaining adequate
ARI management was associated with mothers’ literacy and being of the richest wealth status
category.
61

Factors associated with outcomes
Table 7.1.11. Multivariate logistic regression results for the management of ARI by
medically trained providers
Associated factors
p-
value
ARI management by medically trained providers
Nilphamari Rangpur, Gaibandha Naogaon and Netrokona
and Mymensingh (Control)
OR (95% CI ) p- OR (95% CI) p- OR (95% CI)
value
value
Mothers literacy
• Can read and write – – – – .035 1.84 (1.05 – 3.23)
Husband’s education
• Primary or higher .010 5.57 (1.42 – 20.45) – – – –
Wealth index
• Richest – – – – .003 3.45 (1.52 – 7.83)
7.1.12 Management of diarrhoea by trained providers
Univariate analyses shows that maternal literacy status, educational level of the mother, and amount
of land owned were significantly associated with the treatment-seeking behaviour for the
management of diarrhoea in Nilphamari (Annex 3.12). All these three variables were found to have
positive effect on the management of diarrhoea by trained providers. No covariate was associated
with this outcome variable in Rangpur, Gaibandha and Mymensingh. The mother being both literate
and having achieved a higher level of education, not being eligible for BRAC, and being relatively
wealthier as indicated by a) the amount of land owned and b) one’s position on the wealth index
were found to be significantly associated with the management of diarrhoea by trained provider in
the two control areas.
Carrying out multiple logistic regressions for the management of diarrhoea by trained provider
identified in Nilphamari that literate mothers and higher education level attained by the mothers in the
control districts were significantly associated with adequate management of diarrhoea (Table
7.1.12). No association between any of the covariates and diarrhoea management by a trained
provider was found in Rangpur, Gaibandha and Mymensingh.
Table 7.1.12. Multivariate logistic regression results for the management of diarrhoea by
trained providers
Associated factors
Mothers literacy
• Can read and
write
p-
value
Diarrhoea managed by trained provider
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
OR (95% CI ) p- OR (95% CI) p- OR (95% CI)
value
value
.007 6.21 (1.65 –
23.29)
Mother’s education
• Primary or higher .000 4.22 (2.13 – 8.34)
62

Changes of MNCH during 2008-2010
Chapter
8
Discussion
This report compares baseline (2008) and follow-up data (2010) to record the benchmark changes
made in various aspects of MNCH as a result of BRAC-MNCH programme in four intervention and
two control districts in northern part of Bangladesh. This study followed the previous study that was
carried out in the same settings in 2008. The district of Nilphamari has been considered as the index
district for assessing changes in performance of ‘objectively verifiable indicators’ of the logical
framework developed for the BRAC MNCH programme. Results are discussed on the aspects of
maternal, neonatal and under-5 health.
8.1 MATERNAL HEALTH
8.1.1 Family planning
Family planning method is the key to reduce fertility and unwanted pregnancies, to increase birth
spacing, to improve women’s health, and to decrease population growth with measured
developmental benefits (Moreland et al. 2010, Glasier et al. 2006). Consistent with a research in
northern part of Bangladesh (Ahmed and Rana 2009), the result of the mid-term survey 2010
revealed that the contraceptive prevalence rate (CPR) of 60-70% was found to be higher in all
intervention districts compared to the national average of 56% (BDHS 2007). Use of modern family
planning method in the intervention areas was also found to be notable. However, CPR (modern
methods) has increased from 61 to 67% during 2008-2010 in Nilphamari, but a borderline significant
reduction has observed in other three intervention districts including Rangpur, Gaibandha and
Mymensingh. These three intervention districts are also lagged behind compared to the control
districts. It may not be due to the facts of lacking awareness, but due to concerns and negative
attitudes towards some methods, particularly the permanent methods. Our findings are also
consistent with this and show that permanent methods continued to play a minor role indicated by
lower use rate of ligation and vasectomy in Nilphamari (5%), other three intervention districts (2%)
and control districts (9%) and also remained unchanged during 2008-2010. Government field
workers were the principal source of contraceptive provision and BRAC field workers were
contributing in a smaller range. Moreover, a significant proportion of women were found to report
side-effects of the family planning methods. Most of them did nothing and a negligible percentage
reported to stop using methods or switch to another method. Hence, appropriate behaviour change
communication (BCC) needs to be undertaken to remove negative perception of permanent
methods and on proper management of side effects with special emphasis in Rangpur, Gaibandha
and Mymensingh.
8.1.2 Adolescent motherhood
Bangladesh has one of the world's highest rates of adolescent motherhood based on the proportion
of women under the age of 20 giving birth every year. Twenty-eight percent of adolescent women
63

Discussion
(age 15-19) are already mothers with at least one child and another 5% are pregnant (BMMS 2001).
The number of deaths among adolescent mothers is double the national average. Comparable to
the national adolescent fertility rate of 26%, the impact assessment survey 2010 indicates that
Nilphamari is facing the worst situation in adolescent motherhood recognized by the level of fertility
among adolescent girls of 27% (BDHS 2007). Other districts have lower adolescent fertility rates
compared to national average. The proportion of adolescent mothers has increased in Nilphamari
over time compared to other intervention and control areas where no change was observed. The
results also indicate a low use of modern family planning methods (51-57%) among adolescent
mothers compared to the national rate of 65% (BDHS 2007). Hence the family planning programme
needs reinvigoration, with service delivery focusing outreach more on newly married couples in all
intervention districts particularly in Nilphamari.
8.1.3 Abortion and menstrual regulation
Unsafe abortion is one of the major causes of maternal mortality (UNICEF 2009a, WHO 1996).
According to WHO, 13% of all maternal deaths occur due to unsafe abortion (WHO 2007). The
result of mid-term survey revealed high rates of abortion (lifetime) in all study areas (9% in
Nilphamari, 14% in other three intervention, and 16% in control districts) with the majority of
spontaneous. Induced abortion decreased in all the three study areas during 2008-2010 with the
control area reported the lowest (10%) and Rangpur, Gaibandha and Mymensingh experienced the
highest (23%) level. Furthermore, complications faced by the respondents after abortion were also
high (44 to 70%). It is alarming that the percentage has risen in all the study areas and most of them
sought treatment from private chamber and informal sector. It is understood that the MNCH
programme is not fully addressing abortion care. However, adequate attention should be given to
improve maternal health. Family planning and MR services need to be readily available to prevent
unwanted pregnancies and unsafe abortion.
8.1.4 Antenatal care (ANC)
ANC is an important determinant of safe delivery and a strategy to reduce maternal mortality (Bloom
et al. 1999, Nuraini and Parker 2005). Health information and services offered through ANC can
significantly improve health of women and their infants (WHO and UNICEF, 2003). Empirical
evidence suggests that four visits are sufficient for uncomplicated pregnancies and more are
necessary only in the cases of complications (Villar et al. 2001). BRAC rural MNCH survey shows a
remarkable achievement regarding ANC practices in all the intervention districts. The proportion of
receiving recommended four or more ANC visits ranged between 68-92% in the intervention districts
which is substantially higher than the national average of 23% (BMMS 2010). Looking at the change
over period (2008-2010), compared to the national median of 3, we see that significant increase
regarding median number of ANC takes place in both Nilphamari (7) and other three intervention
districts (5) with most notable increase has observed in Rangpur, Gaibandha and Mymensingh
districts; while the control districts experienced no change.
Another noteworthy finding of the 2010 survey indicates of improvement in seeking ANC earlier in
gestational week compared to 2008. In 2010, the median months of pregnancy when the first ANC
visit occurred was three in Nilphamari and four in Rangpur, Gaibandha and Mymensingh; both of
them are lower compared to five months as observed at national data (BMMS 2010). These findings
have important public health implications for essential diagnosis of pregnancy complications and
their treatment regimens, and to become risk-free of anemia and STI (AbouZahr and Wardlaw 2003).
Another notable achievement of receiving ANC from a trained provider in all the intervention areas
has been observed. It may be the fact that in BRAC MNCH intervention areas, ANCs are provided
by BRAC SKs. Findings also revealed that the mothers in intervention areas who went to trained
care providers to seek ANC, most of them went for recommended four visits. This indicates that
women are able and willing to seek ANC, but not about the quality of care that may be a further
research agenda.
64

Changes of MNCH during 2008-2010
8.1.5 Birth preparedness
It is anticipated that from antenatal care, women are assisted to develop a birth plan that ensures
birth preparedness and readiness in the eventuality of pregnancy or childbirth complication
[McPherson et al. 2006, Johns Hopkins Programme for International Education in Gynecology and
Obstetrics (JHPIEGO) 2001]. Such a birth plan is expected to assist women in making choices that
would contribute to good pregnancy outcome. The key elements of the birth plan package include
recognition of danger signs, a plan for a birth attendant, a plan for the place of delivery, saving
money for transport and other costs in case the need arises, identification of a potential blood
donors and a decision maker (JHPIEGO 2001; Kaye et al. 2003).
Our study shows a positive trend in intervention areas regarding preparing mothers for delivery by
determining place and attendant and also saving money for emergency or complications. Nilphamari
achieved the highest level (76%) but the most significant improvement was achieved in Rangpur,
Gaibandha and Mymensingh during 2008-2010 (46% in 2008 and 60% in 2010). On the other hand,
a significant decrease has been observed in the control districts. Except for arranging transport, the
remarkable positive changes have been observed for place, attendant and saving money in all the
intervention areas. While increasing percentage of determining place was an encouraging finding,
the disappointing fact was that the mothers who determined place of birth, 90% had determined
home as the possible place of delivery and hence no changes has been observed for hospital
delivery over the two years. The study provides relevant information of birth preparedness and
complication readiness for women in rural areas, and identifies missed opportunities for interventions
to improve emergency obstetric care (EmOC). The opportunity for developing and implementing a
birth plan is often missed such that pregnant women are ill-equipped to make appropriate choices in
the case of pregnancy complications.
8.1.6 Delivery care
Ensuring skilled attendance at delivery is a proxy indicator for monitoring progress in reducing
maternal and perinatal mortality (AbouZahr and Wardlaw 2001). The likelihood of the mother or the
baby becoming ill or dying is reduced when childbirth takes place in a properly equipped health
facility with the assistance of a skilled birth attendant, who also checks regularly on the mother and
baby in the 24 hours after delivery (UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and
the World Bank 2010). The impact assessment survey results revealed that delivery at home has
been the commonest practice throughout the study area though the frequency of home delivery
decreases over two years (79 to 73% in Nilphamari, 86 to 80% in other three intervention). However,
the rate of decrease seems to be slow and the percentage of home delivery is still very high (>70%)
in both intervention and control areas. Consequently, a slow progress was observed in relation to
facility delivery (public/private) with the highest level achievement in Nilphamari.
Although birth is recommended under the supervised care by skilled birth attendants (United Nations
2010), the impact assessment findings were not so encouraging, but, even then an increasing trend
of delivery by medically trained birth attendants was observed in all the survey areas. In 2010,
Nilphamari has the highest achievement (27%) compared to all the surveyed areas (21-24%), but,
the state of increase over the two-year period since 2008 was not statistically significant. The most
notable increase was observed in Rangpur, Gaibandha and Mymensingh from 15% in 2008 to 21%
in 2010. Cord tying and cutting practices with the use of sterile instrument was found to be universal
in Nilphamari. Although not significant, improvement has also been observed in the other
intervention and control districts.
As facility delivery has increased, it would be expected that birth with skilled attendance would
increase. To meet the targets of MDG 5 by 2015, the government and NGOs including BRAC has
undertaken a comprehensive programme on community skilled birth attendants (CSBA) to have a
continued role in serving communities with difficult access. However, it is highly unlikely that even a
65

Discussion
strengthened CSBA programme can contribute substantially towards the 50% MDG 5 targets for a
skilled birth attendance. Further research on knowledge and practices of CSBA at community levels
need to have an immediate consideration.
8.1.7 Postnatal care (PNC)
The percentage of receiving three or more PNC visits has been increased across the study areas
between 2008 and 2010, with the notable achievement in Nilphamari. As an estimated two-thirds of
maternal deaths occur during late pregnancy through 48 hours after delivery (AbouZahr 1998), the
first two days following delivery is very crucial for assessing and treating complications arising from
the delivery as well as ensuring newborn survival (Campbell and Graham 2006). Results show that,
the first PNC visit within 48 hours of delivery was found to be high in Nilphamari (85%) compared to
other three intervention districts, also notable increase between 2008 to 2010 in all districts
indicating encouraging performance. Furthermore, early PNC is critical to promote health household
practices such as exclusive breastfeeding and using family planning. Moreover, the use of SBA
guarantees the care in the immediate postpartum is available. However, to achieve MDG 5 target,
the programme should achieve the universal level in providing both immediate and subsequent
PNCs.
8.1.8 Maternal danger signs, complications and management
The high frequency of home delivery and insufficient birth preparedness indicates poor women are
exposed to higher risks and complications along with delay in referral to facilities. According to
Biswas, reduction in the number of maternal deaths requires timely access to effective, affordable
and appropriate EmOC services (Biswas et al. 2005). Efforts to support an EmOC strategy in
programme such as the MNCH programme have mostly focused on raising families’ awareness of
danger signs with information, education and communication (IEC) on instituting birth preparedness
and facilitating referral. Assessment of IEC interventions suggest that this method is not effective at
reducing delays, partly because the danger sign messages are complex (Stanton 2004). The survey
results reveal that more women (47%) have retained knowledge of three or more (maximum five)
primary danger signs in Nilphamari compared to other areas (25% in Rangpur, Gaibandha and
Mymensingh, and 24% in control districts). A small proportion of women in the intervention districts
knew the BRAC referral mobile number or calling BRAC SS/SK for management of maternal danger
signs. But, most of them (95% in Nilphamari, 82% in other three intervention, and 79% in control)
know about the referral places or hospital to go when any complication arises. About half of the
mothers in Nilphamari reported to face these danger signs whilst it was one in three mothers in
Rangpur, Gaibandha and Mymensingh and even higher (58%) in control areas. More than half of the
mother facing maternal danger signs sought treatment from public or private health facilities in
Nilphamari while the negligible proportion in other study areas.
Consistent with the findings from the maternal mortality survey 2010, the impact assessment survey
reveals that a substantial proportion of women suffered from maternal complications during
antenatal, delivery and postnatal period, which has increased from 2008 to 2010. This maybe
because BRAC-MNCH intervention not only aware women on the issue, but also increase
community health workers’ capacity to detect complications. The percentage of women seeking
treatment from medically trained provider and health facility for such complications also increased in
all the intervention areas. This maybe an effect of BRAC-MNCH programme referral system that
tends to train the community health workers to recognize complication and to refer the complicated
cases to appropriate referral facilities as early as possible. Although BRAC workers in Nilphamari
have made significant number of referral compared to other intervention districts, and increased the
number of referral from 2008 to 2010, findings from the impact assessment survey are not
conclusive enough to judge the quality and timeliness of referral. Nonetheless, model for effective
referral system of BRAC urban MNCH intervention (Manoshi) exhibits that women-focused
development intervention reduces first and second delays, but not the third delays in accessing
66

Changes of MNCH during 2008-2010
EmOC in urban slums of Bangladesh (Nahar et al. 2011). Hence, to make a programme to be
successful, there must be a combination of effective referral as well as functional referral
infrastructure.
Still more than one-third of women sought care from informal sectors (village doctor, drug seller,
traditional healers, and homeopaths). The impact assessment surveys revealed some factors for not
accessing the formal care or going to the referral centre. These are costs, perceived dissatisfaction
with formal care, and disapproval from family members. Keeping in mind these barriers, the
programme may think to address husbands and mothers-in-law through its IEC component.
8.1.9 Inequity in maternity care
Poorer groups within developing countries use less healthcare (Gwatkin et al. 2000) and poor-rich
inequalities in maternity care and maternal mortality have been described (Gwatkin. 2004; Graham et
al. 2004). Poor-rich inequalities might also be larger when services require action at a specific time.
For instances, deliveries have a short time-window in which care can be sought compared to ANC
(Amopti-Kaguna and Nuwaha 2000), for which there is more time to seek care. Moreover, the onset
and timing of labour is less predictable.
The impact assessment survey 2010 suggests that, in Nilphamari district MNCH health status and
service utilization levels were not conditioned by membership of a certain group (e.g. literate mother)
compared to its counterpart (mothers who could not read and write). One such example was related
to treatment-seeking for delivery complications. No socio-demographic variables were predictive of
accessing treatment for delivery complications, for instance literacy status, wealth index position,
parity, inter alia amongst women in Nilphamari. This finding contrasts with those for the other
intervention and control districts. Accordingly differentials were identified across a series of
independent variables which were indicative of higher levels of accessing care for delivery
complications depending on, for instance, the literacy status of the mother, wealth status, and age
of first conception. In the control districts, highly significant results were obtained for the associations
of independent variables with outcome variables on univariate and further multiple logistic regression
analysis. Such results highlighted the disadvantage in terms of MNCH posed by certain groups (e.g.
illiterate mothers) in the absence of the BRAC MNCH programme.
Consistent with the incidence from other least developed countries (Kobilinsky et al. 1999; Victoria et
al. 2010), BRAC MNCH intervention appears to have achieved relatively similar health status and
service utilization levels in Nilphamari independent of one’s literacy, wealth or reproductive profile.
However, this is clearly not the case in the control districts as better health status and service
utilization are conditioned by several socio-demographic, wealth and reproductive profile
characteristics. This suggests that supply factors play an important role in minimizing the poor-rich
inequalities in maternity care in rural Bangladesh. Because a large number of BRAC outreach health
workers are ensuring home-based maternity care and providing subsidy to the poor in the case of
referred EmOC.
8.2 NEWBORN CARE
Receiving newborn care on the day of birth would reduce the risk of neonatal mortality by two-thirds
among neonates who survived the first day of life, and receiving the care on the second day reduce
the risk of mortality by 64% (Baqui et al. 2009). Newborns lacking appropriate care are at high risk of
poor health and reduced productivity in childhood and later life. Preventing newborn death begins
with the health of mother to be provided during pregnancy, labour and delivery, and postnatal
period. Consistent with a community-based home care strategy to promote an integrated package
of preventive and curative care in Sylhet, Bangladesh (Baqui et al. 2009), our findings show that
community-based interventions, such as health education to improve neonatal care practices, ENC
and care for illnesses are effective in improving neonatal health.
67

Discussion
8.2.1 Essential newborn care (ENC)
A key indicator of ENC is skilled attendance at delivery which has increased from 30 to 71% in
Nilphamari and 15 to 34% in other three districts during 2008 to 2010. This is promising since it
speculates that skilled attendance at delivery provides the best opportunity to address the neonatal
death due to birth asphyxia at community setting. It has greater public health implications as birth
asphyxia causes one-fifth of neonatal death (BDHS 2004). The median knowledge regarding ENC is
almost equal everywhere out of a maximum possible five 1 knowledge. The knowledge scale reflect a
positive increase while ‘poor’ 2 and ‘medium’ 3 knowledge levels are amalgamated; progress goes
almost 100 from 88% in Nilphamari; though a slight decrease is observed in other three intervention
and control clusters. Another remarkable success at the practice level of ENC has flagged the
advancement of BRAC’s MNCH intervention and draws the critical attention on enormous
contribution and successful replications of lessons that has been learned way back since 2006.
Receiving all ENC has increased significantly in three intervention districts (from 42 to 55%), but a
slight decrease was found in Nilphamari and a substantial decrease in control cluster.
Studies show that home visits by trained community health workers has brought some events in
newborn lives, for instances home visits in the first two days of an infant’s life can significantly reduce
the risk of neonatal mortality by two-thirds (Baqui et al. 2009). Another study revealed that the village
women who are trained on maternal and neonatal care contribute on reducing 60% neonatal death
in the remote areas of central India (Tinker et al. 2010). Here in BRAC’s intervention, 60% case of
home delivery has ensured ENC services through BRAC SS in Nilphamari and 18% in other three
intervention districts.
8.2.2 Thermal care
Thermal care is important for all newborns, especially vital for LBW babies as to risk of acquiring
hypothermia. The South-East Asian region has a high prevalence of babies born with weight

Changes of MNCH during 2008-2010
8.2.3 Newborn feeding
The breastfeeding tradition in Bangladesh is the best in the world (Ted 1997). The Bangladesh
fertility survey (BFS) in 1975-76 found that 98% infants are breastfeed and the rate is reported similar
in BDHS 2007. Breastfeeding within an hour or within two hours of delivery is associated with the
establishment of longer and more successful breastfeeding, and of exclusive breastfeeding (Holman
and Grimes 1993). However, challenge exists in the timing of initiation of breastfeeding immediately
after birth, and perhaps it is usually substituted by so called pre-lacteal feeding. Initiation of
breastfeeding as soon as possible after delivery, preferably within the first hour of life is widely
recommended. Our survey revealed that 95% of the mothers fed colostrum immediately after birth
across the intervention area which is a bit higher than the national average (92%) (BDHS 2007).
Four in every 10 women exclusively breastfeed their babies and no improvement was observed in
exclusive breastfeeding practices over time in the country (BDHS 2007). However, our survey
revealed an increased trend (from 47% in 2008 to 62% in 2010) in Nilphamari, but a decreased
trend in other three intervention districts which seems less than the national average (26%). On the
other hand, delaying the initiation of complementary food was seen in all the intervention areas.
Hence, the programme needs to provide attention to promote exclusive breastfeeding.
8.2.4 Neonatal danger signs and illnesses
Research indicates that the primary causes of neonatal mortality in low income countries are
infections and birth asphyxia (Baqui et al. 2009). The situation on neonatal danger signs and
illnesses are quite impressive in Nilphamari, but not in other three intervention districts. The
knowledge about neonatal danger sign was quite high in Nilphamari (55%) indicated by the level of
moderate knowledge (recognized 2-3 danger sign). Almost 95% of women knew that they need to
go to hospital or referral place once a danger sign was detected, and a gradual inclination in the
awareness to call BRAC SS/SKs through mobile in emergency.
The Lancet series on neonatal health reported that the direct causes of neonatal death include
severe infections (36%) [sepsis/pneumonia (26%), tetanus (7%), and diarrhoea (3%)] and
complications of asphyxia (23%) (MoHFW 2009). Birth asphyxia accounts one in every five neonatal
deaths in Bangladesh (UNICEF 2009a). In our intervention areas, the prevalence of reported birth
asphyxia to be 10%, whereas 67% of the cases in Nilphamari and 44% in other three districts are
managed by trained care providers (Qualified doctor/nurse/SS/FWV/MA/SACMO). Only 6-7% cases
of birth asphyxia are treated by BRAC SS in the intervention areas. A study in central remote India
shows that a significant number of birth asphyxia is being successfully managed by the communitybased
health workers with a limited training (Baqui et al. 2009). The neonatal sepsis is reduced
significantly in three intervention areas but it remains same in Nilphamari. Half of the neonatal sepsis
is treated by the medically trained providers (MBBS doctor, MA/SACMO, nurse, paramedic) in
intervention areas is indeed a remarkable achievement. However, based on lessons learned from
other studies (Baqui et al. 2009, Bang et al. 2005), it is recommended that programme would act
more vibrantly to engage its SS to recognize as well as manage the newborn illnesses.
8.3 HEALTH OF CHILDREN UNDER-5 YEARS OF AGE
Reducing childhood mortality and morbidity is critical because healthy children attribute to the
security, economic growth and civil stability of a nation. In this study, prevalence and management
strategies of ARI, diarrhoea and other illnesses of under-5 children and immunization attributes are
explored.
69

Discussion
8.3.1 Vaccination of the under-5 children
Worldwide, immunization helps avert more than three million deaths annually from vaccine
preventable diseases and tends to save millions suffering from illness and disability (WHO 2009).
Bangladesh has experienced tremendous advances to complete vaccination coverage over the last
two decades when they officially started EPI programme accepting WHO mandate, reaching 76% in
2007 among the children aged 12-59 months (BDHS 2007) and this needs to be sustained. The
impact assessment survey 2010 indicates that, one of the most notable achievements in child health
is vaccination coverage, particularly in Nilphamari where it was found to be increased to 89%
starting from 87 in 2008. However, no such change has been observed in other intervention
districts. BRAC’s vaccination-mobilization strategy at community level needs to be strengthened in
these districts to reach the target of MDG 4 by 2015.
It is important to have the vaccination card since parental recall of vaccination information often
gives erroneous results (Suarez et al.1997). Though not statistically significant, the percentage of
children with vaccination card has been increased from 58 to 63% in Rangpur, Gaibandha and
Mymensingh, and 72 to 73% in Nilphamari during 2008 and 2010. Although the percentage of
children with vaccination card is still low in all study areas, it is higher than that of the national figure
(58%) (BDHS 2007). Overall, vitamin A intake was found to be satisfactory, nearly nine out of every
ten children were given oral vitamin A capsule on 26 May 2010 which is consistent to the national
achievement of 88% (BDHS 2007).
8.3.2 Acute respiratory infection (ARI)
ARI is one of the most predominant causes of childhood death after the first month of life in
Bangladesh (BDHS 2007). The prevalence of different forms of ARI such as pneumonia and severe
pneumonia was found to be decreased among the children aged

Changes of MNCH during 2008-2010
8.3.3 Diarrhoea prevalence and management
Introduction of ORS in Bangladesh results a tremendous decrease in diarrhoea prevalence (Ruxin
and Joshua 1994). In 1975-1977, diarrhoea was the most significant cause of under-5 child death
(15 children per 1000 live births) (Chen et al.1980). By the year 2007, only five deaths per 1000 live
births occurred due to diarrhoea in Bangladesh (United Nations 2010). This signifies the accelerated
use of ORS over time in Bangladesh. The MNCH midline survey of 2010 found the same pattern
indicated by 8 in every 10 diarrhoea affected children in intervention areas received ORS for the
treatment of diarrhoea. This signifies the importance of community-based health and nutrition
education programme through community health workers as done in IMNCS project (Pahwa et al.
2010). This high level of ORS intake in the intervention areas together with increased awareness and
improved quality treatment may result in lower prevalence of diarrhoea over time compared to the
control area where actually the diarrhoea prevalence increased over the last two years.
Zinc treatment is recommended along with ORS for treating diarrhoea. A study indicated that around
92% of the caregiver of the diarrhoea-affected children was willing to pay the required amount of
money for zinc treatment (Akhter and Larson 2010). However, the impact assessment survey
showed that the intake of zinc for diarrhoea was low in 2008 and that the situation did not improve
over time. It has been postulated that breastfeeding protects the baby from diarrhoea (Feachem and
Koblinsky 1984). However, it is promising that breastfeeding rate supposed to be very high, around
90% among all diarrhoea-affected children in our study areas.
8.3.4 Management of other illnesses among under-5 children
Except fever, the prevalence of other common childhood diseases including skin diseases,
dysentery, mouth ulcer, and worm infestation was found to be reduced in the intervention areas over
time, which is similar to that in other parts of the country (BDHS 2007). Consistent with other studies
(Mahmood et al. 2010) increasingly more children are getting treatment from village doctors which
may be due to the same reasons of low cost, and proximity as found for ARI and diarrhoea.
However, positive trend of receiving treatment from qualified doctors in intervention districts further
explaining the effectiveness of the project.
8.4 METHODOLOGICAL CONSIDERATIONS
The quasi-experimental nature of this study presents certain limitations in terms of conclusively
affiliating the observed changes in MNCH status and health service utilization across the intervention
and control settings with the implementation (or not) of the BRAC MNCH programme. This limitation
is predicated on the fact that in the control districts similar maternal and child health services were
available through ministry of health facilities as well as being provided by NGOs within the districts
under study.
As we intend to observe the changes among population on MNCH issues, and randomization was
followed from sub-district to household level in each district, it is possible to generalize the results for
rural population in northern and central Bangladesh, but does not represent the urban scenario.
Structured face-to-face interviews with pre-tested questionnaires were used to elicit information
from the respondents. Several biases are common in this kind of interview survey. Recall bias may
arise in many cases when the reports were retrospective, such as abortion, MR, etc. Interviewer bias
may occur when certain characteristics such as experience and knowledge base of the interviewers,
and quality of the interviewer-respondent interaction influence the responses. There may also be
information bias due to respondent answering in a certain way to please the interviewer (Hardon et
al. 2001). To reduce these biases, several strategies were adopted. These include, recruitment of
experienced interviewers, standardized training on questionnaire contents, interview algorithm,
probing techniques, strategies to establish rapport and neutrality essential to complete and accurate
71

Discussion
data collection, and avoidance of inter-observer variation and interviewer bias. We also used early
deployment of interviewers in the field to allow time for rapport building activities and assuring the
respondents of confidentiality of data for information bias. Finally, intensive supervision, on-the-spot
checking for inconsistencies, and a random post-enumeration survey of 5% of the households
surveyed in the 72 hours were carried out.
However, the findings of this report support the benefits of the BRAC MNCH Programme. This is
substantiated throughout the report when observing the positive changes that have taken place
during 2008 to 2010 in the intervention areas. One limitation in the presentation of results has been
the conglomeration of the data in the three intervention districts of Rangpur, Gaibandha and
Mymensingh, on the basis that the BRAC MNCH programme was introduced into these areas in the
same year (2008). The same observation and limitation exists vis-à-vis the two control districts
Naogaon and Netrokona which have been treated for analysis purposes as a single setting, despite
their non-contiguous geographical location, among other potential differences.
By having presented the results on a ‘study group’ rather than ‘district-specific’ basis, the findings
may not have adequately reflected differences between districts in either the intervention or control
districts, respectively. One such important issue may have been access to institutional delivery or
treatment of ARI in young children by qualified doctors. The distribution of healthcare service delivery
is not homogenous across various districts yet the pooling of data from the districts into larger
groupings may have precluded identification of relevant findings for the study.
8.5 CONCLUSION AND PROGRAMMATIC IMPLICATIONS
Ultimate target of IMNCS programme of BRAC is to contribute achieving MDGs 4 and 5 and BRAC
is helping the government to fulfill the commitment. This report identifies that in BRAC-IMNCS areas,
there are remarkable improvement in certain maternal health indicators, such as receiving 4+ ANCs
and ANCs from trained provider, birth preparedness, delivery by trained providers, receiving PNC
from trained providers and also within 48 hours of delivery, etc.; neonatal health indicators on
management of birth asphyxia and neonatal sepsis; and under-5 child-health on management of ARI
and diarrhoea by medically trained providers. The 2010 survey also recognizes the gaps and
challenges, and understands factors behind the current maternal, neonatal and child healthcare
practices. These findings have a number of programmatic implications as follows:
Maternal health
1. Considering persistent early marriage and early childbearing in the intervention areas over time,
the family planning programme needs reinvigoration, targeting more on newly married couples
and adolescent mothers. The programme needs to focus on educating people on
misconceptions about long-term family planning methods. Husbands must be particularly
involved in the education process.
2. The rate of abortion and the subsequent complications has been found to be reasonably high,
and the least proportion of complications is managed by qualified service providers. Hence the
threat of malpractice always exists. IMNCS programme thus needs to integrate the abortion
care services particularly BCC, management and referral of complications to the appropriate
facilities.
3. Now that achievement has been made on frequency of ANC visits, attention should be given to
its content and improve quality of ANC services.
4. The programme has made an overall impact on birth planning. But a hidden threat remains as
majority of women prefer their home as their birth place instead of hospital or any healthcare
facility. Therefore, an extended effort is required to promote institutional delivery in Bangladesh.
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Changes of MNCH during 2008-2010
5. Deliveries by skilled attendance increased but the lower percentages remind us about the
challenge of improving the situation. On the other hand, deliveries by trained attendant
increased substantially, but still remains as a challenge.
6. Over time, the programme has achieved success in providing the number of PNC visits. But
more attention need to be paid on the timing of PNC, as less success is indexed on first PNC
visit within 48 hours of delivery. This is crucial because this visit provides opportunity for all
newborn receiving the ENC that supposed to reduce the risk of neonatal mortality by two-thirds
(Baqui et al. 2009).
7. Though the maternal complications increased in the intervention areas over time, seeking
treatment from medically trained provider also increased which may conclude the programme’s
achievement. However, the programme should be continued to lessen complications. Proper
programmatic actions to improve knowledge of family and community members may be helpful
in this regard.
8. The 2010 survey results reveal that half of the women had no or very poor knowledge about
maternal danger signs and a very low number of women in the intervention districts know the
BRAC referral mobile number where more initiatives need to be taken immediately. The
proportion of people who knew about the referral place or hospital or BRAC cell phone number
is responding passionately; indicates that the existing referral system might give good result if
the message could be disseminated widely.
Neonatal health
1. Knowledge on ENC remains stagnant since last two years. The indicator of thermal care for
LBW babies is still in a critical state, and hence a massive attention or better health promotion is
required.
2. In the three new intervention districts, the progress of ENC coverage offered by the trained and
skilled health professionals has been increasing in a less stipulate fashion where faster progress
would be ensured, otherwise the progress that already been achieved might give a phase of dim
advancement.
3. The programme needs to work more in recording birth weight particularly for births that occur at
home.
4. Critical challenge still exists on breastfeeding immediately after birth; perhaps it is usually
substituted by pre-lacteal feeding. The programme may contribute in feeding practice arena
through community mobilization.
Under-5 child health
1. The programme has made successful achievement on significant reduction in the prevalence of
pneumonia but challenge remains on its management. A substantial proportion of pneumonia
and ARI cases are managed by the non-formal health providers in the programme areas. The
programme ought to emphasize strengthening health system support parallel to the awareness
rising in the community.
2. Fever is the prominent illness that the children have experienced frequently in programme areas
compared to any other illness. The programme needs to pay more attention on it.
3. Considering the lower immunization coverage in the new intervention districts, the programme
should pay special attention in community mobilization and campaigning before the vaccination
day.
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Changes of MNCH during 2008-2010
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78

Changes of MNCH during 2008-2010
Annexures
Annex 1. Revised logical framework
Narrative
Summary
Goal:
To contribute to
reduction in
maternal,
neonatal and
child mortality
and morbidity,
particularly
among the poor
and socially
excluded
population
Purpose:
To improve
community
MNCH
practices and
utilization of
quality MNCH
care and
services in the
project
supported
districts
Objectively Verifiable Indicators
• Reduced maternal mortality ratio from
320 to 260 per 100,000 LB
• Reduced neonatal mortality from 41 to 28
per 1000 LB
• Reduced under-five mortality from 85 to
50 per 1000 LB
1. Proportion of women who received at
least four ANCs increased from 14% at
baseline to 80% by EoP
2. Proportion of women delivered by skilled
birth attendants increased from 15% at
baseline to 30% by EoP
3. Proportion of mothers and newborn who
received a PNC by trained providers
within 48 hours increased from 12% at
baseline to 80% by EoP
4. Met need for EmOC: Proportion of
complicated pregnancies appropriately
managed at functional facilities in project
supported districts increased from 23%
at baseline to 50% by EoP.*
5. Proportion of newborn protected with
thermal care (drying and wrapping within
10 minutes) increased from 18.5 (BDHS
2007) at baseline to 50% by EoP
6. Proportion of newborn initiated
breastfeeding within one hour of birth
increased from 51% to 85% by EoP
7. Proportion of under-five children suffered
from ARI managed by trained providers
increased from 21% at baseline to 75%
by EoP
Means of
Verification
• Bangladesh
Demographic
Health survey
• Bangladesh
Maternal
Mortality
survey
• Project MIS
data
• Baseline and
End-of-
Project (EoP)
surveys
• Pooled
LQAS survey
data for
annual
tracking
• BRAC MIS
data for
monthly
tracking
• GoB HMIS
Report for
indicator # 4
Risks and Assumptions
Assumptions
• Donor commitment and
availability of funds
• Health systems
weaknesses addressed
• Risks
• Resource flow
• Political stability
• Natural disasters
• Supply of
contraceptives is
beyond BRAC’s control.
• Natural disasters
Assumptions
• Knowledge of danger
signs etc. will lead to
better decision making
and care seeking
• Utilization of improved
services will increase
• Access and affordability
of community to
services will increase
• Both private and public
will offer better quality
services
• MNCH human
resources and
commodities available
Risks
• Social barriers
• Logistics and
communications
systems weaknesses
• Political stability
• Subject to GoB initiative
to train CSBA
(Annex 1. continued....)
79

Annexures
(.........Continued Annex 1)
Narrative Objectively Verifiable Indicators
Summary
Output: 1
Increased
knowledge and
improved
MNCH
practices in
communities
Output: 2
Improved
provision of
quality MNCH
services at
household and
community
levels.
1. % of delivered women aware of
maternal danger signs knows what
needs to be done (BRAC referral mobile
number and hospital) rise from 7% at
baseline to 50% by EoP
2. % of delivered women having adequate
knowledge of neonatal danger signs (5)
know what needs to be done rise from
18% at baseline to 50% by EoP
3. % of women having a birth plan
increases from 2% at baseline to 50%
by EoP
4. % of LBW babies received special care
(frequent breastfeeding, proper
wrapping and hand washing) rise from
X% at baseline to 60% by EoP
5. % of eligible couple using modern
contraceptive method increased from
55% at baseline to 65% by EoP
6. % of married adolescent girls giving
birth decreased from 26.6 % at baseline
to 15% by EoP
7. % of married adolescent girls using
modern contraceptives from 52% at
baseline to 70% by EoP
1. % pregnancies identified by SS/SK in
first trimester rises from 25% at baseline
to 60% by EoP
2. % of women who received at least four
ANCs from SKs increased from 14% at
baseline to 80% by EoP
3. Proportion of women delivered by
skilled birth attendants increased from
15% at baseline to 30% by EoP
4. % PNC delivered by SKs within 48
hours for home deliveries rises from
0.4% at baseline to 80% by EoP
5. % of neonates with sepsis received
care from trained providers increase
from 19% at baseline to 70% by EoP
6. % children with pneumonia managed
by trained providers increase from 0%
at baseline to 90% by EoP
Means of
Verification
• Baseline and
End-of-Project
(EoP) surveys
• Pooled LQAS
survey data for
annual
tracking
• BRAC MIS
data for
monthly
tracking
• Baseline and
End-of-Project
(EoP) surveys
• Pooled LQAS
survey data for
annual
tracking
• BRAC MIS
data for
monthly
tracking
Risks and Assumptions
Assumptions
• Individual, households
and community have
enhanced knowledge
through interactive
communications
• Knowledge can lead to
significantly behavior
change
Risks
• Social stigmas
• Cultural and religious
barriers
Assumptions
• SS/SKs are properly
trained on MNCH issues
• SS/SKs provide MNCH
services regularly
• Central BRAC interprogramme
committee
meets and give
necessary decisions
regularly in time
Risks
• UN programmme starts
in time
• SS/SKs can not cope
with new responsibilities
(Annex 1. continued....)
80

Changes of MNCH during 2008-2010
(.........Continued Annex 1)
Narrative Objectively Verifiable Indicators
Summary
Output: 3
Increased
availability and
access to
quality
continuum of
MNCH care and
services at
facilities
Output 4:
Increased
participation,
accountability
and
responsiveness
to communities’
voice in MNCH
services
1. 60% of the project supported District
Hospitals in MNCH districts provide
quality services (availability of 24/7
services,oxytocin,MgSO4,antibiotic)
2. Al least 80% of the target population is
within 2 hours travel from home to a
CEmONC facility
3. Proportion of all birth in all facilities at
project supported districts rises from
12.6% to at least 30 % by EoP
4. CS rate at all CEmONC facilities in
project supported districts rises from
4.8% at baseline to 5-15% by EoP
5. Case fatality rate at all EmONC facilities
for maternal complications in project
supported districts remains at

Annexures
Annex 2. Profiling the changes over time (2008-2010)
Annex 2.1. Socioeconomic characteristics
Annex 2.1a. Distribution of wealth index by district (Nilphamari, Rangpur and Gaibandha)
Nilphamari Rangpur Gaibandha
2008 2010 p-value 2008 2010 p-value 2008 2010 p-value
N 1200 720 1200 720 1200 718
Poorest 19.5 21.5 0.097 16.0 17.4 0.711 16.5 17.0 0.474
Second 24.3 22.5 20.2 19.4 21.5 24.4
Middle 22.2 18.6 21.3 21.1 22.8 22.7
Fourth 17.4 21.3 19.8 17.8 21.0 20.3
Richest 16.6 16.1 22.8 24.3 18.2 15.6
Annex 2.1b. Distribution of wealth index by district (Mymensingh, Naogaon and Netrokona)
Mymensingh Naogaon Netrokona
2008 2010 p-value 2008 2010 p-value 2008 2010 p-value
N 1200 720 1200 720 1200 720
Poorest 21.8 21.5 0.899 13.8 16.5 0.102 32.3 33.8 0.727
Second 18.9 18.6 15.1 17.9 20.1 20.0
Middle 17.7 19.3 19.4 19.9 16.5 17.6
Fourth 20.4 20.4 24.2 21.3 17.6 16.9
Richest 21.2 20.1 27.5 24.4 13.6 11.7
Annex 2.2. Maternal health
Annex 2.2.1. History of abortion
Nilphamari Rangpur, Gaibandha and Naogaon and Netrokona
Mymensingh
(Control)
2008 2010 p-value 2008 2010 p-value 2008 2010 p-
value
N 1200 720 3600 2158 2400 1440
Ever had abortion 10.5 9.0 .297 13.6 13.9 .742 16.6 15.9 .574
Frequency of abortion
• None
• 1
• ≥ 2
89.5
8.8
1.7
91.0
6.9
2.1
86.4
11.6
2.0
86.1
11.5
2.4
83.4
14.1
2.5
84.1
13.8
2.1
N 148 85 574 361 474 271
Type of abortion
• Induced
• Spontaneous
20.3
79.7
14.1
85.9
.240 30.7
69.3
23.0
77.0
.011 18.6
81.4
10.0
90.0
.002
82

Changes of MNCH during 2008-2010
Annex 2.2.2. Complication during abortion and its management
Nilphamari
Rangpur, Gaibandha and
Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 p- 2008 2010 p-value 2008 2010 p-value
value
N 148 85 574 361 474 271
Any complication faced after 48.0 48.2 .969 39.4 44.0 .158 43.2 69.7

Annexures
Annex 2.2.3. History of MR
Nilphamari
Rangpur, Gaibandha and
Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 p-
value
2008 2010 p-
value
2008 2010 p-
value
N 1200 720 3600 2158 2400 1441
Ever had MR 3.2 4.2 .251 3.4 4.5 .029 2.6 4.4 .002
Frequency of MR
• None 96.8 95.8 96.6 95.5 .030 97.4 95.6 .004
• 1 2.9 3.8 2.9 4.1 2.4 3.9
• ≥ 2 0.3 0.4 0.5 0.4 0.2 0.5
N 43 34 146 111 66 74
Any complication faced 18.6 41.2 .029 21.2 31.5 .061 30.3 36.5 .439
after MR
N 8 14 31 35 20 27
Types of complication
faced after MR
• Fever 12.5 28.6 25.8 28.6 25.0
• Foul smelling
0.0 0.0 19.4 0.0 10.0
discharge
• Vomiting 0.0 7.1 6.5 2.9 15.0 25.9
• Excessive bleeding 37.5 64.3 51.6 48.6 45.0 0.0
• Abdominal pain 75.0 64.3 41.9 48.6 45.0 0.0
• Headache 0.0 0.0 3.2 0.0 0.0 37.0
Action taken after MR
complication
• Did nothing 0.0 0.0 9.7 5.7 5.0 11.1
• Self treatment 0.0 0.0 0.0 5.7 0.0 7.4
• Treatment from HCP 100.0 100.0 90.3 88.6 95.0 81.5
N 8 14 28 31 19 22
Treatment provider for MR
complication
• Village doctor 12.5 14.3 39.3 29.0 36.8 31.8
• FWV/MA/SACMO/ 0.0 28.6 17.9 12.9 52.6 27.3
Nurse
• Homeopath 0.0 0.0 3.6 3.2 5.3 9.1
• Qualified doctor 62.5 57.1 50.0 18.4 15.8 31.8
• Drug seller 25.0 0.0 3.6 6.5 0.0 4.5
• BRAC SS/SK 0.0 7.1 0.0 0.0 0.0 0.0
Place of treatment for MR
complication
• District hospital 0.0 7.1 10.7 6.5 0.0 4.5
• UHC/MCWC/FWC 12.5 42.9 10.7 22.6 42.1 27.3
• Private hospital/Clinic 12.5 14.3 10.7 12.9 0.0 9.1
• Other NGO clinic 0.0 0.0 3.6 3.2 0.0 0.0
• Private chamber 62.5 28.6 42.9 25.8 26.3 45.5
• Drug seller 25.0 7.1 3.6 9.7 5.3 9.1
• Others (Satellite
clinic/home)
0.0 7.1 25.0 19.4 36.8 4.5
84

Changes of MNCH during 2008-2010
Annex 2.2.4. Knowledge on antenatal care
Nilphamari
Rangpur, Gaibandha
and Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 p-
value
2008 2010 p-
value
2008 2010 p-
value
N 544 384 1571 1104 1040 716
Knows about antenatal care 99.1 99.7 .218 96.0 98.1 .002 97.8 96.9 .262
(ANC)
Knowledge on importance of
receiving ANC
• For early recognition of 42.1 18.5 51.9 15.4 41.5 6.8
complication
• For safe delivery 57.0 55.7 44.0 28.6 56.3 19.6
• To know the position of - 25.0 - 48.1 - 61.5
baby
• To know mother’s
- 0.0 - 21.9 - 5.4
wellness
• For weakness - 0.3 - 0.1 - 0.4
• For wellbeing of mother
and child
- 0.0 - 0.8 - 2.5
Annex 2.2.5. Knowledge on birth preparedness
Nilphamari Rangpur, Gaibandha and
Mymensingh
Naogaon and Netrokona
(Control)
2008 2010 p-value 2008 2010 p-value 2008 2010 p-value
N 544 384 1571 1104 1040 716
Knowledge on birth
plan
• No knowledge 3.1 0.0 < .001 4.3 21.7 < .001 6.7 41.6 < .001
(0 plan)
• Moderate
51.1 69.5 56.8 53.4 68.3 53.5
knowledge
(1-2 plans)
• Good knowledge 45.8 30.5 38.9 24.9 25.0 4.9
(maximum 3
plans)
Median (range) 2(0 - 4) 2(1-4) 2(0-4) 2(0-4) 2(0-4) 1(0-4)
knowledge on birth
plan
Knowledge on
individual birth plans
• Place 89.7 93.8 .031 87.0 61.6 < .001 82.2 29.1 < .001
• Attendant 80.5 69.5 < .001 71.2 53.9 < .001 78.3 24.6 < .001
• Save money 50.7 56.5 .083 55.1 43.3 < .001 31.7 32.4 .767
85

Annexures
Annex 2.2.6. Respondents faced complications during antenatal period
2008
N =
544
Nilphamari
2010
N =
384
p-value 2008
N =
1571
Rangpur, Gaibandha and
Mymensingh
2010
N =
1104
Naogaon and Netrokona
(Control)
2010 p-
N = value
716
p-value 2008
N = 1040
Any complication 37.3 52.9

Changes of MNCH during 2008-2010
Annex 2.2.7. Treatment-seeking behaviour for antenatal complications
Nilphamari Rangpur, Gaibandha
and Mymensingh
2008 2010 p- 2008 2010 p-
value
value
N 203 203 711 638 489 523
Action taken for
complication
• No treatment 30.0 13.8 31.5 25.7 17.8 21.6
• Self treatment 4.4 7.4 3.8 7.2 3.7 3.4
• Treatment from HCP 65.5 78.8 64.7 67.1 78.5 75.0
N 61 28 224 164 87 113
Reasons for not taking
any action
• Thought treatment
was not necessary
Naogaon and Netrokona
(Control)
2008 2010 p-
value
73.8 46.4 50.0 60.4 52.9 46.9
• Lack of
24.6 50.0 48.2 28.0 43.7 47.8
money/expensive
• Others 1.6 3.6 5.8 15.9 8.0 11.5
N 203 203 711 638 489 523
Place of treatment*
• No treatment 30.0 13.8 31.5 25.7 17.8 21.6
• Self treatment 4.4 7.4 3.8 7.2 3.7 3.4
• District hospital 4.9 2.0 5.1 3.0 4.9 3.3
• UHC/MCWC 9.4 14.8 7.6 8.3 14.7 13.8
• FWC/Satellite clinic 3.0 9.4 1.5 1.6 3.7 3.8
• Private hospital/clinic 3.9 3.9 6.0 7.4 4.1 7.1
• NGO clinic 3.9 9.9 1.8 1.9 3.7 3.3
• Private
30.0 25.1 36.0 30.1 44.4 46.1
chamber/pharmacy
• Home 16.7 20.7 8.9 16.6 8.4 3.4
• Others 1.0 0.5 1.1 2.2 0.6 0.2
Provider of treatment*
• No treatment 30.0 13.8 31.5 25.7 17.8 21.6
• Self treatment 4.4 7.4 3.8 7.2 3.7 3.4
• Village doctor 19.2 12.8 19.3 19.0 20.7 19.1
• BRAC (SS/SK) 4.9 11.8 1.1 4.7 1.4 0.6
• Govt. health worker** 4.4 10.3 1.8 1.9 3.5 4.6
• Homeopath 11.8 9.4 7.7 7.5 9.0 11.7
• Traditional healer 3.0 1.0 1.5 1.7 1.6 1.0
• Qualified doctor 26.1 33.5 32.3 30.3 40.9 38.4
• Drug seller 2.0 0.5 1.1 3.3 3.9 1.1
• Nurse/paramedics/CS 0.0 6.4 2.4 3.9 3.7 2.9
BA
• Others*** 2.5 7.9 0.1 0.2 0.8 1.9
Treatment received*
• No treatment 30.0 13.8 31.5 25.7 17.8 113(21.
6
• Self treatment 4.4 7.4 3.8 7.2 3.7 3.4
• Counseling 24.6 71.4 15.6 30.3 6.3 28.7
• Allopathic medicine 47.8 61.6 53.3 48.4 68.7 49.5
• Traditional treatment 3.0 1.5 2.1 2.4 1.8 1.3
• Homeopathic
11.8 8.4 8.2 7.7 9.0 11.5
medicine
• Referred 6.4 3.0 3.2 0.3 2.9 0.0
• Others 2.5 24.6 3.9 19.3 0.2 19.3
(Annex 2.2.7 continued......)
87

Annexures
(.....Continued Annex 2.2.7)
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
2008 2010 p-
value
2008 2010 p-
value
2008 2010 p-
value
Decision making for
seeking or not seeking
care for complications
• Self 15.8 2.0 17.9 16.0 13.3 10.1
• Husband 3.4 0.0 6.9 7.7 8.0 11.9
• Jointly with husband 50.2 80.3 57.5 57.5 56.0 58.1
• Jointly with in-laws 20.7 14.8 10.0 9.2 12.7 11.1
• In-laws 2.5 1.0 1.4 1.3 1.0 0.8
• Partners/natal
5.4 1.5 6.0 6.9 8.4 7.1
relatives
• Others(SS/SK/TBA 2.0 0.5 0.3 1.4 0.6 1.0
/TTBA/FWV/FWA)
* Multiple response questions * *FWV/FWA/MA/SACMO ***TTBA/TBA/other NGO worker etc.
Annex 2.2.8. Complications faced during delivery period
Nilphamari
2008 2010 P-
value
N N
=544 =384
Complication faced 165 193
(30.3) (50.3)
Complications*
• Substantial
bleeding
Rangpur, Gaibandha
and Mymensingh
2008 2010 P-
value
N N
=1571 =1104
509
(46.1)

Changes of MNCH during 2008-2010
Annex 2.2.9. Treatment-seeking behaviour for delivery complications
Nilphamari Rangpur, Gaibandha
and Mymensingh
2008 2010 P- 2008 2010 P-
value
value
N 165 193 452 509 338 421
Action taken for
complications
• None 11.5 4.7 21.7 13.4 22.8 19.7
• Self treatment 5.5 5.2 3.8 3.7 3.0 3.6
• Treatment from HCP 83.0 90.2 74.6 82.9 74.3 76.7
N 19 9 98 68 77 83
Reason for not taking any
action
• Felt treatment was
unnecessary
Naogaon and Netrokona
(Control)
2008 2010 P-
value
47.4 66.7 63.3 70.6 58.4 55.4
• Lack of money 42.1 33.3 34.7 23.5 40.3 38.6
• Other 10.5 0.0 9.2 8.8 16.9 10.8
N 165 193 452 509 338 421
Place of treatment
• None 11.5 4.7 21.7 13.4 22.8 19.7
• Self treatment 5.5 5.2 3.8 3.7 3.0 3.6
• District hospital 5.5 6.2 6.6 8.6 7.4 5.2
• UHC/MCWC/FWC 26.7 23.3 10.2 13.9 15.1 14.3
• NGO clinics 1.2 2.6 1.1 1.4 0.9 0.2
• Private hospital/clinic 5.5 5.7 10.6 9.0 16.9 14.7
• Private chamber 3.6 0.5 7.1 4.1 4.4 7.8
• Home 40.0 50.3 136.5 43.2 28.4 32.8
• Other 0.6 1.6) 2.9 3.9 1.2 2.6
Provider of treatment
• None 11.5 4.7 21.7 13.4 22.8 19.7
• Self treatment 5.5 5.2 3.8 3.7 3.0 3.6
• Village doctor 30.9 36.3 34.3 34.4 21.0 23.8
• BRAC health worker 4.2 13.0 0.2 2.0 0.0 0.2
• FWV/MA/SACMO 7.9 1.6 3.8 1.4 2.7 3.3
• Homeopath 1.8 4.7 1.8 4.1 3.6 7.8
• Qualified doctor 26.7 32.6 27.4 34.4 34.3 31.8
• Nurse 4.2 23.3 3.3 13.2 7.1 9.7
• Others 7.9 2.6 3.8 5.5 5.6 6.7
Treatment received
• None 11.5 4.7 21.7 13.4 22.8 19.7
• Self treatment 5.5 5.2 3.8 3.7 3.0 3.6
• Didn’t receive any 1.2 0.0 0.9 0.0 0.0 0.0
treatment
• Counseling 16.4 72.0 10.4 21.4 1.5 22.1
• Allopathic medicine 63.0 51.8 53.5 34.2 54.7 24.9
• Traditional 4.8 0.5 3.3 1.6) 0.3 1.9
• Homeopathic
1.8 4.7 2.0 4.1 3.8 8.3
medicine
• Surgery/c-section 7.9 6.7 8.0 11.4 12.4 14.3
• Saline 9.7 47.2 18.6 49.5 1.8 39.7
• Injection 11.5 53.4 7.5 53.0 0.9 40.6
• Referred 15.2 11.4 4.6 1.0 3.6 0.2
• Others 1.2 4.7 3.1 5.3 6.5 4.8
Decision making for
seeking or not seeking
care for complications
(Annex 2.2.9 continued......)
89

Annexures
(.....Continued Annex 2.2.9)
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
2008 2010 P-
value
2008 2010 P-
value
2008 2010 P-
value
• Self 4.8 0.5 .002 4.6 5.1 .001 7.7 4.
• Husband 2.4 1.6 11.1 7.3 9.8 14.0
• Jointly with husband 40.0 55.4 40.0 46.0 29.9 37.3
• Jointly with in-laws 33.9 25.9 22.8 13.8 18.6 12.8
• In-laws 3.6 1.6 2.9 2.2 2.7 1.7
• Partners/natal
9.1 13.5 16.6 22.2 27.2 28.3
relatives
• Others(SS/SK/TBA/T
TBA/FWV/FWA)
6.1 1.6 2.0 3.5 4.1 1.9
Annex 2.2.10. Respondents faced complications during postnatal period according to
area
Nilphamari Rangpur, Gaibandha and
Mymensingh
Naogaon and Netrokona
(Control)
2008 2010 p-
value
2008 2010 p-
value
2008 2010 p-
value
N 539 383 1553 1091 1026 700
Any complication faced 27.1 43.1

Changes of MNCH during 2008-2010
(.....Continued Annex 2.2.11)
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
2008 2010 p-
value
2008 2010 p-
value
2008 2010 p-
value
• Husband/mother in law 9.5 0.0 8.2 1.5 13.0 3.2
disapproved
• Lack of money 33.3 36.8 49.4 34.3 59.3 55.9
• Others 4.8 0.0 3.5 4.5 3.7 3.2
N 146 165 389 407 317 412
Place of treatment
• No treatment 14.4 11.5

Annexures
Annex 2.2.12. Referrals for maternal complications
Nilphamari Rangpur, Gaibandha and
Mymensingh
Naogaon and Netrokona
(Control)
2008 2010 p-value 2008 2010 p-value 2008 2010 p-value
N 544 384 1571 1104 1040 716
Suffered from maternal 59.2 78.6

Changes of MNCH during 2008-2010
Annex 2.3. Neonatal health
Annex 2.3.1. Knowledge of feeding children aged up to 12 months
Nilphamari Rangpur, Gaibandha and
Mymensingh
Naogaon and Netrokona
(control)
2008 2010 P- 2008 2010 P- 2008 2010 P-value
value
value
N 539 383 1553 1091 1026 700
Initiation of breast
feeding after birth
• Within 1 hour 81.3 74.9

Annexures
Annex 2.3.3. Experiencing neonatal danger signs and its management
Nilphamari Rangpur, Gaibandha and
Mymensingh
Naogaon and Netrokona
(control)
2008 2010 p-value 2008 2010 p-value 2008 2010 p-value
N 383 1091 700
Faced neonatal danger signs
• Couldn’t suckle milk 6.3 6.2 11.7
• High fever/Hypothermia 11.2 13.5 22.1
• Chest in drawing 10.7 7.1 14.3
• Redness of eye 1.6 2.1 3.3
• Lethargic/Unconscious 2.1 3.3 6.1
• Convulsion 0.5 1.4 1.9
• Umbilical infection 7.8 6.9 6.7
• Swelling of abdomen
/Frequent vomiting
2.1 3.3 6.1
N 91 304 263
Action taken on recognizing
neonatal danger signs
• No action taken 6.6 8.9 9.5
• Help from BRAC stuff 12.1 6.3 1.9
• Help from facility (public
35.2 32.2 37.3
or private)
• Others (Village doctor,
Homeo doctor, Pir/Fakir,
traditional healer, drug
seller, etc)
46.2 52.6 51.3
94

Changes of MNCH during 2008-2010
Annex 2.4 Child health
Annex 2.4.1. Management of ARI among children aged 0-59 months
Number of Children aged less
than 2 months with pneumonia
managed by*
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
2008 2010 2008 2010 2008 2010
2 0 8 1 6 8
• Medically trained provider 0.0 0.0 25.0 0.0 0.0 37.5
• Others (Homeopath/Village 100.0 0.0 75.0 100.0 100.0 75.0
doctor/Drug seller)
Number of Children aged less 3 0 3 6 4 1
than 2 months with severe
pneumonia managed by*
• Medically trained provider 66.7 0.0 33.3 83.8 100.0 0.0
• Others(Homeopath/Village
doctor)
66.7 0.0 66.7 66.7 25.0 100.0
Number of Children aged
102 10 417 112 364 123
2 – 59 months with pneumonia
managed by*
• Medically trained provider 17.6 30.0 21.3 23.2 27.2 23.6
• BRAC SS/SK 1.0 0.0 0.2 0.0 0.0 0.0
• Others (Village
73.5 80.0 77.5 90.2 67.9 67.5
doctor/Homeopath/Drug
seller)
Number of children aged
133 20 328 81 236 118
2-59 months with severe
pneumonia managed by *
• Medically trained provider 36.1 45.0 33.5 28.4 47.5 34.7
• BRAC SS/SK 1.5 0.0 0.0 1.2 0.0 0.0
• Others (Village
70.7 70.0 72.6 86.4 55.9 73.7
doctor/Homeopath/Drug
seller)
* Multiple responses
Annex 2.4.2. Prevalence of diarrhoea and related feeding practices
Nilphamari Rangpur, Gaibandha and
Mymensingh
Naogaon and Netrokona
(Control)
2008 2010 P-value 2008 2010 P-value 2008 2010 P-value
N 1111 674 3284 1946 2184 1276
Children suffered from 13.8 13.8 .987 15.0 11.7 .001 9.9 14.9

Annexures
Annex 2.4.3. Treatment of other illnesses among children aged 0-59 months
Nilphamari
Rangpur, Gaibandha
and Mymensingh
Naogaon and
Netrokona
(Control)
2008 2010 P-
value
2008 2010 P-
value
2008 2010 P-
value
N 412 542 1234 1413 798 693
Treatment received during other 85.9 93.4

Changes of MNCH during 2008-2010
Annex 3 Univariate analyses for identifying factors
Annex 3.1. Identification of factors predictive of receiving 4+ ANCs
Factors
Percentag
e
Nilphamari
4+ ANC from Trained provider
Rangpur, Gaibandha
and Mymensingh
Naogaon and
Netrokona
(Control)
p-value Percentage p-value Percentag
e
p-
value
Mother’s literacy
• Can read and write 91.7 .059 69.4 .005 25.5 .000
• Can’t read and write 85.6 61.2 8.1
Mother’s education
• Primary incomplete 84.6 .013 60.2 .000 9.4 .000
• Primary or higher 92.3 70.5 26.3
Husband’s literacy
• Can read and write 89.5 .781 69.5 .011 24.9 .000
• Can’t read and write 88.6 62.2 11.1
Husband’s education
• Primary incomplete 87.4 .263 62.6 .013 11.3 .000
• Primary or higher 91.0 69.8 26.1
Amount of land
• None 92.4 .432 68.1 .116 18.2 .005
• ≤50 decimal 88.8 63.7 14.8
• > 50 decimal 86.9 70.5 25.1
BRAC eligible
• Yes 87.1 .294 64.1 .279 13.3 .003
• No 90.5 67.2 21.9
Wealth index
• Poorest 88.9 .163 59.8 .020 7.2 .000
• Second 92.7 65.5 12.7
• Middle 81.6 61.6 14.4
• Fourth 92.4 68.9 27.2
• Richest quintile 88.7 73.6 33.8
Reproductive indicators
Age at first marriage
• ≤ 17 years 88.7 .784 66.2 .605 16.2 .007
• > 17 years 92.1 64.2 25.5
Age at first conception
• ≤ 19 years 88.7 .599 66.3 .556 17.3 .131
• > 19 years 92.5 64.2 23.0
Parity
• Primiparous 92.5 .146 67.0 .613 24.9 .002
• Multiparous 87.5 65.4 15.2
Child death
• None 88.2 .202 67.1 .077 19.7 .025
• One or more 93.7 60.7 11.0
97

Annexures
Annex 3.2. Identification of factors predictive of safe delivery
Safe delivery (Delivery by trained birth attendant)
Factors
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
Percentage p-value Percentage p-value Percentage p-value
Mother’s literacy
• Can read and write 78.8 .014 59.8

Changes of MNCH during 2008-2010
Annex 3.3. Identification of factors predictive of PNC from trained providers
PNC from trained providers
Factors
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
Percentage p-value Percentage p-value Percentage p-value
Mother’s literacy
• Can read and write 93.5 .359 67.6 .058 38.6

Annexures
Annex 3.4. Identification of factors predictive of treatment-seeking for delivery
complications
Factors
Treatment-seeking for delivery complications
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
Percentage p-value Percentage p-value Percentage p-value
Mother’s literacy
• Can read and write 40.3 .874 44.4 .007 48.2

Changes of MNCH during 2008-2010
Annex 3.5. Association of different socioeconomic factors with the use of modern FP
methods
Use of modern FP method
Factors
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
Percentage p-value Percentage p-value Percentage p-value
Age group of respondent
• ≤ 19 years 56.6 .009 51.2 .092 52.7 .029
• 20 – 34 years 70.0 57.0 61.8
• ≥ 35 years 65.7 59.7 56.1
Mother’s literacy
• Can read and write 69.0 .239 58.5 .023 62.7 .018
• Can’t read and write 64.9 53.6 56.6
Mother’s education
• Primary incomplete 67.5 .842 52.7 .001 56.5 .009
• Primary or higher 66.8 59.6 63.3
Husband’s literacy
• Can read and write 68.6 .485 58.4 .094 63.7 .015
• Can’t read and write 66.2 54.8 57.4
Husband’s education
• Primary incomplete 66.8 .741 55.1 .109 58.6 .108
• Primary or higher 67.9 58.5 62.8
Amount of land
• None 67.8 .456 49.8 .014 55.6 .472
• 1-50 decimal 64.8 55.9 59.5
• >50 decimal 69.9 60.6 61.9
BRAC eligibility
• Yes 63.9 .111 51.9 .001 61.4 .341
• No 69.5 59.4 58.9
Wealth index
• Poorest 54.8 .003 48.5 17 years 73.4 55.6 58.1
Age at first conception
• ≤ 19 years 67.8 .239 57.8 .002 62.5 19 years 61.3 49.4 49.1
Parity
• Primiparous 66.5 .840 57.2 .613 62.1 .312
• Multiparous 67.3 56.0 59.2
Child death
• No 67.5 5.96 57.9 .001 61.6 .005
• Yes 65.0 48.8 51.7
101

Annexures
Annex 3.6. Association of different socioeconomic factors with the use of modern FP
among married adolescent girls
Use of modern FP among married adolescent girls
Factors Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
Percentage p-value Percentage p-value Percentage p-value
Mother’s literacy
• Can read and write 60.2 .166 53.7 .178 53.6 .697
• Can’t read and write 47.6 45.9 50.7
Mother’s education
• Primary incomplete 56.8 .966 41.9 .013 48.7 .377
• Primary or higher 56.4 56.1 54.9
Husband’s literacy
• Can read and write 60.6 .387 56.8 .042 57.3 .169
• Can’t read and write 53.4 45.6 47.9
Husband’s education
• Primary incomplete 57.7 .844 49.4 .380 49.5 .278
• Primary or higher 56.1 54.2 56.9
Land ownership
• None 65.0 .282 47.8 .666 57.1 .844
• 1-50 decimal 57.1 53.1 51.2
• >50 decimal 47.6 48.3 54.5
BRAC eligibility
• Yes 54.7 .687 48.3 .271 48.4 .265
• No 58.0 54.3 56.0
Wealth index
• Poorest 46.2 .498 40.6 .288 45.5 .455
• Second 62.1 49.4 65.0
• Middle 64.3 54.1 52.0
• Fourth 53.1 56.3 48.9
• Richest 64.7 58.1 53.8
Parity
• Primiparous 59.0 .326 51.2 .978 55.8 .119
• Multiparous 50.0 51.1 43.9
Child death
• No 60.2 .004 53.4 .008 53.8 .166
• Yes 16.7 27.6 33.3
102

Changes of MNCH during 2008-2010
Annex 3.7. Association of different socioeconomic factors with having all birth plans
Having all birth plans
Factors Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
Percentage p-value Percentage p-value Percentage p-value
Mother’s literacy
• Can read and write 80.6 .011 65.8 19 years 87.5 63.4 33.3
Parity
• Primiparous 81.7 .070 58.4 .626 37.1 .105
• Multiparous 73.1 60.0 31.0
Child death
• No 76.6 .378 59.4 .837 33.3 .685
• Yes 71.4 60.2 31.4
Sought 4+ ANCs (Trained
provider)
• Yes 77.9

Annexures
Annex 3.8. Association of different socioeconomic and maternal factors with receiving all
essential newborn care
Received all essential newborn care
Factors
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
Percentage p-value Percentage p-value Percentage p-value
Mother’s literacy
• Can read and write 53.2 .422 60.3 .000 41.3 .142
• Can’t read and write 49.1 48.6 35.8
Mother’s education
• Primary incomplete 46.3 .085 48.0 .000 35.6 .085
• Primary or higher 55.2 61.2 42.0
Husband’s literacy
• Can read and write 51.1 .865 58.4 .035 44.3 .004
• Can’t read and write 52.0 52.0 33.7
Husband’s education .9
• Primary incomplete 51.9 .875 52.1 .019 33.4 .001
• Primary or higher 51.1 59.2 45.7
Land ownership
• None 53.3 .387 65.0 .041 41.9 .162
• 1-50 decimal 54.1 53.4 36.3
• >50 decimal 46.3 55.1 43.8
Wealth index
• Poorest 60.5 .259 48.8 .051 33.9 .337
• Second 47.6 51.0 45.1
• Middle 46.1 57.7 36.9
• Fourth 54.9 58.9 41.2
• Richest 45.3 60.7 39.5
Age at first marriage
• ≤ 17 years 52.5 .225 54.4 .234 40.6 .106
• > 17 years 42.1 59.2 33.5
Age at first conception
• ≤ 19 years 51.9 .599 53.5 .021 40.7 .050
• > 19 years 47.5 62.0 31.1
Parity
• Primiparous 59.7 .031 56.6 .560 42.2 .229
• Multiparous 47.7 54.7 37.5
Child death
• No 52.8 .224 56.6 .064 39.0 .960
• Yes 44.4 49.5 38.8
Sought 4+ ANCs (Trained
provider)
• Yes 48.8 .719 45.8 .000 37.8 .166
• No 51.8 60.2 44.4
104

Changes of MNCH during 2008-2010
Annex 3.9. Association of different socioeconomic and maternal factors with birth
asphyxia managed by trained providers
Birth asphyxia managed by trained providers
Factors
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
Percentage p-value Percentage p-value Percentage p-value
Mother’s literacy
• Can read and write 68.2 .809 46.5 .493 58.7 .032
• Can’t read and write 64.3 40.0 36.7
Mother’s education
• Primary incomplete 66.7 1.00 40.0 .493 37.5 .021
• Primary or higher 66.7 46.5 61.5
Husband’s literacy
• Can read and write 77.8 .157 47.5 .414 58.1 .043
• Can’t read and write 55.6 40.0 37.3
Husband’s education
• Primary incomplete 57.9 .238 38.1 .165 36.8 .016
• Primary or higher 76.5 50.9 62.2
Land ownership
• None 63.6 .962 38.9 .185 57.1 .562
• 1-50 decimal 68.8 39.1 42.9
• >50 decimal 66.7 58.6 53.1
Wealth index
• Poorest 57.1 .198 26.3 .272 28.6 .032
• Second 58.3 40.0 50.0
• Middle 40.0 58.8 50.0
• Fourth 83.3 43.5 44.4
• Richest 100.0 54.5 80.0
Age at first marriage
• ≤ 17 years 62.5 .278 44.0 .985 44.7 .304
• > 17 years 100.0 43.8 57.9
Age at first conception
• ≤ 19 years 66.7 1.00 45.1 .652 44.2 .195
• > 19 years 66.7 40.0 61.1
Parity
• Primiparous 62.5 .635 44.1 .983 69.2
• Multiparous 70.0 43.9 39.1
Child death
• No 70.8 .453 40.0 .109 52.6 .040
• Yes 58.3 57.7 26.3
Sought 4+ ANCs (Trained
provider)
• Yes 65.6 1.00 40.3 .306 70.6 .034
• No 75.6 50.0 42.3
Delivered by trained birth
attendant
• Yes 68.8 .588 46.4 .526 55.7 .029
• No 50.0 40.4 32.4
105

Annexures
Annex 3.10. Association of different socioeconomic and maternal factors with neonatal
sepsis managed by qualified doctors
Neonatal sepsis managed by qualified doctors
Factors
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
Percentage p-value Percentage p-value Percentage p-value
Mother’s literacy
• Can read and write 50.0 .080 51.6 .491 51.0 .002
• Can’t read and write 48.3 45.1 27.8
Mother’s education
• Primary incomplete 50.0 .932 43.4 .292 28.4 .000
• Primary or higher 49.0 53.3 55.0
Husband’s literacy
• Can read and write 55.6 .271 54.9 .195 50.0 .015
• Can’t read and write 43.2 42.6 31.9
Husband’s education
• Primary incomplete 40.4 .075 40.8 .040 33.3 .026
• Primary or higher 60.6 61.0 50.0
Land ownership
• None 40.7 .540 41.7 .262 44.4 .038
• 1-50 decimal 52.9 44.1 33.9
• >50 decimal 55.0 60.6 54.9
Wealth index
• Poorest 44.0 .686 40.0 .439 26.8 .010
• Second 47.6 40.0 38.7
• Middle 35.7 51.9 40.5
• Fourth 60.0 60.0 46.7
• Richest 83.3 62.5 71.4
Age at first marriage
• ≤ 17 years 49.3 .971 46.7 .389 41.0 .816
• > 17 years 50.0 57.1 38.7
Age at first conception
• ≤ 19 years 48.7 .675 50.6 .478 39.9 .656
• > 19 years 60.0 42.9 44.4
Parity
• Primiparous 48.3 .882 68.8 .007 52.7 .027
• Multiparous 50.0 40.7 35.0
Child death
• No 48.5 .735 47.5 .698 42.3 .367
• Yes 53.3 51.5 34.2
Sought 4+ ANCs (Trained
provider)
• Yes 50.0 1.00 44.6 .315 52.2 .224
• No 40.0 54.2 38.8
Delivered by trained birth
attendant
• Yes 51.5 .390 61.7 .003 43.4 .346
• No 38.5 34.0 36.2
106

Changes of MNCH during 2008-2010
Annex 3.11. Association of different socioeconomic and maternal factor with management
of ARI by medically trained providers
ARI managed by medically trained providers
Factors
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
Percentage p-value Percentage p-value Percentage p-value
Mother’s literacy
• Can read and write 29.6 .840 21.6 .299 30.7 .001
• Can’t read and write 32.1 17.2 15.7
Mother’s education
• Primary incomplete 30.0 .873 18.4 .540 17.4 .004
• Primary or higher 32.0 20.9 30.6
Husband’s literacy
• Can read and write 40.0 .183 22.2 .293 30.3 .007
• Can’t read and write 23.3 17.9 18.1
Husband’s education
• Primary incomplete 14.3 .007 19.3 .698 18.2 .003
• Primary or higher 48.1 20.9 31.8
Land ownership
• None 20.0 .379 20.0 .915 30.4 .009
• 1-50 decimal 27.6 19.3 19.4
• >50 decimal 43.8 21.3 35.2
BRAC eligibility
• Yes 30.4 .949 17.9 .389 18.1 .008
• No 31.3 21.4 30.1
Wealth index
• Poorest 33.3 .679 20.0 .331 14.4

Annexures
Annex 3.12. Association of different socioeconomic and maternal factor with management
of diarrhoea by trained providers
Diarrhoea managed by trained providers
Factors
Nilphamari Rangpur, Gaibandha
and Mymensingh
Naogaon and Netrokona
(Control)
Percentage p-value Percentage p-value Percentage p-value
Mother’s literacy
• Can read and write 30.6 .004 17.9 .483 42.7

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