Socioeconomic determinants of inequalities in maternal health service utilization in haor (wetland) of Bangladech : the case study of Kishoreganj district

다국어 초록 (Multilingual Abstract)

In this study, a cross-sectional survey was conducted to evaluate the maternal healthcare service utilization in the haor (wetland) regions of Bangladesh. Maternal mortality is a leading cause of death and disability among the women of reproductive age in Bangladesh. Being a signature member of the UN, Bangladesh is committed to achieving SDG Target 3.1, which is reducing maternal mortality by 70 per 100,000 live births by 2030. However, achieving this target is still a daunting challenge for Bangladesh, as the utilization of essential maternal healthcare services is not equitable across the country. Many hard-to-reach areas of Bangladesh, such as haor areas, are significantly lagging behind in utilizing maternal healthcare services. Therefore, it is a pertinent need to evaluate the status of maternal healthcare service utilization in the hoar area of Bangladesh through the lens of equity. In this study, I conducted a cross-sectional survey (n = 428) in the haor 4 haor-prone Unions of the Tarail Upazilla of Kishoreganj district, Bangladesh and collected responses from the women of reproductive age (15-49 years) who had given birth within last five years of this study. I analyzed the proportion of maternal healthcare services utilization, concentration curve, and concentration index to examine the inequity in maternal healthcare service utilization, and logistic regression model to explore the major determinants of maternal healthcare-seeking behaviour in this haor area. Initially, I explored a very low proportion of usage of delivery care in this region. From the concentration curve and concentration index analysis of this study, a profound income-based inequality in maternal healthcare services utilization can be witnessed in this area, especially for delivery care services. From the regression analysis, I found that higher parental education, particularly maternal educational attainment higher than secondary education, is a major determinant of maternal healthcare-seeking behaviour of this region, as women belonging to this education category are two to five times more likely to receive all the maternal healthcare services. I also noticed wealthier women (household with monthly income above 25,000 BDT tend to seek all maternal healthcare services two to three times more than other women. Interestingly, I noticed that membership to the microfinance institutions that promote health awareness program significantly influences maternal healthcare services utilization in this area. From the empirical findings of this study, it can be recommended to outline equitable policy interventions by targeting those factors affecting maternal healthcare service utilization most in the haor area of Bangladesh to ascertain safe motherhood and achieve the SDG target.

목차 (Table of Contents)

• I. INTRODUCTION 1
• 1.1 Background of the study 1
• 1.2. Rationale and Significance of the Study 5
• 1.3. Research questions 6
• 1.4. Operational definition of concepts 7
• 1.4.1. Maternal mortality and morbidity 8
• 1.4.2. Maternal health inequality 8
• 1.4.3. Maternal healthcare 9
• 1.5. Outline of the thesis 10
• II. MATERNAL HEALTH: GLOBAL AND BANGLADESH PERSPECTIVES 12
• 2.1. Overview of global maternal mortality 12
• 2.2. Global initiatives in reducing maternal health care 13
• 2.3. Health system in Bangladesh 17
• 2.3.1. Public healthcare system in Bangladesh 17
• 2.3.2. Private and informal healthcare system 22
• 2.4. Health workforce in Bangladesh 23
• 2.4.1. Domiciliary health workers 24
• 2.5. Health financing in Bangladesh 25
• 2.6. Maternal health infrastructures, policies, and initiatives in Bangladesh 27
• 2.7. Maternal health care financing in Bangladesh 31
• 2.8. Maternal health status in Bangladesh 32
• III. THEORETICAL FRAMEWORK AND LITERATURE REVIEWE 36
• 3.1. Theoretical framework: the social determinants of health 36
• 3.1.1. Socioeconomic and political context 38
• 3.1.2. Socioeconomic positions 39
• 3.1.3. Intermediary determinants 40
• 3.1.4. Key domains of social determinants of health 41
• 3.2. Literature review 41
• 3.2.1. Inequalities in maternal healthcare services utilization 42
• 3.2.2. Social determinants of maternal health care service utilization 47
• IV. METHODOLOGY 53
• 4.1. Research design 53
• 4.2. Variables 53
• 4.2.1. Independent variables 53
• 4.2.2. Dependent variables 55
• 4.2.3. Maternal healthcare outcome variables 55
• 4.3. Study area 56
• 4.4. Target population 57
• 4.5. Sample size 57
• 4.6. Data collection 58
• 4.7. Statistical methods 60
• 4.7.1. Concentration curve 60
• 4.7.2. Concentration index 61
• 4.7.3. Logistic regression model and odds ratio 63
• 4.8. Statistical analysis 65
• V. RESULTS 66
• 5.1. Demographic characteristics of respondents 66
• 5.2. Distribution of respondents by maternal healthcare outcome variables 72
• 5.3. Income-based inequality in utilizing maternal health care services 74
• 5.4. Multivariate logistic regression between socio-demographic variables and maternal healthcare outcome variables 81
• VI. DISCUSSION AND IMPLICATIONS, POLICY RECOMMENDATIONS, LIMITATIONS AND CONCLUSION 89
• 6.1. Discussion and Implications 89
• 6.2. Policy recommendation 96
• 6.3. Limitations 97
• 6.4. Conclusion 98
• BIBLIOGRAPHY 101
• APENDIX 112