Are they really protected? Photo: Quddus Alam / Drik News

HEALTH experts are becoming more conscious about human behaviour in quality health care provision. In order to meet the community demand, health systems need to be more adaptive in considering their strategies. Experts have to take into account the findings from behavioural studies.
Our study discusses the factors to consider during health planning. It is built on knowledge, attitudes and practices (KAP) surveys as they are the most frequently used studies in health-seeking behaviour research.
No clear-cut and definite health policy has emerged even after 37 years of liberation. The utilisation of the health care delivery system is pathetic, especially for females. The burden of disease is the same for females as for males. But their probability of seeking health care outside the household was found to be less than that of males.
Women of reproductive age (15-49) constitute about one fourth of the total population. The contraceptive prevalence rate is 58 (1997-2005). Although the maternal mortality ratio has declined from 554 per 100,000 live births in 1990 to 320-400 in 2001, the status of maternal health remained an area of significant challenges in Bangladesh. Because of the relatively low status of woman in Bangladesh and lack of access to reproductive health services, maternal mortality remains unacceptably high.
This study assesses health seeking behaviour regarding reproductive health care of rural women so that researchers, government, politicians, non-government organisations (NGOs) and international agencies can take the appropriate direction to meet the targets of the Millennium Development Goal (MDG) of 75% reduction of maternal mortality between 1990 and 2015.
Current scenario
The present structure and functioning of the health services in Bangladesh is oriented towards delivery of primary health care to the vast rural population. At the union level, each health sub-centre is posted with one medical officer, one medical assistant and one pharmacist at the upazilla health and family welfare complex. Besides these, ESP (essential service packages) is delivered at upazilla level and lower through the establishment of community clinics with a family welfare visitor (FWV) and one health assistant each.
These clinics are "one stop" first-level services in the villages and are free of cost. But the utilisation of government facilities by the poor is very low. A recent study by the Department of International Development (DID) has shown that mostly the rich are utilising public sector services.
A study of the Matlab demographic surveillance system shows that a total of 1037 women of reproductive age died during a 10 year period (1976-85), and 37% of them were maternal deaths. Haemorrhage, eclampsia, prolonged/obstructed labour, puerperal sepsis and abortion-related deaths are found to be the main causes of death.
Over three-quarters of all maternal deaths were from direct obstetric complications needing timely and adequate medical intervention. Preventing unplanned pregnancies alone could avert around one-quarter of maternal deaths, including those that result from unsafe abortion.
In the development war, we are poised at the midpoint between declaration of MDG and the 2015 target date. There are obviously some gains, and success is still possible in most parts of the world. But they also show how much remains to be done.
Study findings
240 women of reproductive age, with at least one under-five child, were randomly selected and interviewed from two different villages in Gabtoli Upazilla -- Chaksadu and Shakatia.
Most of the respondents were between 15-30 years in age, and a majority of them were housewives. A few had higher secondary education or above, but the illiterate group was nearly three times as big as the higher secondary group. Most of them were poor. Only about 10.54% of women had earning (total family income) above Tk.500. Those earning less than Tk.2000 per month income were about four times as many as the previous income group.
Their housing also corresponds to their income level. For example, 23% of them had pucca (brick built house). Tinned roof houses were the maximum, which were three times more than brick built houses. Among these people, only 4.13% of women went for routine medical checkup if they felt sick. But a majority of them sought medical care when some complications arose or persisted, which accounted for 15 times more than routine medical checkup.
The number of people who went for medical care if there was severe complication was 12 times greater than the routine care group. A majority of the women sought allopathic treatment, which was 19 times more than Ayurvedic/Unani treatment and was followed by Homeopathic treatment, which was just above 4 times as much as Ayurvedic/Unani treatment.
It is surprising that 15% women were not taking ante-natal checkup, though there were community clinics within 3 kilometers of their villages. Most astonishing was the fact that 84% of births took place at home, which was 5 times greater than institutional delivery. In the case of home delivery, only 17.5% births were assisted by trained birth attendants.
On the other side, untrained dais or relatives conducted 82.5% of the births, which was around five times more than the previous case. The number of women who were against going to non-qualified persons to seek treatment was 44.46%, followed by the "not costly" mentality.
The positive and promising findings of the survey were that under-five children were 100% immunised and 100% families were practicing family planning. Among them, 90% females participated in family planning in the form of injection (56%), oral pill (30%), intra-uterine contraceptive device (IUCD) (10%), others (4%), where men had 10% family planning participation.
Out of 460 upazillas, the study was conducted in two villages of a single upazilla. So, a definite conclusion is not in order. But the study gives us a glimpse of health seeking behaviour of the rural women of the reproductive age.
It is clear that the effectiveness of the government maternal and child health services is not dissatisfactory. Moreover, NGO health centers provide their services to that area. To sum up, due to lower socio-economic and literacy level, stigma, and unawareness, women do not seek appropriate quality reproductive health care.

Dr. Rashida Begum is an EMSRHS Scholar, University of Deusto, Spain and doctor in Shaheed Ziaur Rahman Medical College.

Runa Laila works for Gender development Studies, Institute of Social Science, Netherland and is Assistant Professor, Dhaka University.