Quality of antenatal care and its potential impacts on delivery services and postnatal care compliance among reproductive women of Bangladesh

doi:10.21203/rs.3.rs-3241685/v1

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Quality of antenatal care and its potential impacts on delivery services and postnatal care compliance among reproductive women of Bangladesh

https://doi.org/10.21203/rs.3.rs-3241685/v1

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Background: Ensuring quality antenatal care (ANC) and postnatal care (PNC) is crucial for reducing maternal and neonatal mortality rates. However, there are gaps in assessing the quality of ANC, leading to the proposal of standards by the World Health Organization. The study aims to examine the impact of quality ANC on delivery services and PNC compliance in Bangladesh using data from the Bangladesh Demographic and Health Survey (BDHS), providing insights for policymakers to improve maternal and neonatal health outcomes.

Methods: This study used data from the 2017 Bangladesh Demographic and Health Survey (BDHS) to investigate the impact of quality antenatal care (qANC) on delivery services and PNC in Bangladesh. The study population included ever-married women aged 15-49 years who had experienced a recent pregnancy. The analysis assessed the relationship between qANC and facility delivery, skilled birth attendant (SBA)-assisted delivery, and PNC services within 48 hours of delivery. The study employed a two-stage stratified cluster sampling design, and data analysis was conducted using generalized linear models and considered various demographic and socioeconomic factors.

Results: Key findings include a low rate of qANC services (18%), with pregnancy-related counseling being the lowest component. About 82% received at least one ANC visit, but only 18.3% received a quality visit. Higher compliance with facility delivery, SBA-conducted delivery, and PNC was observed when quality ANC was received. Factors such as completing secondary education, engaging in skilled/unskilled manual labor, higher wealth quintile, and birth parity of 1 were associated with better delivery and post-delivery outcomes.

Conclusion: Ensuring qANC and expanding PNC service use remain challenging in Bangladesh. Increasing the provision of qANC is crucial as it is associated with higher adherence to PNC.

Antenatal care

postnatal care

reproductive women

Bangladesh Demographic and Health Survey (BDHS)

In order to lower maternal and infant mortality rates, it is essential to provide women with high-quality prenatal and postnatal care. The World Health Organization has proposed standards to fill the voids in determining the quality of ANC. Using information from the Bangladesh Demographic and Health Survey (BDHS), the researchers hope to learn how better maternal and newborn health outcomes can be achieved by ensuring that all pregnant women have access to high-quality antenatal care.

Using information from the 2017 Bangladesh Demographic and Health Survey (BDHS), researchers in this article looked into how antenatal care quality affects postnatal care (PNC) and labor and delivery in the country. Women who had recently given birth and were married at the time of the study were included. The investigation looked at how qANC related to having a baby in a hospital, having a birth supported by a skilled birth attendant, and having postnatal care (PNC) within 48 hours of giving birth. Analysis of the data was performed using generalized linear models, and a number of demographic and socioeconomic characteristics were taken into account.

One of the most important things they found was that only 18% of qANC treatments were provided, with counseling about pregnancy being the least common. About 82% had at least one visit from the ANC, but only 18.3% had a good meeting. When quality ANC was given, there was more compliance with facility delivery, service by the SBA, and PNC. Better delivery and post-delivery outcomes were linked to things like finishing high school, doing skilled or unskilled manual work, being in a wealthier quintile, and having only one child.

In Bangladesh, it is still difficult to ensure qANC and increase the use of PNC services. In order to improve PNC adherence, expanding access to qANC is essential.

A crucial component of ensuring maternal and newborn health and wellbeing is providing proper care before, during, and after pregnancy. According to World Health Organization (WHO), about 2,95,000 mothers died from pregnancy and childbirth-related complications in 2017 (1). Sub-Saharan Africa and Southern Asia accounted for 86% of the deaths; Southern Asia was responsible for 58,000 (20%) of the deaths (1). India alone stood for around 12% of the global maternal deaths during that year (1). In 2015, almost 830 women died per day worldwide due to difficulties during pregnancy or childbirth, and roughly 99% of these deaths occurred in underdeveloped countries, as reported by a systematic analysis conducted by the United Nations (UN) Maternal Mortality Estimation Inter-Agency Group (MMEIG) (2, 3). Even in 2017, roughly 810 women per day were dying from preventable causes related to pregnancy and delivery, therefore the situation has only slightly improved over the past two years (4). However, ensuring quality antenatal care (ANC) and postnatal care (PNC) could have substantially reduced the risks during and after pregnancies and childbirth (2), saving hundreds of thousands of lives in these countries. According to some studies, quality ANC alone has the capacity to reduce maternal deaths by 20% on regular attendance (3, 5).

Contrary to the past belief that the quality of ANC provided could be assessed by focusing on the number of contacts between women or newborns with the healthcare system, recent studies noted critical gaps in the measurement and reporting of the quality of services through this approach (6-8). Consequently, the WHO has proposed standards of care and measures for assessing the quality of maternal and newborn health care (6), highlighting the importance of both the quality and content of ANC services while assessing the quality of care (9). A total of 8 standards have been proposed to define the quality assurance in terms of service provision, such as; 1. Evidence-based practices for routine care and complications management 2. Actionable information system 3. Functional referral system 4. Effective communication 5. Respect and preservation of dignity 6. Emotional support 7. Competent and motivated healthcare personnel and 8. Availability of essential physical resources (6).

An ANC session is primarily designed for ensuring the wellbeing of the mother and upcoming newborn through detection of pregnancy complications and resolving them through proper measures, answer to mothers’ concerns and preparing her for a safe delivery as well to promote health among the mothers (10). ANC services are also meant to enhance health outcomes, reduce maternal and neonatal mortality, lower postpartum anemia, and ensure appropriate weight at birth [2,10,11]. A healthcare provider is able to inform women about the danger signs and symptoms through ANC services and recommend immediate actions to remedy the problems [12]. In developing nations, ANC utilization has increased manifolds since the introduction of WHO’s focus ANC (FANC) model in 2002, which is a goal oriented and individualized approach to identify pregnancy complications in the earlier period and provide evidence based specialized care to resolute the complications (11). This model classifies pregnant women into two groups based on the presence of pre-existing risk factors and need for special care, as a result number of visits get reduced for mothers who require only routine ANC sessions at four time points (before 16 weeks, between 16-24 weeks, between 30-32 weeks and between 36-40 weeks) (12). Reduced visits lead to reduced financial expenditures and also enable the pregnant women to engage more of their time for other activities particularly in low-resource settings (13).

Focused ANC model also promotes healthy birth preparedness practices (selection of delivery place, preference on mode of delivery and delivery care provider) and thus enhances mother’s autonomy in the decision-making process (14). It also emphasizes over the importance of immunization to both mother and child, importance of personal hygiene and recipient of PNC (13, 14).

In Bangladesh, the utilization of maternal health services such as facility delivery, delivery by a skilled birth attendant (SBA), and PNC for mothers and children have increased remarkably. Unfortunately, despite the strong efforts of the government , the maternal mortality ratio (MMR) decline has halted in recent years (15), and the Maternal Mortality Rate (MMR) is still very high (170 per 100,000 live births), as is the Neonatal Mortality Rate (NMR, 28 per 1000 live births). Evidences from sub-Saharan African countries suggest that 71% of deaths in newborns, 33% of stillbirths, and 54% of deaths in mothers happen per year can be forestalled simply by increasing the quality of ANC and PNC (16).

Therefore, to properly understand the extent of reduction in MMR and NMR that could be achieved over the coming years, it is highly essential to understand the quality of ANC in Bangladesh. Furthermore, the potential impacts on delivery services and PNC compliance among reproductive women of Bangladesh need to be studied, as past studies suggest that ANC experiences play a pivotal role in the uptake of PNC and thus, directly affect the health conditions of mothers and neonates after the delivery (2, 8, 17-19). Given this research gap, the present study attempts to identify the potential impact of quality ANC on delivery services and PNC compliance using data from the Bangladesh Demographic and Health Survey (BDHS) to offer insights to policymakers about the different public health strategies to increase the quality of ANC, PNC and in greater aspect reduce neonatal and maternal mortality rate in Bangladesh.

Data Source

This study analyzed the data from the 2017 Bangladesh Demographic and Health Survey (BDHS), administered as a part of the global Demographic and Health Survey program, to assess the impact of quality ANC (qANC) on delivery and PNC. BDHS is a cross-sectional survey implemented by Mitra and Associates and conducted under the supervision of the National Institute of Population Research and Training (NIPROT) and the Ministry of Health and Family Welfare.

Study population and survey design

All the 15-49 years old ever married women who had a pregnancy in last 3-5 years were our study population. And our particular objective was to examine the impact of qANC on delivery and PNC services for mother and child by medically trained healthcare providers within 48 hours of delivery. The survey used a two-stage stratified cluster sampling design to select respondents from households. Samples were collected covering urban (in two stages) and rural (in three stages) areas from all the administrative divisions in Bangladesh: Dhaka, Chottogram, Rajshahi, Sylhet, Barisal, Khulna, Rangpur and Mymensingh. A list of total 650 enumeration areas (EAs) (250 in urban areas and 425 in rural areas) was used as a sampling frame provided by the Bangladesh Bureau of Statistics (BBS) referring to the 2011 Population and Housing Census of the People’s Republic of Bangladesh (BBS 2011). EAs’ were also the primary sampling unit (PSU) covering an average of 120 households. During the first stage of sampling, rural wards were chosen, then PSUs, and finally families were chosen from PSUs. In urban areas, the PSUs method was used to choose wards, and one EA was chosen from each PSU. Then, in the second sampling stage, systematic sampling was implemented to select an average of 30 households per EA to provide statistically reliable estimates of the key demographic and health variables for the whole country, for urban and rural areas separately and for each administrative division. A detailed description of the survey design, methodologies, sample size and questionnaires have been provided in the final summary report of 2017–2018 BDHS (20).

Dependent variable

The main outcomes of our study were qANC, facility delivery, a skilled birth attendant (SBA) conducting the delivery and PNC services for both mother and child within 48 hours of delivery. When a mother has received all the five core components of ANC such as measurement of blood pressure, measurement of weight, blood test for hemoglobin, urine test for albumin, and counselling on maternal danger signs during the antenatal visits; she was considered to receive a qANC. The participants were asked about whether the healthcare providers performed these five components at least once at any ANC visit irrespective of pregnancy trimester, through a recall interview to determine the proportion of qANC among all ANC visits.

Explanatory variables

The explanatory variables included in the study were selected based on previous literatures reporting the quality of maternal and newborn care services and also the structure of BDHS reports. Participants (ever married women of 15-49 years age who experienced a pregnancy within last 3-5 years) reported their age in years (categorized as >19 years, 20-29 years, 30-39 years, 40-49 years), education level (categorized as no education, primary, secondary incomplete, secondary complete/higher), residence (urban, rural), division (Dhaka, Chottogram, Rajshahi, Sylhet, Barisal, Khulna, Rangpur, Mymensingh), wealth quintile, occupational status of the participants and their husbands (not working, agriculture, skilled/unskilled manual, services/sales) and birth order (1, 2-3, 4). Principal component analysis was conducted using data obtained on household construction materials and housing characteristics (i.e., source of water, sanitation facility, housing structure) along with ownership of durable assets to determine the wealth status of households for further determination of socioeconomic status; then the wealth status was stratified into quintiles (richest, richer, middle, poorer, poorest).

Data Analysis

Women aged 15-49 years and having at least one live birth in last 3-5 years were considered as the study population. The number of ever-married women in BDHS 2017 was 47,828. For the analysis, continuous variables mother's age, education, parity and birth order, were converted into categorical variables. The main outcomes of the study were facility delivery, an SBA conducting the delivery, and PNC services for both mother and child within 48 hours of delivery.

In this study, a mother was considered to have received qANC when each of the five recommended components of ANC were provided to the mother at least once at any ANC visit irrespective of pregnancy trimester. These five components include (i) measurement of blood pressure, (ii) measurement of weight, (iii) blood test for hemoglobin, (iv) urine test for albumin, and (v) counseling on danger signs. PNC is referred to as the care provided to the mother and child after the delivery. In this study, we examined the effect of qANC on receiving PNC from a medically trained provider (MTP) within 48 hours after the delivery.

Descriptive statistics were used to assess the sociodemographic characteristics of the targeted population. To evaluate the impact of qANC on PNC and delivery care, generalized linear model with binomial family and log link was fitted. Mother’s age, education, occupation, husband’s occupation, birth order, and wealth quintile were considered as potential confounders based on previous literatures. All associations were considered statistically significant if p value was less than 0.05. Stata 14.0 (StataCrop. 2015. Stata Statistical Software: Release 14. College Station, TX: Stata Crop LP) was used to analyze the data.

Demographic Characteristics

A general overview of the background characteristics of the study participants is presented in Table 1. The mean age of the mothers in the BDHS 2017 survey was 24.9+5.6 years. A majority (61%) of the participants belonged to the 20-29 years’ age group, and very few (1%) belonged to the age group 40 years and above. A significant number (40%) of mothers had started high school but could not complete their secondary education. In contrast, about 8% of the mothers had not received any formal education. A considerable number of mothers (61%) were unemployed, and another 27% were engaged in agricultural work. Only 3% of the participants were engaged in any service/sales-related work. On closer inspection of the occupations of the partners, a majority (58%) of the husbands were found to be engaged in skilled/unskilled manual labor, with only 8% involved in agriculture. (Table 1).

About half of the mothers had 2-3 birth parity, and around 12% had a parity of more than 4. Over one-fourth (26%) of the mothers were urban residents, and the remaining (73%) lived in rural areas. The mothers did not have any distinct differences in terms of wealth quintiles. (Table 1)

Quality of ANC

The quality of ANC services that the mothers received, as analyzed based on the five core ANC components, is reported in Figure 1. The pregnancy-related counseling during ANCs was found to be lower than other components. Only two-fifth (40%) of the mothers had received counseling on pregnancy-related danger signs, whereas about two-thirds (66% and 73%, respectively) had blood and urine tests done. However, majority of the participants had their weight and blood pressure (89% and 94%, respectively) measured during ANCs. The overall qANC service provision rate was only 18%. (Figure 1)

Distribution of ANC exposure, delivery and post-delivery service outcomes

The results suggest that only 18% of the mothers did not receive an ANC during their pregnancies. Overall, a high proportion (82%) of the study participants were found to have received at least one ANC from an MTP. However, less than half (47%) of the mothers had 4+ ANC visits during their pregnancies.

Less than one-fifth (18.3%) of the mothers had obtained a quality visit (MTP performed all five core components). There was no significant differentiation among the mothers in terms of having a facility delivery, an SBA conducting the delivery, and receiving PNC services (mother and child) within the 48 hours after birth. (Table 2)

Distribution of delivery and PNC service compliances

Table 3 shows the distribution of delivery and PNC service compliances based on ANC visits during pregnancies and the background characteristics of the surveyed mothers. The results suggest that higher compliances to facility delivery (77.9%), delivery by an SBA (80.9%), and PNC for both mother and child within 48 hours after delivery (81%) could be achieved when qANC could be ensured to mothers during pregnancies. Additionally, a considerably higher percentage of facility delivery, delivery by an SBA, and PNC services was observed amongst mothers who had either completed their secondary education, were engaged in skilled/unskilled manual labors, belonged to the richest wealth quintile, or had a birth parity of 1. These three outcomes were also highly prominent amongst mothers from Dhaka and Khulna divisions and less distinct in mothers from Barisal, Mymensingh, and Sylhet. (Table3)

Association between demographic characteristics and outcome variables

Table 4 shows the adjusted multivariable logistic regression model for association between qANC and outcome variables (facility delivery, delivery by an SBA, and PNC services).

Receiving qANC was found significantly associated with facility delivery (ARR: 1.3; 95% CI: 1.27-1.41), delivery by an SBA (ARR: 1.3; 95% CI: 1.24-1.35) and PNC services for both mother (ARR: 1.3; 95% CI: 1.24-1.35) and child (ARR: 1.3; 95% CI: 1.23-1.35) within 48 hours. Mothers who completed their secondary education were more likely to receive facility delivery (ARR: 2.3; 95% CI: 1.96-2.76) and PNC services within 48 hours for them (ARR: 2.2; 95% CI: 1.88-2.57) and their child (ARR: 2.2; 95% CI: 1.92-2.62) compared to mothers with no formal education. Similarly, mothers belonging to the richest wealth quintile were more likely to receive facility delivery, delivery by an SBA and PNC services than those from the reference category.

This study assessed the data from BDHS 2017 survey and reported three crucial and unique findings. First, this study demonstrated that nearly half of the women (47%) had four or more ANC visits during their pregnancies, which is a 16% increase compared to reports from previous BDHS survey between 2012 and 2014. Second, the findings highlight the importance of achieving faster progress in ensuring at least one ANC visit during pregnancy, as the percentage of women receiving at least one ANC increased by only 3.95% in three years (from 78.6% in 2012-2014 to 81.9% in 2017) (2). Third, despite the increases in ANC visits, only 18% of the mothers were receiving qANC during their pregnancies. Indications are clear that although the increasing trend in receiving ANC amongst pregnant women is encouraging, more focus is required to ensure the ANCs receipt conform to qANC standards.

According to our findings, amongst the five qANC core components (blood pressure measurement, weight measurement, blood test for hemoglobin, urine test for albumin, and counseling on danger signs), the most commonly received components were blood pressure (94%) and body weight (89%) measurements. The least prominent qANC component was counseling on danger signs (40%), which is concerning as expectant mothers must be able to quickly recognize the danger symptoms to seek medical assistance on time. Hence, an increase in both the quantity and quality of counseling remains critical to ensuring qANC (21).

Our analysis found a positive association between exposure to qANC and outcomes such as facility delivery, an SBA conducting the delivery, and compliance with PNC services for both mother and child within 48 hours. In the adjusted model, all outcomes were higher among the women who received qANC compared to those who did not. The ARR values of getting facility delivery, delivery by an SBA and PNC services within 48 hours were about 1.3 times among the women who got qANC. A longitudinal study in Bangladesh (22) also revealed that ANC had a positive impact on PNC utilization. Findings from systematic analysis and meta-analysis conducted in Ethiopia (19, 23-25), as well as a meta-analysis conducted in low- and middle-income countries (26) concur with this finding.

Mothers' education level and belonging to the higher income quintiles were found to be significantly and positively associated with facility delivery, an SBA conducting the delivery, and compliance with PNC services. This conclusion of a strong influence of maternal education on optimal utilization of maternal care services is in agreement with previous studies in countries similar to Bangladesh (23, 24). A possible explanation for these observed results might be that educated mothers are more likely to understand the necessity of well-being during their maternity period and are aware of the resources that are best suited for ensuring a safe pregnancy. Additionally, income-generating activities can enhance a mother's decision-making capacity, position in families, and, thus, the ability to undertake health-beneficial decisions during pregnancies (18).

Although ANC services are being utilized more frequently, ensuring qANC and expanding PNC service utilization have remained a challenge for Bangladesh. Since qANC is associated with increased adherence to PNC, providing high-quality prenatal care to women may be the most effective method to promote PNC service utilization in the country.

ANC – Antenatal Care

ARR – Adjusted Risk Ratio

BBS – Bangladesh Bureau of Statistics

BDHS – Bangladesh Demographic and Health Survey

EA – Enumeration Area

FANC – Focus Antenatal Care

MMR – Maternal Mortality Ratio

MTP – Medically Trained Provider

NMR – Neonatal Mortality Rate

PNC – Postnatal Care

PSU – Primary Sampling Unit

qANC – Quality Antenatal Care

SBA – Skilled Birth Attendant

UN – United Nations

WHO – World Health Organization

Ethics approval and consent to participate

As the study relied on the existing dataset from the BDHS, which is publicly available, there was no need for the researchers to seek additional ethical clearance. The BDHS reports provide comprehensive details regarding the ethical considerations and procedures followed during the data collection process.

Consent for publication

Not applicable

Availability of data and materials

The datasets analyzed during this current study are freely available online in the DHS website https://dhsprogram.com/data/available-datasets.cfm

Competing interests

The authors declare that they have no competing interests.

Funding

The research received no external funding

Authors’ contributions

MN, MSS defined the objectives of the study and led the study design and development. MN, MSS contribute to data analysis, interpretation of data, and MN, MSS, TH, SMR, SDP, RK, TMM drafted the article. MPH, AS, MHK, AYMA critically reviewed and MN, MSS, TH, SMR, SDP, RK, TMM revised the article for content and language with the help and input of all listed co‑authors. All authors approved the final version of the manuscript.

Acknowledgments

The authors want to sincerely thank all men and women participating in Bangladesh Demographic and Health Survey 2017.

Author details

¹Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka-1212, Bangladesh.²WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR.³Laboratory of Data Discovery for Health Limited, Hong Kong Science Park, New Territories, Hong Kong SAR. ⁴International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Shaheed Tajuddin Ahmed Sarani, Mohkhali, Dhaka-1212, Bangladesh.⁵Arnold School of Public Health, University of South Carolina, Columbia, USA.⁶ Imperial College Healthcare NHS Trust.⁷Chief Economist's Unit, Bangladesh Bank, Head office, Dhaka-1000. ⁸binary data lab, Mohammadpur, Dhaka-1000. ⁹School of Planning, University of Waterloo, ON, Canada.

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Table 1: Background characteristics of women aged 15-49 who had a live birth in the BDHS 2017 survey

Background characteristics	Number of women	%
Mother's age
<19y	904	17.9
20-29y	3086	61.1
30-39y	1006	19.9
40-49y	55	1.1
Mother's education
No education	390	7.7
Primary	1502	29.7
Secondary education incomplete	2031	40.2
Secondary/higher education complete	1129	22.3
Mother's occupation
Unemployed	3104	61.5
Agricultural	1365	27
Manual labor (skilled/unskilled)	411	8.1
Service/sales	171	3.4
Husband's occupation
Not working	666	13.2
Agricultural	428	8.5
Manual labor (skilled/unskilled)	2928	58
Service/sales	1030	20.4
Birth order
1	1931	38.2
2 - 3	2503	49.6
4+	617	12.2
Residence
Urban	1356	26.8
Rural	3695	73.2
Division
Barisal	288	5.7
Chittagong	1071	21.2
Dhaka	1293	25.6
Khulna	464	9.2
Mymensingh	431	8.5
Rajshahi	587	11.6
Rangpur	534	10.6
Sylhet	383	7.6
Wealth quintile
Poorest	1042	20.6
Poor	1036	20.5
Middle-class	969	19.2
Rich	1018	20.2
Richest	986	19.5

Table 2: The background characteristics of ANC visits, nature of deliveries, and PNC services received by the study participants

Background characteristics	Number of women	(%)
Any ANC by MTP
No	914	18.1
Yes	4137	81.9
Number of ANC
None	405	8
1	661	13.1
2	830	16.4
3	781	15.5
4+	2374	47
Quality of ANC
No	4093	81.7
Yes	919	18.3
Facility Delivery
No	2533	50.1
Yes	2519	49.9
SBA
No	2379	47.1
Yes	2672	52.9
PNC for mother within 48 hours
No	2354	46.6
Yes	2697	53.4
PNC for child within 48 hours
No	2349	46.5
Yes	2702	53.5

Table 3: Distribution of outcomes by ANC exposure and background characteristics, n (%)

Background characteristics	Facility Delivery	Delivery by SBA	PNC for mother within 48 hours	PNC for child within 48 hours
Quality ANC
No	1824(43.9)	1950(46.8)	1975(47.5)	1979(47.6)
Yes	695(77.9)	722(80.9)	722(80.9)	722(81)
Mother's age
<19y	461(50.9)	495(54.7)	506(55.9)	502(55.5)
20-29y	1559(50.5)	1649(53.4)	1653(53.6)	1665(54)
30-39y	474(47.1)	500(49.6)	510(50.6)	506(50.3)
40-49y	26(47.1)	29(53.1)	29(53.1)	29(53.1)
Mother's education
No education (0 years)	105(26.8)	115(29.4)	119(30.5)	118(30.3)
Primary education (1-5 years)	497(33.1)	522(34.8)	531(35.4)	539(35.9)
Secondary incomplete (6-9 years)	1048(51.6)	1132(55.7)	1149(56.6)	1145(56.4)
Secondary complete or higher (10+ years)	869(77)	904(80)	898(79.5)	901(79.8)
Mother’s occupation
Not working	1713(55.2)	1802(58.1)	1814(58.4)	1815(58.5)
Agricultural	506(37.1)	550(40.3)	558(40.9)	560(41)
Skilled/unskilled manual	225(54.8)	240(58.5)	242(58.9)	243(59.2)
Service/sales	75(43.9)	80(46.5)	84(49)	84(48.9)
Husband’s occupation
Not working	274(41.2)	290(43.6)	297(44.6)	295(44.3)
Agricultural	115(26.9)	125(29.2)	126(29.4)	128(29.9)
Skilled/unskilled manual	1532(52.3)	1624(55.5)	1638(56)	1643(56.1)
Service/sales	597(58)	633(61.5)	636(61.7)	636(61.8)
Birth order
1	1175(60.9)	1247(64.6)	1253(64.9)	1251(64.8)
2-3	1178(47)	1240(49.5)	1251(50)	1261(50.4)
4+	166(26.9)	185(29.9)	193(31.3)	190(30.8)
Residence
Urban	862(63.5)	918(67.7)	918(67.7)	918(67.7)
Rural	1657(44.8)	1754(47.5)	1779(48.1)	1784(48.3)
Division
Barisal	113(39.1)	136(47.3)	136(47.1)	135(46.8)
Chittagong	500(46.7)	544(50.8)	557(52)	556(51.9)
Dhaka	743(57.4)	780(60.3)	780(60.3)	783(60.5)
Khulna	283(61)	296(63.7)	301(64.9)	300(64.6)
Mymensingh	167(38.8)	178(41.2)	179(41.6)	180(41.7)
Rajshahi	309(52.7)	321(54.7)	325(55.3)	326(55.6)
Rangpur	254(47.5)	263(49.1)	263(49.2)	263(49.2)
Sylhet	150(39.2)	154.5(40.3)	157(40.9)	160(41.6)
Wealth quintile
Poor	274(26.3)	289(27.8)	297(28.5)	295(28.3)
Poorest	387(37.4)	418(40.3)	422(40.7)	430(41.5)
Middle	473(48.8)	510(52.6)	522(53.8)	524(54)
Rich	610(59.9)	641(62.9)	642(63.1)	641(63)
Richest	775(78.5)	814(82.5)	815(82.6)	813(82.4)

Table 4: Association between outcomes and exposures (Adjusted Risk Ratio, ARR)

Background characteristics	Facility Delivery	Delivery by SBA	PNC for mother within 48 hours	PNC for child within 48 hours
Quality ANC
No	Ref	Ref	Ref	Ref
Yes	1.3(1.27 - 1.41)	1.3(1.24 - 1.36)	1.3(1.24 - 1.35)	1.3(1.23 - 1.35)
Mother's age
<19y	Ref	Ref	Ref	Ref
20-29y	1(0.92 - 1.02)	1(0.92 - 0.99)	1(0.92 - 1)	1(0.92 - 1)
30-39y	0.9(0.9 - 1.03)	0.9(0.9 - 1)	1(0.91 - 1.01)	1(0.9 - 1.02)
40-49y	0.8(0.72 - 1.11)	0.9(0.75 - 1.07)	0.9(0.76 - 1.08)	0.9(0.76 - 1.09)
Mother's education
No education (0 years)
Primary education (1-5 years)	1.2(1.03 - 1.47)		1.2(0.98 - 1.36)	1.2(1 - 1.39)
Secondary incomplete (6-9 years)	1.8(1.52 - 2.13)		1.8(1.5 - 2.04)	1.8(1.52 - 2.08)
Secondary complete or higher (10+ years)	2.3(1.96 - 2.76)		2.2(1.88 - 2.57)	2.2(1.92 - 2.62)
Mother’s occupation
Not working
Agricultural	0.9(0.84 - 0.98)	0.9(0.87 - 1)	0.8(0.77 - 0.88)	0.8(0.77 - 0.88)
Skilled/unskilled manual	1(0.93 - 1.06)	1(0.94 - 1.05)	1(0.89 - 1.02)	1(0.9 - 1.02)
Service/sales	0.8(0.72 - 0.99)	0.8(0.71 - 0.96)	1(0.86 - 1.14)	1(0.85 - 1.13)
Husband’s occupation
Not working	Ref
Agricultural	0.8(0.7 - 0.99)	0.9(0.72 - 1.01)	0.8(0.71 - 1)	0.9(0.73 - 1.02)
Skilled/unskilled manual	1.1(0.99 - 1.2)	1.1(1.01 - 1.21)	1.1(1.01 - 1.2)	1.1(1.02 - 1.21)
Service/sales	1.1(1 - 1.21)	1.1(1 - 1.21)	1.1(1.01 - 1.21)	1.1(1.03 - 1.23)
Birth order
1
2-3
4+
Residence
Urban	Ref	Ref	Ref
Rural	0.9(0.97 - 1.07)	0.9(0.96 - 1.04)	1(0.96 - 1.05)	1(0.96 - 1.04)
Wealth quintile
Poor	Ref	Ref	Ref	Ref
Poorest	1.4(1.2 - 1.55)	1.4(1.24 - 1.59)	1.4(1.22 - 1.56)	1.4(1.26 - 1.6)
Middle	1.7(1.53 - 1.95)	1.8(1.59 - 2)	1.8(1.6 - 2.01)	1.8(1.62 - 2.03)
Rich	2(1.78 - 2.25)	2(1.8 - 2.26)	2(1.79 - 2.23)	2(1.8 - 2.25)
Richest	2.4(2.13 - 2.7)	2.4(2.17 - 2.72)	2.4(2.18 - 2.71)	2.4(2.18 - 2.71)

No competing interests reported.

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Quality of antenatal care and its potential impacts on delivery services and postnatal care compliance among reproductive women of Bangladesh

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Abstract

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Plain English summary

Background

Methods

Data Source

Study population and survey design

Results

Demographic Characteristics

Quality of ANC

Distribution of ANC exposure, delivery and post-delivery service outcomes

Distribution of delivery and PNC service compliances

Association between demographic characteristics and outcome variables

Discussion

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

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