Birth preparedness, complication readiness and participation in maternity care among men in a rural community, odisha, India

Dharitri Swain

Assistant Professor, College Of Nursing, All India Institute of Medical Sciences (AIIMS), Sijua, Bhubaneswar, Odisha-751019

*Corresponding author Email:

ABSTRACT:

Birth preparedness and complication preparedness (BPACR) is a key component of globally accepted safe motherhood programs, which helps ensure women to reach professional delivery care when labor begins and to reduce delays that occur when mothers in labor experience obstetric complications.In Indian community like Odisha, pregnancy and childbirth continue to be regarded as exclusively women’s affairs, But male are considered as primary decision maker and financier for women’s health. Hence it is observed that due to lack of involvement of husband in maternity care, proper decision cannot take for women to access care for obstetric emergency which lead to disastrous consequences. This situation makes men critical partners for the improvement of maternal health and reduction of maternal mortality by raising their awareness about emergency obstetric conditions, and engaging them in birth preparedness and complication readiness.

A descriptive cross-sectional study was undertaken among 200 ever married men in Mendhasal village, Khorda District which is a rural community in odisha state, India. Multi-stage sampling was used to select the samples and questionnaires was administered to assess men’s birth preparedness, complication readiness and attitude of women towards male participation in maternity care and in-depth interviews was done to find out reasons for poor involvement of their husband in maternity care. The study found that majority of pregnancies was unplanned (96%). Only 28.5% of men ever accompanied their spouses for maternity care. There was very little preparation for skilled assistance during delivery (6.2%), savings for emergencies (19.5%) or transportation during labour (24.2%). Young paternal age, formal education and Hindu male were independent predictors of male participation in maternity care.

In Indian community set up, the role of men in maternity care is very poor, despite their economic dominance and decision making power. There is a need to increase involvement of men in their partner’s maternity care through peer-led, culturally-sensitive community education and appropriate health system reforms.

KEY WORDS: Maternity care, Birth preparedness, Complication readiness, Attitude, High risk pregnancy.

INTRODUCTION:

Maternal and child health is the key component of national health. Pregnancy complication mostly developed in rural set up due to lack up birth preparedness and complication readiness of both partner.

Globally, more than half a million women still die annually as a result of complications of pregnancy and childbirth¹. A disproportionately high burden of these deaths is borne by developing countries, like India. In India, every five minutes one women die of complications related to pregnancy and childbirth. This adds up to a total of 1, 21,000 women per year^2. . India accounts for nearly 10% of the global estimates of maternal mortality². Within India, Odisha has one of the worst maternal mortality ratios in the world³. In order to address this disturbing trend, the International Conference on Population and Development (ICPD) urged that special efforts should be made to emphasize Men’s awareness and promote their active involvement in maternity care⁴. Although in most Indian community like Odisha, pregnancy and childbirth continue to be regarded as exclusively women’s affairs

In many health set up generally men do not accompany their wives for antenatal care and are not expected to be in the labour room during delivery⁵. However, men are socially and economically dominant especially in country like India; they exert a strong influence over their wives, determining the timing and conditions of sexual relations, family size, and access to health care. This situation makes men critical partners for the improvement of maternal health and reduction of maternal mortality. Strategies for involving men include raising their awareness about emergency obstetric conditions, and engaging them in birth preparedness and complication readiness⁶. This is based on the premise that increased awareness of men will enable their support for early spousal utilization of emergency obstetric services.

Preparing for birth and being ready for complications could reduce all three phases of delay and thereby positively impact birth outcomes. Birth-preparedness and complication readiness is a comprehensive strategy aimed at promoting the timely utilization of skilled maternal and neonatal health care. The key elements include: knowledge of danger signs; plan for where to give birth; plan for a birth attendant; plan for transportation and plan for saving money⁶. In addition, a potential blood donor and a decision maker needs to be identified. This is because every pregnant woman faces the risk of sudden, unpredictable complications that could end in death or injury to her or to her infant⁶.

Many studies on men participation in maternity care are reported from Nigiria⁶. Odimegwu and colleagues observed a high level of awareness and participation of men in maternity care in Osun state⁷. Also Morhason-Bello and others reported that 86% of antenatal clients in University College Hospital, Ibadan⁸, preferred their husbands as companions during labour while only 7% and 5% favored their mothers and siblings respectively⁷. However, little such research has been conducted in India-a culturally distinct region contributing disproportionately to the country’s high maternal mortality ratio. The aim of this study was therefore, to assess men’s perception of high risk pregnancy and danger signs; birth preparedness and complication readiness, and participation in maternity care. In addition, the attitude of their wives towards such participation was also assessed. The study was conducted in a rural community of Odisha in India. This study will shed light on men’s participation in maternity care and provide information for the development of culturally sensitive strategies for inclusion of men in maternal health care delivery.

STUDY OBJECTIVES:

1. Assess perception of men regarding high risk pregnancy and danger signs during pregnancy.

2. Assesses men’s birth preparedness and complication readiness.

3. Assesses attitudes of women towards husband participation in maternity care.

4. Find the association of male participation and with selected demographic variables.

MATERIAL AND METHODS:

Study Population

The study population was married men, whose Wife/wives have ever been pregnant. The study was conducted in Mendhasal CHC, khorda district, Odisha state, which is a local rural community, has a projected population of 3373 population. Data was collected from two villages under the CHC.

Study design and sampling

Descriptive and cross-sectional design was used to conduct the study. A sample size of 200 was obtained using the hypothesis testing method and based on the following assumptions: 95% confidence level, findings from a previous study and a 5% margin of error. For the selection of respondents, a multistage sampling technique was used. After house numbering, a total of 250 houses were selected from the community. Then 200 houses were selected using the systematic sampling technique with the starting point obtained using a random number table. Where more than one household was found in a house, one was selected by a single one-time ballot. Finally, eligible men (and their wives or most senior wife) in the sampled household were approached to participate in the study.

Instrument Description/Data Collection

In the first step of data collection, pre-tested Questionnaires containing both open and closed-ended questions was administered among married men to determine their birth preparedness and complication readiness. Attitude of their wife for involvement of their husband in the maternity care was assessed through administration of attitude scale. An in-depth interviews (IDI) was conducted to elicit reasons for low participation of husband in maternity care.

Informed consent was obtained from prospective respondents prior to commencement of the interviews. The content of the consent form was translated into local language (Odiya). Literate respondents indicated acceptance by signing the consent form, while illiterate participants used a thumb print. The questionnaire was pre-tested and revalidated at chandaka village, under Mendhasala PHC with similar characteristics to the study area. Some of the questions were rephrased for clarity based on observations made during the pretest. The interviews were conducted in Odiya language. A separate in-depth interview guide was developed and administered to elicit reasons for low participation of women in maternity care

The tool was divided into six parts to collect necessary information from the target samples:

Part I-The first section inquired about personal data, including age, occupation, parity, family type, religion and educational level.

Part II-The second part elicited information about perception of high risk pregnancy and danger signs during pregnancy.

Part III-The third section assessed birth preparedness and complication readiness of men

Part IV- The fourth part inquired about attitudes of women towards husband participation in maternity care

Part V- The fifth part includes rreasons for low male participation in maternity care

Part VI-Level of men participation in maternity care and associated factors of male participation.

Data Analysis

The data was cleaned, validated and analyzed using SPSS Version

- Quantitative variables were summarized using range, mean and standard deviation.

-Categorical variables were tabulated using frequencies and percentages. The Chi-square test was used for testing the significance of association between categorical variables. The level of significance was set at P < 0.05.

Schematics representation of research methodology

Research approach – Descriptive survey approach

Research design – Cross-sectional design

Table 1: Socio-demographic characteristics of respondents (N=200)

Characteristic

Frequency No (%)

Characteristic

Frequency No (%)

Age of men

20-29

30-39

40-49

≥50

46 ( 23% )

96 (48%)

35 (17.5 %)

23 (11.5% )

Years of Marriage

One -five Year

five- ten Years

Ten years and More

Divorced

56(28% )

76(38 %)

04(2 %)

Educational status

non-formal

primary

secondary

tertiary

60 (30% )

36 (18%)

52 (26%)

Occupation

Farmer

Employed

Business and other works

142(71 %)

32(16 %)

26(13%)

Religion

Hindu

Muslim

Christian

146(73% )

52(26 %)

02( 01% )

Sources of knowledge

Health personnel

Media

Relatives

Others

82(41 % )

75(37.5 % )

22( 11% )

21(10.5 %)

Type of marriage

Monogamy

polygamy

178(89) %

22(11%)

Family type

Nuclear family

Joint family

112(56 % )

88( 44% )

Table 2: Men’s perception of high risk pregnancy and danger signs in pregnancy (N=200)

Variable

Frequency (%)

YES

Total

Pregnancies considered as high risk

1. Pregnancy in the sick

2. Pregnancy while breastfeeding.

3.Too frequent pregnancies

4.Pregnancy in the young mother

5.Previous operative delivery

6.Pregnancy in the older mother

7. Twin pregnancy and multiple pregnancy

Danger signs in pregnancy

1.Bleeding

2.Convulsions

3.Loss of consciousness

4.Paleness

5.Swollen legs/face

6.Baby stops kicking

7.Water breaks before labour pains

8. Difficulty in breathing.

9.Dizziness/Blurred vision

10.Severe Headache

11. High Fever

102(51%)

49(24.5 %)

51(25.5 %)

39(19.5 %)

34(17% )

32(16% )

08(4%)

103(51.5%)

76(38% )

73(36.5% )

34(17% )

44(22% )

29(14.5% )

26(13% )

12(06% )

22(11% )

18(09% )

16(08% )

98(49 %)

192(96% )

149(74.5 %)

151(75.5 %)

161(80.5% )

194(97% )

168(84% )

97(48.5% )

124(62% )

127(63.5% )

166(83% )

156(78% )

171(85.5 %)

174(87% )

188(94 %)

178(89 %)

182(91% )

184(92% )

200(100% )

Figure: 1-Distribution of men according to birth preparedness and complication readiness planning.

C) Men’s Birth preparedness and Complication Readiness

Majority of pregnancies were unplanned (96%). Figure 1 shows that most of them made plans for the baby are naming ceremony (71.5%). Less than a third made plans for mother’s health care (30.8%), transportation (24.2%), delivery (23.5%) and baby/mother’s clothes (22.6%). Only 19.5% of respondents made savings for obstetric emergencies and a mere 10.5% identified a decision-making process in case of obstetric emergency. Similarly, decision on place of delivery, arrangement for skilled assistance at delivery and preparations for blood donation were made by only 9.0%, 6.2% and 0.8% of respondents respectively.

D) Women’s Attitude for Husband Participation

Table-3 shows that while most wives were in agreement with husbands accompanying their spouses for antenatal care (71%), delivery (45%) and postnatal care (77.5%). However, there was a strong opposition to the physical presence of husbands in the labour room (43%) and 24% could not decide about it.

Table 3: Attitude of wives toward husband’s participation in maternal care N=200

Statement

Frequency (%)

Husband should accompany wife

during ANC

Strongly Agree

Agree

Undecided

Disagree

Strongly Disagree

Husband should accompany wife to hospital during delivery

Strongly Agree

Agree

Undecided

Disagree

Strongly Disagree

Husband should be present in labour room

Strongly Agree

Agree

Undecided

Disagree

Strongly Disagree

Husband should accompany wife for postnatal care

Strongly Agree

Agree

Undecided

Disagree

Strongly Disagree

56(28 %)

86(43 %)

38(19 % )

17(8.5 % )

03(1.5 %)

38(19% )

52(26 % )

32(16 % )

56(28% )

22(%11 )

28(14% )

38(19 % )

48(24 % )

62(31 %)

24(12 % )

82(41 % )

73(36.5 % )

21(10.5 % )

13(6.5 %)

11(5.5 % )

E) Reasons for low male participation in maternity care

Women who were disagreeing about their husband participation in delivery were interviewed to express the reason behind it. The main reason cited by women opposing men’s presence is that it is against our culture and religion for men to witness the delivery of the baby (28.4%). Similarly, women’s perceived reasons for low participation of their spouses in maternity care were as follows: Accepted practice since ages by the elders (20.6%), financial reasons (16.0%), pregnancy and delivery are women affairs (25.6%), lack of interest and knowledge (12.5%).

Key: A = Accepted practice since ages C =Financial Reason, B = cultural and religious factors D = restriction of health workers, E = Ignorance

Figure: 2 -Distribution according to Reasons for low participation of men in maternity care

F. Level of participation of men in antenatal, delivery and postnatal care.

Overall, only 32.1% of husbands accompanied their wives at least once to the hospital for antenatal, delivery or postnatal care. Table 4 shows that for routine antenatal care, most respondents provided money for transport and medication (79.5%). Only 16.0% of respondents accompanied their spouses to the hospital for routine antenatal care.

Table: 4 Men’s participation in Antenatal, Delivery and Postnatal care N=200

Level of involvement

Frequency (%)

During antenatal care

a. Gives permission only

b. Money for transport/drugs

c. Personally accompanies

d. Donating blood

e. Personally accompanies during complication

f. Donated blood during complication

During Delivery

a. Gives permission only

b. Money for transport/drugs

c. Personally accompanies

d. Donating blood

e. Personally accompanies during complication

f. Donated blood during complication

Postnatal care

a. Gives permission only

b. Money for transport/drugs

c. Personally accompanies

d. Donating blood

e. Personally accompanies during complication

f. Donated blood during complication

38 (19%)

159 (79.5%)

32 (16%)

3(1.5%)

37 (36.5%)

21(10.5%)

13 (6.5%)

123 (61.5%)

21 (10.5%)

09(4.5%)

75(32.5%)

31 (15.5%)

23 (11.5%)

106 (53%)

43 (21.5%)

5(2.5%)

67(33.5%)

20 (10%)

However, when complications arose, a significantly higher proportion of men (36.5%) (P<0.001) accompanied their spouses to hospital and a higher proportion (10.5%) donated blood. A similar pattern occurred during delivery whereby in the absence of complications, most respondents (61.5%) provided money for transport/drugs with only 10.5% personally accompanying their spouses to the hospital and only 3.7% donating blood. However, when complications occurred, the proportion of respondents that accompanied their wives rose significantly to 32.5% (P<0.001). A higher proportion (15.5%) also donated blood. The trend was maintained during postnatal care where for routine postnatal care, majority of respondents gave money for transport/drugs with only 21.5% accompanying their spouses and 2.5% donating blood. However, when complications occurred, a significantly higher proportion (33.5%) (P<0.001) of respondents accompanied their wives. Those who donated blood increased from 10%.

G. Associated factors of male participation in maternity care

Table -5 represents that, twenty four men out of forty six respondents under the age of 30 years (52.1%) ever accompanied their wives to the hospital for maternity care compared to 69 (44.8%) 30 years or older. This difference was statistically significant (P<0.01). Men who had formal education (n=140, 55.71%) were more likely to participate in maternity care compared to (n=60, 25%) those with non-formal education (P<0.001). Similarly, a significantly higher proportion (n=178, 51.1%) of men in monogamous marriages accompanied their spouses for maternity care compared to (n=22, 9.09%) of their polygamous counterparts (P<0.001). Furthermore, a higher proportion (n=146, 51.37%) of Hindu men participated in maternity care compared to other religion (n=54, 33.3%) (P<0.01).

DISCUSSION:

In the present study the participants perceived the following pregnancy groups as being high risk: sick women, breastfeeding women, high parity mothers, very young women and women with previous operative delivery. This finding concurs with results from a study of man in South West Nigeria⁷. Husbands that perceive pregnancies under the preceding conditions as high risk are more likely to support the use of family planning for their spouses or themselves compared to those who don’t perceive such pregnancies as high risk. Also it was found from the present study that a substantial proportion of men correctly identified vaginal bleeding, convulsions and loss of consciousness as obstetric emergencies. Other conditions identified were paleness, cessation of foetal movement, preterm labour, headache, fever and dizziness. These responses are similar to those mentioned by men in Osun state, south west Nigeria⁷. In India like country male are main decision-maker and financier of maternal and child care. Hence it is utmost important for husband to identify obstetrics complications and immediate action for emergency situations, otherwise it will create disastrous consequences for mother and her child.

This present study found the low participation of men in maternity care (32.1%) is similar to findings among men in South Africa (33.3%) ⁸ but lower than the level among men in Osun (93.9%) ⁷ and Oyo (72.5%) ⁹states in south west Nigeria. Similar finding also observed in Northern part of India (98.2%)¹⁰. It is also in agreement with the participation rate of men in Nepal (40.0%) ¹¹. The findings are also in contrast with findings from El Salvador (90%) ¹² and with results of a study in Greece which showed that only 10% of Greek fathers attended the birth of their last child ¹³. When men accompany their wives to hospitals, they have more access to reproductive health information and could result in greater communication between men and women on subjects related to reproductive health and child care. This improved inter spousal communication could enhance pregnancy planning, birth preparedness and complication readiness as. Observed in MIMS India Research Evaluation Of Intervention ¹⁰.

This study also found that men were more likely to accompany their wives and pay for treatment when complications arose. In both routine care and treatment of problems, husbands participated more often by paying for care than accompanying their wives. Men also considered maternity units as exclusively meant for women.

Table 5: Factors associated with male participation in maternity care

Characteristics

Ever participated (Frequency (%)

Never participated (Frequency (%)

Total

P-value

Age group (yrs)

<30

>30

Total

24(52.1%)

69 (44.8%)

93(46.5%)

22(47.8%)

85(55.1%)

107(53.5%)

46(100.0)

154(100.0)

200(100.0)

0.003

Educational status

Non-formal

Formal

Total

15(25%)

78(55.71%)

93(46.5%)

45(75%)

62(44.28%)

107(53.5%)

60(100.0)

140(100.0)

200(100.0)

<0.001

Type of marriage

Monogamy

Polygamy

Total

91(51.1%)

02(9.09%)

93(46.5%)

87(48.87%)

20 (90.9%)

107(53.5%)

178(100.0)

22(100.0)

200(100.0)

<0.001

Religion

Hindu

others

Total

75(51.37%)

18(33.33%)

93(46.5%)

71(48.63%)

36(66.6%)

107(53.5%)

146(100.0)

54(100.0)

200(100.0)

<0.01

In addition, attitude of health staff and poor conditions in health centres imply that even husbands who accompany their wives to clinics are often ignored or made to stay outside as they considered pregnancy is exclusively women’s affair. Associated factors identified for low male participation in maternity care were cultural, religious and health system issues as well as poverty and ignorance. This concurs with the findings from other African and Asian studies ^14,
15.

In most settings in India reproductive health education provided to women ,however man play important role as primary decision maker and act as gatekeepers to women's access to reproductive health services and hold the decision-making power over such matters, even if the life of the mother is at stake. Men decide on when and where to seek emergency obstetric care, the place of delivery and use of family planning methods during the postpartum period. Fortunately, there is a growing awareness and acceptance that men have an important influence on women's health and also have distinct reproductive health needs of their own. Involvement of men as partners may improve spousal communication and may help in early decision-making for seeking care if complications arise. This study found that men gave high priority to making plans for naming ceremonies rather than critical components of birth preparedness such as deciding on place of delivery, skilled assistance and identification of a blood donor. More worrisome is the lack of plans for decision making and savings for obstetric emergencies. The variation in level of preparedness could be due to differences in literacy level, cultural practices, and poverty and in effectiveness of implementation of safe motherhood by the different national health systems.

Expectedly a substantial proportion of wives in the present study disapproved of their husband’s presence in the labour room in contrast to antenatal attendees in the University College Hospital Ibadan. This could be due to existing cultural mindset and variations in literacy level among women. The observed higher participation among younger educated men is similar to the findings among African men. This could be due to the fact that younger men are more adventurous and likely to challenge cultural norms. In addition, education is known to positively influence health seeking behaviour¹⁵. Furthermore; cultural factors may act as deterrents for the participation of Indian men in maternity care.

The hospital setup must have written policy to involve men at maternity care and welcome husbands to share responsibility for routine care and treatment of maternal problems. Many Men expressed that they didn’t know they were expected to be involved and perceived hospitals as unwelcoming, even if they want to participate in their spouses’ maternity care. In order to address maternal mortality, low contraceptive uptake and mother to child transmission of HIV, men involvement in maternity should be considered a key priority¹⁶. Very little can be achieved for either mothers or infants unless reproductive health programmers and providers realize the strategic position occupied by men and the important roles they can play in the provision of reproductive services. Active steps need to be taken towards involving men in reproductive health services. Development partners and non-governmental organizations need to place this issue on the agenda in health policy.

CONCLUSIONS:

Educational efforts on maternal care with men should go beyond basic information to also include specifics of pregnancy planning, birth preparedness and complication readiness. There is a need to create an enabling environment by working with the health system in improving conditions – such as lack of privacy – that make it difficult for husbands to participate, and identify other ways health staff could encourage husbands to be present. In this study, the educated and younger husbands tend to accompany their wives for maternity care. This provides an opportunity for NGOs to identify and train a critical mass of these “change agents” as peer educators to enlighten and encourage others to participate. Health care workers should be trained in interpersonal communication skills to improve their attitudes towards men who accompany their spouses. Another long term strategy is to educate the young, since younger educated men were more likely to participate in maternity care. This can be enhanced by inclusion of responsible parenthood in family life education for schoolboys in anticipation of their future roles as husbands.

Implications

From the findings of the study the following implication are stated.

-Present study would help nurses and other healthcare personnel to understand the important of male participation in maternity care so that early decision-making can be made for seeking care if obstetric complications arise.

-Present study would the society to understand the immense role of husband in birth preparedness and complication readiness and take the responsibility to accompany their wife during antenatal, delivery and postnatal check up.

- The findings would help the health policy maker to understand the involvement of male partner in maternity care so that early steps could be taken to reduce maternal and newborn morbidity and mortality. The nurse administrator would further recommend the hospital policy to practice husband participation for better access of maternity care by the women.

RECOMMENDATIONS:

- This type of study may be conducted in different region of India to know the gender dynamics in maternity care.

- Training strategy for health worker can be implemented to welcome all husbands for their active participation in women’s health issues.

- Parenthood in family life education for schoolboys in anticipation of their future roles as husbands should included in general curriculum.

ACKNOWLEDGEMENT:

I would like to thank all the experts for guiding my research work and I also extend my heartfelt thanks to all participants for their cooperation throughout my study.

REFERENCES:

1. UNFPA. Population and development, program of action adopted at the International Conference on Population and Development (ICPD), Cairo, 5–13 September 1994 Volume 1. New York, United Nations, 1995: paragraph 4.27 (ST/ESA/SER.AS/149).

2. WHO, UNICEF, UNFPA and World Bank. Maternal mortality in 2005. Geneva: WHO; 2007.

3. Evaluation Study of National Rural Health Mission (NRHM) In 7 States. Programme Evaluation Organisation Planning Commission Government of India, New Delhi. February 2011.

4. Mullick S, Kunene B and Wanjiru M. Involving men in maternity care: health service delivery issues. Agenda Special Focus 2005:124-135.

5. JHPIEGO. Maternal and neonatal health. Monitoring birth preparedness and complication readiness, tools and indicators for maternal and newborn health. Johns Hopkins, Bloomberg school of Public Health, Centre for communication programs, Family Care International; 2004. Available at: http://pdf.dec.org/pdf_docs/PNADA619.pdf. Accessed November 2008

6. Zubairu Iliyasu et.al Birth preparedness, complication readiness and fathers’ participation in maternity care in a Northern Nigian community. African journal of Reproductive Health.14(1); 2010:21-31

7. Odimegwu C, Adewuyi A, Odebiyi T, Aina B, Adesina Y, Olatubara O and Eniola F. Men’s Role in Emergency Obstetric Care in Osun State of Nigeria. Afr J Reprod Health 2005; 9(3):59-71.

8. Morhason-Bello IO, Olayemi O, Ojengbede OA, Okuyemi OO and Orji B. Attitude and preferences of Nigerian antenatal women to social support during labour. Journal of Biosocial Science 2008; 40(4):553-562.

9. Olayemi O, Bello FA, Aimakhu CO, Obajimi GO, Adekunle AO. Male participation in pregnancy and delivery in Nigeria: A survey of antenatal attendees. Journal of Biosocial Science 2009; 41:493-503

10. Population council. Men in maternity study. Summary of findings from pre-intervention interviews with women and their husbands attending antenatal clinics at ESIC facilities in Delhi. Frontiers research update 2002:13-23

11. Husband’s Participation in Pregnancy Care: the Voices of Nepalese Men. Available from:. http:\www.princeton.edu/ download.aspx. Accessed 23rd July 2008.

12. Carter MW, Speizer I. Salvadoran fathers’ attendance at prenatal care, delivery and postpartum care. Rev Panam Salud Publica. 2005; 18(3):149-56.

13. Dragonas TG. Greek fathers’ participation in labour and care of the infant. Scand J Caring Sci. 1992; 6(3):151-9

14. Shahjahan M and Kabir M. Why males in Bangladesh do not participate in reproductive health: lessons learned from the focus group discussions. Int Q Community Health Educ. 2006-2007; 26(1):45-59

15. Haque MN. Individual’s characteristics affecting maternal health services in Bangladesh. The Internet Journal of Health 2009; 8(2):15-23.

16. UNICEF. State of the world’s children 2007. Available at http://www.unicef.org/publications/index.html Accessed June 2007

Received on 20.11.2014 Modified on 22.12.2014

Int. J. Nur. Edu. and Research 3(1): Jan.-March, 2015; Page 56-63

DOI: