Academic journal article Journal of Health Population and Nutrition

Cultural Theories of Postpartum Bleeding in Matlab, Bangladesh: Implications for Community Health Intervention

Academic journal article Journal of Health Population and Nutrition

Cultural Theories of Postpartum Bleeding in Matlab, Bangladesh: Implications for Community Health Intervention

Article excerpt


Haemorrhage is the leading cause of maternal deaths worldwide (1-2). Of the 14 million women who suffer severe postpartum haemorrhage (PPH) (>1,000 mL of blood loss) every year, 140,000 die, and 1.6 million survive with long-term disability due to anaemia (3). Response to PPH is time-sensitive. Yet, more than 60 million women give birth in the home, mostly in developing countries and in underserved areas, attended by family members, neighbours, or traditional birth attendants (TBAs) (4). These care givers are usually ill-equipped to identify and manage PPH, and rates of referral to more expert care are often low, even where referral is possible (5). Adverse outcomes due to PPH are almost exclusively in low-resource settings where birth in the home is common and emergency care is scarce. This presents a daunting challenge for global safe motherhood. Targeting PPH in these vulnerable populations with effective, culturally-appropriate interventions is necessary to achieve Millennium Development Goal 5, which aims at reducing maternal mortality by 75% by 2015 (6-9).

The Delay Model has guided safe motherhood programming and research for over a decade (10), and it provides a useful framework for exploring the relevant context for life-threatening complications, such as PPH (10). This model proposes that delays in obtaining appropriate emergency care occur at three points: decision to seek care (predicated by recognition of problem), reaching care, and receiving emergency obstetric care. Each delay is influenced by a combination of sociocultural, economic, environmental and health service factors. The premise is that a reduction in the delays will lead to decreased mortality and morbidity.

There is a paucity of research focusing on the first delay--decision to seek care in the event of PPH (8-9). To address this gap, during 2005-2006, the Center for Research on Maternal and Newborn Survival of Emory University and the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) initiated a study among childbearing women and maternity-care providers in Matlab, Bangladesh. The overall aim of the study was to improve our understanding of recognition of and response to PPH and to use this understanding for informing health communications, provider-training, and future research.

Important to recognition of and response to PPH, and the focus of this paper, is the system of beliefs or cultural theories that women and home-based care givers have about the signs, causes, and treatment of normal and abnormal postpartum bleeding. Using cultural domain analysis, we describe here these cultural theories and identify clinically-important differences in knowledge about signs, causes, and treatments for PPH among professional skilled birth attendants (SBAs), TBAs, and community lay women.


Location of study

In Bangladesh, approximately 90% of women deliver in the home, and 86% deliver with unskilled attendants. PPH remains a major cause of death (11). ICDDR,B supports research through its Matlab health services research area, located 56 km southeast of Dhaka. Since 1966, ICDDR,B has maintained a demographic and health surveillance system (HDSS) that covers an area dominated by a relatively-poor, rural population of about 220,000 whose main economic activities are farming and fishing. A community hospital at Matlab township, with four subcentres, provides 24-hour care, covering half of the population. In 2005, about 2,700 births took place in this area, and of these births, 52% occurred in the home (12).


Preliminary phase

The study had two phases--preliminary and main. In the preliminary phase, locally-salient terms for signs, causes, and treatments of normal and abnormal postpartum bleeding were derived from semi-structured successive free-listing interviews within a stratified random sample of women, aged 18-49 years, who delivered in the previous year (2005), women aged 50+ years living in an extended family and likely to be influential in matters of childbirth, TBAs, and SBAs (n=80, 20 per subgroup). …

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