Rural-Urban Determinants of Receiving Skilled Birth Attendants among Women in Bangladesh: Evidence from National Survey 2017-18

Background SBAs (skilled birth attendants) play a crucial role in reducing maternal mortality. The proportion of maternal healthcare in Bangladesh that receives quality care at birth has increased; the reasons for this are unknown. The purpose of this study is to see if there has been a change in the use of specific maternal healthcare indicators in urban and rural areas, as well as significant risk factors. Materials and Methods The data set was extracted from a nationally representative survey based on a cross-sectional study, the Bangladesh Health and Demographic Survey (BDHS) 2017-18. The frequency distribution reveals the general state of SBAs. To identify the association, we performed the chi-square test. Finally, multiple logistic regression was used to analyse the factors associated with SBAs and determine the degree of SBAs disparity between urban and rural areas. Results In Bangladesh, 53% of women received SBAs during childbirth, with urban and rural areas receiving 68.1 and 52.2 percent, respectively. Women with secondary (AOR: 1.79, CI: 1.05–3.08) and higher (AOR: 4.18, CI: 2.09–8.50) education were more likely to receive SBAs than women in urban areas who were illiterate. Husband's education, women's working status, wealth index, children's birth order, and number of ANC visit are significant factors in receiving SBSs in both urban and rural areas. Higher educated husbands are 1.83 times (AOR = 1.83, CI: 1.04–3.25, p = 0.037) and 1.82 times (AOR = 1.82, CI: 1.29–2.59, p = 0.001) more likely to attend skilled births than uneducated husbands in both urban and rural areas. Respondents from the richest families are more likely to attend skilled births than those from the poorest families in both urban and rural areas. Conclusion During delivery, significant risk factors are substantially related to SBAs. More attention must be given to rural and illiterate populations, who are less likely to obtain these services, to minimize maternal and neonatal mortality. Special programs could be developed to raise awareness and facilitate the poor in receiving the basic necessities of maternal care.


Introduction
Maternal and child mortality is a major public health concern all over the world. Te majority of complications during pregnancy and childbirth are unanticipated and occur during delivery and postpartum. Tis is why all pregnant women should have access to skilled birth attendants (SBAs), who will ensure that a normal birth goes smoothly and that any complications are discovered and reported as soon as possible to the appropriate healthcare institutions [1]. Te "the single most critical factor in avoiding maternal fatalities" is SBAs' attendance at birth [2]. SBAs' presence at delivery is also critical in reducing stillbirths and boosting neonatal survival [1,3].
Even though maternal mortality during pregnancy and delivery has decreased from 451,000 in 2000 to 295,000 in 2017, the current fgure is still concerning [4,5]. Every year, an estimated 6000 women die in Bangladesh as a result of inadequate maternal health care services due to a lack of resources [6]. Nevertheless, between 1990 and 2015, the maternal mortality rate (MMR) in Bangladesh fell by 69 percent, from 574 to 176 deaths per 100,000 live births [7].
Making matters worse, more than 2.6 million children died in their frst month of life worldwide in 2016, with South Asia accounting for 39 percent of those deaths [8][9][10][11]. Every year, in worldwide, roughly 40% of all under-fve-year-old children die within their frst month of life [8,[12][13][14][15]. A skilled birth attendant is an essential component in reducing maternal and infant mortality [16,17]. In September 2015, members of the United Nations (UN) approved 17 SDGs (Sustainable Development Goals), one of which is SDG-03 (3.1-3.2); it aims to reduce MMR to less than 70 per 100,000 people by 2030 and new-born mortality to 12 per 1,000 live births worldwide [18,19]. Skilled birth attendants are health professionals such as doctors, nurses, and midwives who are trained to provide medical coverage to women and newborn's before and during birth to handle normal deliveries and diagnose, treat, or guide obstetric complications [20][21][22]. In Bangladesh, one out of every fve births uses an SBA, although the percentage is much lower in slums and tribal areas [23]. Te fourth Health Population and Nutrition Sector Development Program of the Government of Bangladesh aimed for 65 percent SBA usage during delivery by 2022 [24].
It is critical to identify the elements that infuence SBA delivery. Previous research has found that variables at diferent levels, such as individual, family, or socioeconomic circumstances, infuence SBAs' decision to deliver [7,[25][26][27][28][29]. Inequality exists in Bangladesh, both in rural and urban areas, as well as by area and division. Te rural context of Bangladesh has been the primary focus of research on equity in the use of skilled birth attendants. Te structure of health service delivery varies greatly between urban and rural areas in Bangladesh [30]. A study of a home-based SBA program in rural Bangladesh found that fnancial constraints are signifcant barriers to healthcare utilization. Only 16% of the poorest households used the program, compared with 63% of the richest quintiles [31]. Te goal of this research was to see if there were diferences in patterns between urban and rural areas in order to identify underprivileged areas and signifcant factors while also raising awareness.

Data Sources & Study Design.
Tis study uses data from the most recent Bangladesh Demographic and Health Surveys (BDHS) from 2017-2018. It is a cross-sectional data set for reproductive age  women measured nationally [32]. Because this research relies on a secondary data source, ethical clearance is not required. Te information was gathered after submitting an application to the distributing authority [33]. A two-stage stratifed sampling method was used in the BDHS 2017-18 [33]. Tere were 675 randomly selected clusters, 250 of which were in urban areas and 425 in rural areas. In the second stage, 30 randomly selected households from each cluster were chosen. Te survey consisted a total of 20127 completed interviews of ever-married women aged 15-49 years, with 7374 (36.64%) from urban areas and 12753 (63.36%) from rural areas. Te adjusting dataset for this analysis included 4974 respondents chosen for the fnal research. 1333 (26.8%) of respondents were urban, while 3641 (73.2%) were rural.

Dependent and Predictor
Variables. Te study's dependent variable is the presence or absence of a skilled birth attendant (SBA) during delivery. For this purpose, skilled birth is defned as the presence of a skilled doctor, nurse, midwife, paramedic, or family welfare visitor during the delivery. Te SBA's service variable is not directly held on to in the BDHS 2017-18 data [32]. Tis variable is created by reversely categorizing the utilization of skilled birth attendance information, with the value 0 for an unskilled birth attendant and 1 for a skilled birth attendant.
Based on previous research, ten independent variables were chosen for this study. Te independent variables were classifed and are shown in Table 1.

Statistical Analysis.
First, we performed a univariate analysis to examine the frequency distribution for this study. In the case of bivariate analysis, the changes in associated variables are shown in relation to the cross-tabulation outcome variable. Because all variables in this study were categorical, bivariate analysis is used to perform a chi-square test [34]. Te data were presented as a contingency table with one of the variables as rows and the other as columns in Table 2. Te test statistic is a chi-square(χ 2 ) random variable defned by the following equation: Multiple logistic regression was used to model determinants that signifcantly explain the SBAs in various aspects for multivariate analysis by equation (2) in Table 3. Te logistic regression model can also be written in the form of a log of odd- where X � (X 1 , X 2 . . . X n ), β � (β 0 , β 1 . . . β n ). p is the expected probability of occurrence of the outcome, X is the independent variable, and β is the regression coefcient. Equation (2) can be defned as where m � 1, 2, . . . , n To fnd the log-odd ratio, the probability of each event is calculated. Te odds ratio measures the incidence when the independent variable increases by one unit. Te odds ratio is defned as Te classifcation is to predict the women in the presence of skilled birth attendants. From the calculated coefcients,    the probability of each sample is calculated. Te probability is defned as P(Y � m) � exp (g(x))/1 + exp (g(x)) while for the reference category, P(Y � 0) � 1/1+ exp (g(x)).

Results and Discussion
3.1. Univariate Analysis. Table 4 lists the baseline characteristics of urban and rural respondents. Te Dhaka division has 46.9% of the urban respondents. Te majority of women (24.3%) have a higher education and are unemployed (71.6%). 45.6% of the respondents come from the richest family. More than half of the respondents (51.2%) women gave birth to their frst child at the age of 19 or older, with the majority (59.0%) reporting ANC visits more than four times. 80.5% of respondents have had media exposure. One-third (34.4%) of the participants' husbands have secondary education in an urban area. For the rural population, most of the respondents are from the Chittagong division (22.2%). Only several respondents have higher education (14.6%) and are unemployed (59.7%). 10.1% of the respondents belong to the richest family. More than half of the respondents (59.9%) women gave birth to their frst child at 18 or below years, and most of them (48.2%) reported ANC visits more than 1-3. Majority of the respondents (60.4%) have media exposure. 35.3% participant's husbands had primary education in rural area.
In 1996-1997, the proportion of skilled birth attendants in urban and rural areas was 18.  Table 2 shows the bivariate correlation with individual characteristics for selected SBA predictors for urban and rural women. In urban areas, the majority of respondents who had experienced skilled birth are from Dhaka (73.3%) and Khulna (74.4%) divisions. Women who had skilled birth had higher education (93.5%) and were unemployed (72.3%); on the other hand, the majority of their husbands had higher education (92.3%). Women from the wealthiest families (86.7%) had more skilled births.

Bivariate Analysis.
Te majority of respondents (77.0%) went to skilled birth and had their frst child at the age of 19 or older (75.3%). Women who visited ANC more than four times (80.6%) and had media exposure (74.3%) had skilled births. Figure 2 also showed that the percentage of skilled births was higher in urban areas than in rural areas, where the following factors were highly associated, such as education level for both husband and wife and wealth index.

Discussion
Tis study identifed various socio-demographic and economic features, indicating that incorporating individual-level aspects may not be sufcient for evaluating health care services. Tis study aims to understand the impact of infuencing cases on skilled help during delivery care in urban and rural areas of Bangladesh using data from a national demographic and health survey conducted in 2017-18. Our fndings indicate that skilled birth attendance is substantially correlated with place of residence. Where skilled, birth attendance is less likely among rural residents. A similar result was found in a study conducted in India, Bangladesh, and Nepal [16]. Diferent studies in Bangladesh have also shown similar results [35,36]. Te division has a signifcant association with skilled birth attendance. Another study in Afghanistan and Kazakhstan coincides with the present study [37][38][39]. Low usage of SBAs services in some areas in Bangladesh is attributable to low-quality services, service unavailability and inaccessibility, lack of support workers, pharmaceutical shortages, equipment, and lack of support awareness. Te respondent's level of education is a signifcant determinant of skilled birth attendance and respondents with greater education are more likely to engage in skilled birth during delivery in both rural and urban. A study conducted in Bangladesh, India, and Nepal came to the same conclusion [16]. A study in Bangladesh does not coincide with this study [40]. Nevertheless, some other research showed a similar result [1,35,36,41]. Women who have received an education are often well-informed about numerous health challenges, including difculties in fnding conventional, nonscientifc, and inexpensive remedies. It makes them reconsider using the same service that their predecessors did.
Te wealth index has a signifcant association with skilled birth attendance. Women with higher economic positions in both urban and rural were more likely to hire safe delivery services when compared to those with lower economic status. Research in Nepal, India, and Afghanistan showed the same result [2,4]. Previous studies in Bangladesh have also stated similar fndings [35,36,40,42]. Te cost of SBA services is inaccessible to households in the lowest wealth quintile. Tey avoid going to hospital or using other types of healthcare since doing so would require them to forgo purchasing necessities like food and clothing. Because few skilled professionals work in Bangladesh's remote regions, SBAs prefer to assist those houses that pay them well.
Respondent's age at 1 st birth is associated with skilled birth attendance in both urban and rural areas. Other researchers have come to the same conclusion [16,26,36,43]. Many young women who had their frst child while they were teenagers may have trouble getting SBA. Tese barriers include the price of maternal healthcare services, stigma, and a poor perception of healthcare workers.
Birth order is a prominent factor where this research shows that women with the frst birth order were more anxious about using SBAs than women with other birth orders, according to the observed birth order predictors. Te similarity was found in several research studies conducted in diferent countries [16,36,44,45]. Women with 1 st or 2 nd birth order appear to be more conscious about their children and tend to attend skilled births in urban and rural. Nevertheless, as the birth order increases, their consciousness becomes lower.
According to our fndings, the expectations of using SBAs were higher in women who had more antenatal care (ANC) visits. Te increased ANC usage and SBAs among urban and rural during the recent delivery had a strong relationship, consistent with a prior study [40]. Tis might mean that ANC examinations can help respondents understand the need for experienced caregivers to deliver their babies. Previous research has revealed that professional maternity services pay more attention to ANC visits [46,47]. Tere is a higher concentration of ANC visits in these populations, indicating that they are more aware of the benefts of employing SBAs than traditional birth attendants.
Individual predictors of media access and women using high-density mass media in both urban and rural access strongly correlated with SBAs' care. A previous study established a link between media exposure and SBAs' care similarly [36,40]. One likely explanation is that after watching television, reading magazines or newspapers, or listening to the radio, people are easily encouraged to employ delivery assistance. As a result, pregnant women should be encouraged to use mass media such as television, radio, magazines, and newspapers to reach out to support of safe and professional delivery techniques.
Tis study also found a considerable infuence of the respondent profession on competent health care during delivery among urban and rural women. In both urban and rural areas, our study indicated that working women are less likely to hire skilled delivery attendants.
In this study, SBAs discovered a link between the husband's higher education and encouragement for delivery. Previous research in Bangladesh and elsewhere has found a high level of agreement between education, professional delivery support, and other maternal health treatments [35,40]. Advances in spouses' educational levels prompted the likelihood of SBAs' care. Tis may increase decision-making involvement by increasing economic independence and autonomy, intensifying health-seeking behaviour and expanding social capital via widening social interfaces. A well-educated spouse may have an educated impression of his neighbours, exposing them to those who want to be more involved in choosing the SBAs' care. 8 International Journal of Clinical Practice

Conclusions
Tis study discovered several characteristics associated with SBAs during delivery in Bangladesh. According to our fndings, certain characteristics such as age, education, husband's and respondent's education, wealth index, employment, and ANC visits have a signifcant infuence on SBAs. SBAs during pregnancy are associated with characteristics such as residency, media access, more than four ANC visits, and respondents from well-educated and wealthy families. Te fndings of the study are critical for informing the government, health planners, and other public health stakeholders in Bangladesh about how to reduce socioeconomic disparities in SBA services among underprivileged and uneducated women. Rural women may require education, knowledge, media access, and monetary assistance to increase their use of SBA services. It is also a good idea to plan awareness events around SBA-related variables. Tis could help to reduce maternal and infant mortality in Bangladesh.

Conflicts of Interest
Te authors declare that they have no conficts of interest.