Women’s Descriptions of Postpartum Health Problems: Preliminary Findings from Matlab, Bangladesh

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Women’s Descriptions of Postpartum Health Problems:Preliminary Findings from Matlab, BangladeshLynn M. Sibley, CNM, PhD, Lauren S. Blum, MPH, PhD, Nahid Kalim, MSS,Daniel Hruschka, MPH, PhD, Joyce K. Edmonds, BSN, MPH, and Marge Koblinsky, PhD

Complications of childbirth kill more than 500,000 women each year. Postpartum hemorrhage (PPH) is theleading cause of death. Because nearly half the women who give birth at home in developing countries arecared for by unskilled attendants, it is critical to understand how women and their caregivers recognizebleeding and decide to seek help when needed. Using an approach that combined systematic qualitative datacollection and multivariate analysis, we identified local cultural theories that women and traditional birthattendants in rural Bangladesh use to recognize and care for postpartum problems, including PPH. Thesepreliminary findings will be used to further explore cultural norms related to PPH and their possible modesof transmission. The overall approach may be used to develop or improve birth preparedness andcomplication readiness, a core global safe motherhood intervention. J Midwifery Womens Health 2007;52:351–360 © 2007 by the American College of Nurse-Midwives.
keywords: correspondence analysis, maternal morbidity, postpartum hemorrhage, qualitative data analysis
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NTRODUCTION

orldwide, more than 500,000 women die each yearrom complications related to childbirth, with 99% ofeaths taking place in developing countries.1 Most ma-ernal deaths (77%) occur during labor, birth, and theostpartum period, where the leading cause of death isostpartum hemorrhage (PPH).2 The estimated averagenterval from onset of bleeding to death during PPH isess than 2 hours.2–3 Almost half the women who giveirth at home are assisted by unskilled attendants, includ-ng family and traditional birth attendants (TBAs).4

nskilled attendants are not usually prepared to handlePH, yet referral rates for emergency obstetric care are

ypically low.5–6 Therefore, there is a tragic discontinuityetween onset of the problem, response time, attendantkill, and health care-seeking, which all too often resultsn maternal death.

Birth preparedness and complication readiness, a coreafe Motherhood intervention encompassing the knowl-dge, intentions, and actions that affect timely andppropriate use of emergency obstetric care, attempts toddress this mismatch.7 Birth preparedness/complicationeadiness is based on a framework that has guided Safe

otherhood programming and research for the past 15ears, the Delay Model, which proposes that delays inare may occur at three points along a “pathway tourvival”: 1) problem recognition and decisions to seekare; 2) reaching care; and 3) receiving adequateare.8–10 Effectiveness of birth preparedness/complica-ion readiness will depend upon how well predisposing,nabling, and reinforcing factors associated with each ofhese delays are addressed. Factors associated with prob-

ddress correspondence to Lynn M. Sibley, CNM, PhD, FACNM, Nell

sodgson Woodruff School of Nursing, Emory University, 1520 Cliftonoad NE, Suite 428, Atlanta, GA 30322. E-mail: [email protected]

ournal of Midwifery & Women’s Health • www.jmwh.org

2007 by the American College of Nurse-Midwivesssued by Elsevier Inc.

em recognition and decisions to seek care are especiallymportant to understand and incorporate into birth pre-aredness/complication readiness if we are to reduceaternal morbidity and mortality caused by PPH.11–13

The objectives of this inquiry were to understand theecognition of and response to PPH in Matlab, Bang-adesh, and to apply the findings to birth preparedness/omplication readiness through targeted behavior changeommunications and health worker training. The specificims were first to describe the cultural theories aboutausation and care of bleeding after childbirth and theossible modes of transmission for these cultural theo-ies, and second, to map the process of recognition andesponse to PPH, examining relationships between cul-ural theories (above) and the health beliefs and experi-nces of individual women and caregivers faced withPH. Note that we distinguish the concepts “theories”nd “beliefs” because we are interested in understandinghe system of beliefs that guide the behaviors of womennd their caregivers. Specifically, we are attempting tohow how these ideas (theories) have stable relations toach other, so that women assign similar causes andreatments to problems characterized, for example, by aever (relative to problems related to trauma). Beliefsmply a single supposition and therefore does not capturehese systemic properties. In this article, we present thepproach and preliminary findings that will allow us toddress the first aim: women’s descriptions of postpar-um health problems.

ETHOD

he study was implemented in Bangladesh for twoeasons: while maternal mortality has declined to 322aternal deaths per 100,000 live births,14 PPH remains aajor cause of death; and the International Center foriarrheal Disease Research is uniquely positioned to

upport field research. The center has an extensive

351

1526-9523/07/$32.00 • doi:10.1016/j.jmwh.2007.02.020

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emographic and health surveillance system, in placeince 1966, at both community and facility levels, for aural population of about 220,000.15 The site selected forhis study is the Matlab Health Research Center servicerea, located 56 kilometers southwest of the capitalhaka, where an extensive maternal, child health, and

amily planning program has been operating to comple-ent the government’s services since 1978. The rural

opulation is predominantly Muslim. After marriage,oung women typically leave their natal family andove into the husband’s parental home. The area is poor,

nd the main economic activities are farming and fishing.he service area has four subcenters that provide 24-hourervices by paramedical staff. The subcenters and fieldctivities are supported by the hospital at Matlab Town-hip. About 2700 births take place each year, of which8% occur in a health facility.15

The study protocol was approved by Emory University’snstitutional Review Board as the International Center foriarrheal Disease Research’s Ethical Review Committee.erbal voluntary informed consent was obtained from all

ubjects following standard disclosure procedures.To ensure the breadth and depth of terms and concepts,

e obtained a sample of 20 informants from each of theollowing groups (N � 80): 1) women of reproductivege who gave birth in 2005; 2) women between the agesf 50 and 70 years who lived in an extended familyetting, which is potentially influential regarding child-irth; 3) TBAs; and 4) skilled birth attendants (SBAs)ho staff the subcenters and Matlab Township hospital.

nformants were identified through the International Cen-er for Diarrheal Disease Research’s health and demo-raphic surveillance system and lists of TBAs and SBAs.articipants were selected randomly from these lists.ample size was determined assuming a low level ofultural sharing (.50) and a high degree of accuracy (.95)nd confidence (.95).16–18

We developed a semi-structured questionnaire to elicitocal words and short phrases associated with postpartum

ynn M. Sibley, CNM, PhD, FACNM, is Associate Professor, Lillianarter Center for International Nursing and Director, Center for Researchn Maternal and Newborn Survival, Nell Hodgson Woodruff School ofursing, Emory University, Atlanta, GA.

auren S. Blum, MPH, PhD, is a Consultant, International Center foriarrheal Disease Research: Center for Health and Population Research,haka, Bangladesh.

ahid Kalim Kanti, MSS, is Senior Research Officer, International Centeror Diarrheal Disease Research: Center for Health and Population Re-earch, Dhaka, Bangladesh.

aniel Hruschka, MPH, PhD, is Post Doctoral Fellow, Santa Fe Institute,anta Fe, New Mexico.

oyce K. Edmonds, BSN, MPH, is a Doctoral Fellow, Center for Researchn Maternal and Newborn Survival, Nell Hodgson Woodruff School ofursing, Emory University, Atlanta, GA.

arge Koblinsky, PhD, is Director, Public Health Services Division,

pnternational Center for Diarrheal Disease Research: Center for Health andopulation Research, Dhaka, Bangladesh.

52

onditions, generally, as well as those associated withleeding, specifically.19–21 The questionnaire consistedf open-ended questions eliciting women’s spontaneousesponses. First, informants were asked to name all of theigns of a woman who has no problem from birth to 14ays postpartum. For each sign mentioned, they weresked about causes, kinds of care given, and conse-uences to the woman if no care is given. This line ofuestioning, called successive free-listing, was repeatedor a woman who may have a problem and one whoefinitely has a problem. Secondly, the same line ofuestioning was repeated for bleeding from birth to4-hours postpartum, except for the question about aoman who may have a problem, because the informantsere unable to describe such a woman in relation toleeding during the pretesting phase. The questionnaire,hich also included questions to elicit standard demo-raphic and social information as well as experience withhildbirth, was translated/back-translated, pretested, andevised before use.

Three trained bilingual interviewers conducted andudio tape–recorded the face-to-face interviews in theocal language, Bangla. Each interview, conducted at aime and place convenient for the informant, took ap-roximately 45 minutes. Interviewers recorded verbatimesponses directly on the questionnaire form and clarifiedmbiguities before concluding the interview. Afterward,hey listened to the entire tape-recorded interview, veri-ying responses against the completed form. Verifieduestionnaires were translated into English directly inton identical electronic version of the questionnaire.

We entered demographic and social data into SPSSor Windows (Version 13.0; SPSS Inc., Chicago, IL)nd described these using simple statistics. In thisrticle, we focus on the conditions, signs, causes, andare practices that would be observed and inferredefore seeking assistance outside the home, so theollowing analyses excludes the SBA group and fo-uses on the participants who would be most involvedn the care giving and decision-making processes inhe home. Analyzing the data involved identifyingrequently listed and theoretically relevant postpartumroblems and related features (i.e., signs, causes, andare practices). To identify the set of problems andeatures, we first reduced the informants’ descriptionso common words and phrases through a codingrocess using the qualitative data management pro-ram Atlas/ti (Version 5.0; Scientific Software Devel-pment, GmBH Berlin, Germany) and examined codesith high interrater agreement (kappa � 0.8).22 We

nalyzed all problems that were listed by at least 20%f informants or were of theoretical interest and allelated signs, causes, and care practices that wereisted in at least 20% of descriptions for at least one
roblem.21 This approach yields the most common and
Volume 52, No. 4, July/August 2007

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heoretically relevant kinds of problems and theireatures.

We summarized the data in frequency tables of prob-ems by related features: one table for postpartum prob-ems, generally, and another for bleeding, specifically.hese tables provide valuable information about theo-occurrence of specific problems, signs, causes, andare practices. Because tables containing raw frequenciesan be difficult to interpret, we used an exploratoryechnique, correspondence analysis, to visually representhe patterns of co-occurrence described in the tables.21

orrespondence analysis23 does this by creating a two-imensional graph of the co-occurrence of problems,igns, causes, and care practices, in which the proximityetween items in the graph reflects the relative co-ccurrence of items in informants’ descriptions. Forxample, if the informants frequently describe trauma tohe birth area as a cause of severe bleeding, these itemsill appear close together in the graph. Moreover, if theyescribe similar sets of signs, causes, and care practicesor two different problems (e.g., too little bleeding andevere abdominal pain) these will also appear close toach other. We conducted the correspondence analysessing SAS for Windows (Version 9.1.3; SAS Institurenc., Cary, NC), where each row in the table represented

unique description and each column counted theccurrence of a particular sign, cause, and care practicen that description (an occurrence counting as 1, other-ise 0). Because descriptions of a particular problemay differ in terms of related signs, causes, and care

ractices, we included a 95% confidence ellipse for eachroblem, reflecting the degree of certainty that theverage description of the problem falls in a particularegion of the graph.

Any attempt at cross-cultural translation and interpre-ation raises concerns about the validity and meaningful-ess of one’s final results. The study took steps at manytages, including questionnaire construction, interviewerraining, transcription, translation, coding, and analysis,o ensure that the final results accurately reflected partic-pants’ descriptions of postpartum problems. An impor-ant part of the quality control process was the involve-ent in the research team of native Bangla speakers who

re fluent in English as a second language. Translationnd transcription occurred directly after the interviews ondaily basis. As a result, we were able to discuss any

uestions about the meaning of particular local terms andhrases, as needed, and we developed a glossary tomprove consistency in translation and coding. Thislossary was discussed with several local women’sealth care providers and further refined, as needed.oreover, the coding process involved regular discus-

ions between independent coders and the research teamf native Bangla speakers to ensure the meaningfulnessnd reliable assignment of particular codes. The coding
rocess also involved intercoder reliability checks. l

ESULTS

haracteristics of Informants

lmost all of the informants were women, parity 1 to 3,arried, and Muslim with no formal education or no

rimary education beyond the fifth year. While theyanged, by research design, from 18 to 70 years of age, theverage age was 46 years. Women of reproductive age wereaturally younger, of lower parity, and reported receivingore formal education than the TBAs and elder influentialomen. Asset scoring indicates that the TBAs showedreater variability in wealth than did other participants, withbimodal distribution of wealthy and poor TBAs. Most of

he TBAs had attended 10 or fewer births in the previousear, although some were more active (Table 1).

escriptions of A Woman Who Has No Problem and Whoay Have A Problem

nformants described “no postpartum problem” using aumber of nonspecific indicators, such as a woman whoan move around easily and can feed her baby (80%), hasgood appetite (70%), and looks and feels good (48%).are practices mentioned included giving the womanproper” healthy foods (82%); applying hot fomentationr a warm compress to the abdomen, lower back, or birthrea to dry or cure this area (50%); keeping the birth arealean (47%); giving the woman hot foods and fluids toarm the body (47%); advising her to restrict daily

hores (40%); to restrict strenuous activity (35%); toeep warm (32%); and giving foods that dry or cure theody (21%). Descriptions of normal postpartum bleedingncluded these same signs and care practices at substan-ial frequencies (�20%).

There were 61 descriptions of a woman who may haveproblem. The associated signs were also nonspecific,

uch as not being able to move the body or feed her baby51%); feeling and looking ill (31%); appetite loss41%); and feeling weak (30%). The only commonly-ited causes were diet related (38%), and care practicesentioned were watchful waiting (40%); giving proper

ealthy food (33%); and medicines (28%). Most of theseescriptions (64%) did not provide sufficient detail to belassified as a particular kind of problem. The remainingescriptions for a woman who may have a problem wereniformly distributed at very low frequencies (�20%)cross a wide range of common conditions, includingaving a cold with fever, bleeding, trauma to the birthrea, diarrhea, constipation, vitamin deficiency, jaundice,nd gastritis.

escriptions of A Woman Who Definitely HasPostpartum Problem

total of 143 descriptions reflecting seven problemsccurring in the postpartum period were mentioned by at
east 20% of the women. The frequency and order of
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hese problems suggests that cold-fever/jor (45%); toouch or severe bleeding/beshi rokto gele (42%); womb

alls out/paidul ber hoy (38%); and trauma to the birthrea/chire (37%) are of greatest salience to the women,ollowed by diarrhea/laminya sutika (23%); severe ab-ominal pain/adhlar kamar (22%); and a complex ofigns described as tonkor or tetanus (22%). Anotherroblem, khichuni or shaking/convulsions (10%), is in-luded because of the possible association with eclamp-ia. Except for cold-fever and severe abdominal pain/dhlar kamar, these problems are thought to beotentially deadly if left untreated. These problems are

Table 1. Demographic and Social Characteristics of Informants

Characteristic

TBA (n � 20)

n %

ge (y)�20 0 —21–30 1 5.031–40 4 20.0�40 15 75.0

enderFemale 20 100.0Male 0 0.0

arity0 0 —1–3 5 25.04–6 7 35.0�6 8 40.0

ducationNever attended 14 70.0Primary (grades 1–5) 6 30.0Secondary (6–10) 0 —Secondary (11–12) 0 —Graduate (�12) 0 —

arital statusMarried 12 60.0Widowed 8 40.0Never married 0 0.0

eligious preferenceHindu 3 15.0Muslim 17 85.0

ocioeconomic status by quintile*1st 8 40.02nd 0 0.03rd 3 15.04th 3 15.05th 6 30.0

umber of births attended previous year0–10 14 70.011–20 2 10.021–30 2 10.031–40 1 5.041–50 0 —51–60 0 —�61 1 5.0

IW � elder influential woman; TBA � traditional birth attendant; WRA � woman

Socioeconomic status based on asset scoring, calculated using the World Bank sc

riefly described below. a

54

auses and Care Practices for a Woman Who Definitely HasPostpartum Problem

old-fever/jor was characterized by informants asever, cough, inability to move the body (lethargy),oor appetite, and severe body pain; caused by touch-ng cold things (e.g., water) and improper diet (e.g.,ating or drinking cold foods or fluids); and treatedith medicine/fever medicine, applying cold to theody (e.g., wet cloths), watchful waiting, keeping theoman warm, giving healthy foods/fluids that warm

he body. Care is sought from both the untrained

RA (n � 20) EIW (n � 20) Total (n � 60)

% n % n %

15.0 0 — 3 5.050.0 0 — 11 18.330.0 0 — 10 16.75.0 20 100.0 36 60.0

100.0 20 100.0 60 100.0— 0 — 0 0.0

— 0 — 0 0.085.0 1 5.0 23 38.310.0 7 35.0 16 26.75.0 12 60.0 21 35.0

15.0 17 85.0 34 56.740.0 3 15.0 17 28.340.0 0 — 8 13.35.0 0 — 1 1.7

— 0 — 0 0.0

100.0 2 10.0 34 56.7— 18 90.0 26 43.3— 0 — 0 0.0

15.0 4 20.0 10 16.785.0 16 80.0 50 83.3

15.0 2 10.0 13 21.725.0 6 30.0 11 18.315.0 6 30.0 12 20.025.0 4 20.0 12 20.020.0 2 10.0 12 20.0

N/A N/A N/A N/A N/A

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odern medicines, and also the trained allopathicoctor.Too much/severe bleeding/beshi rokto gele is associ-

ted with extreme weakness, inability to move the bodyr lethargy, dizziness, and pale/whitish skin color;aused by too much activity; and treated with medicine/ablet to stop bleeding, giving healthy foods, watchfulaiting, hot fomentation, as well as giving saline and

piritual treatments (e.g., an amulet, blessing, and/orrayer). Care is sought mainly from a trained allopathicoctor, but also the village doctor and the kobiraj, orpiritual healer.

Womb falls out/paidul ber hoy is caused by too muchctivity and bearing down (e.g., by pushing duringelivery, coughing, or speaking too loudly); and treatedith hot fomentation, surgery (e.g., cutting and removing

he uterus), as well as spiritual treatments, herbal reme-ies, and watchfulness. Care is sought mostly from therained allopathic doctor and sometimes the kobiraj.

Trauma to the birth area/chire is associated withearing, pain, and swelling in the birth area; caused byrauma during birth (e.g., mishandling the delivery by theirth attendant or a big baby); and treated with hotomentation, medicines, keeping the birthing area clean,atchfulness, healthy foods, and sometimes stitching the

orn area. Care is sought mainly from the trained allo-athic doctor but also village doctor.Diarrhea/laminya sutika is associated with weight loss,

oor appetite, and weakness; caused by improper dietnd evil spirits or alga; and treated with herbal remedies,piritual treatments, watchfulness, saline, diarrhea med-cines, and healthy foods. Care is sought from theobiraj, village doctor, and trained allopathic doctor.

Severe abdominal pain/adhlar kamar is associatedith blood clotted in the womb; is caused by something

biting” the inside of the womb; and treated with variousptions including a tablet/medicine for pain, hot fomen-ation to break up the clots, herbal remedies and healthyoods, spiritual treatments (as above), and watchfulaiting. Care is sought mainly from the village doctor ifeeded (this problem is considered self-limiting, to lastess than a week, to become increasingly severe withubsequent pregnancies).

Tetanus/tonkor is associated with twisted limbs orramping, as well as trembling, shaking, or shivering;aused by touching cold things, trauma to the birth area,ailure to give hot fomentation, and improper diet; treatedith hot fomentation, applying cold to the body (e.g., wet

loth), oil and herb/garlic massage, injections, keepinghe woman warm, and watchfulness. Care is soughtainly from the trained allopathic doctor but also the

illage doctor.Shaking or convulsions/khichuni is characterized by

wisted limbs and trembling, shaking, or shivering. Otherigns include fever, faintness, or unconsciousness; lock-
aw; and “acting crazy” (delirium). It is treated with o

assage and injections and care is sought from theillage doctor.Correspondence analysis allows us to see the relation-

hips among signs, causes, and care practices for theseroblems. Figure 1 demonstrates this process using theymptoms of two conditions—khichuni and tonkor/teta-us. The nearly complete overlap of the 95% confidencellipses for khichuni and tonkor/tetanus suggests thathese two problems reflect similar illness categories withommon signs, causes, and care practices. Both areharacterized by trembling and shaking, “twisted limbs,”nd to a lesser extent, being faint and unconscious,aving lockjaw, and “acting or talking crazy.” Infor-ants also describe massage and treatment with injection

s relatively unique treatments for these two problems.Correspondence analysis of eight general postpartum

onditions reveals differentiation into five broad kindsf problems: 1) fever-related (jor, tonkor, khichuni);) bleeding-related (beshi rokto gele, adhlar kamar);) diarrhea-related (laminya sutika); 4) womb falls out orrolapsed uterus (paidul ber hoy); and 5) trauma to theirth area (chire). It also shows that spiritual treatmentsnd seeking a kobiraj, or spiritual healer, are not associ-ted with any problem in particular, but rather, with aariety of bleeding problems including diarrhea as wells prolapsed uterus.

escriptions of A Woman Who Definitely HasBleeding Problem

ll informants were asked about bleeding in greateretail. A total of 87 descriptions reflecting three prob-ems: too much/severe bleeding/beshi rokto gele, tooittle bleeding, and severe abdominal pain/adhlar kamarere mentioned (Table 2).Too much/severe bleeding/beshi rokto gele is charac-

erized further as continuous, fast, and/or forceful, withelated signs including faintness/falling unconscious. In-ormants described the bleeding in a number of ways. Forxample:

The woman’s body becomes blue (nila hoiya jay)from continuous bleeding. The blood goes out in acontinuous, swift flow or gush (dhala dhala), itoverflows the place. Two or three jute-made bags(chala-chula) will not control or stop the blood.The [woman’s] clothing gets soaked within a veryshort time. She [the woman] must change clothingfrequently.

When bleeding is severe, it comes out withforce, gushing like water comes from a tube well(koltaya rokto ber hoy).

Participants quantified severe bleeding in a variety ofays, including measures such as kilograms, sheer (a

ocal measure of weight), liters, as well as counts of
bjects filled or soaked, such as pads, clothes, buckets,
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ute mats, and saris. While some informants mentionedvil spirits or alga as causes, many did not know theause of severe bleeding. The only risk factor commonlyescribed was that some women, such as larger women,ave more blood than others because of better nutrition,nd that they are likely to bleed more. Care practicesnclude giving medicine/tablets, healthy foods, hot fo-entation, injections, and saline; care is sought from

oth village and trained allopathic doctors, as described.Too little bleeding/rokto na jay on the other hand, is

ssociated with signs of severe abdominal pain and bloodlotted in the womb. Informants attributed this problemo the blood clot, like a “hard ball” in the womb, or theyid not know the cause. This problem is treated withedicine and hot fomentation and healthy foods; care is

ought from both village and trained allopathic doctors.Severe abdominal pain/adhlar kamar, mentioned only

y five informants in relation to bleeding, is includedecause it shares characteristics with too little bleeding:evere abdominal pain (always) and blood clotted in theomb. The cause, however, was given as something

igure 1. Correspondence analysis of signs, causes, and care practices fthe relative location of signs, causes, and care practices (smalllocations of conditions (larger font). Bangla terms can be tranbleeding); Laminya sutika (Diarrhea); Paidul ber hoy (Womb falls(Shaking or Convulsions); Tonkor (Tetanus); and Jor (Cold-Fevcorrespondence analysis and represent important axes of differ

iting the inside of the womb (described above). It is a

56

reated with medicine/tablets, hot fomentation, and spir-tual treatments, and care is sought from both the villagend trained allopathic doctors. One TBA provided nar-ative presumed to describe this condition:

There is bite of adhlar kamar . . . . There is astory that one evil spirit wants to eat the babywhen it is in the ovum and other gods want thechild to be born alive. They help the baby to beborn. Then [when] the evil spirit comes and seesthat the baby is not inside . . . and bites there. InBangla we say adhlar kamar. There is pain . . . itis severe pain. It happens just after delivery.

Severe bleeding was mentioned by all but one infor-ant; too little bleeding was mentioned less often (by

0% of women of reproductive age, 25% of eldernfluential women, and 30% of TBAs), while severebdominal pain/adhlar kamar was mentioned infre-uently and almost exclusively by women of reproduc-ive age (20%).

Correspondence analysis allows us to see the relations

general postpartum conditions. The points (labeled in English) represent. Ellipses (labeled in Bangla) represent 95% confidence intervals for meanas follows: Beshi rokto gele (Too much bleeding); Rokto na jay (Too littleire (Trauma to birth area); Adhlar kamar (Severe abdominal pain); Khichuniensions 1 and 2 are the first and second dimensions derived from then among conditions, signs, causes, and care practices.

or eighter font)slatedout); Ch

mong these bleeding problems (Figure 2). First, it


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hows a finer-grained distinction between severe abdom-nal pain/adhlar kamar and severe bleeding/beshi roktoele than reflected in Figure 1. Severe abdominal pain/dhlar kamar is more closely associated with too littleleeding/rokto na jay than with severe bleeding/beshiokto gele. Moreover, we see, as in Figure 1, thatreatments such as an amulet, blessings, or prayer are notssociated with a particular condition, but are actuallyentioned for both severe bleeding and severe abdomi-

al pain/adhlar kamar, and constitute a set of descrip-ions focused on spiritual causes or alga.

There were a total of 63 descriptions of severe bleed-ng; 21 descriptions for each of the three groups, withignificant differences between the groups in care seek-ng advice for severe bleeding (�2 tests; P � .05). TBAsere more likely to describe seeking a trained allopathicoctor (81% of descriptions), followed by women ofeproductive age (67%), and elder influential women38%). Conversely, elder influential women (67% ofescriptions) and women of reproductive age (57%) wereore likely to describe seeking a village doctor than were

Table 2. Frequency and Percentage of Mention of Signs, Causes, and T

Beshi rokto gele(n � 63)*

n %

leeding signs†

Continuous bleeding 25 39.7Fast, forceful bleeding 18 28.6

elated signsCan’t move body 32 50.8Extreme weakness 31 49.2Fainting, falling unconscious 18 28.6Pale, whitish skin 16 25.4Severe pain — —Blood clotted in uterus — —

ausesDon’t know 23 43.4Evil spirits (alga) 13 20.6Clot in uterus — —Adhlar bites — —

are practicesMedicine 34 54.0Treat with tablet 23 36.5Fomentation 15 23.8Give healthy foods 19 30.2Treat with injection 15 23.8Give saline 13 20.6Spiritual treatment 9 14.3

are seekingSeek trained doctor 38 60.3Seek village doctor 32 50.8Seek kobiraj 7 11.1

dhlar kamar/adhlar bites � severe abdominal pain (cramping); beshi rokto gele �

One woman did not describe excessive bleeding and 4 gave two distinct descripti

Bleeding signs mentioned in free-list description (not in explicit questions about b

BAs (29%). Though only marginally significant, the t


lder influential women were also more likely to suggesteeking a spiritual healer or kobiraj (24%) than werenformants from the other categories (5%); moreover,hey were more likely to attribute severe bleeding topiritual causes (33%), compared with TBAs (22%) andomen of reproductive age (5%).

ISCUSSION AND CONCLUSION

n this study, we combined systematic qualitative dataollection with multivariate analysis to identify localheories about postpartum problems, including bleeding.hrough successive free listing and correspondence anal-sis, we were able to identify locally salient postpartumroblems, including bleeding, and their related signs,auses, and care practices.

The problems mentioned by at least 20% of womenuggest a variety of morbid postpartum conditions thatould be targeted by care providers. Three are of concernnd require further investigation: prolapsed uterus (i.e.,rolapsed uterus, cystocele, or unrepaired vaginal tear) and

ts for Three Postpartum Bleeding Problems

o na jay� 19)

Adhlar kamar(n � 5)

Total(n � 87)

% n % n %

— — — 25 28.7— — — 18 20.7

5.3 — — 33 37.9— — — 31 35.6— — — 18 20.7— — — 16 18.3

52.6 5 100 15 17.236.8 2 40.0 9 10.3

26.3 1 20.0 29 33.310.5 — — 15 17.242.1 1 20.0 9 10.315.8 3 60.0 6 6.9

52.6 4 80.0 48 55.215.8 3 60.0 29 33.347.3 3 60.0 27 31.021.1 — — 23 26.45.3 — — 16 18.45.3 — — 14 16.15.3 1 20.0 11 12.6

42.1 3 60.0 49 56.342.1 3 60.0 43 49.410.5 1 20.0 10 11.5

ch, severe bleeding; kobiraj � traditional healer; rokto na jay � too little bleeding.

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otential impact on women’s gynecologic health and qual-ty of life; and the complex of signs called tetanus/tonkornd khichuni, which may be associated with eclampsia, anmportant cause of maternal death in Bangladesh.14

Surprisingly, less than half of informants (42%) spon-aneously mentioned severe bleeding as a problem.escriptions of a woman who has no problem wereonspecific and informants were unable to describe aoman who may have a problem. They had no difficulty,owever, describing a woman who definitely has aroblem. Signs of too little bleeding, and the closely-elated severe abdominal pain/adhlar kamar suggest theiologic phenomenon of afterbirth pains. Signs of severeleeding, both quality and quantity, were vividly ex-ressed through metaphor and/or a wide variety of (and

igure 2. Correspondence analysis of signs, causes and care practicescauses, and care practices in the lower left quadrant of gFaint/unconscious, Continuous bleeding, Fast/forceful bleeding,village doctor, and Seek trained doctor. Points (labeled in EngliEllipses (labeled in Bangla) represent 95% confidence intervalfollows: Beshi rokto gele (Too much bleeding), Rokto na jay (To2 are the first and second dimensions derived from the corresposigns, causes, and care practices.

idely varying) measures and counts. Causes of severe b

58

leeding, however, were largely unknown, though someomen attributed bleeding to too much activity, and stillthers, mostly elder influential women, to spirits or alga.oreover, the most commonly cited care practices were

eneral (e.g., healthy foods and hot fomentation). Fi-ally, women with different roles in postpartum homeare showed marked differences in their approach to careeeking for excessive postpartum bleeding. TBAs andomen of reproductive age were more likely than elder

nfluential women to mention that care is sought from arained allopathic doctor, while elder influential womenere more likely to mention the village doctor or kobiraj

spiritual healer). Together, the findings suggest that PPHs not well differentiated in terms of causes or careractices, irrespective of women’s experience with child-

e postpartum bleeding problems. *Because of the high density of signs,abels for these points are listed here: Feels weak, Can’t move body,h skin, Give saline, Give injection, Give proper foods, Give medicine, Seekesent relative location of signs, causes, and care practices (smaller font).ean locations of conditions (larger font). Bangla terms are translated asbleeding), and Adhlar kamar (Severe abdominal pain). Dimensions 1 andanalysis and represent important axes of differentiation among conditions,

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Possible implications that these initial findings have inegard to birth preparedness/complication readiness inhe Matlab area include the following: 1) many womeno not spontaneously think of PPH as a common prob-em; 2) although the range of signs and symptoms citedoints to difficulties in defining PPH, the way thatleeding was characterized indicates perceived serious-ess (when recognized); 3) perceptions of risk suggesthat larger, healthier women are at greater risk for PPH,hich, in this context where more than 50% of women

re malnourished, implies that many women may not feelhat they are at risk or need to prepare or plan for PPH;) general descriptions of care practices, similar to careractices for too little bleeding, suggest the use ofemedies at home before seeking care with a professionalealth provider. While there appears to be a range oferspectives elicited on care-seeking, elder influentialomen who play a primary role in decision making forbstetric care are more likely than other respondents topt for sources of care ill-equipped to deal with PPH.hese differences observed between the participantroups should be interpreted cautiously in the light of themall sample sizes for each group (n � 20). In the secondhase of this study, we will conduct structured interviewssing a questionnaire that will be developed using theerms and concepts obtained from the initial free lists asescribed in this article. This will permit a more detailedormal analysis of the similarities and differences inarticipant’s theories based on their care-giving role.Our next step is to answer the following questions: Is

here a shared set of cultural theories with regard toleeding? What is the degree of sharing and how is thisnowledge best summarized, that is, what is shared, whats not? From whom do women acquire their knowledgebout what constitutes normal and abnormal bleeding:rom their mothers, neighboring women, their TBAs? Inddition, we will map the process of recognition andesponse to PPH, examining relationships between cul-ural theories, individual health beliefs, and experiencesf women and caregivers faced with PPH.We will integrate the final study results into birth

reparedness/complication readiness through health ed-cation consisting of locally appropriate messages thatre targeted to those who are the main channels ofultural knowledge (e.g., elder influential women orBAs versus the general population) as well as healthorker training that includes earliest relevant “cues to

ction,” with the aim of contributing to more timelyecognition and initial response to PPH. We will subse-uently apply the approach to improve birth prepared-ess/complication readiness in relation to other difficulto recognize conditions that cause significant morbiditynd mortality in the study area, specifically, prolongedabor and birth asphyxia. We believe others may applyhe approach used in this study either to develop or refine
his core global safe motherhood intervention in any 2

etting characterized by homebirth with unskilled atten-ants.

We would like to thank Gery Ryan, Clarence Gravlee, and Joe Henrich fortheir generous advice in applying the study methods to the problem ofpostpartum hemorrhage, and Roslin Botlero, Jasmin Khan, Moni Paul, andM. D. Mohitush Sami for their contributions to implementation. The studyis a collaboration between the Center for Research on Maternal andNewborn Survival, Emory University, and the International Center forDiarrheal Disease Research: Center for Health and Population Research,funded through the Woodruff Health Sciences Center Foundation grant tothe Center for Research on Maternal and Newborn Survival, Nell HodgsonWoodruff School of Nursing, Emory University. The views expressed by thenamed authors are solely the responsibility of the authors and in no wayreflect the official opinion of the funding body.

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NOTICE

CALL FOR MANUSCRIPTS

The Journal of Midwifery & Women’s Health is soliciting manuscripts for a themeCEU issue titled “The Effects of Violence and Trauma on Women’s Health.” Weinvite submissions that address the health effects of violence and/or trauma.Submissions will be considered if received by November 2007.

Direct queries to JMWH at [email protected] or to Janice Humphreys, RN, PhD, GuestEditor, Associate Professor Dept. of Family Health Care Nursing, School of Nursing,University of California at San Francisco at [email protected]


Women’s Descriptions of Postpartum Health Problems: Preliminary Findings from Matlab, Bangladesh

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