The demographic, socioeconomic, and geographic characteristics of the ten husbands whose youngest child was delivered by a skilled birth attendant (doctor, nurse, midwife, or CSBA) were compared to the characteristics of the ten husbands whose youngest child was delivered by an untrained dhatri (Table ). Due to the small sample size, tests for statistical significance across the groups are not very informative, so they are not presented. We display the raw count data and make general observations about differences across the two groups. A larger proportion of households using a skilled birth attendant had only one child and these households appeared to have a higher monthly income per family member compared to households that used an untrained dhatri. The higher monthly income per family member may simply be a reflection of the smaller family size among households using a skilled birth attendant.
Sociodemographic characteristics of men interviewed (n = 20)
Each husband's interview was coded in two ways: (1) themes that were similar across all respondents, or common themes, and (2) themes that differed according to the type of provider utilized during childbirth, or divergent themes. We first present three common themes, or barriers, related to delivery care before presenting the underlying, divergent factors related to delivery care, including husbands' provision of social support and perception of social norms related to childbirth.
The interviews with husbands revealed a number of common themes related to the decision about whether or not to seek professional delivery care. Each theme was found in each of the interviews, irrespective of the type of provider.
Each household in the sample was at least five kilometers away from the nearest health facility equipped to perform deliveries. The condition of roads and availability and cost of local transportation were mentioned as barriers to hospital-based deliveries. There are only 18 kilometers of pucca roads (good quality, black-topped roads) in all of Durgapur. The remaining roads are dirt, which turn into mud during the rainy season. Nine husbands mentioned the condition of the roads as a major barrier to using health facilities.
Everything depends on transportation. People don't go [to the hospital] very often since they need to hire three to four boats [to cross the rivers]. Also, the condition of the road is very poor. If the pregnant woman travels by rickshaw or motorcycle or push car, then she may get hurt and face more problems. - 26-year old husband, CSBA home delivery
Local transportation is often perceived as too expensive and hard to find. Types of transportation available in Durgapur include (from most to least expensive) the tempo (a small three-wheeled motorized vehicle), motorcycle, boat, rickshaw, push cart, and walking. Many families need to use more than one form of transportation when traveling to the hospital, especially during the rainy season.
Lack of money
Another major barrier to utilizing professional health services are direct costs--such as the cost of transportation, medicine, and hospital fees--and indirect costs--such as opportunity costs related to leaving household responsibilities and taking time away from work. The costs associated with the utilization of professional delivery care are often equated to the cost of selling one's land or forfeiting one's livelihood.
It's a money matter. [People in our village] can't go [to the hospital] due to the scarcity of money. So if we can solve it in the village, if Allah wants it like this, we don't need to go. So we delay the matter and observe the [birthing] situation. Then, if the problem is serious, we go to the clinic. But it's almost like solving the problem by selling your land. - 43-year old husband, dhatri home delivery
The danger of childbirth
The perception that one is not susceptible to complications during childbirth could act as a barrier to the utilization of professional delivery care, but childbirth was perceived as risky by all of the husbands interviewed. Most agreed that complications could arise during delivery, but this belief did not always lead to the utilization of a skilled birth attendant during delivery.
Definitely [childbirth] is dangerous. After conceiving a baby it becomes dangerous. There is tension that anything can happen at any time. There is tension about whether the baby will be born healthy or not. - 25-year old husband, hospital delivery
To me, it is a risky thing.... Both mother and child can die. Sometimes it is seen that the baby dies and the mother is alive. Again, it is seen that the mother dies and the baby is alive. If it is normally done, then it is done. But, if not then there is a lot of suffering. - 28-year old husband, dhatri home delivery
Divergent themes: social support and perceived social norms
There were many themes identified through the open coding process that provided insight into the unique role of husbands during childbirth, in addition to the themes above that showed similarity across respondents. However, our goal was to focus on themes that (1) differed between husbands whose wives utilized a skilled birth attendant and those whose wives utilized an untrained dhatri, and (2) were grounded in sociological and psychosocial theories related to health care utilization. The two themes that met these two criteria were social support during labor and delivery and perceived social norms related to delivery.
Social support is the term used to describe the functional content of social relationships. Social support differs from other functions of social relationships because it is consciously provided by the sender and is intended to be helpful to the receiver. This distinguishes it from other forms of social influence that are intentionally negative or passively experienced by the receiver. Social support often attempts to influence the behaviors of the receiver in a caring, trusting, and respectful context [27
]. Social support can be categorized into four broad types of supportive behaviors: emotional support, instrumental support, informational support, and appraisal support. We draw upon the first three categories of social support--emotional, instrumental, and informational--to describe the type of support provided by husbands to their wives during childbirth. However, there were also situations where the husband did not provide any of these types of support to his wife during the labor and delivery period.
Emotional support involves the provision of empathy, love, trust and caring [27
]. However, in order for emotional support to have a positive influence it must be perceived as helpful by the recipient [28
]. The majority of husbands whose wives utilized professional delivery care exhibited some level of emotional involvement with their wives during pregnancy and childbirth. However, a husband's emotional involvement was not always perceived as supportive by his wife. Therefore, we will refer to this theme as emotional involvement. Emotional involvement was often found in the form of prayer, which is a way of expressing love or caring when the husband is not physically present. However, emotional stress, such as worry and tension, was also coded as emotional involvement. A husband's stress during labor and delivery showed a level of emotional investment that often led to other supportive behaviors. The tension and worry usually arose from the husband's perception that his wife was at risk for a complication during delivery or a previous experience with the death of a child or family member during delivery.
In my mind I felt there were some problems. I was worried. I thought I should go [to see her] earlier. I wanted to observe what happened. I could be present on the spot. I am her husband and she is my wife. That is why I was interested to come [home] early; otherwise I would come the next morning. - 26-year old husband, CSBA home delivery
How could I sleep! The light was on and I was awake for the whole night.... At first I was not thinking about the hospital, but later, when I was tense, I took her [to the hospital] the next day. - 35-year old husband, hospital delivery
Instrumental support involves the provision of tangible assistance that directly helps a person in need [27
]. Husbands whose wives utilized professional delivery care, and those that utilized an untrained dhatri
, each provided some level of instrumental support. However, the type of instrumental support differed depending on whether the delivery took place in a hospital or at home. In all cases the husband typically provided instrumental support to his wife once she started the first stage of labor. Husbands whose wives delivered at a hospital often arranged transportation and collected money for the hospital fees. Husbands whose wives delivered at home provided support by calling the birth attendant or going to the birth attendant's home to inform her of the impending delivery. Husbands whose wives delivered at home often knew the birth attendant personally (i.e., she was a family member or an acquaintance from the village).
Yes, I called. I went there to call chachi (father's brother's wife) saying, 'Chachi, I have a problem. The placenta is not removed.' Then she asked, 'Why? What is the problem? Was there not any dhatri in your home? No dhatri?' I said that the dhatri was there and [she] asked [me] to bring you here. Then she said, 'You go, I am coming.' When I saw that she was late, then I went to her again. - 31-year old husband, CSBA home delivery
Some husbands were able to arrange resources to pay for the transportation and hospital fees. Although public hospitals are free of charge, the majority of the respondents preferred the private fee-for-service health facilities. There were two exceptional cases where a husband saved money to pay for an ambulance and where a husband used his land as collateral to repay a loan for hospital fees. Typically, the husband collected money from neighbors and relatives during the first stage of labor.
Husbands whose wives needed to travel to the hospital for delivery were also involved in coordinating or providing the transportation.
She has a younger brother. Though we rented a thelagari (push car), her brother and I pulled it to take her to the hospital. We admitted her in the hospital and I was there all the time. - 31-year old husband, hospital delivery
Additionally, husbands prepared food for their wives and other visitors as well as purchased medicine for their wives.
I explained the whole situation [to the village doctor] that my wife could not deliver the baby in spite of severe pain. Then he suggested some medicine and I brought the medicine for her. - 32-year old husband, dhatri home delivery
Informational support involves the provision of advice and suggestions that a person can use to address a problem [27
]. Informational support was typically provided by husbands whose wives utilized professional delivery care at home or at the hospital. In our context, informational support refers to the active provision of information from the husband to his wife. The husband provided his opinion about the type of provider his wife should use during delivery and in some cases he made the final decision about the type of provider. Some husbands in our study planned in advance to go to the hospital or to call a CSBA when the labor pains started. However, most husbands asserted their opinion when they perceived the labor to be progressing poorly.
I said to my wife, 'If you have doubt in your mind and if you face trouble, then you can be admitted to the hospital...' She said, 'You pray for me and keep faith in Allah.' My intention was to take her to the hospital if she faced any trouble. - 26-year old husband, CSBA home delivery
... after [my wife was in labor] the whole night, in the morning at 8 am, I said [the delivery] will not work at home. We have to go to the doctor. Then, in a hurry, I called the [push car] and then took her to the hospital. By the blessing of Allah I found the doctor when we reached [the hospital]. - 35-year old husband, hospital delivery
Uninvolved during childbirth
Not all of the husbands were involved in providing social support during the delivery of their youngest child. Husbands whose wives utilized an untrained dhatri at home were typically not involved in any aspect of the labor and delivery process. Husbands who were uninvolved did not necessarily make a conscious decision to be absent during childbirth. Many factors could have contributed to a husband's absence, including his wife's lack of knowledge about the labor process or a general lack of communication between spouses. Lack of involvement appeared in three different forms: (1) the husband's passive agreement with his wife's decision with no input of his own; (2) the lack of communication between the husband and wife during pregnancy, such that the husband was unaware of the timing of the delivery; and (3) the husband's belief that his presence was not necessary once labor started and female family members took control.
When they tell me to bring [the dhatri], I have to bring her. I have to consider her a good nurse. - 43-year old husband, dhatri home delivery
I: Were you there when the pain started?
R: No, I went for work.... Later the news reached me that the baby [was born].
I: Why did you go away? Didn't you know that the baby would be born that day?
R: We don't know about this a lot. The woman knows about this matter. (Laugh)" - 48-year old husband, dhatri home delivery
R: I didn't have to do anything. I called my younger sister. Then my older sister came and after her arrival the delivery was over within half an hour.
I: Didn't you hear about when the labor started?
R: I didn't know that it was time to deliver. I went to the marketplace. - 28-year old husband, dhatri home delivery
Perceived social norms
The second divergent theme on which we focused was the husband's perception of social norms related to childbirth. Social norms can influence the type of support a husband provides his wife during delivery. According to Lewis and colleagues [29
], social norms are "... expectations held by social groups that dictate appropriate behavior and are thought of as rules or standards that guide behavior" (p. 254). In Bangladesh, perceived social norms of the husband are important to his wife because of their close social relationship and because of his decision-making power within the household. There are many social norms related to childbirth in Bangladesh; however, this study focuses on one in particular--the medicalization of childbirth.
Medicalization of Childbirth
The medicalization of childbirth refers to the redefining of physiological reproductive processes as biomedical problems that can be treated by the medical profession [30
]. This view differs from the traditional view in Bangladesh, in which childbirth is perceived as a natural process that should be experienced at home according to local customs [6
]. In many Western countries the medicalization of childbirth is often associated with unnecessary biomedical interventions. However, the idealization of "natural childbirth" can often lead to major complications for women in developing countries who do not have access to emergency obstetric care. Therefore, in the context of this study, the medicalization of childbirth refers to a contemporary view, which holds that timely access to professional medical care is necessary to prevent the primary causes of maternal mortality in the event of problems during delivery.
The concept of medicalization is particularly relevant in Bangladesh, a country with a history of medical pluralism. In rural Bangladesh, indigenous medical traditions exist parallel to contemporary, allopathic medical systems. Deciding which type of provider to use during a medical emergency is a complex process, which requires the input of many influential individuals [31
]. For the purpose of this study, the perception of medicalization of childbirth among the husbands emerges in the contrast between old day
and modern age
thinking. These in vivo
codes--terms taken from or derived directly from the language of the informant--came from an interview with a husband whose wife delivered at home with the assistance of a trained CSBA.
I: What if the delivery is done at home?
R: I suppose home is preferred by the elderly people of old day. In this consideration, it is better not to keep the expectant [mother] at home.
I: What are the problems that can be faced at home?
R: It is not possible to do everything at home. Women who are ignorant and not up-to-date think that the delivery is always done normally. It is foolish if we don't keep pace with the modern age. In present circumstances, it is better to contact the doctor. A nurse is needed to stay beside the patient all the time in order to look after her meals and medicine. - 26-year old husband, CSBA home delivery
Husbands who were coded as "old day" along the medicalization spectrum mentioned expectations of "normal" or "natural" deliveries at home. They also described traditional practices during childbirth and their reluctance to involve a doctor. Many of these husbands described the pressure from other family members, including their wives, for a home delivery. The majority of husbands whose wives utilized an untrained dhatri at home displayed old day thinking.
I: Which [place] do you prefer most [for delivery]; at home or at the hospital?
R: If [my wife] is comfortable at home, then at home. I don't find any logic in communicating with a doctor. If she is well at home, then home is better. - 43-year old husband, dhatri home delivery
I: Why did you apply telpora (sacred oil)?
R: Telpora was at home. After applying it, pain develops and [the delivery] won't be hard.
I: How did you come to know [that you should use telpora]?
R: Kabiraj (traditional practitioner) told me. He was my grandfather and he told me to [use telpora] like this, and then the baby will be born. - 32-year old husband, dhatri home delivery
Husbands who were coded as "modern age" mentioned the importance of going to the hospital for delivery, technology at the hospital, and consulting a doctor during pregnancy. One respondent was a migrant laborer who traveled to the capital city for work and brought modern ideologies back to his village. Others had close social connections to trained health providers or to non-governmental organizations, which promoted a biomedical approach to delivery care. The majority of husbands whose wives utilized professional delivery care displayed modern age thinking.
I: Aren't nuns and dhatris doing [deliveries] as well?
R: No, they are from old time. Now time has changed. We are not in the old era now. Now the trained people are doing their jobs.... Suppose, if the patient's condition became complicated, [the family would] carry them to the hospital. And doing delivery by the nurse is better. - 35-year old husband, CSBA home delivery
Everything can be found [in the hospital]. Nothing can be found in the village. In the hospital, they gave medicine to the baby. Can they do that in the village? - 35-year old husband, hospital delivery