Household food insecurity is independently associated with poor utilization of maternal healthcare services in Bangladesh

The key role that maternal healthcare services (MHS) plays in reducing maternal mortality rate (MMR) has been substantiated by researchers both in developed and developing country contexts (Cleland et al. 2006; Dowswell et al. 2010; Adegoke et al. 2012; Finlayson and Downe 2013). However, developing regions, especially South Asia and sub-Saharan Africa, are lagging behind the rest of the world in their capacity to put this knowledge into practice (Bishwajit 2015). Initiatives led by the maternal health-related millennium development goal (MDG) 5 initiative saw a 34% decline in MMR since 1990 (Dynes et al. 2013). Despite that, MMR in low- and middle-income countries (LMICs) remains alarmingly high and reveals a continuing disparity in the provision and utilization of MHS in these countries (Kassebaum et al. 2014). A systematic review found that LMICs together account for almost all of the total maternal mortalities (99%) (Hogan et al. 2010), with South Asian countries representing about one third of the global total (Zanconato et al. 2006). Globally, about 97% of the unsafe abortions occur in LMICs and this contributes to about 15% of total maternal mortality (Baer et al. 2015).

The difference in the burden of MMR between high-income countries (HICs) and LMICs coincides with that of the utilization of MHS. In developed countries about 98% of women receive adequate antenatal care (ANC) services and skilled birth attendants supervise 94% of the deliveries (Zanconato et al. 2006), whereas in LMICs about half of all women remain deprived of basic ANC (Finlayson and Downe 2013). This strikingly high divide is generally attributed to poor healthcare infrastructure, health illiteracy, underutilization of maternal health care and family planning, and inadequate access to obstetric care (Lewis 2003; Cleland et al. 2006; Zanconato et al. 2006; Nour 2008), all of which are widely prevalent across south Asian countries including Bangladesh.

Bangladesh has made appreciable progress in its pursuit of reducing maternal and under-five child mortality rates. Despite that, the mortality rates continue to be noticeably high when compared with high-income countries. Generally, this discrimination is attributed to the underutilization of MHS, and financial and infrastructural barriers to access to quality care in the current socioeconomic context. For instance, researchers mentioned that although the lack of affordability of healthcare is a major problem, the role of women empowerment and decision-making power for proper utilization of MHS is also a key issue in the country (Yaya et al. 2017). MHS is provisioned mainly through public and private establishments, as well as community healthcare centers, with traditional care providers being more prevalent in the rural areas. The costs of care vary widely, with the private hospitals being the most expensive and hence unaffordable for the majority of the population. To overcome this barrier, the government has taken initiatives to provide service through community healthcare centers that are widely distributed throughout the country.

Previous studies have reported that in Bangladesh, the majority of maternal deaths occur during the time between the third trimester and the first week following delivery (Winch et al. 2005). These deaths could be prevented to a considerable extent by proper information and guidance for maternal health-seeking behavior disseminated through prenatal/maternal education programs (Moran et al. 2007). However, designing such programs will require massive efforts, including a great amount of financing and research work to develop a deep understanding of the factors that influence maternal healthcare-seeking behavior (HSB). This can be a crucial step towards evidence-based health policy making that targets better infant and maternal health outcomes (Darmstadt et al. 2005).

Maternal HSB, like any health-related behavior, is by nature a complex psychological construct that is shaped at individual, familial, and social levels by various demographic, economic, and sociocultural forces. In the domain of behavioral psychology, the stress agents (stressors) hold a central position as they have been shown to affect almost all aspects of psychosocial life via behavioral pathways, e.g., mood, lifestyle factors, perception of health, and well-being (Moran et al. 2007). Food insecurity, although generally thought of as an outcome of financial or resource constraints (Baer et al. 2015), is also found to be affected by behavioral aspects (Timmer 2012). Previous studies have outlined the impact of proximate socioeconomic stressors such as poverty and food vulnerability on HSB (Sundari Ravindran 2014; Young et al. 2014). It is, therefore, assumable that women who face hardships to secure food will face the trade-off between nutrition and medical care that will eventually lead to non- or under-utilization of maternal healthcare. A previous study on American households reported that housing instability and food insecurity were associated with poor access to healthcare (Bhargava and Lee 2016). Based on current literature, we hypothesized that household food insecurity (HFI) would be associated with suboptimal utilization of MHS. Given the high rate of HFI and maternal and infant mortality, the findings are expected to be of crucial importance for public health policy making in the country.

This study documents the factors influencing the non- and under-utilization of MHS in Bangladesh. To our knowledge, this is first study to establish an association between HFI and MHS utilization status. The findings of the study were well in line with the study hypothesis. In addition to the main findings, the study also revealed that the rate of MHS attendance in the sample population was quite low. A review of the literature suggests that a similar scenario exists in most other countries in South Asia (Moran et al. 2007; Singh et al. 2012), contributing to the remarkably high MMR among the impoverished population (Vora et al. 2009; Yaya et al. 2017).

HFI, as the explanatory variable of primary interest in this study, was found be significantly associated with MHS utilization status. Previous studies have demonstrated the link between chronic food vulnerability and the poor uptake of healthcare services (Kushel et al. 2001). Poor households usually have to spend the bulk of their income on food, and as a consequence face hard trade-offs between food and other competitive necessities such as education and healthcare (Bishwajit et al. 2014). Findings are similar even from studies in the USA where the expenditure on food as a percentage of total disposable income is one of the lowest among all countries (Kushel et al. 2001). A study following the food crisis of 2008 exploring households’ coping strategies in Bangladesh found that the rise in food prices was associated with the decreased consumption of rice (a staple food in Bangladesh), increased student dropout at the high school level (with higher proportions for girls), and elevated levels of domestic violence, which all result in significantly adverse effects on the utilization of MHS (Raihan 2009). The Bangladesh Government has periodically launched many food security initiatives to safeguard the health and nutrition of its marginalized population. The findings of this study suggest that national food policy making targeting the promotion of food security among socioeconomically disadvantaged communities will substantially contribute to the increased utilization of MHS. Successful integration of social awareness programs targeting the sociocultural barriers to promoting maternal health and countrywide food security programs can prove highly rewarding. Nonetheless, mothers and female children were found to be deprived of food in households (Kushel et al. 2001; Baig-Ansari et al. 2006).

To our knowledge, there is no prior study exploring the association between MHS and HFI using nationally representative data. A strong point of this study is that we used data from the latest DHS survey performed in the country. Also of importance is the cluster sampling method of the study population, which means that sample participants were representative of the general population. However, using secondary data meant that authors had no control over the selection of variables, the quality of the data, and the measurement of the indicators. The rate of MHS utilization rate might have changed since the survey was conducted. Moreover, we did not control for geographic barriers to MHS, which has been shown to have influences on HSB.

Women from food insecure households are less likely to receive MHS than their food secure counterparts. Household wealth status and individual educational level were also strongly correlated with the demand for MHS. The findings of this study bear important policy implications for designing reproductive healthcare services in Bangladesh. Health policies targeted at promoting maternal health and services utilization must emphasize improving food security and the economic empowerment of marginalized households, especially when there is a pregnant woman. Further studies should focus on the potential of food-security-based approaches to improve maternal health utilization in Bangladesh.

The authors wish to acknowledge the provision of the datasets by the DHS program.