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A

Degree project

On

Author: Tanbin Sultana Supervisor: Yahya Jani Examiner: Martin Gren

Faculty of Health and Life Sciences

Department of Health and Caring Sciences LINNAEUS UNIVERSITY.

Course name & code: Health Science, Degree

A quantitative study on:

Women’s reproductive health complication

termination of pregnancy among ever-married

women of Bangladesh.

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Abstract:

Termination of pregnancies is a public health concern in many developing countries. In Bangladesh women faces barrier to access health care service for pregnancy termination. Moreover induced termination is illegal, against religion and moral grounds therefore, many pregnancies termination performed by untrained and unsafe way in Bangladesh which leading to maternal morbidity and mortality. On the other side, unintended pregnancy termination such spontaneous abortion, miscarriage occurs due to disease, trauma, genetic defect or biochemical incompatibility of mother and fetus and climate change related vulnerabilities. This study investigates the prevalence and associated factors of terminated pregnancy among Bangladeshi ever-married women.

Secondary data was obtained from Bangladesh Demographic Health and Survey (BDHS) for the year of 2017-18. Data was included 20127 samples of ever- married women of reproductive age 15-49 year. Descriptive analysis (chi- square test) and one way- ANOVA (Analysis of Variance) test was conducted to understand the association between factors and pregnancy termination.

The study finding revealed that 21% ever-married women had terminated pregnancy and there were statistically association between terminated pregnancy and demographic, socio-economic and reproductive health related factors. Termination of pregnancy is prevalent in Bangladeshi women and need to apply heath policy for preventing and intervening programme to eliminate geographic and socio-economic inequalities. For example, providing education and counselling program about reproductive health care service and family planning method help to avoid unintended or unsafe pregnancy termination.

Keywords: Pregnancy termination, prevalence, ever-married women, reproductive health, Bangladesh.

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Acknowledgement

Firstly, I would like to acknowledge my university Linnaeus university (LNU) for giving me such an opportunity for research facilities.

Secondly, I like to give special thanks to my supervisor Yahya Jani for his sincere guidance, valuable suggestion, constructive and constant inspiration throughout the entire period of the study to prepare my dissertation. I would also like to give thanks to my course coordinator and other teachers for their support, cooperation and encouragement. With great pleasure I would like to express my deepest sense of gratitude to my family, friends and well-wisher for giving me mental support and encouragement.

Lastly, I would also like to acknowledged Bangladesh Demographic Health and Survey for giving me permission to collect data for my research purpose.

Tanbin Sultana

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Contents

1 Introduction: ... 1

1.1 Women reproductive health : ... 1

1.2 Bangladesh profile: ... 3

1.3 Women status in Bangladesh: ... 4

1.4 Socio-economic and demographic factors: ... 5

1.5 Climate change as a factor: ... 6

1.6 Project description: ... 8

2 Literature review: ... 9

2.1 Women reproductive health and terminated pregnancy: ... 9

2.2 Climate change and women reproductive health: ... 10

2.3 Knowledge gap: ... 12

3 Study aim: ... 13

3.1 Research questions: ... 13

4 Theoretical framework: ... 1

4.1 Integrated ecological Model (IEM): ... 1

4.2 Feminization of poverty concept: ... 3

5 Method: ... 4

5.1 Study design: ... 4

5.2 Data collection: ... 4

5.2.1 Secondary data source:... 4

5.3 Ethical considerations: ... 5

5.4 Measurement of outcome variable: ... 6

5.5 Measurement of explanatory variable: ... 6

5.6 Statistical analysis: ... 7

6 Result and discussion:... 8

6.1 Factors affecting prevalence of a terminated pregnancy: ... 9

6.1.1 Age in 5 -year group: ... 9

6.1.2 Highest education level: ... 12

6.1.3 Geographical division: ... 16

6.1.4 Type of place of residence: ... 19

6.1.5 Wealth index combined: ... 21

6.1.6 Respondent employment status: ... 24

6.1.7 Number of household member:... 27

6.1.8 Total children ever born: ... 29

6.1.9 Wanted pregnancy when became pregnant: ... 32

6.1.10 Desire for more children: ... 34

6.1.11 During pregnancy given or bought any iron tablet or syrup: ... 37

6.1.12 Knowledge of ovulatory cycle: ... 39

6.1.13 Ever used anything or tried to delayed or avoid getting pregnant: ... 42

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7 Project relevancy to human and non-human health in the context of climate

change: ... 45

8 An account for transdisciplinary position of the degree project: ... 46

9 Conclusions: ... 49

10 Strength and limitation of the study: ... 50

11 Recommendations for further studies: ... 50

12 References: ... 1

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List of figures Name

Figure1 Map of eight division in Bangladesh.

Figure 2 The percentage of ever had a terminated pregnancy.

Figure 3 Effect of age on Pregnancy termination.

Figure 4 Pregnancy termination within education level.

Figure 5 Percentage of pregnancy termination according to geographical division.

Figure 6 Pregnancy termination percentage within type of place of residence.

Figure 7 Pregnancy termination within wealth index combined.

Figure 8 Percentage of terminated pregnancy according to respondent

employment status.

Figure 9 Percentage of termination of pregnancy according to household

member.

Figure 10 Pregnancy termination within total children ever born.

Figure 11 Percentage of pregnancy termination according to wanted

pregnancy.

Figure 12 Pregnancy termination within desire of more children.

Figure 13 The effect of iron tablet taking on pregnancy termination.

Figure 14 Percentage of pregnancy termination according to knowledge of ovulatory cycle.

Figure 15 Percentage of pregnancy termination according to ever used

anything tried to delayed or avoid getting pregnant.

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List of abbreviations:

BBS Bangladesh Bureau of Statistics UNICEF United Nations International

Children’s Emergency Fund ICPD International conference on population and Development

WHO World Health Organization

UNPFA United Nation and Population Fund

BDHS Bangladesh Demographic Health and Survey

NIPORT National Institute for Population Research and Training USAID US Agency for International

Development

MICS Multi Indicator Cluster Survey

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Appendix:

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1 Introduction:

1.1 Women reproductive health :

According to the International conference on population and Development (ICPD) reproductive health is defined as “state of complete physical, mental and social well-being and not merely absence of disease or infirmity, in all matter relating to the reproductive system and its functions and process”

(United Nation and Population Fund (UNPFA), 2004). Reproductive health problem is a major leading cause of death and disability for girls and women in developing countries (UNPFA, 2017). World Health Organization (2017) reported that approximately 300,000 women died due to mostly preventable causes directly related to pregnancy and childbirth. Pregnancy, fertility and reproductive health problem all are part of reproductive health system. There are many types of complications related to reproductive health and termination of pregnancy is one of them as it adverse outcomes of pregnancy lead to miscarriage, abortion and stillbirth among women at their reproductive age and induced abortion is not directly linked to adverse pregnancy outcomes (Asamoah et al., 2017). Pregnancy termination can be defined in the form of induced abortion, miscarriage, stillbirth (Zahan & Feng, 2020). The expulsion of a fetus from the uterus before it reached at the stage of viability, usually 20 weeks of gestation, when abortion occurs spontaneously it is called early pregnancy loss and miscarriage, and when it bought purposefully then it is called induced abortion (Britannica, 2019). Another definition from Moodley et al. (2021) study that miscarriage and stillbirth defined as a pregnancy loss and miscarriage was defined pregnancy loss of <28 weeks gestational duration whether, stillbirth was defined as one of pregnancy outcomes of a dead infant of gestational age> 28 weeks (Moodley et al., 2021). According to Ganatra et al. (2017) about 55.7 million pregnancy termination occurred in 2010-2014,

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among them 88.0% from developing countries. According to Zahan & Feng (2020) Bangladesh alone placing at the 7th for stillbirth in 2015.

Bangladesh is one of the highest adolescent fertility in the world, which contribute to negative outcomes related to maternal health and population growth (Alam et al., 2020). Most of women of reproductive age at higher risk of unintended pregnancies which lead them terminated pregnancies.

Unintended pregnancies is one of the most important cause of induced pregnancy termination. Induced abortion is terminating pregnancy to reduce fertility not affecting fecundability (Teitelbaum, 2020) But in Bangladesh induced abortion is still illegal, so unsafe pregnancies termination is high among women, and women used informal and traditional methods for pregnancy termination (Gipson & Hindin, 2008). According to Zahan & Feng (2020) unsafe pregnancy termination is a major public health concern among reproductive age women in many developing countries. Induced abortion normally done for many reasons such preserve the life or physical and mental well-being of mother or to prevent a birth for social or economic reason, for example to prevent youth age pregnancy (Britannica, 2019). Moreover, if a fetus detects as a malformed might have undergone elective termination of pregnancy (Asamoah et al., 2017).

On the other side, spontaneous abortion, miscarriage occurs due to many reasons such as disease, trauma, genetic defect or biochemical incompatibility of mother and fetus (Teitelbaum, 2020). According to Asamoah et al. (2017) malformed would be end up in miscarriage and stillbirth. The important component of sexual and reproductive health is appropriate health care service that will help women to safely go through pregnancy and childbirth (Khan- foundation, 2015). WHO (2015) stated that access to quality service of reproductive health during pregnancy, delivery, and postnatal period can make the difference between survival and death for both mother and child. However, there has been limited progress because of less attention from policy makers

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and lack of coordinated efforts by government, non-government and community-based organization (Alam et al., 2020).

1.2 Bangladesh profile:

Bangladesh is a developing country in South-Asia with more than 142 million population with 33% of poverty level and also lots of health- related issues (Rajia et al., 2019). After liberation war in 1971 Bangladesh endure many challenges including poverty, political turmoil and frequent natural disaster. It has eight divisions and 64 districts (Zila) and 488_ sub-districts (Upzila). The divisions are, as you can see in figure 1. Bangladesh has humid and warm climate and experience severe local storms, cyclone, flood and tornadoes. The average temperature is 25◦C to 31℃ in hot season and 13 to 26◦C during cool season throughout the year (Ministry of Foreign Affairs, 2018). Across the globe Bangladesh is known by the most vulnerable country under climate change. The climate vulnerabilities related to extreme weather such as water hazard related to cyclone, flood, and drought and its topological and geographical location makes it more vulnerable in extreme climate events. Its biophysical factors such as being a flat and low delta not only make it climate vulnerable but also its socio-economic factors such as high dependence on agriculture, population density and poverty make it more climate vulnerable (Thomas et al., 2013). According to Ministry of Foreign Affairs of the Netherlands (2018) some of Bangladesh’s regions are increasingly prone to drought and it is measured in the northwest of the country, highest temperature recorded in the southwest part of the country and lowest temperature in the northeast of the country.

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Figure 1: Map of eight division in Bangladesh.

1.3 Women status in Bangladesh:

The ratio of men to women are equal in Bangladesh and about 46% of women are in reproductive age (Rahman et al., 2003). Women in Bangladesh relatively disadvantaged in term of their social, economic and health condition. This is because of strong patriarchal structure of society, which resulted poor status of women in family and society (Rahman et al., 2003). Many barrier and impediment make more impossible for women to realize their sexual and reproductive health and right.

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1.4 Socio-economic and demographic factors:

There are many socio-economic and demographic factors which effecting women reproductive health, women empowerment and education. These socio- economic and demographic factors vary from society to society and from one geographic location to another in the same country. In Bangladesh, women constitute half of the population and 80% of them are living in rural area (Hossain et al., 2011). In one study in Bangladesh researcher found that geographical location is one of the most important determinants of health care service utilization in rural area of Bangladesh (Chakraborty et al., 2003).

Patriarchal society like Bangladesh women are lower position and men hold the power to control households and society (Zhan & Feng, 2020). Being a patriarchal society have restriction on women’s mobility and decision making, especially in the situation of family planning (space between pregnancies, number of total pregnancy and pregnancy termination) (Gipson & Hindin 2008).

According to Hossain et al. (2011) educational qualification, occupation, income and modern facilities are considered as socio-economic factors related to reproductive health. For example, high pregnancy rate among adolescent girls are associated with lack of education, less decision making power in household and family planning, less reproductive health knowledge, poverty and early marriage (Rana et al., 2019). Education is the most important variable which influenced the women reproductive health related knowledge (Rana et al., 2019). Hossain et al. (2011) mentioned that women low literacy rate and low education causes low social status and their dependence on men. The demographic factors which influences reproductive health age of women, influential person in case of family planning, the number of children, and the number of family members. Hossain et al. (2011) also mentioned that girls who marry at young age are more likely to experience multiple pregnancies, recurrent miscarriage, and termination of pregnancy and delivery

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complications. According to Zahan & Feng (2020) in developing countries socio-demographic factors are associated with pregnancy termination.

One third of married teenage girls in Bangladesh became mothers or are pregnant by their 18th’s birthday. BDHS (2017-2018) reported that marriage occurs early for women in Bangladesh and the median age at first marriage among women is 16.3 years. It is important that cultural, demographic, social and economic factors play important role in shaping marriage in society, as well as family planning (Dixon, 1971; as cited in Hossain et al., 2011).

1.5 Climate change as a factor:

Climate change it doesn’t directly affect the women health, the natural disaster and man- made socially constructed system have made the situation and climate change play in instigating the vulnerabilities (Rahman, 2015). All species on the earth will be affected by climate change, human is no exception. The Intergovernmental panel on climate change (IPCC) present an evidence about global warming and the impacts of human activities on global climate change, over the last 30 years the frequency of extremes weather is increased such drought, heavy precipitation (Rylander et al., 2013).

According to Lancet commission climate change affects human health though different paths: lack of food and safe drinking water, poor sanitation, population migration, changing disease pattern and morbidity, more frequent extreme weather and lack of shelter (Rylander et al., 2013). Costello et al. (2009) stated that ‘climate change is the biggest global health threat of the 21st century’

(Costello et al., 2009; as cited in Rylander et al., 2013, p.2). Especially the developing countries in tropical areas are likely to suffer climate change because of poverty, high population density, poor sanitation, poor health care system and political instability which is government ability to cope with external crisis.

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The impact of climate change on health determine by how a health care system is responding to climate sensitive outcomes. Pregnant women and developing fetus are considered as the most vulnerable to environment effects of climate change and which is already marginalized in many countries. In developing countries climate change will increase the risk of infant and maternal mortality, birth complication and poorer reproductive health. Yearly 3 million maternal death and stillbirth are attributable to maternal health condition such as poor nutritional status, deprived living environment and infectious disease (Rylander et al., 2013). Not only developing countries, more industrialized regions of the world reported relationship between higher ambient temperature and adverse pregnancy outcomes such as preterm delivery, low birth weight and pregnancy loss (Kuehn & McCormick, 2017; Bekkar et al., 2020).

Rylander et al. (2013) mentioned that ’climate change related to specific complication during pregnancy such as spontaneous abortion and premature contraction. Natural disaster or extreme events will reduce the food, safe drinking water by creating drought and flood, reduce the crop production, livestock death and create malnutrition, diarrhea and cholera. According to Rylander et al. (2013) it is evident that the shortage of food and malnutrition are going to be key issue with climate change. Evident from Bunket et al. (2016);

Matte et al. (2016) studies it is suggested that climate change and ambient heat changes have major harmful effect on human health, such as vector-born transmission disease and mortality related to heat stress. Because already in poor countries food is scarce and climate change add a pressure for populations.

According to Ministry of Foreign Affairs of the Netherlands (2018) large population of Bangladesh already placed significant pressure on land and water resources, leading to pollution, depletion of ground water resources and impacts on food production. Thus, exacerbated the challenges by the effect of climate change. In addition, reduce food production and reduce source of drinking water, natural disaster is identified as one of the most important climate change factors for deaths of women, especially during pregnancy (Abdullah et al.,

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2019). Disaster also impacts on reproductive health through spontaneous abortion, birth defects and low birth weight of the baby (Nour 2011; Harville et al., 2010). Bangladesh is one of the most disastrous experienced natural hazard prone countries and flood is one of the most common disaster faced by the people of Bangladesh regularly and 18% of the country affected by flood every year (Abdullah et al., 2019). Abdullah et al. (2019) stated that source of the healthcare inundated with flood water and access to healthcare for immunization and antenatal care became limited for pregnant women. A study done by UNFPA in nine district of Bangladesh it was found that during flood disaster 32,000-33,600 pregnant mother are affected by flood out of 1,876,636 (Abdullah et al., 2019).

1.6 Project description:

For my study project I worked on the prevalence of reproductive health problem termination of pregnancy and factors associated with ever-married women of Bangladesh. According to United Nations ‘ever married women or men are person who have been married at least once in their lives although their current status may not be ‘married’’. Bangladeshi women normally married at age 15.

According to BDHS (2017-18) report average martial age for Bangladeshi women is 16.2 years.

My study area is Bangladesh, because most of the area of Bangladesh are at risk from natural disaster and meteorological disturbance due to climate change.

Global climate change has been contributing to growing natural disaster across the world, especially in global south (Fatema, 2020). The climate change vulnerabilities are the most severely experienced by those living in low and middle-income counties (Jagnoor et al., 2019). Masika (2003) mentioned that it is widely accepted that distribution of vulnerabilities to climate hazard and environmental degradation is not equal in societies and countries. According to

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Basu et al. 2010; Van Zutpher et al. 2012 mentioned that there are evident that climate change effect on human, but limited studies on the impact of climate change and pregnancy outcomes are limited.

Bangladesh is highly susceptible to many natural disasters such as floods, cyclones, droughts, riverbank erosion and earthquakes almost every year because of low-lying geographical position and climate features (Fatema, 2020). According to Alam and Rahman (2014), not only Bangladesh, most of the coastal area of the world is at risk of natural disaster and meteorological disturbance from climate change. They also mentioned that the frequency and intensity of weather-related events such as extremes events and increase of average temperature will accelerate these impacts (Alam & Rahman, 2014).

Jagnoor et al. (2019), estimated that two-thirds of people in Bangladesh is living in region of flood risk and one quarter is living in region of cyclone risk area.

2 Literature review:

2.1 Women reproductive health and terminated pregnancy:

Globally 529,000 women die due to pregnancy and childbirth related complications every year (Sayem and Nury, 2011). These complications cause more deaths and disability than any other reproductive health problems (Chakraborty et al., 2003). Evidence from developing world indicates that one- third to one- half of women became mothers within 19 years of age, making pregnancy related causes as leading causes of death. In south Asia teenage pregnancies is high due to common practice of early marriage and social expectation to have a child soon after marriage. In South Asia, teenage pregnancies are high with 35% in Bangladesh followed by Nepal and India with 21% (Sayem and Nury, 2011). According to Rajia et al. (2019) maternal and child health is one of the most important issues in developing countries like

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Bangladesh. The underlying factors leading to poor maternal situation in Bangladesh is that a very low percentage of women actually seek professional medical assistance for pregnancy related care, deliveries and complication.

According to Bongaarts (1997) women at reproductive age are at risk of unwanted pregnancies and maybe seek away to terminate the pregnancy.

Besides, unsafe and untimely menstrual regulation is a major maternal health problem in Bangladesh (Rana et al., 2019). Zahan and Feng (2020) also mentioned that in Bangladesh most of pregnancy termination (induced abortion) are done by untrained service provider and unsafe condition. According to Teitelbaum (2020) 20% pregnancies recognized as fail spontaneously and stillbirth. Among type of pregnancy termination in 2014, 1,194,000 induced abortion and in 2015, 83 thousand of stillbirths occurred alone in Bangladesh (Blencowe et al., 2016; Rana et al., 2019).

2.2 Climate change and women reproductive health:

Studies have shown that women especially those who are in poverty experience a greater burden of climate change, which impact on women’s health (Sorensen et al, 2018). Especially, nutritional demands during pregnancy which place them at risk of suffering from climate-sensitive disease. Women have faced gendered pattern of disadvantage during natural disaster and long term climate change (Sorensen et al., 2018). Threats to women’s health in time of emergency can arise from restricted access to healthcare, economic disadvantage, harmful social norms and barriers to maternal, contraceptive and abortion care. In most developing countries, the poorest women have the least power to decide whether, when or how often to become pregnant, because the poorest women also have the least access to quality care during pregnancy and childbirth (UNFPA, 2017). Women are more vulnerable because of social construction,

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responsibilities, economically vulnerable position, gender inequalities, exposure to violence, health problem especially sexual and reproductive health problem before, after and during climate induced change.

According to Rahman (2013) it is established fact that the environmental consequences of climate change pose different scenario for men and women in term of disaster induced impact and failed their life, women are more vulnerable and susceptible to adverse impact of climate change. Such as poor health and calorie deficiency make women more vulnerable during climate indeed catastrophes. Moreover, they also receive less or poor quality of health care compare to men (Rahman, 2013). The general effect of climate change and lack of healthcare make women are more vulnerable to reproductive and sexual health problem (Rahman, 2013). This not only true for women living in disaster affected area but a fact for all women in Bangladesh. Epstein (2020) mentioned that, women living in severe drought area had reporting controlling partner behaviour and experiencing physical and sexual violence. The social, economic, cultural and political context of Bangladesh make women more vulnerable to climate change related disaster and global warming (Islam, 2010). According to Rahman (2013) the rate of mortality and morbidity statistics of environmental disaster in term of their impact on gender/sex have shown discrepancies. In 1991 cyclone and flood the mortality rate of women were fivefold high compared to men in Bangladesh. After disaster it is common that the pregnant, breastfeeding and menstruating women are at greater risk for compromising their health.

According to Islam (2010) women are more vulnerable to reproductive and sexual health problem such as adverse reproductive health outcomes, early pregnancy loss, premature delivery, delivery related complication, and sexually transmitted diseases. Another problem is the absence of hygienic facilities when women migrant to another places. Pardhi et al. (2020) stated that, pregnant

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women are the worst sufferer from the migration and lack of antenatal care more likely to lead adverse pregnancy outcomes and maternal mortality. In addition social taboos about menstruation and norms about behaviour have contributed to health problem of young women in disaster situation. According to World Health Organization report (WHO, 2005) - during the flooding in 1998 in Bangladesh there was an increase in perinea rashes and urinary tract infections in adolescent girls, because they were not able to properly wash and dry their menstrual rags. Another problem faced by women is the lack of pure drinking water and sanitation facilities (Pardhi et al., 2020). Women needed to go long distance to collect pure water for entire household uses. The carry of water for long distance poses great threat to women health especially reproductive health.

There is limited access to food and water which negatively affect the women sexual and reproductive health. From Rahman (2013) study it is stated that health problem of women during disaster consequently occur and from the primary data it is seen that 63.33% of women suffering from various health diseases.

2.3 Knowledge gap:

Many studies have been done on women reproductive health, the prevalent of reproductive health problem is high in Bangladesh. According to Rana et al.

(2019) the prevalent of untimely menstrual regulation is prevalent among Bangladeshi women and associated with geographic location and socio- economic status. The study of Feng et al. (2021) found that the prevalence of reproductive tract infection is high among women of childbearing age in Bangladesh is 13.39%, 13.93% and 11.11% respectively in 2007, 2011 and 2014. Pregnancy termination is the adverse outcomes of pregnancy either it is induced abortion or spontaneous abortion or stillbirth. There is no current nationwide population based study have done on pregnancy termination related

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to socio-demographic and pregnancy related information as a factors and this is specific reproductive health problem among Bangladesh women. According to Zahan and Feng (2020) to understanding the serious consequences of pregnancy termination with risk factors can help policy maker to develop targeted prevention and intervention program. So, in my study I will focus on the prevalence of reproductive health problem termination of pregnancy and associated factors, which is specific health problem of women in reproductive age. From this study we will understand what kind of reproductive health problem women are faced and what the causes are. This study will help to understand the healthcare requirement for reproductive health problems of women. This study also applicable in another disaster prone Asian countries like India, Pakistan.

3 Study aim:

To investigate the prevalence and factors associated with terminated pregnancy among ever-married women of Bangladesh.

3.1 Research questions:

1. What is the prevalence of terminated pregnancy among ever-married women in Bangladesh?

2. What are the factors/causative factors associated with terminated pregnancy among ever-married women of Bangladesh?

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4 Theoretical framework:

There are many theories and concepts which can explain why women suffer from reproductive health related complications. Among them I choose integrated ecological model and feminization of poverty

4.1 Integrated ecological Model (IEM):

Integrated ecological model (Hessie, 1998) expressed by nested circle where individual relationship with family context, immediate social context and broader social context (Premkumar, 2018). The model helps to understand how women reproductive health and different factors interact in each level.

First level; the innermost microsystem level presented individual characteristics with family context such as age, education, income, decision making, socialization, dropout school. According to World Bank study report limited role in household decision-making, limited access and control over household resources (physical and financial assets), inadequate knowledge and skill and restricted mobility makes women more vulnerable to reproductive health. Thus, in this level people need to improve their personnel attitude and behaviour to improve reproductive health and right.

Second level; Exo-system level which represent social context where individual relationship with family are embedded. In society like Bangladesh are patriarchal, where women are lower position and man hold the all power to control household and society as whole (Hossain et al., 2011). In that case, after marriage female low social status limit their ability to control their own lives, including fertility, their access to health care and rarely became decision maker in family. Specially, in the situation of family planning such as birth intervals,

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total number of pregnancies and pregnancy termination all are influenced by the decision of husband. According to Mallick et al. (2020) in male dominated societies, women with lack of autonomy can be a barrier to accessing maternal health care. The prevention strategies in this level focused on family system and promote healthy relationship to adopt proper family planning system. To promote social environment for women like proper workplace and improving economic opportunities, provide social support.

Third level; macro-system level referring to the larger social context a set of cultural values, believes, laws and policies (PremKumar, 2018) in a word reduced women reproductive health related vulnerabilities can be promote in this level. In many countries women have no right to attain education, their work only cooking food, giving birth children and taking care of family members and they have no job except household work. This concept supported by another research according to Khan- Foundation (2015) in Bangladesh women responsibilities are only childbearing, cooking and taking care of others family member and man responsibilities are earning wages. According to Nibedata et al., (2019) the main challenges at the facility level are lack of services, shortage of medicines, equipment and trained health worker, because all these challenges women have very low opportunity of seeking care of maternal health related to care, deliveries and complication. In this level the prevention strategies are making women empower by providing education because education is the most important variable which influence women reproductive health related knowledge. Moreover, applying some policy related to reproductive health knowledge and rights can improve reproductive health condition of women in Bangladesh.

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4.2 Feminization of poverty concept:

Feminization of poverty means increasing differences between men and women in respect to income, living standard and inequality in health. According to Christensen (2019)” “The feminization of poverty” refers to the phenomenon that women and children are disproportionately represented among the world’s poor compared to men” (Christensen (2019), p.1). The term of feminization of poverty coined by American Sociologist Diana Pearce after documenting how women became disproportionate among the population of low income individuals in the United States and globally. The main causes of feminization of poverty are family structure, economy and labor forces and these social and economic factors differently effected women over time and across the context.

According to Hossain et al. (2011) in Bangladesh poverty and reproductive health is inter-twined. Because of low income and lack of income service women get marriage at early age and almost became adolescent mother. They also mentioned that poor access to reproductive health facilities is not a health disadvantage as well as social and economic disadvantage.

Poverty measured by household level, according to Christensen (2019) household headed by single women are at higher risk of living poverty line (Christensen, 2019). There are two reasons household headed women live in poverty first, single women living with children than single men. Second one, parenthood leads to women less working outside, which contribute to lower income and income inequality and gender poverty gap. However, up to 30%

income inequality is due to inequality within household structure. Globally, 122 women aged 25-34 years living in extreme poverty compare to men of the same age group (Manandhar et al., 2018).

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5 Method:

5.1 Study design:

For my study I used cross-sectional quantitative survey method to inquire about prevalence of pregnancy termination among ever-married women of Bangladesh and associated factors. According to Creswell and Creswell (2018) choice of research approach depend on the research problem and problem being studied. Cross-sectional quantitative survey method to inquire about prevalence of pregnancy termination among ever-married women and associated factors in Bangladesh. According to Hennekens and Buring (1987) cross-sectional studies are the representative of the population, for that a large sample needed to estimate the prevalence of the conditions of interested. In my study the prevalence of terminated pregnancy answered my research questions for example frequency and causes of the terminated pregnancy among ever-married women. According to Fatema (2020) quantitative approach will be used to address the causes and consequences of health vulnerabilities such as physical and psychological health.

5.2 Data collection:

5.2.1 Secondary data source:

I collected my secondary data from the lasted nationally representative Bangladesh Demographic Health and Survey (BDHS) 2017-18 and it is the eighth national survey to report on the demographic and health status of women and children (National Institute for Population Research and Training, 2020).

This survey was conducted by the National Institute for Population Research and Training (NIPORT), Ministry of Health and Family Welfare, Bangladesh, Mitra and Associates, US Agency for International Development (USAID). The survey is carried out on two stage stratified sample of household and data

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collected from about 20,127 ever-married women age 15-49. At the survey time Bangladesh was divided into eight division, these division allow the country as whole and separated into rural and urban area. The survey collected information on the socio-economic and demographic characteristics age, education, place of residence, marital status, employment and wealth status of the ever-married women and information related reproductive health is fertility, fertility preference, pregnancy, family planning, maternal and child health and maternal health service utilization etc. I got registered with BDHS send request with my study title and with more explanation why I need this data. After getting permission, I downloaded the individual recorde file from the survey data set.

Where I found the all data related to my work. Socio-economic, demographic and reproductive health data of ever-married women of reproductive age in Bangladesh.

5.3 Ethical considerations:

Creswell and Creswell (2018) mentioned that in a research proposal, it is important to engage in ethical practices which can be arise during the study process. For my study I used secondary data collection approach. But I was careful when selecting my secondary data sources, if they take ethical consideration during their study such as giving privacy, safety issue of interviewer or interviewee and make clear purpose of the study and consent of the participation. I collected data from Bangladesh Demographic Health and Survey (BDHS) 2017-18 and that has previously de-identified all participants (Zahan and Feng, 2020). So no ethical approval needed for my present study, but to maintained ethical considerations I need to confirm with BDHS the data only keep with author protected personal device. No one except author supervisor can see the data. Moreover, the data analysis results presented in group form, so no personal information identified from the study result.

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5.4 Measurement of outcome variable:

The outcomes variable of this study is prevalence of “terminated pregnancy”

which is derived from the question “Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth” and response were coded 0=

No and 1= Yes from Bangladesh Demographic Health and Survey (BDHS) 2017-18 survey questionnaire.

5.5 Measurement of explanatory variable:

For this study socio-demographic and reproductive health information were selected as a factor variables related to pregnancy termination based on a scan of relevant literature (Dankwah et al., 2018; Dickson et al., 2018; Zahan & Feng, 2020). The variable included Age in 5 year group, highest education level, division, type of place of residence, number of household member, wealth index, respondent working status, total number of ever born children, wanted pregnancy when became pregnant, desire for more children, during pregnancy given or bought iron tablet or syrup and reproductive health related knowledge of ovulatory cycle, ever used anything tried to delayed or avoid getting pregnant. Age in 5 year group categorized into 1=15-19, 2=20-24, 3=25-29, 4=30-34, 5=35-39, 6=40-44, 7=45-49. Highest education level coded as 0=no education, 1=primary complete, 2=secondary complete and 3=higher.

Geographical division also categorized as 1=Barisal, 2= Chattogram, 3= Dhaka, 4=Khulna, 5=Mymensingh, 6=Rajshahi, 7=Rangpur and 8=Sylhet. Type of place of residence coded by 1=urban, 2=rural. Wealth index coded by 1=poorest, 2=poorer, 3=middle, 4= richer and 5=richest. In Bangladesh Demographic Health and Survey (BDHS) assessed the wealth indices by the weighted score through household level of ownership of various assets (bicycles, car, television, radio etc.) and housing characteristics (toilet facility, drinking water source, floor, wall material etc.), then divided the score into five equally wealth quintiles from 1 (lowest) to 5 (highest) (Zahan & Feng, 2020).

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Respondent employment status coded by 0=no, 1=yes. Wanted pregnancy when became pregnant captured by 1=then, 2=later, 3=no more. Desire for more children is coded by Wants within 2 years=1, Wants after 2 years=2, Wants, unsure timing=3, Undecided=4, Wants no more=5, Sterilized (respondent or partner) =6, Declared infecund=7. Respondent taking iron tablet or syrup during pregnancy coded by 0=no, 1=yes, 8= don’t know. Knowledge of ovulatory cycle coded by during her period=1, after period ended=2, middle of the cycle=3, before period begins=4, at any time=5, other=6, don’t know=8. Ever used anything or tried to delayed or avoid getting pregnant 0=no, 1=yes used outside calendar, 2= yes used in calendar.

5.6 Statistical analysis:

To compare the mean and standard deviation one-way ANOVA test was conducted by IBM SPSS.20 version. To examine the variable frequencies, percentage and relationship between factors and terminated pregnancy Pearson Chi-square test (Dickson et al., 2018) was conducted by IBM SPSS.20 version.

The hypothesis to examine the relationship between factors and terminated pregnancy are; the null hypothesis (H0) and alternative hypothesis (H1)

H0= Factors is not associated with pregnancy termination H1= Factors is associated with pregnancy termination If P> 0.05, then reject the null hypothesis,

P< 0.05, there is association

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6 Result and discussion:

Statistical analyses was done on socio- demographic Characteristics and pregnancy related information among ever-married women in Bangladesh (DHS 2017-18). The socio-demographic characteristics (respondent’s current age, highest education level, geographical division, type of place of residence, number of household member, wealth index and respondent current employment status) and pregnancy related information (Age in 5 year group, total children ever born, wanted pregnancy when became pregnant, desire for more children, during pregnancy given or bought iron tablet or syrup, knowledge of ovulatory cycle and ever used anything or tried to delay avoid getting pregnant) of the study respondents. A total of 20127 ever-married women between 15 and 49 year of age were interviewed among them 4226 women reported that they have had terminated pregnancy which represented 21% of the sample which is about one-fifth of ever-married women in reproductive age of Bangladesh and 79.0% reported that they don’t have terminated pregnancy (Figure 2).

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Figure 2: The percentage of ever had a terminated pregnancy.

6.1 Factors affecting prevalence of a terminated pregnancy:

6.1.1 Age in 5 -year group:

Table 1: Statistical analysis of age in 5 -year group.

Variable Percentage of

terminated pregnancy

Level of significance

Age in 5 year group

Frequency Mean Standard deviation

Yes No

15-19 1951 .12 .324 11.9% 88.1%

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20-24 3514 .21 .410 21.3% 78.7%

P=0.000

25-29 3572 .20 .398 19.8% 80.2%

30-34 3462 .20 .403 20.4% 79.6%

35-39 2953 .22 .411 21.6% 78.4%

40-44 2329 .25 .434 25.1% 74.9%

45-49 2346 .26 .439 26.0% 74.0%

Table 1 each column represent the variable frequency, mean, standard deviation, percentage of terminated pregnancy and level of significance according to the variable age in 5 -year group, each row represent the categories of the variable. From statistical analysis it was shown that highest mean and standard deviation shown in high age group and lowest one for younger age group .From figure 2 statistically shown that among seven age groups highest prevalence of terminated pregnancy reported in high age group and the proportion is 25.1% in 40-44 and 26.0% in 45-49 age year group and lowest prevalence reported among younger age group. For Chi-square test conducted by the test statistic cross-tabulation table is 7 × 2 and degree of freedom is 6 and corresponding statistic test p-value is 0.000 which represent small count.

The level of significance is P<0.05, so statistically there is association between ever had a terminated pregnancy and age in 5- year group.

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Figure 3: Effect of age on Pregnancy termination.

Discussion:

The result from the study suggested that women with high age group reported more terminated pregnancy than younger age group of respondents. The age group represented at the survey time respondents age. May be among listed termination of pregnancy of the survey respondents, high age group 40-44 and 45-49 had induced abortion or spontaneous abortion (miscarriage). According to George (2006) high maternal age is risk factor for spontaneous abortion. He also mentioned that the risk of spontaneous abortion increased sharply after the age of 35. Which is consistent with my study finding. So it is predict that women with older age in Bangladesh high risk of early pregnancy loss. Other side, to terminate unwanted or unintended pregnancies, or may be terminated the

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

15-19 20-24 25-29 30-34 35-39 40-44 45-49

percentage of pregnancy termination

Age in 5 year group

Ever had a terminated pregnancy with yes% within age in 5 year group

(33)

pregnancy when reached their desired family size. The problem with induced abortion is done by unsafe way, complications due to unsafe pregnancy termination leads to high maternal mortality. This statement supported by Dankwah et al. (2018) study on Ghanaian women that 88% induced abortion done by unsafe way, this lead maternal mortality among Ghanaian women. In Zahan and Feng (2020) study stated that the probability of having higher termination of pregnancy is expected to be higher among old respondent than young respondent. Moreover, they explained alternative reason for the observed trend that older women may achieved the desire family size which may resulted pregnancy termination. On the other hand, younger age pregnancy termination is not acceptable in Bangladesh for its conservative society. Thus, pregnancy termination at younger age maybe occur less. Same result was found in previous studies in Ethiopia (Tesfaye et al., 2014), Ghana (Mote et al., 2010) and South Africa (Rambau, 2016) where abortion was found to be high among older women. Other studies in Kenya, Ghana and Ethiopia have found that the prevalence of abortion is high among younger women compared to older ones (Zahan & Feng, 2020). The reason maybe younger women unmet need for contraceptive method and postpone the early childbearing, which will lead to induced abortion. So according to integrated ecological model in this level need to apply proper health care access for induced abortion and apply proper education program such as family planning system to reduced unwanted pregnancies at older age.

6.1.2 Highest education level:

Table 2: Statistical table of highest education level.

Variable Percentage of

terminated pregnancy

Level of significance

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Highest education

level

Frequency Mean Standard deviation

Yes No

P=0.000 No

education

3202 .15 .353 14.6% 85.4%

Primary completed

6340 .21 .406 20.8% 79.2%

Secondary complete

7764 .22 .413 21.9% 78.1%

Higher 2821 .26 .441 26.5% 73.5%

Table 2 column presented the statistical analysis of highest education level frequency, mean, standard deviation and percentage of termination pregnancy who had pregnancy termination and who didn’t had, and level of significance is there any association of education level and termination of pregnancy.

Maximum respondent were complete secondary level of education (table 2).

From table 2 it is seen that maximum mean and standard deviation for higher education level and from figure 3 highest prevalence seen in respondent who had higher level of education is 26.5% respectively. In Chi-square test statistic is based on 4 ×2 cross-tabulation table and the degree of freedom is (df) =3 and corresponding test statistic p- value is 0.000. So, there is significant association between terminated pregnancy and highest education level, because statistically shown that the level of significance P<0.05.

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Figure 4: Pregnancy termination within education level.

Discussion:

Statistical analysis shown that the prevalence of ever had a terminated pregnancy was highest among higher level of education compare to no education. There was statistically association between level of education and termination of pregnancy. Same finding found in previous studies in Ghana where women with higher level of education were more likely have a terminated pregnancy and the reported percentage of prevalence was 17% (Dickson et al., 2018). There are more possibility of having high prevalence of termination pregnancy among women with high education level, because women with higher education are employed and they are financially empowered and they can take decision about their reproductive health by themselves (Zahan & Feng, 2020). According to Santos et al. (2016) it is clear that women with higher

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

No education Primary complete secondary complete Higher

percentage of termination of pregnancy

Highest education level

Ever had a terminated pregnancy yes % within highest education level

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education level of unintended pregnancy go with safer procedure compare to women who don’t have the same social advantage. On the other hand some studies finding stated that educated women are less likely have a history of terminated pregnancy compared to uneducated women (Abir et al., 2017). The possible explanation for this statement may be women with no education don’t have any knowledge of contraceptive method to avoid unintended pregnancies, which lead to terminated pregnancies (Zahan & Feng, 2020). May be women with low education had termination of pregnancy especially induced abortion but it was under reported, may be they used traditional and information method to terminated the pregnancy, to avoid social stigmization. This statement supported by researcher Dankwah et al. (2018) study, they also mentioned that women with low education have limited access to health care service and under reported induce abortion done by outside health care setting. At this level people in society need to change their attitude toward induced abortion, because some cases induced abortion need to perform to save mother’s life and provide easy access of health care facilities who don’t have.

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6.1.3 Geographical division:

Table 3: Statistical analysis based on geographical division.

Variable Percentage of

terminated pregnancy

Level of significanc

e Geographica

l division

Frequenc y

Mea n

Standard deviatio n

Yes No

P=0.000

Barisal 2154 .12 .327 12.2

%

87.8

%

Chattogram 2905 .21 .408 21.0

%

79.0

%

Dhaka 2974 .22 .413 21.8

%

78.2

%

Khulna 2630 .20 .403 20.4

%

79.6

%

Mymensingh 2167 .19 .390 18.7

%

81.3

%

Rajshahi 2576 .22 .413 21.8

%

78.2

%

Rangpur 2492 .25 .431 24.7

%

75.3

%

Sylhet 2229 .26 .440 26.2

%

73.8

%

Each column of the table 3 present the result of statistical mean, std. deviation, frequency, termination pregnancy percentage and level of significance and each

(38)

row shown the result according to division wise. Highest respondent were from Chattagram and Dhaka division but highest mean and std. deviation noticed for Sylhet and Rangpur (.26, .440) and (.25, .431) respectively. Figure 4 percentage of termination pregnancy according to geographical division shown that among 8 division lowest prevalence of ever had a terminated pregnancy is reported 14.6 % in Barisal. Highest prevalence of terminated pregnancy recorded in Sylhet 24.7% and Rangpur 26.2% respectively. There were statistically significant association between termination of pregnancy and geographical division, the level of significance less than 0.05.

Figure 5: Percentage of pregnancy termination according to geographical division.

12.20%

21.00%

21.80%

20.40%

18.70%

21.80%

24.70%

26.20%

Barisal Chattogram Dhaka Khulna Mymensingh Rajshahi Rangpur Sylhet

Percentage of terminated pregnancy

Geographical division

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Discussion:

The respondent who were from Sylhet and Rangpur reported higher termination of pregnancy compared to other division (figure 4). Respondents with this division may be had miscarriage and stillbirth as adverse pregnancy outcomes due to impact of climate change. Kuehn and McCormick (2017) stated that, there is evidence that extremes temperature adversely impact on birth outcomes.

From literature review it is revealed that Bangladesh is highly vulnerable to the change related to climate events. According to Khatun et al. (2016) maximum temperature more than 40℃ recorded in the northwestern and western part of Bangladesh and Rangpur and Sylhet division situated this part of Bangladesh.

According to Zahan and Feng (2020) study finding Sylhet is the high risk region of terminated pregnancies. Hajizadeh et al. (2014); Islam et al. (2020) studies reported that Sylhet and Chattogram division were performing low in term of maternal and reproductive health indicators. On the other side, eastern and southern part of Bangladesh are high disaster prone area due to cyclone and flood. During flood reproductive health care service are unavailable and due to insufficient transportation facilities pregnant women faces problem related to pregnancy complications. At this level need to apply policy to provide health care facilities and services related to emergency reproductive health complication during pregnancy. Zahan and Feng (2020) mentioned that geographical feature is important factor for formulate intervention programme for the termination of pregnancy. Government of Bangladesh has need to give attention on low performing area by providing reproductive health services especially during climate related disaster and reducing regional disparities in term of pregnancy termination.

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6.1.4 Type of place of residence:

Table 4: Statistical analysis table based on type of place of residence.

Variable Percentage of

terminated pregnancy

Level of significance

Type of place of residence

Frequency Mean Standard deviation

Yes No

P=0.000

Urban 7374 .19 .389 18.5% 81.5%

Rural 12753 .22 .417 22.5% 77.6%

Table 4 each column of the table presented frequency, mean, Std. deviation, percentage of terminated pregnancy, significance level for the variable of type of residence. The statistical result revealed that highest respondent from rural area and maximum mean, Std. deviation counted for rural area. Figure 5 pregnancy termination percentage within type of place of residence presented that in rural area 22.4% respondent had ever had a terminated pregnancy, on the other side in urban area the percentage is 18.5%. Type of place of residence and pregnancy termination is statistically significant. The level of significance P<0.01.

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Figure 6: Pregnancy termination percentage within type of place of residence.

Discussion:

The low prevalence seen in the respondent who were from urban area compare to rural area (figure 5). On the other side, women from rural area with low level of education have no knowledge of reproductive health practices which lead them pregnancy termination. According to Dickson et al. (2018) study reported that low prevalence of termination of pregnancy evidence among the women from rural area. They mentioned the reason that women from urban area are educated and employed, they have easy access of contraceptive and family

18.50%

22.50%

1 2

Percentage of pregnancy termination

Type of place of residence

Pregnancy termination yes% within type of place of residence

Urban Rural

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planning method to avoid unintended pregnancies. On the other hand, women from low social and disadvantage area have limited access to health care service and less power to taking decision about family planning matter such as number of pregnancies, birth interval. If they become pregnant due to multiple pregnancies, the pregnancy missed as miscarriage and stillbirth. At this level provide health care service and reproductive health and rights education for all geographically disadvantage area and remove geographic inequalities.

6.1.5 Wealth index combined:

Table 5: Statistical analysis based on wealth index combined.

Variable Percentage of

terminated pregnancy

Level of significance

Wealth index combined

Frequency Mean Standard deviation

Yes No

P=0.000

Poorest 3826 .16 .366 15.9% 84.1%

Poorer 3833 .21 .409 21.3% 78.7%

Middle 3883 .20 .398 19.7% 80.3%

Richer 4088 .21 .411 21.5% 78.5%

Richest 4497 .26 .437 25.8% 74.2%

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Each column of the table 5 presented frequency, mean, Std. deviation, percentage of pregnancy termination of the participants of wealth index combined and also level of significance. The row of the table 5 counted according to categories of the wealth index status. Highest mean and Std.

deviation for richest wealth index status. The figure 6 represented that highest prevalence of pregnancy termination reported by highest wealth index group compare to other wealth status group. Statistically level of significance is P<

0.05 that means there were association of wealth index and termination of pregnancy. Because the degree of freedom is 4 and statistic p-value is 0.000 which is less count.

Figure 7: Pregnancy termination within wealth index combined.

15.90%

21.30%

19.70%

21.50%

25.80%

Poorest Poorer Middle Richer Richest

percentage of pregnancy termination

Wealth index combined

Pregnancy termination yes% within wealth index combined

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Discussion:

It is observed that there was association between wealth index and termination of pregnancy. Despite this observation, this study investigate the association of financial status and pregnancy termination mixed result. Also in literature it is said that the association is complex, in some studies no significant relationship was found between women and socio-economic status and ever had a terminated pregnancy (Zahan & Feng, 2020). Another study reported that the termination of pregnancy was lower in the low socio-economic status of Brazillian and American women (Fusco 2013; Jones et al., 2002). Whereas, other studies reported that the probability of having pregnancy termination was higher in high socio-economic status (Elul, 2011). This is resemble to my study, in the study result it is shown that higher pregnancy termination reported in richest wealth index women compare to poorest one. This is also consistent with other previous studies finding among Nigerian women based Nigerian DHS data (Yaya et al., 2018) and Ghanaian women based Ghana DHS data (Dankwah et al., 2018).

According to Dankwah et al., (2018) such a trend in pregnancy termination in terms of wealth index, increased with increasing financial power of women in higher socio-economic status. In high socio-economic status women access induced abortion through financial means. According to it is possible that high socio-economic status women are able to detect their early pregnancy and seek care for pregnancy loss may be their old is enough to continue the pregnancy and turn as a miscarriage. Previous discussion it already mentioned that high age group is a risk factor for pregnancy termination. At this level the main challenge related to lack of health care services with proper medical setting.

Women have less opportunities to seek care related to pregnancy and pregnancy related complication, even though there are from high socio-economic status.

Health care policy with sufficient equipment and trained health care provider reduce the reproductive health problem among Bangladesh women in all sphere whether it is low or high socioeconomic status.

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6.1.6 Respondent employment status:

Table 6: Statistical analysis on respondent employment status.

Variable Percentage of

terminated pregnancy

Level of significance

Respondent employment

status

Frequency Mean Standard deviation

Yes No

P=0.000

No 10495 .19 .393 19.1% 80.9%

Yes 9632 .23 .421 23.0% 77.0%

From analysis it is calculated that highest mean and standard deviation for the respondent who are currently working compared to the women who are not employed now (Table 6). The figure 7 of percentage of pregnancy termination within employment status revealed that highest terminated pregnancy reported in the respondent who are employed. The percentage are 23.0% for who said yes and 19.1% who said no for employment status. There is statistically association between employment status and terminated pregnancy. Because corresponding p-value is 0.000, which is less than level of significance P<0.05

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Figure 8: Percentage of terminated pregnancy according to respondent employment status.

Discussion:

Employment status is another factor which lead to pregnancy termination among employed women compare to unemployed one. The study finding suggested that women with working status have high prevalence of termination pregnancy compare to non- working women. This result is supported by another study conducted by Zahan and Feng (2020) in Bangladesh women who involve in any occupation had high risk of reported termination of pregnancy and the result supported by another study of Ghanaian women based on Ghana DHS data where increased risk of reported termination pregnancy was high among employed women (Dankwah et al., 2018). According to Zahan and Feng (2020) there are many reason for employed women to experience termination of pregnancy, they have decision making power and prioritizing their carrier over

19.10%

23.00%

No Yes

Percentage of pregnancy termination

Respondent employment status

References

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