Quality of Obstetric Care in Public-sector Facilities and Constraints to Implementing Emergency Obstetric Care Services: Evidence from High- and Low-performing Districts of Bangladesh

This study explored the quality of obstetric care in public-sector facilities and the constraints to programming comprehensive essential obstetric care (EOC) services in rural areas of Khulna and Sylhet divisions, relatively high- and low-performing areas of Bangladesh respectively. Quality was explored by physically inspecting all public-sector EOC facilities and the constraints through in-depth interviews with public-sector programme managers and service providers. Distribution of the functional EOC facilities satisfied the United Nation's minimum criteria of at least one comprehensive EOC and four basic EOC facilities for every 500,000 people in Khulna but not in Sylhet region. Human-resource constraints were the major barrier for maternal health. Sanctioned posts for nurses were inadequate in rural areas of both the divisions; however, deployment and retention of trained human resources were more problematic in rural areas of Sylhet. Other problems also plagued care, including unavailability of blood in rural settings and lack of use of evidence-based techniques. The overall quality of care was better in the EOC facilities of Khulna division than in Sylhet. ‘Context' of care was also different in these two areas: the population in Sylhet is less literate, more conservative, and faces more geographical and sociocultural barriers in accessing services. As a consequence of both care delivered and the context, more normal vaginal and caesarian-section deliveries were carried out in the public-sector EOC facilities in the Khulna region, with the exception of the medical college hospitals. To improve maternal healthcare, there is a need for a human-resource plan that increases the number of posts in rural areas and ensures availability. All categories of maternal healthcare providers also need training on evidence-based techniques. While the centralized push system of management has its strengths, special strategies for improving the response in the low-performing areas is urgently warranted

Causes of Maternal Mortality Decline in Matlab, Bangladesh

Bangladesh is distinct among developing countries in achieving a low maternal mortality ratio (MMR) of 322 per 100,000 livebirths despite the very low use of skilled care at delivery (13% nationally). This variation has also been observed in Matlab, a rural area in Bangladesh, where longitudinal data on maternal mortality are available since the mid-1970s. The current study investigated the possible causes of the maternal mortality decline in Matlab. The study analyzed 769 maternal deaths and 215,779 pregnancy records from the Health and Demographic Surveillance System (HDSS) and other sources of safe motherhood data in the ICDDR,B and government service areas in Matlab during 1976-2005. The major interventions that took place in both the areas since the early 1980s were the family-planning programme plus safe menstrual regulation services and safe motherhood interventions (midwives for normal delivery in the ICDDR,B service area from the late 1980s and equal access to comprehensive emergency obstetric care [EmOC] in public facilities for women from both the areas). National programmes for social development and empowerment of women through education and microcredit programmes were implemented in both the areas. The quantitative findings were supplemented by a qualitative study by interviewing local community care providers for their change in practices for maternal healthcare over time. After the introduction of the safe motherhood programme, reduction in maternal mortality was higher in the ICDDR,B service area (68.6%) than in the government service area (50.4%) during 1986-1989 and 2001-2005. Reduction in the number of maternal deaths due to the fertility decline was higher in the government service area (30%) than in the ICDDR,B service area (23%) during 1979-2005. In each area, there has been substantial reduction in abortion-related mortality—86.7% and 78.3%—in the ICDDR,B and government service areas respectively. Education of women was a strong predictor of the maternal mortality decline in both the areas. Possible explanations for the maternal mortality decline in Matlab are: better access to comprehensive EmOC services, reduction in the total fertility rate, and improved education of women. To achieve the Millenium Development Goal 5 targets, policies that bring further improved comprehensive EmOC, strengthened family-planning services, and expanded education of females are essential

Causes of Maternal Mortality Decline in Matlab, Bangladesh

Bangladesh is distinct among developing countries in achieving a low maternal mortality ratio (MMR) of 322 per 100,000 livebirths despite the very low use of skilled care at delivery (13% nationally). This variation has also been observed in Matlab, a rural area in Bangladesh, where longitudinal data on maternal mortality are available since the mid-1970s. The current study investigated the possible causes of the maternal mortality decline in Matlab. The study analyzed 769 maternal deaths and 215,779 pregnancy records from the Health and Demographic Surveillance System (HDSS) and other sources of safe motherhood data in the ICDDR,B and government service areas in Matlab during 1976-2005. The major interventions that took place in both the areas since the early 1980s were the family-planning programme plus safe menstrual regulation services and safe motherhood interventions (midwives for normal delivery in the ICDDR,B service area from the late 1980s and equal access to comprehensive emergency obstetric care [EmOC] in public facilities for women from both the areas). National programmes for social development and empowerment of women through education and microcredit programmes were implemented in both the areas. The quantitative findings were supplemented by a qualitative study by interviewing local community care providers for their change in practices for maternal healthcare over time. After the introduction of the safe motherhood programme, reduction in maternal mortality was higher in the ICDDR,B service area (68.6%) than in the government service area (50.4%) during 1986-1989 and 2001-2005. Reduction in the number of maternal deaths due to the fertility decline was higher in the government service area (30%) than in the ICDDR,B service area (23%) during 1979-2005. In each area, there has been substantial reduction in abortion-related mortali- ty-86.7% and 78.3%-in the ICDDR,B and government service areas respectively. Education of women was a strong predictor of the maternal mortality decline in both the areas. Possible explanations for the maternal mortality decline in Matlab are: better access to comprehensive EmOC services, reduction in the total fertility rate, and improved education of women. To achieve the Millenium Development Goal 5 targets, policies that bring further improved comprehensive EmOC, strengthened family-planning services, and expanded education of females are essential

Postpartum Haemorrhage and Eclampsia: Differences in Knowledge and Care-seeking Behaviour in Two Districts of Bangladesh

In high- and low-performing districts of Bangladesh, the study explored the demand-side of maternal healthcare by looking at differences in perceived knowledge and care-seeking behaviours of women in relation to postpartum haemorrhage or eclampsia. Haemorrhage and eclampsia are two major causes of maternal mortality in Bangladesh. The study was conducted during July 2006–December 2007. Both postpartum bleeding and eclampsia were recognized by women of different age-groups as severe and life-threatening obstetric complications. However, a gap existed between perception and actual care-seeking behaviours which could contribute to the high rate of maternal deaths associated with these conditions. There were differences in care-seeking practices among women in the two different areas of Bangladesh, which may reflect sociocultural differences, disparities in economic and educational opportunities, and a discrimination in the availability of care

Cultural Theories of Postpartum Bleeding in Matlab, Bangladesh: Implications for Community Health Intervention

Early recognition can reduce maternal disability and deaths due to postpartum haemorrhage. This study identified cultural theories of postpartum bleeding that may lead to inappropriate recognition and delayed care-seeking. Qualitative and quantitative data obtained through structured interviews with 149 participants living in Matlab, Bangladesh, including women aged 18-49 years, women aged 50+ years, traditional birth attendants (TBAs), and skilled birth attendants (SBAs), were subjected to cultural domain. General consensus existed among the TBAs and lay women regarding signs, causes, and treatments of postpartum bleeding (eigenvalue ratio 5.9, mean competence 0.59, and standard deviation 0.15). Excessive bleeding appeared to be distinguished by flow characteristics, not colour or quantity. Yet, the TBAs and lay women differed significantly from the SBAs in beliefs about normalcy of blood loss, causal role of the retained placenta and malevolent spirits, and care practices critical to survival. Cultural domain analysis captures variation in theories with specificity and representativeness necessary to inform community health intervention

Recognition of and Response to Neonatal Intrapartum-related Complications in Home-birth Settings in Bangladesh

Intrapartum-related complications (previously called \u2018birth asphyxia\u2019) are a significant contributor to deaths of newborns in Bangladesh. This study describes some of the perceived signs, causes, and treatments for this condition as described by new mothers, female relatives, traditional birth attendants, and village doctors in three sites in Bangladesh. Informants were asked to name characteristics of a healthy newborn and a newborn with difficulty in breathing at birth and about the perceived causes, consequences, and treatments for breathing difficulties. Across all three sites \u2018no movement\u2019 and \u2018no cry\u2019 were identified as signs of breathing difficulties while \u2018prolonged labour\u2019 was the most commonly-mentioned cause. Informants described a variety of treatments for difficulty in breathing at birth, including biomedical and, less often, spiritual and traditional practices. This study identified the areas that need to be addressed through behaviour change interventions to improve recognition of and response to intrapartum-related complications in Bangladesh

Recognition of and Response to neonatal intrapartum-related complications in home-birth settings in Bangladesh.

Intrapartum-related complications (previously called 'birth asphyxia') are a significant contributor to deaths of newborns in Bangladesh. This study describes some of the perceived signs, causes, and treatments for this condition as described by new mothers, female relatives, traditional birth attendants, and village doctors in three sites in Bangladesh. Informants were asked to name characteristics of a healthy newborn and a newborn with difficulty in breathing at birth and about the perceived causes, consequences, and treatments for breathing difficulties. Across all three sites 'no movement' and 'no cry' were identified as signs of breathing difficulties while 'prolonged labour' was the most commonly-mentioned cause. Informants described a variety of treatments for difficulty in breathing at birth, including biomedical and, less often, spiritual and traditional practices. This study identified the areas that need to be addressed through behaviour change interventions to improve recognition of and response to intrapartum-related complications in Bangladesh