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Understanding barriers to maternal health in remote communities in Bangladesh

29 JAN 2015

A study by icddr,b  and CARE Bangladesh asks why women in remote communities fail to access quality maternal and child health services and recommends providing skilled care in the community and tackling social and cultural barriers to access.   
 
Bangladesh has made considerable progress in reducing maternal and child mortality in recent years – it has met the Millennium Development Goal to reduce under-five mortality, and is considered to be on track to meet the goal of reducing maternal deaths. However, progress has not been uniform in all parts of the country, and in remote regions maternal and child death rates are considerably higher than the national average.
 
A baseline study led by Bidhan Krishna Sarker at icddr,b’s Centre for Reproductive Health in the remote Sunamganj district in Sylhet division (in northeast Bangladesh) examined  the many economic, social and cultural factors that prevent women from accessing quality maternal and neonatal care. The findings lay the groundwork for establishing a community based health programme by CARE Bangladesh aimed at improving maternal, neonatal and child health in remote areas of Bangladesh. 
 
Photo by United Nations / CC BY-NC-ND 2.0
 
The Sylhet division in Bangladesh has shown the least amount of improvement in recent years in both maternal and child health. Maternal mortality in this region is very high – 425 deaths per 100,000 live births, compared with the national average of 194. Similarly infant and under-five child mortality are 67 and 83 per 1,000 live births, compared to a national average of 45 and 56, respectively. Sunamganj district in Sylhet is one of its remotest areas with very poor communication linkages with the rest of the country.
 
The study found that the level of awareness of maternal and child health issues and utilisation of skilled care was very low in Sunamganj: 89% of most recent deliveries took place at home with traditional birth attendants. The overall knowledge of danger signs associated with pregnancy and childbirth was found to be low and less than half of the study participants received information on birth preparedness.
 
Around two thirds of the women in the study had not received any postpartum care. In case of complications during or after birth, more than half of the women said they consulted a village doctor, rather than a trained physician.
 
However, lack of access to skilled health care was not the main reason for using traditional birth attendants and village doctors. These unskilled providers are much less expensive and do not require travel; they also tend to be well known to the community and viewed as a trusted resource. On the other hand, perceptions of poor quality of treatment and of poor communication at government hospitals and private clinics deterred villagers from using these more formal health services. 
 
The study also found that many families have religious objections to taking pregnant women to hospitals for delivery as it is considered a ‘sin’ and violates the modesty of a pregnant woman to be treated by strangers, especially men – a problem that is compounded by the dearth of female doctors at government hospitals. Women also lack decision-making power when it comes to their pregnancy and health care options. These decisions are usually deferred to the husband or mother-in-law who often opt for traditional health care providers such as birth attendants and village doctors. 
 
In order to tackle these multiple barriers to quality care, the authors recommend a multi-pronged approach that includes: introduction of a community-based skilled birth attendant programme; training of existing traditional birth attendants and village doctors to recognise danger signs for both the mother and child and to make timely referrals; and development of strong referral collaboration between the range of providers.
 
At the same time, cultural and social barriers to accessing skilled care at hospitals and clinics need to be removed through awareness building and health education at the remote communities. In particular, husbands and elderly family members need to be involved and educated to ensure that available skilled care is utilised in practice, say the authors
 
This study was conducted in partnership with CARE Bangladesh and supported by funding from GlaxoSmithKline (GSK)’s 20% re-investment initiative, which aims to strengthen community health systems in least developed countries. 

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