Barriers to care-seeking: The tragic persistence of maternal death in Bangladesh

Maternal deaths are tragic because they are usually preventable. Death during pregnancy and childbirth usually occurs due to common complications such as eclampsia, obstructed or prolonged labour, postpartum haemorrhage, etc. These complications are all readily treatable by modern scientific medicine.

Bangladesh needs to improve access to care and prevent maternal deaths. Photo: GMB Akash / icddr,b


In advanced economies, access to healthcare and skilled birth attendance have nearly eliminated deaths due to complications of pregnancy or childbirth. Yet according to the WHO, approximately 830 women continue to die every day of these causes. 99% of these deaths occur in the Global South, mostly in poorer, rural communities that lack access to modern healthcare.

A woman’s lifetime risk for maternal death is 1 in 4900 in developed countries, versus 1 in 180 in developing countries. Much like diarrhoeal disease or childhood malnutrition, the persistence of maternal death across the developing world is a stark reminder of the shocking structural inequalities that divide the rich nations of the world from the poor.

Despite facing many challenges, the Global South has made incredible progress in tackling maternal mortality over the past two decades. Between 1990 and 2015 maternal mortality worldwide dropped by about 44%.

Bangladesh has made particularly exceptional progress in this area. Although Bangladesh has a lower per capita income than India or Pakistan, it has fewer maternal deaths than its richer neighbours. Maternal mortality in Bangladesh declined from 322 deaths per 100,000 live births in 2001 to 194 deaths per 100,000 live births in 2010, a 40 percent decline in nine years. However, much more work remains to be done. The UN Sustainable Development Goals aims to reduce the global maternal mortality ratio to less than 70 deaths per 100,000 live births by 2030.

A 2014 icddr,b study, published by Dr Shams El Arifeen and colleagues in The Lancet, analysed data from the 2001 and 2010 Bangladesh Maternal Mortality Surveys to understand the factors underlying the reduction in maternal mortality in this time. One of the biggest explanatory factors is a dramatic reduction in female fertility from 2001 to 2010, which reduced maternal deaths primarily through the sheer reduction in the total number of births. Aside from the fertility drop, the authors find that care-seeking for delivery care more than doubled from 2001 to 2010. However use of skilled birth attendants remained low (11%) among the poorest socioeconomic groups.

It is important to understand the demographics and causal factors underlying the persisting maternal deaths in Bangladesh if we are to have any hope of achieving the SDG target of less than 70 deaths per 100,000 live births. Two recent studies from icddr,b have shed light on what needs to be done.

icddr,b researcher Dr Rasheda Khanam, alongside collaborators from Johns Hopkins University and the Projahnmo Study Group in Bangladesh, recently published a study examining barriers to care-seeking for maternal complications in a rural district of Sylhet. 24,274 pregnant women were interviewed between June 2011 and December 2013. Women were interviewed within the first week of childbirth to collect data on self-reported antepartum and intrapartum complications, as well as patterns of care-seeking behaviour to treat these complications.

The study found that nearly 40% of women who experienced antepartum or intrapartum complications did not seek care from any provider, and 11.5% -14.9% received care from untrained providers. The authors conclude that geographic and economic barriers to access prevent many women from receiving the care they need. Policies that identify and remove these barriers in a cost-effective and context-sensitive manner are needed to achieve further reductions in maternal mortality.

The second study, published by Dr Aminur Rahman and colleagues at icddr,b, examined inequities in antenatal care utilisation over the last 22 years by analyzing the Bangladesh Demographic and Health Surveys (BDHS) from 2011 and 2014.

In advanced economies, virtually all women receive at least 4 antenatal care visits and the WHO recommends that all pregnant women receive this degree of antenatal care. However, antenatal care utilisation remains low in the Global South, with only 40% of all pregnant women in developing countries receiving the recommended amount of antenatal care in 2015.

Analysis of the BDHS data reveals that utilisation of antenatal care has increased steadily over the last 2 decades. In 1994 only 5.5% of women received 4 or more antenatal care visits - by 2014 this had increased to 31.2%.  However this is still below the national target of 50% set by the government. There are also clear inequities underlying antenatal care utilisation in Bangladesh, with richer, urban women being the most likely to receive the WHO recommended amount of antenatal care. These inequities in antenatal care utilisation present clear targets for policy - interventions to promote antenatal care utilisation among poor, rural women offer an efficient path to achieve further reductions in maternal deaths.

Both these studies empirically demonstrate the existence of severe structural inequalities and economic barriers that prevent the poorest women of the country from accessing proper maternal care. These results demonstrate that more must be done to improve access to care and prevent maternal deaths in our country, particularly among the most vulnerable and underserved communities of Bangladesh.