BackgroundIt is estimated that 18.5 million Caesarean Sections (CS) are conducted annually worldwide and about one-third of them are done without medical indications and described as “unnecessary”. Although developed countries account for most of the rise in the trend of unnecessary CS, more studies report a similar trend in developing countries, putting a strain on existing but limited healthcare resources, jeopardizing families' financial security and presenting a barrier to equitable universal coverage. We examined indications for CS in public hospitals of one district in Bangladesh and explored factors influencing decision to perform the procedure.MethodsRetrospective review of case notes of 530 women who had CS in 5 public hospitals in Thakurgaon District of Bangladesh. Key Informant Interviews (KII) with 18 service providers to explore factors associated with the decision to perform a CS.ResultsThe commonest recorded indications for CS were: previous CS (29.4%), fetal distress (15.7%), cephalo-pelvic disproportion (10.2%), prolonged obstructed labor (8.3%) and post-term dates (7.0%). The majority (68%) of CS were performed as emergency; mainly during daytime working hours. Previous CS and “post-term dates” were common indications for elective CS with “post dates” – the commonest indication for CS in primiparous women. 16.0% of all CS were conducted for cases where alternative forms of care might have been more appropriate. Providers reported not using protocols and evidence based guidelines even though these are available. Pressure from patients and relatives to deliver by CS strongly influenced decision making. External agents from private hospitals receive a financial reward for every CS performed and are present in public hospitals to “lobby” for CS.ConclusionFactors other than evidence based practice or the presence of a clear medical indication influence providers’ decision to perform both elective and emergency CS in public hospitals in Bangladesh.

BackgroundBangladesh has achieved remarkable progress in healthcare with a steady decline in maternal and under-5 child mortality rates in efforts to achieve Millennium Development Goals 4 and 5. However, the mortality rates are still very high compared with high-income countries. The quality of healthcare needs improve to reduce mortality rates further. It is essential to investigate the current quality of healthcare before implementing any interventions. The study was conducted to explore the perception of healthcare providers about the quality of maternal and neonatal health (MNH) care. The study also investigated patient satisfaction with the MNH care received from district and sub-district hospitals.MethodologyBoth qualitative and quantitative methods were used in the study. Two district and 12 sub-district hospitals in Thakurgaon and Jamalpur in Bangladesh were the study settings. Fourteen group discussions and 56 in-depth interviews were conducted among the healthcare providers. Client exit interviews were conducted with 112 patients and their attendants from maternity, labor, and neonatal wards before being discharged from the hospitals. Eight physicians and four anthropologists collected data between November and December 2011 using pretested guidelines.ResultsThe hospital staff identified several key factors that affected the quality of patient care: shortage of staff and logistics; lack of laboratory support; under use of patient-management protocols; a lack of training; and insufficient supervision. Doctors were unable to provide optimal care because of the high volume of patients. The exit interviews revealed that 85 % of respondents were satisfied with the hospital services received. Seven out of 14 respondents were satisfied with the cleanliness of the hospital facilities. More than half of the respondents were satisfied with the drugs they received. In half of the facilities, patients did not get an opportunity to ask the healthcare providers questions about their health conditions and treatments.ConclusionThe quality of healthcare is poor in district and sub-district hospitals in Bangladesh because of the lack of healthcare personnel and logistic support. An integrated quality improvement approach is needed to improve MNH care service in district and sub-district hospitals in Bangladesh.

Verbal autopsy used at community level is an accepted method to identify cause of death and factors contributing to death. Maternal deaths occurring in four districts in Bangladesh over a period of 24 months were identified and community health workers were trained to conduct a verbal autopsy. Of 571 maternal deaths identified almost half (273, 47.8%) occurred at facility level, 97 (17.0%) died en route to a healthcare facility and 201 (35.2%) maternal deaths occurred at home. The majority of maternal deaths occurred in the postpartum period (78.8%) in the first 6 hours after giving birth (41.6% of all postpartum deaths). Women who had accessed care at a healthcare facility were less likely to die in the first 6 hours when compared with women who died at home (relative risk 0.70; 95% confidence interval 0.56-0.88) 70.4% (402) of deaths were classified as direct maternal deaths, 12.4% (71) as indirect and 13.8% (79) as unspecified. The most common cause of death was haemorrhage (38%), followed by eclampsia (20%) and sepsis (8.1%). Almost three out of four women who died had sought care for complications during the index pregnancy. Most mothers who died in Bangladesh had accessed care. It is now crucial that the quality of care received at health facility level is improved. This includes a refocus on strengthening healthcare providers' knowledge and skills to recognise and manage complications and provide emergency obstetric care. The enabling environment must be in place as well as ensuring a fully functional referral pathway between healthcare facilities.

ObjectivesTo explore the experiences, acceptance, and effects of conducting facility death review (FDR) of maternal and neonatal deaths and stillbirths at or below the district level in Bangladesh.MethodsThis was a qualitative study with healthcare providers involved in FDRs. Two districts were studied: Thakurgaon district (a pilot district) and Jamalpur district (randomly selected from three follow-on study districts). Data were collected between January and November 2011. Data were collected from focus group discussions, in-depth interviews, and document review. Hospital administrators, obstetrics and gynecology consultants, and pediatric consultants and nurses employed in the same departments of the respective facilities participated in the study. Content and thematic analyses were performed.ResultsFDR for maternal and neonatal deaths and stillbirths can be performed in upazila health complexes at sub-district and district hospital levels. Senior staff nurses took responsibility for notifying each death and conducting death reviews with the support of doctors. Doctors reviewed the FDRs to assign causes of death. Review meetings with doctors, nurses, and health managers at the upazila and district levels supported the preparation of remedial action plans based on FDR findings, and interventions were planned accordingly. There were excellent examples of improved quality of care at facilities as a result of FDR. FDR also identified gaps and challenges to overcome in the near future to improve maternal and newborn health.DiscussionFDR of maternal and neonatal deaths is feasible in district and upazila health facilities. FDR not only identifies the medical causes of a maternal or neonatal death but also explores remediable gaps and challenges in the facility. FDR creates an enabled environment in the facility to explore medical causes of deaths, including the gaps and challenges that influence mortality. FDRs mobilize health managers at upazila and district levels to forward plan and improve healthcare delivery.

Objectives: To identify the effects of Maternal and Neonatal Death Review (MNDR) in terms of improving maternal and neonatal health at the community level in Bangladesh. Methods: Both quantitative and qualitative methods were undertaken for collecting data in Kashipur Union, Bangladesh. Death notifications from households, subsequent data collections from a focus-group discussion (FGD), a group discussion (GD) and in-depth interviews (IDIs) were obtained using structured tools and guidelines. Results: A total of four maternal deaths, 21 neonatal deaths and 15 still births were reported in the MNDR death notification system at Kashipur Union in 2010. Data were presented to local programme managers, who took various initiatives including awareness programmes, pregnancy registration, antenatal care, birth planning, and also the revitalization of a community clinic. The coverage of antenatal care, delivery in clinics, postnatal care and referral of complications increased through the active participation of the community. Community healthcare providers, care recipients and members of the community expressed satisfaction with the quality of maternal and neonatal services. In the preceding two years, maternal and neonatal deaths substantially reduced in Kashipur (in 2011 maternal death = 1, neonatal death = 20, still birth = 8; in 2012 maternal death = 1, neonatal death = 8, still birth = 13). Conclusions: The MNDR system successfully delivered notification of all maternal and neonatal deaths in the defined area and collected information for the formulation and implementation of specific interventions, which resulted in visible and tangible changes in care-seeking and client satisfaction.

BackgroundBetter data on cause of, and factors contributing to, neonatal deaths are needed to improve interventions aimed at reducing neonatal mortality in low- and middle-income countries.MethodsCommunity surveillance to identify all neonatal deaths across four districts in Bangladesh. Verbal autopsy for every fifth case and InterVA-4 used to assign likely cause of death.Findings6748 neonatal deaths identified, giving a neonatal mortality rate of 24.4 per 1000 live births. Of these, 51.3% occurred in the community and 48.7% at or on the way to a health facility. Almost half (46.1%) occurred within 24 hours of birth with 83.6% of all deaths occurring in the first seven days of life. Birth asphyxia was the leading cause of death (43%), followed by infections (29.3%), and prematurity (22.2%). In 68.3% of cases, care had been provided at a health facility before death occurred. Care-seeking was significantly higher among mothers who were educated (RR 1.18, 95% CI: 1.04–1.35) or who delivered at a health facility (RR 1.48, 95% CI 1.37–1.60) and lower among mothers who had 2–4 previous births (RR 0.89, 95% CI 0.82–0.96), for baby girls (RR 0.87, 95% CI 0.80–0.93), and for low birth weight babies (RR 0.89, 95% CI 0.82–0.96).InterpretationMost parents of neonates who died had accessed and received care from a qualified healthcare provider. To further reduce neonatal mortality, it is important that the quality of care provided, particularly skilled birth attendance, emergency obstetric care, and neonatal care during the first month of life is improved, such that it is timely, safe, and effective.

The study was conducted using the exit interview with patients (n=120), in depth interview with health care providers (n=87) and focus group discussion (n=16) with stakeholders to assess the perceived level of quality of care in maternal and newborn health at public facilities in Bangladesh.  Both clients and providers expressed dissatisfaction for inadequate quality of care represented by poor cleanliness, long waiting time with less consultation time, poor compassion by providers, inadequate supply of drugs and unnoticed cost for services varied by level of facilities. Inadequacy in human resource and absenteeism and poor laboratory service were reported to worsen the condition especially at lower level of service delivery. Thus this study explored some important factors like poor quality of care, inadequate technical competencies, information exchange and follow-up services. A deficit in supplies and logistics are strong barrier in regards to quality of care at various levels which needs to be addressed immediately.Keywords: Bangladesh; Maternal health; Newborn health; Quality of careOnline: 13 August 2009DOI: 10.3329/bmrcb.v35i2.3044Bangladesh Med Res Counc Bull 2009; 35: 53-56

This study explored the community perception of maternal deaths influenced by natural disaster (flood), and the practice of maternal complications during natural disaster among the rural population in Bangladesh. It also explored the challenges faced by the community for providing healthcare and referring the pregnant women experiencing complications during flood disaster. Three focus group discussions (FGDs) and eight in-depth interviews (IDIs) were conducted in the marginalized rural communities in the flood-prone Khaliajhuri sub-district, Netrakona district, Bangladesh. Flood is one of the major risk factors for influencing maternal death. Pregnant women seriously suffer from maternal complications, lack of antenatal checkup, and lack of doctors during flooding. During the time of delivery, it is difficult to find a skilled attendant, and referring the patient with delivery complications to the healthcare facility. Boats are the only mode of transport. The majority of maternal deaths occur on the boats during transfer from the community to the hospital. Rural people feel that the maternal deaths influenced by natural disaster are natural phenomena. Pre-preparation is needed to support pregnant women during disasters. There is unawareness of maternal health, related care, and complications during disasters among local health service providers and volunteers.