A decade of inequality in maternity care: antenatal care, professional attendance at delivery, and caesarean section in Bangladesh (1991–2004)

Abstract

BackgroundBangladesh is committed to the fifth Millennium Development Goal (MDG-5) target of reducing its maternal mortality ratio by three-quarters between 1990 and 2015. Since the early 1990s, Bangladesh has followed a strategy of improving access to facilities equipped and staffed to provide emergency obstetric care (EmOC).MethodsWe used data from four Demographic and Health Surveys conducted between 1993 and 2004 to examine trends in the proportions of live births preceded by antenatal consultation, attended by a health professional, and delivered by caesarean section, according to key socio-demographic characteristics.ResultsUtilization of antenatal care increased substantially, from 24% in 1991 to 60% in 2004. Despite a relatively greater increase in rural than urban areas, utilization remained much lower among the poorest rural women without formal education (18%) compared with the richest urban women with secondary or higher education (99%). Professional attendance at delivery increased by 50% (from 9% to 14%, more rapidly in rural than urban areas), and caesarean sections trebled (from 2% to 6%), but these indicators remained low even by developing country standards. Within these trends there were huge inequalities; 86% of live births among the richest urban women with secondary or higher education were attended by a health professional, and 35% were delivered by caesarean section, compared with 2% and 0.1% respectively of live births among the poorest rural women without formal education. The trend in professional attendance was entirely confounded by socioeconomic and demographic changes, but education of the woman and her husband remained important determinants of utilization of obstetric services.ConclusionDespite commendable progress in improving uptake of antenatal care, and in equipping health facilities to provide emergency obstetric care, the very low utilization of these facilities, especially by poor women, is a major impediment to meeting MDG-5 in Bangladesh.

Public-sector Maternal Health Programmes and Services for Rural Bangladesh

“…Five years after the initiation of the CSBA programme, the CSBAs conducted only 0.1% of deliveries (2). The use of ANC, SBAs, institutional delivery, and caesarean section is substantially lower in the three lower socioeconomic quintiles (13). To address the equity issue, the Government piloted a demand-side financing scheme (popularly known as the maternal health voucher programme) in two upazilas in 2007 and has scaled up to 33 upazilas (6% of upazilas/thanas) in 2008.…”

Does the Safe-Motherhood Programme Reach the Poor in Uttar Pradesh, India?

“…child mortality, maternal health and HIV/AIDS, and malaria and other diseases, has been slow and uneven, both across and within countries Carr 2004;Collin et al 2007;DeBrouwere & Van Lerberghe 1998;Koblinsky et al 2006;Kunst & Houweling 2001;Lawn et al 2006;Nanda et al 2005;National Institute of Population Research and Training (NIOPRT) et al 2001;UNICEF 1999). Related to these goals, inequalities in maternal health*measured by two monitoring indicators, namely, the maternal mortality ratio and births attended by skilled health professionals*is at a maximum (Graham et al 2004;Houwleing et al 2007).…”

Couples’ reports of household decision-making and the utilization of maternal health services in Bangladesh

“…The current literature on antenatal care and delivery care in Bangladesh focuses on socioeconomic, demographic, and geographical barriers to service utilization (Collin et al, 2007). Studies that address interpersonal factors related to maternal health service utilization, such as decision-making and husband’s involvement, tend to focus on specific, non-representative subpopulations (Amin et al, 2010; Choudhury & Ahmed, 2011).…”