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Achieving Millennium Development Goal 5 in Bangladesh calls for an appreciation of the evolution of maternal healthcare within the national health system to date plus a projection of future needs. This paper assesses the development of maternal health services and policies by reviewing policy and strategy documents since the independence in 1971, with primary focus on rural areas where three-fourths of the total population of Bangladesh reside. Projections of need for facilities and human resources are based on the recommended standards of the World Health Organization (WHO) in 1996 and 2005. Although maternal healthcare services are delivered from for-profit and not-for-profit (NGO) subsectors, this paper is focused on maternal healthcare delivery by public subsector. Maternal healthcare services in the public sector of Bangladesh have been guided by global policies (e.g. Health for All by the Year 2000), national policies (e.g. population and health policy), and plans (e.g. five- or three-yearly). The Ministry of Health and Family Welfare (MoHFW), through its two wings--Health Services and Family Planning--sets policies, develops implementation plans, and provides rural public-health services. Since 1971, the health infrastructure has developed though not in a uniform pattern and despite policy shifts over time. Under the Family Planning wing of the MoHFW, the number of Maternal and Child Welfare Centres has not increased but new services, such as caesarean-section surgery, have been integrated. The Health Services wing of the MoHFW has ensured that all district-level public-health facilities, e.g. district hospitals and medical colleges, can provide comprehensive essential obstetric care (EOC) and have targeted to upgrade 132 of 407 rural Upazila Health Complexes to also provide such services. In 2001, they initiated a programme to train the Government's community workers (Family Welfare Assistants and Female Health Assistants) to provide skilled birthing care in the home. However, these plans have been too meagre, and their implementation is too weak to fulfill expectations in terms of the MDG 5 indicator-- increased use of skilled birth attendants, especially for poor rural women. The use of skilled birth attendants, institutional deliveries, and use of caesarean section remain low and are increasing only slowly. All these indicators are substantially lower for those in the lower three socioeconomic quintiles. A wide variation exists in the availability of comprehensive EOC facilities in the public sector among the six divisions of the country. Rajshahi division has more facilities than the WHO 1996 standard (1 comprehensive EOC for 500,000 people) whereas Chittagong and Sylhet divisions have only 64% of their need for comprehensive EOC facilities. The WHO 2005 recommendation (1 comprehensive EOC for 3,500 births) suggests that there is a need for nearly five times the existing national number of comprehensive EOC facilities. Based on the WHO standard 2005, it is estimated that 9% of existing doctors and 40% of nurses/midwives were needed just for maternal healthcare in both comprehensive EOC and basic EOC facilities in 2007. While the inability to train and retain skilled professionals in rural areas is the major problem in implementation, the bifurcation of the MoHFW (Health Services and Family Planning wings) has led to duplication in management and staff for service-delivery, inefficiencies as a result of these duplications, and difficulties of coordination at all levels. The Government of Bangladesh needs to functionally integrate the Health Services and Family Planning wings, move towards a facility-based approach to delivery, ensure access to key maternal health services for women in the lower socioeconomic quintiles, consider infrastructure development based on the estimation of facilities using the WHO 1996 recommendation, and undertake a human resource-development plan based on the WHO 2005 recommendation. [ABSTRACT FROM AUTHOR]

This paper assesses both out-of-pocket payments for healthcare and losses of productivity over six months postpartum among women who gave birth in Matlab, Bangladesh. The hypothesis of the study objective is that obstetric morbidity leads women to seek care at which time out-of-pocket expenditure is incurred. Second, a woman may also take time out from employment or from doing her household chores. This loss of resources places a financial burden on the household that may lead to reduced consumption of usual but less important goods and use of other services depending on the extent to which a household copes up by using savings, taking loans, and selling assets. Women were divided into three groups based on their morbidity patterns: (a) women with a severe obstetric complication (n=92); (b) women with a less-severe obstetric complication (n=127); and (c) women with a normal delivery (n=483). Data were collected from households of these women at two time-points--at six weeks and six months after delivery. The results showed that maternal morbidity led to a considerable loss of resources up to six weeks postpartum, with the greatest financial burden of cost of healthcare among the poorest households. However, families coped up with loss of resources by taking loans and selling assets, and by the end of six months postpartum, the households had paid back more than 40% of the loans. [ABSTRACT FROM AUTHOR]

Although India has made slow progress in reducing maternal mortality, progress in Tamil Nadu has been rapid. This case study documents how Tamil Nadu has taken initiatives to improve maternal health services leading to reduction in maternal morality from 380 in 1993 to 90 in 2007. Various initiatives include establishment of maternal death registration and audit, establishment and certification of comprehensive emergency obstetric and newborn-care centres, 24-hour x 7-day delivery services through posting of three staff nurses at the primary health centre level, and attracting medical officers to rural areas through incentives in terms of reserved seats in postgraduate studies and others. This is supported by the better management capacity at the state and district levels through dedicated public-health officers. Despite substantial progress, there is some scope for further improvement of quality of infrastructure and services. The paper draws out lessons for other states and countries in the region. [ABSTRACT FROM AUTHOR]

This paper describes associations among delivery-location, training of birth attendants, birthing practices, and early postpartum morbidity in women in slum areas of Dhaka, Bangladesh. During November 1993-May 1995, data on delivery-location, training of birth attendants, birthing practices, delivery-related complications, and postpartum morbidity were collected through interviews with 1,506 women, 489 home-based birth attendants, and audits in 20 facilities where the women from this study gave birth. Associations among maternal characteristics, birth practices, delivery-location, and early postpartum morbidity were specifically explored. Self-reported postpartum morbidity was associated with maternal characteristics, delivery-related complications, and some birthing practices. Dais with more experience were more likely to use potentially-harmful birthing practices which increased the risk of postpartum morbidity among women with births at home. Postpartum morbidity did not differ by birth-location. Safe motherhood programmes must develop effective strategies to discourage potentially-harmful home-based delivery practices demonstrated to contribute to morbidity. [ABSTRACT FROM AUTHOR]

Background: Proper utilization of antenatal and postnatal care services plays an important role in reducing the maternal mortality ratio and infant mortality rate. This paper assesses the utilization of health care services during pregnancy, delivery and post-delivery among rural women in Uttar Pradesh (UP) and examines its determinants.Methods: Data from a baseline survey of UP Community Mobilization (UPCM) project (2013) was utilized. A cross-sectional sample of currently married women (15 to 49 years) who delivered a baby 15 months prior to the survey was included. Information was collected from 2208 women spread over five districts of UP. Information on socio-demography characteristics, utilization of antenatal care (ANC), delivery and postnatal care (PNC) services was collected. To examine the determinants of utilization of maternal health services, the variables included were three ANC visits, institutional delivery and PNC within 42 days of delivery. Separate multilevel random intercept logistic regressions were used to account for clustering at a block and gram panchayat level after adjusting for covariates.Results: Eighty-three percent of women had any ANC. Of them, 61% reported three or more ANC visits. Although 68% of women delivered in a health facility, 29% stayed for at least 48 h. Any PNC within 42 days after delivery was reported by 26% of women. In the adjusted analysis, women with increasing number of contacts with the health worker during the antenatal period, women exposed to mass-media and non-marginalized women were more likely to have at least three ANC visits during pregnancy. Non-marginalized women and women with at least three ANC visits were more likely than their counterparts to deliver in an institution. Contacts with health worker during pregnancy, marginalization, at least three ANC visits and institutional delivery were the strong determinants for utilization of PNC services. Self-help group (SHG) membership had no association with the utilization of maternal health services.Conclusions: Utilization of maternal health services was low. Contact with the health worker and marginalization emerged as important factors for utilization of services. Although not associated with the utilization, SHGs can be used for delivering health care messages within and beyond the group. [ABSTRACT FROM AUTHOR]