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Indigenous women's health in low and middle-income countries continues to experience exclusions from the mainstream context and has remained underrepresented in health research, including qualitative research. Based on mixed methods research (comprising qualitative and quantitative methods) into Indigenous women in Bangladesh, this article addresses the reflexivity of a non-Indigenous researcher studying Indigenous women's health issues in the Chittagong Hill Tracts of Bangladesh. As reflexivity is a crucial strategy to ensure rigor in qualitative research, understanding how the characteristics and experiences of the study may influence the research process is of paramount importance. For non-Indigenous researchers working in an Indigenous context, the imperative to understand one's impact and position within the research becomes even more critical. Unfortunately, non-Indigenous researchers often avoid providing appropriate detail on reflexivity aspects in conducting research, particularly mixed-method research, among Indigenous communities in low- and middle-income countries like Bangladesh. In this reflexive evaluation, the researchers of this mixed method study evaluate the introspective reflexivity; reflect on the pre-research stage in developing collaborative and negotiated design and reflect on positionality during fieldwork and data analysis to consider interpersonal and collective dynamics during the research process. Strategies are offered to harvest the benefits of the researcher's familiarity with the subject and limit any unfavorable consequences. Directions for future research include integration of research methods, using qualified Indigenous researchers, engaging Indigenous community leaders, and collecting data using native language to respect and value the culture and voice of Indigenous communities. [ABSTRACT FROM AUTHOR]

Bangladesh has achieved notable success in improving maternal health by increasing women's access to good quality and low-cost maternal health care (MHC) services. However, the health system of Bangladesh has earned criticism for not ensuring equitable MHC access for all women, particularly for Indigenous women in the Chittagong Hill Tracts (CHT). Little is known about Indigenous communities' perspectives on these inequalities in MHC service access in the CHT. Therefore, this study aimed to explore Indigenous communities' perspectives on challenges and opportunities for improving MHC service access in the CHT. This qualitative descriptive study was conducted in two sub-districts of Khagrachhari between September 2017 and February 2018. Eight Indigenous key informants from three Indigenous communities (Chakma, Marma and Tripura) were recruited via snowballing and purposive techniques and participated in face-to-face, semi-structured interviews. Key informants comprised community leaders and health care providers. Data were analysed thematically using Nvivo12 software. Findings suggest that distance, poor availability of resources and infrastructure, lack of community engagement in the design of health interventions, Indigenous cultural beliefs, misconceptions about MHC services, and maltreatment from health care providers were the key barriers to accessing MHC services; all are interconnected. Indigenous women faced humiliation and maltreatment from MHC staff. Failure to provide a culturally-safe environment suggests a lack of cultural competency among health staff, including Indigenous staff. Findings suggest that cultural competency training for all health care providers is needed to improve cultural appropriateness and accessibility of services. Refresher training and undisrupted supply of basic MHC services for front-line care providers will benefit the entire community and will likely be cost-effective for the government. Designing health programmes through extensive community consultation is essential. [ABSTRACT FROM AUTHOR]

Background: Prevalence of accessing antenatal care (ANC) services among Indigenous women in the Chittagong Hill Tracts (CHT) is unknown. This study aims to estimate the prevalence of accessing ANC services by Indigenous women in the CHT and identify factors associated with knowledge of, and attendance at, ANC services. Methods: Using a cross-sectional design three Indigenous groups in Khagrachari district, CHT, Bangladesh were surveyed between September 2017 and February 2018. Indigenous women within 36 months of delivery were asked about attending ANC services and the number who attended was used to estimate prevalence. Socio-demographic and obstetric characteristics were used to determine factors associated with knowledge and attendance using multivariable logistic regression techniques adjusted for clustering by village; results are presented as odds ratios (OR), adjusted OR, and 95% confidence intervals (CI). Results: Of 494 indigenous women who met the inclusion criteria in two upazilas, 438 participated (89% response rate) in the study, 75% were aged 16–29 years. Sixty-nine percent were aware of ANC services and the prevalence of attending ANC services was 53% (n = 232, 95%CI 0.48–0.58). Half (52%; n = 121) attended private facilities. Independent factors associated with knowledge about ANC were age ≥30 years (OR 2.2, 95%CI 1.1–4.6), monthly household income greater than 20,000 Bangladeshi Taka (OR 3.4, 95%CI 1.4–8.6); knowledge of pregnancy-related complications (OR 3.6, 95%CI 1.6–8.1), knowledge about nearest health facilities (OR 4.3, 95%CI 2.1–8.8); and attending secondary school or above (OR 4.8, 95%CI 2.1–11). Independent factors associated with attending ANC services were having prior knowledge of ANC benefits (OR 7.7, 95%CI 3.6–16), Indigenous women residing in Khagrachhari Sadar subdistrict (OR 6.5, 95%CI 1.7–25); and monthly household income of 20,000 Bangladeshi Taka or above (OR 2.8, 95%CI 1.1–7.4). Conclusion: Approximately half of Indigenous women from Chittagong Hill Tracts Bangladesh attended ANC services at least once. Better awareness and education may improve ANC attendance for Indigenous women. Cultural factors influencing attendance need to be explored. [ABSTRACT FROM AUTHOR]

Background: Increased maternal health care (MHC) service utilisation in Bangladesh over the past decades has contributed to improvements in maternal health outcomes nationally, yet there is little understanding of Indigenous women's experiences of accessing MHC services in Bangladesh. Methods: Face-to-face semi-structured qualitative interviews with 21 Indigenous women (aged 15–49 years) within 36 months of delivery from three ethnic groups (Chakma, Marma and Tripura) were conducted between September 2017 and February 2018 in Khagrachhari district. Purposive sampling was used to recruit women representative of the population distribution in terms of age, ethnic community and service use experience. All interviews were conducted in Bangla language and audio-recorded with consent. Interviews were transcribed directly into English before being coded. Data were analysed thematically using a qualitative descriptive approach aided by NVivo12 software. Results: Of the 21 women interviewed, 14 had accessed at least one MHC service during their last pregnancy or childbirth and were categorised as the User group. The remaining seven participants were categorised as 'Non-users' as they had not access antenatal care, facility delivery or postnatal care services. Women reported that they wanted culturally relevant, respectful, home-based and affordable care, and generally perceived formal MHC services as being only for complications and emergencies. Barriers to accessing MHC services included low levels of understanding about the importance of MHC services, concerns about service costs, limited transport and fears of intrusive practices. Experiences within health services that deterred women from accessing future MHC services included demands for unofficial payments and abusive treatment by public facility staff. Conclusion: Improving access to MHC services for the CHT Indigenous women requires improved understandings of cultural values, priorities and concerns. Multifaceted reform is needed at individual, community and health systems levels to offer culturally appropriate health education and flexible service delivery options. [ABSTRACT FROM AUTHOR]

Objective: To estimate the prevalence of facility delivery knowledge and access during childbirth amongst Indigenous women in the Chittagong Hill Tracts, Bangladesh and to identify factors associated with facility delivery service utilisation., Design: A cross-sectional study design using a structured self-report survey., Setting: Two Upazilas (subdistricts) of Kharachhari hill district of the Chittagong Hill Tracts., Participants: Indigenous women of reproductive age (15-49 years) within 36 months of delivery., Measurements and Findings: A modified national survey about accessing maternal health services, including delivery services was administered to all Indigenous women that met eligibility, guided by community leaders. Data collected included socio-demographic characteristics and reproductive history. Main outcome variables were the proportion of women having prior knowledge about and access to facility delivery services for childbirth in the three years prior to the survey. Secondary outcomes were sources of information about facility delivery services, decision making about delivery place, and factors associated with knowledge and attendance at facility delivery services. Factors associated with knowledge and attendance were estimated using logistic regression with results reported as adjusted odds ratios and 95% confidence intervals. With an 89% response rate, a total of 438 Indigenous women (220 Chakma, 100 Marma, 118 Tripura) participated in the survey, and 75% were aged 16-29 years. Relatives played a vital role as a source of information about delivery services (59%). Nearly three-quarters (73%) were aware of facility delivery services, however, prevalence of accessing delivery services was 33% (n = 143; 95% CI 0.28-0.37). Relatives were the key decision-makers for accessing facility delivery services (60%). Independent factors associated with knowledge about facility delivery were higher household income (AOR 5.3, 95%CI 2.2-13); having knowledge of nearest health care facilities (AOR 5.8, 95%CI 3.0-11); and attending antenatal care visits during last pregnancy (four or more AOR 3.1, 95% CI 1.3-7.2 and one to three visits AOR 2.7, 95% CI 1.5-5.0). Independent factors associated with accessing facility delivery services at childbirth were attending antenatal care visit; having access to media; higher level of education of partners; and residing at Khagrachhari Sadar compared to Matiranga subdistrict., Key Conclusions and Implications for Practice: Indigenous women in Chittagong Hill Tracts, Bangladesh have sub-optimal knowledge of, and attendance at, facility delivery services for childbirth. Maternal health related interventions should target Indigenous women in order to educate and motivate them to access facility delivery services at childbirth. Rigorous research is needed to explore Indigenous cultural practices related to childbirth that might influence their access to facility delivery services., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2020. Published by Elsevier Ltd.)

Objectives: This study aimed to estimate the prevalence of, and factors associated with, accessing maternal healthcare services (MHC) by Indigenous women in the Chittagong Hill Tracts (CHT), Bangladesh., Design: This was a cross-sectional survey among Indigenous women of reproductive age., Setting: Two upazillas (subdistricts) of Khagrachhari hill district of the CHT., Participants: Indigenous women (15-49 years) within 36 months of delivery were surveyed about accessing MHC services (antenatal care, delivery and postnatal care) for their last pregnancy and delivery., Primary Outcome Measures: The primary outcome for this analysis is the prevalence of accessing any MHC service and secondary outcome is factors associated with access to MHC services for Indigenous women during their last pregnancy and childbirth., Results: Of 438 Indigenous women (220 Chakma, 100 Marma, 118 Tripura) who participated, 75% were aged 16-30 years. With an 89% response rate, a total of 258 (59%) women reported accessing at least one MHC service (Chakma 51.6%, Marma 28%, Tripura 20.5%; p=<0.001). Independent factors associated with accessing MHC after adjusting for clustering were attending secondary school and above (OR 2.4; 95% CI 1.2 to 4.9); knowledge about nearest health facilities (OR 3.8, 95% CI 1.8 to 7.8) and knowledge of pregnancy-related complications (OR 3.0, 95% CI 1.5 to 5.8)., Conclusion: Findings suggest that the prevalence of accessing MHC services is lower among Indigenous women in the CHT compared with national average. MHC access may be improved through better education and awareness raising of local services., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)