Quality of Obstetric Care in Public-sector Facilities and Constraints to Implementing Emergency Obstetric Care Services: Evidence from High- and Low-performing Districts of Bangladesh

Abstract

This study explored the quality of obstetric care in public-sector facilities and the constraints to programming comprehensive essential obstetric care (EOC) services in rural areas of Khulna and Sylhet divisions, relatively high- and low-performing areas of Bangladesh respectively. Quality was explored by physically inspecting all public-sector EOC facilities and the constraints through in-depth interviews with public-sector programme managers and service providers. Distribution of the functional EOC facilities satisfied the United Nation's minimum criteria of at least one comprehensive EOC and four basic EOC facilities for every 500,000 people in Khulna but not in Sylhet region. Human-resource constraints were the major barrier for maternal health. Sanctioned posts for nurses were inadequate in rural areas of both the divisions; however, deployment and retention of trained human resources were more problematic in rural areas of Sylhet. Other problems also plagued care, including unavailability of blood in rural settings and lack of use of evidence-based techniques. The overall quality of care was better in the EOC facilities of Khulna division than in Sylhet. ‘Context' of care was also different in these two areas: the population in Sylhet is less literate, more conservative, and faces more geographical and sociocultural barriers in accessing services. As a consequence of both care delivered and the context, more normal vaginal and caesarian-section deliveries were carried out in the public-sector EOC facilities in the Khulna region, with the exception of the medical college hospitals. To improve maternal healthcare, there is a need for a human-resource plan that increases the number of posts in rural areas and ensures availability. All categories of maternal healthcare providers also need training on evidence-based techniques. While the centralized push system of management has its strengths, special strategies for improving the response in the low-performing areas is urgently warranted.

Availability and Quality of Emergency Obstetric and Newborn Care in Bangladesh

“…First, signal functions for assessment of EmNC in this study did not include provision of prophylactic antibiotics to the mother in case of preterm or prolonged premature rupture of membranes, which may limit the ability to compare the findings with other studies. In addition, the number of basic EmONC facilities has fluctuated over the years, 21,32,53,62 possibly due to supply failure or inability to deliver the service (e.g., lack of drugs or absence of a provider, and renovations of maternity wards). Studies that enable a better understanding of this gap will help to guide future preventive interventions.…”

“…A previous study found that lack of job openings in government health facilities for nurses was a common barrier to obstetric care programs in rural Bangladesh. 62 The most common limitations to recruitment and retaining health staff include the lack of desire to work in remote rural areas, and low morale among staff working in public facilities that are often overcrowded and underequipped. 63 The lack of trained staff has been suggested as one of the major obstacles in ensuring high-quality neonatal care.…”

Care seeking at time of childbirth, and maternal and perinatal mortality in Matlab, Bangladesh

“…Little is known about the quality of obstetric care in hospitals in Bangladesh, but Research there is some evidence of substandard care within public facilities. 22,23 There are substantial constraints on human resources, and some staffing positions may be left unfilled. The costs of care to patients are high; patients invariably have to buy some medicines -particularly for obstetric surgery -and evidence-based practices, such as the use of magnesium sulfate or the partograph, are far from universal.…”

Barriers to access in maternal healthcare services in the Northern Bangladesh

“…The worst quality was found at upazila level. 6 The study (Table 11) found that half of the health personnel interviewed did not have any training on baby delivery. Only three had training and two of them were in NGOs.…”