Bangladesh has made tremendous achievements in the health sector over the last few decades. According to Ahmed (2011) and Anderson (2012), the population growth rate has come down from 3% in 1975 to 1.58 % at present, the fertility rate has declined from 6 to 2.55, the contraceptive prevalence rate rose to 56% from 7.7% in 1975, the infant mortality rate has come down to 48 from more than a 100 per 1,000. There was an increase of ten years in the life expectancy between 2007 (64) and 2022 (74). The main contributing factors for such an acclaimed achievement include the up-gradation of rural health centres, the establishment of new medical colleges and institutes, increasing the involvement of Non-Government Organisations (NGOs) in service provision along with the government organisations (GOs), bringing reform in the health sector thereby decentralizing service delivery pattern (Ahmad, 2013; Rahman, 2007).
Maternal mortality in Bangladesh impacts inequities in access to primary health services with a huge gap between women in advantaged and disadvantaged socioeconomic communities (Memirie et al., 2016). About 800 women die per day due to preventable causes associated with reproductive health concerns (WHO, 2012). Furthermore, the lifetime threat of maternal deaths related to childbearing was higher in remote areas and low resources settings. According to the World Health Organization (WHO), about 99% of maternal deaths happen in low- and middle-income countries. In 2015, the maternal mortality ratio (MMR) was 239 per 100,000 live births in low- and middle-income countries compared to 12 per 100,000 live births in high-income countries. Bangladesh has in recent decades made significant achievements in maternal health indicators, with MMR being dramatically reduced. Statistics has shown that large number of women in rural areas of Bangladesh encounter severe complications during pregnancy and childbirth. Sometimes, the women do not know about health care services existing for their use, while under-utilization of healthcare services could lead to maternal morbidity and mortality.
Health care seeking behavior model was used to investigate maternal health services utilization for women's reproductive age in Bangladesh (Haque M. 2009). Delay in accessing gynaecological and obstetric care is also a major factor in women’s health. The delay is mainly associated to maternal morbidity and mortality in rural areas of Bangladesh (Killewo J. Et al. 2006). While Bangladesh has achieved notable achievement in improving the health of the population, some health indicators still remain poor. One of the foremost factors contributing to this situation is the under-utilization of community clinic services (CCS). Reasons for under-utilization of CCS have been attributed to distance of the facility from home, lack of awareness on the value of services, perceived poor quality of care, cultural and social belief systems, discrimination against those of low socio-economic status and perceived high access costs (Aktar S. 2012). The rural level facilities such as the CCs becomes demanding to provide health care services to the most-at-risk and vulnerable women. Consequent upon this, the CCs system was developed to ameliorate the situation. But, less awareness is available to describe the importance of utilizing the CCS (Normand C, et al. 2012). There are some noticeable problems related with women healthcare services. The identified problems are:
Lack of decision making power of women
Women usually experience discrimination in every stage of their lives. This discrimination in food intake and other facilities, such as education and recreation, has deleterious effects on their health. It has been argued that feeding practices, favoring boys over girls from childhood to adulthood, result in under nutrition and micronutrient deficiency in girls and women, which might ultimately bring adverse effects on pregnancy and in its aftermath (Kutzin J 1993). In addition, a large number of women do not have decision making power and opportunities to move outside of family for various purposes, including seeking healthcare services. The decision for seeking healthcare services is mainly made by male members of the household, husband in particular (Ahmed S. et al. 1995 and Khanum SM. et al. 2003).
Gender dynamic
Gender of health personnel is an important factor that influences pregnant mothers’ decisions about utilization of formal MHC services. As Bangladesh is a conservative country and the urban slum dwellers and rural women researched have traditional ideas and beliefs, female patients are hesitant to go to the centre for receiving treatment from male doctors during the complication period, despite the availability of female paramedics for primary care. Some authors have identified a number of key constraints Bangladesh rural women have been facing in receiving health services e.g. purdah, the unavailability of female doctors etc.84 Women also need more personalized and emotion-laden services during the delivery period. Like many other cultures, childbirth-related activities in Bangladesh are deemed to be female activities. It has been observed during the fieldwork that heads of all service centres except two were males. For this reason, cultural practices and taboos may deter pregnant women from receiving healthcare services from there (third delay).
Quality of Care
Adequate physical facilities, such as health personnel, infrastructure, and medicine, behaviour and attitude of service providers towards service users, service providers’ extent of knowledge and use of hygienic procedures when dealing with patients are important determinants of understanding the quality of services. A few studies found the pitiable condition of physical facilities in rural healthcare centres and harsh, rude, and uncaring behaviour of service providers towards patients. During delivery, pregnant mothers prefer people as their assistants who are well-mannered. As pregnant mothers perceive rude and harsh behaviours of health personnel working at government hospitals, they prefer to seek assistance from TBAs or local unqualified ‘doctors’ during baby delivery (Banik BK. Rural Health Services 2003 and GUS 2008). In addition, as reported in a study, 90% of patients who had visited qualified private and unqualified practitioners were satisfied with their behaviours and attitudes towards them. Only 66% were satisfied with government service providers. It also found that government officials behaved roughly with patients who came from poor socio-economic background. Another study documented that overall quality of EmOC in all public health centres except the medical college hospital was poor. The worst quality was found at upazila level (Anwar I, Kalim N, Koblinsky M ,2009). Moreover, Banik (2016) found some practical problems related with women health services, such as:
- Poor women with limited access to maternal healthcare services face tremendous health problems.
- Situation of maternal health in Rajsahi division is worse compared to other divisions in Bangladesh.
- Social and organisational barriers are more prevalent than physical barrier in the study areas.
- All these barriers apparently delay in seeking, availing and receiving healthcare services.
- Rescheduling the opening and closing times of the healthcare service centre, recruiting and posting female health staff, formulating a guiding principle and making emergency ob-stetric care free are the possible ways of im-proving maternal health situation.
Waiting time
Sometimes patients need to wait for healthcare services. If this waiting time becomes longer, they are discouraged from going to health centres. Increasing the number of health personnel in these centres is one way to address this issue. Many organizations (government and private, including NGOs) in urban areas endeavor to provide services in a timely manner so that patients do not lose their patience. With more choices, the urban folk can so easily make decisions about seeking care from any particular centre where, as perceived, they need not wait too long for treatment. For instance, around 80% service recipients at urban centres run by an NGO reported the waiting time to be less than 20 minutes (Banik B 2010).
In many cases, women from rural and urban slum areas with low levels of formal education do not know where to go for proper treatment. They usually spend more time locating an appropriate health centre. This long search process puts some pregnant mothers at great risk or may even prove fatal for both mother and child. For instance, a pregnant mother commonly goes to a local dai-traditional birth attendant (TBA). If the dai identifies any anomalies in the pregnancy, she is sent to either the village doctor, who has no proper training, or the union health centre. As rural health centres are not well equipped with essential drugs and medical aids, pregnant mothers are sent to the upazila health complex (UHC). If the UHC fails to provide the required treatment, the patient is finally sent to either the district hospital or mother and child welfare centres (MCWCs) located at the district level (Chowdhury RH, Chowdhury Z 2009).
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Opportunity costs
Uncertainty and fear about the government hospital’s formal atmosphere and the not-so-friendly attitude of health staff there generally discourage rural people from visiting them. This delays making decisions about seeking healthcare from public hospitals. Expectant mothers often find it difficult to get someone who knows the hospital environment and staff well and who is willing to provide time to accompany them. Even after being there on time and with a companion, it is not always easy to get the treatment commenced immediately or even in a short time. All these factors can be a waste of time and energy for both patient and her companion. For instance, a study depicts how Papreen’s mother-in-law failed to convince Monira to go as an accompanying person to the UHC during Papreen’s first baby delivery: “We must convince Monira to go with us. We don’t know anything in the hospital. Doctors and nurses will be annoyed if we can’t communicate with them” (Afsana k 2005).
The time spent by attendants diverts them from income generating activities and other domestic work, such as cooking and taking care of family members, particularly children. Another study rightly mention, “Time spent getting to, waiting for and receiving health services is time lost from other, more productive activities, such as farming, fetching water and wood for fuel, herding, trading, cooking and so on” (Thaddeus S, Maine D. 1994). The other study documented that mothers, sisters, mothers-in-law, husband’s sisters, husband’s brothers or cousins and their wives, and wives of husband’s uncles provided support during and after their pregnancies (Edmonds JK et al. 2011).
Inefficient distribution of benefits
The UPHCP, one of the important non-government service providers in the study urban areas, has a provision to cater 30% of its services free to the poor. The question that emerges then is how the poor are to be defined and the extent of free services gauged. If all patients who come one day to the centres are poor, are they all rendered free services? The project manager reported during the field visit that local political leaders created pressures on him to give free services to the non -poor. He also showed many fake documents that many non-poor used for receiving free services. One of the main reasons for entertaining undue requests causing exclusion error, as mentioned by the manager, is to continue project activities smoothly. Another study indicates that the poor have been defined based on reports made by local health workers who could be biased towards someone that can cause both inclusion and exclusion errors (Banik B 2010). As observed, it also introduced an ANC package worth 50 Taka for pregnant mothers reaching the last trimester to monitor the progression of pregnancies. Higher delivery costs for the Caesarean are not fully waived for the poor women. So the lack of well-defined free services and high costs of comprehensive MHC services could create tensions among poor mothers that deter from going there for treatment.
FAQ Here:
Why is primary health care important for women in Bangladesh?
Primary health care is important for women because it provides them with basic health care such as pregnancy, childbirth, child health, and family health care. In addition, by receiving early treatment for health problems, women are less likely to have long-term health problems and die.
What are the main challenges to primary healthcare for women in Bangladesh?
The main challenges to primary healthcare for women in Bangladesh are infrastructure constraints, lack of healthcare workers, and access to healthcare in rural areas. In addition, social and cultural barriers also pose a threat to women's access to primary healthcare.
What steps should be taken to improve primary healthcare for women?
To improve primary healthcare for women, the government needs to strengthen health infrastructure, increase the number of health workers in rural areas, and increase health education and awareness among women. In addition, the establishment of special healthcare centers for women and the use of digital healthcare can also be helpful.