Despite the implementation of programs that provide home-based skilled birth attendants, Bangladeshi women who are poor or uneducated are still far less likely than wealthier, highly educated women to use maternal health care services.1 For example, women whose household assets place them in the wealthiest quintile are more likely than those in the poorest quintile to have used skilled birth attendants (odds ratio 2.9), had a cesarean delivery (2.6) or received postnatal care (1.5) for their most recent birth. Use of these maternal services also differed by women's educational level, religion, proximity to a hospital and receipt of prenatal care.

In the past decade, the Bangladeshi government has made emergency obstetric care and, more recently, the provision of home-based skilled birth attendants the focal points of its efforts to reduce maternal mortality. Although these programs (and related programs offered by nongovernmental organizations) have often provided services at little or no cost, it has not been clear whether the women who most need such services, such as those of low socioeconomic status, have been receiving them.

To find out, researchers examined utilization of skilled birth attendants in regions served by two maternal health care programs, both run by nongovernmental organizations in areas where government services were also available. In the first program, implemented between 1992 and 1997, women in a rural region south of Dhaka were trained to be midwives, enabling them to perform safe deliveries and provide antenatal and postnatal care. The second program, conducted in rural and periurban areas throughout the country, provided refresher training to midwives and nurses in 2005. The following year, researchers at the International Centre for Diarrhoeal Disease Research, Bangladesh, used self-weighted cluster sampling to survey a representative cohort of 2,164 women who lived in areas served by these two programs and who had given birth in the previous 12 months. Women were asked about their use of antenatal care, skilled birth attendants, cesarean delivery and postnatal care. In addition, the researchers assessed various measures potentially associated with receipt of services, including wealth (determined by household assets), distance to the nearest government hospital, religion, and women's and husbands' education. Associations between use of services and background characteristics were assessed using multivariate logistic regression models that controlled for age and parity.

Most participants were Muslim (95%) and had completed at least one year of schooling (80%). More than four-fifths (81%) were aged 20–35, and one-third (35%) had been pregnant only once.

About two-thirds (65%) of deliveries had been performed at the woman's home, without the presence of a skilled birth attendant; another 12% had taken place at home, but with a skilled attendant supervising. The remaining 23% of deliveries had occurred in health facilities. The vast majority of women (93%) had had at least one prenatal care visit, and half of these women had had at least four visits. Postnatal visits, however, were far less common (28%). Eleven percent of respondents had had a cesarean delivery.

Use of maternal health care services differed according to women's education level, wealth, distance from hospital, religion and antenatal visits. For example, women from the wealthiest quintile of households were more likely than those from the poorest quintile to have had a skilled birth attendant (63% vs. 16%), a cesarean delivery (28% vs. 3%) or a postnatal care visit (39% vs. 22%).

In multivariate analyses, women were more likely to have used a skilled birth attendant if they had had at least 10 years of education (odds ratio, 2.7) or their husbands had had this level of education (2.3) than if they or their husbands had had no education, respectively. Similarly, the odds of birth attendant use were greater among women in the wealthiest quintile (2.9), those who were not Muslim (2.1) and those who had had two (2.4), three (2.9), or four or more (3.8) prenatal care visits, compared with women in the poorest quintile, Muslim women, and those who had had no prenatal visits, respectively. Women who lived more than five kilometers from a hospital were less likely than women who lived closer to a facility to have used a skilled birth attendant (0.7).

Use of cesarean deliveries and postnatal care also differed by subgroup. Women had elevated odds of having had a cesarean delivery if their husband had had at least 10 years of education (odds ratio, 2.0), if they were in the wealthiest quintile (2.6) or if they were not Muslim (2.1). Postnatal care usage was elevated among women who had had at least four prenatal care visits (2.7) and among those in the wealthiest quintile (1.5).

Overall, the findings suggest that inequality in the use of maternal health care services remains "substantial" and that costlier, facility-based services, such as cesarean delivery, are "more inequitably distributed…than front-line, less-expensive, preventive services," such as prenatal care, the authors note. Improving women's educational opportunities and reducing socioeconomic inequality "should be viewed as a central policy and programme goal" if maternal mortality is to be reduced, they contend. In addition, there is a need for "implementation and evaluation of interventions that are efficient and that benefit the poor," such as voucher programs for maternal health services.—P. Doskoch


1. Anwar I et al., Inequity in maternal health-care services: evidence from home-based skilled-birth-attendant programmes in Bangladesh, Bulletin of the World Health Organization, 2008, 86(4):252–259.