The challenges of meeting rural Bangladeshi women's needs in delivery care.

Despite initiatives and interventions undertaken at national and international levels, maternal health is still neglected in Bangladesh, and the maternal mortality ratio remains one of the highest in the world. In order to improve rural women's access to maternity care, in 1996 the Bangladesh Rural Advancement Committee (BRAC) instituted services for birthing women in 21 health facilities in each Thana. This paper reports on research conducted three years later, based on interviews with women who gave birth in one BRAC Health Centre (BHC) and women who gave birth at home, interviews with staff of the BHC and observation of provider-patient relations. Acceptance of delivery in a health facility by rural women is still minimal. Most women only attended the BHC due to complications, yet the BHC was unable to handle most complications and referred women to the district hospital, where they received poor quality care. Cost, fear of hospitals and the stigma of an 'abnormal' birth were also important constraints. Female paramedics who attended normal deliveries were praised for being caring, but made women deliver lying down, did not always use aseptic procedures and were too busy to give information, making birth a passive experience. Recommendations to provide comprehensive emergency obstetric care at the BHC and upgrade staff skills, introduce rural health insurance and others have already begun to be implemented.