Non-professional health practitioners and referrals to facilities: lessons from maternal care in Bangladesh.

Over half a million women in the developing world die of pregnancy and childbirth related causes each year, despite well-known interventions to manage most maternal complications. One problem facing policy makers is that women in low-income settings often seek care from a range of non-professional sources when they have trouble with pregnancy and childbirth. Questions remain as to the best way to engage with such providers to encourage use of professional care, in part because little policy-oriented research has attempted to study the roles of non-professional practitioners, and the specific situations which can encourage or discourage referral behaviour. This paper investigates the roles played by alternative health practitioners in referral to facilities for maternal care in Bangladesh. In-depth case studies were used to investigate labour experiences, decision-making processes and the roles played by key individuals in deciding to use professional services. Findings show that the commonly used heading of 'traditional birth attendant' is often too broad for programmatic use, as it encompasses a range of individuals with different reasons to work with, or oppose, professional services. It was found that women seek care from multiple non-professional cadres who each have differing services, scopes and linkages to professional care. Policy makers need to understand the roles of different providers and potential links to professional care which can be built upon to encourage the use of professional emergency care for maternal complications in low-income settings.