Institutional births and poor outcomes for the poor
The markedly larger socioeconomic differentials in neonatal mortality for those born in hospitals suggests strongly that provision of care at birth is particularly failing to meet the needs of disadvantaged women and their newborns. Both the descriptive and regression results clearly demonstrate that wealth has a markedly greater impact on neonatal outcomes for those giving birth in institutions compared to those giving birth at home. This suggests poor women are either arriving too late, or the care they receive is inadequate. While the descriptive analysis for education shows a very similar pattern, evidence from the multivariate analysis is less compelling: while not significant, there is a marked increase in OR for neonatal death for no education, primary and secondary education for women giving birth at home compared to those with higher education. The lack of significance may well be as a result of small sample size, and the findings may reflect the fact that the reference group of those women who have received further education is a particularly small and elite group with very low overall neonatal mortality.
The difference in neonatal outcomes from institutions between the urban and rural poor is also marked. This could be either because the characteristics of the two groups are different, or because access to services is more difficult in rural areas. In many countries rural poverty may be deeper and more chronic than in urban areas, and the population may be less educated. There is some evidence that the rural population in this study are indeed different in character: we cannot directly compare wealth between urban and rural groups using the asset index, but if we examine education, over half (53%) of the rural quintiles 1–4 had no education compared to 34% of urban quintiles 1–4. However, another plausible reason could be the increased journey time when seeking care for rural women, which could detrimentally impact on outcome. The Bangladesh Maternal Health Services and Maternal Mortality Survey 2001 found that only 26% of rural women with complications reported travelling less than 30 minutes to reach a provider or facility compared with 59% of urban respondents. Around 8% of women reported travelling for more than 3 hours, which obviously is likely to have negative consequences.
While utilisation data are often disaggregated, data on institutional outcomes are not routinely analysed – indeed the idea of inequity in outcomes from services is not well developed within the literature. This work suggests that such measures could be important, and provide a much more comprehensive picture than utilisation data alone. For instance, an apparent increase in utilisation among the poorest might mask the fact that many of these women are only arriving at hospital once complications are well advanced, thus reducing their chance of positive outcomes. Ideally such analysis should include attention to fresh stillbirths, which are often used as an indicator of care at birth. However, very limited data are available: DHS infrequently collect data on stillbirths, and quality is questionable, along with a further limitation that fresh and macerated stillbirths are not differentiated. Indeed, it is worth considering that the extremely negative outcomes experienced by poor women would be even more concerning if stillbirths could be included, as poor or delayed intrapartum care may often result in the foetus dying during labour, so will not be included as a neonatal death.
The fact that due to sample size quintiles 1–4 were grouped together probably also results in an underestimation of the disadvantage faced by the poorest in terms of neonatal outcomes. Examining the difference in mortality between the top and bottom socio-economic groupings is a commonly used method of examining inequality, but has the limitation of failing to ascertain the distribution of mortality across the population. Another measure that could address this would be calculation of concentration curves or indices for the different groups as this takes into account mortality for the whole range of wealth. Further studies using this technique may be valuable.
Analysis over time of perinatal institutional outcomes can provide valuable evidence on quality of care. It would be assumed that as uptake of skilled care at birth increases, outcomes would improve as more and more women with uncomplicated pregnancies make an active choice to give birth in hospital. However, there are suggestions that in some cases increased demand actually has a negative impact on quality, as staff and resources are placed under greater pressure. Monitoring of institutional mortality rates, particularly among the poorest could give some indication of any unintended negative consequences resulting from efforts to increase uptake of services.
Why are institutional outcomes so poor for women in Bangladesh?
While this study were able to identify groups of women who experienced particularly poor outcomes, our descriptive analysis is unable to demonstrate that any group has significantly reduced mortality as a result of utilising institutional care at birth when compared with babies born at home with similar socioeconomic characteristics. In an environment such as Bangladesh many mothers in the higher socio-economic groups may use hospital care at birth only in response to complications. While their outcomes may be better because of faster recognition of, and response to, complications than their poorer counterparts, their underlying condition will still affect the neonatal outcome.
It is also possible that if quality of care is relatively poor for all women (not just the poorest), the potential benefits from institutional birth may be reduced or in some cases even negated. There are ongoing concerns in connection with poor quality of maternal health care covering the entire period reflected in this study. An assessment of the Bangladesh Maternal Mortality programme in 1997 found patients’ wellbeing placed at risk by a lack of drugs and sterilised equipment and poor hygiene practices. Dysfunctional staff configurations, inadequately skilled staff and poor infrastructure were also identified as barriers to quality care. More recently Chowdhury et al. discovered constraints such as inadequate drug supplies, insufficient specialist staff, human resource absenteeism and long waiting times that all contributed to poor quality care. While data is again limited, there is also growing evidence that the potential for improved outcomes from an increase in facility births in developing countries may be reduced by the high incidence of hospital-acquired (nosocomial) infections in newborns.
As this study covers a considerable period of time, the question arises as to whether the situation has improved between 1997 and 2007. While Bangladesh has made some progress since the data used in this study was collected, the proportion of women receiving skilled care in Bangladesh is still amongst the lowest in the world and it could be questioned how much impact such limited progress would have on improving neonatal outcomes. Despite this, the limited data we present seems to suggest that most gains in reducing neonatal mortality have been in hospital births, and the most recent survey (2007) suggests that at the national level there are now similar levels of neonatal mortality in institutions and at home. This may imply that either quality has improved, or women with complications are recognising and seeking care more promptly. These changes can be considered within the rather surprising context of strong reductions in maternal mortality during this period. As the increase in skilled attendance has been so modest, it has been suggested that this reduction could be partly driven by improved knowledge of, and health seeking for complications, and increased access to emergency obstetric care, which would support our premise. More research is needed to understand the factors driving reductions in maternal and neonatal mortality in Bangladesh, and how their impact can be maximised.
Efforts to improve timely uptake of services for all women (not just those with complications) is extremely challenging in contexts such as Bangladesh, and will require a number of both demand- and supply-side interventions to improve access to and quality of services and also increase understanding of the need for skilled attendance at all births. In addition, services must be accessible to all sectors of the community, which will require innovative and far-reaching solutions to solve the problems of both formal and informal health care costs.