This study has revealed important upward trends for antenatal care in Bangladesh between 1991 and 2004, but progress for deliveries attended by health care professionals was disappointingly small. This latter finding brings up-to-date an earlier analysis of trends in delivery care in Bangladesh which was based on the first three DHS . Births with a professional increased from an extremely low level of 9% in the early nineties to a mere 13% in the new Millennium, though near universal coverage was reached among urban, wealthy and highly educated women. Births by caesarean also rose, but this effect was only seen among wealthier women. A comparison of the extreme ends of the social spectrum revealed huge gaps in access to caesarean sections, with the urban rich and educated having excessive caesareans (at a rate of 34.8%) compared to the rural uneducated poor among whom caesarean sections were almost non-existent (at a rate of 0.1%).
The limited progress towards increasing skilled attendance at birth is perhaps not surprising, given the focus of the national programme on upgrading EmOC facilities rather than training and deploying midwives. Wider provision of EmOC has clearly increased access to obstetric surgery, although much of the increase occurred in the private sector (data not shown), and only the wealthier women benefit from these interventions. The majority of caesarean sections in Bangladesh are performed at private facilities,  and whether the increasing caesarean section rates reflect actual gains towards meeting the need for obstetric care is difficult to say. All-cause caesareans may comprise women who need a surgical intervention in order to save their or their baby's life as well as women for whom there is no clinical need, hence interpreting crude caesarean rates is difficult . Even though not all caesarean sections are necessarily life-saving, caesarean section rates of less than 1% indicate an unmet need for potentially life-saving care [20, 21]. Data from the rural Matlab area of Bangladesh suggest that the met need for obstetric care is increasing,  but whether this is true at national level is not known.
The Government of Bangladesh has set a specific MDG target to increase skilled attendance at birth to 50% by 2010. With the current rate of progress, this target will not be reached, and the challenges are huge. The density of midwives was estimated at 1.8 midwives per 10,000 population in 2004 . This falls within the range reported for neighbouring Malaysia and Sri Lanka (3.4/10000 and 1.6/10000 respectively), countries which have rates of skilled attendance above 97% . However, in urban areas, where the density of midwives is likely to be higher and where other physical barriers such as transport are unimportant, skilled attendance is still only 32%, suggesting that supply alone is not the solution. Women in Bangladesh may have a strong attachment to home-based birth traditions, and may prefer traditional birth attendants with whom they have closer social links . Similarly for EmOC; our findings suggest that the problem is not one of upgrading facilities, but rather in persuading women to use these facilities.
Financial barriers to utilization of facility-based care are prohibitive among the poor, even where the actual care is free-of-charge [26–29]. The introduction of a maternal health voucher scheme for poor mothers in 21 sub-districts of Bangladesh is certainly a great step forward, but the challenges in implementing and scaling-up this type of demand-side financing program are considerable . Removing financial barriers alone will not eliminate the poor-rich gap, and further strengthening of the demand side will be necessary [31, 32].
The levels of maternal mortality in Bangladesh are remarkably low given the extremely low levels of uptake of maternity care. The maternal mortality ratio has been estimated at between 320 and 400 per 100,000 live births, and it may have fallen since the late 1980s . The reasons for this fall remain a puzzle. A decreasing trend of maternal mortality with corresponding increases in population based caesarean section rates, and without increase of professional attendance at birth, support the views expressed by Maine and others that the accessibility of EmOC plays a large role in shaping maternal outcomes exclusive of the use of skilled attendance at births . This together with a reduction in abortion mortality, lower fertility and general improvements in health may explain part of the decline .
The study has some limitations. First, data on area of residence in the three DHS surveys were not strictly comparable because, unlike the 1999–2000 survey, the 1993–1994 and 1996–1997 surveys categorized "other urban" areas as "rural". Second, the recall periods were different; 3 years for the first survey, 5 years for the other surveys. This issue, along with that of birth-based versus woman-based analyses, is explored in detail by Bell et al . We decided that the disadvantage of the difference in recall error between the oldest survey and the other three surveys would be more than offset by the gain in power obtained by aggregating all available data. We concurred with Bell et al in choosing a birth-based analysis, despite the bias which this denominator introduces due to over-representation of poorer women who tend to have more children . Third, the construction of a pooled asset score over a 16-year period, ignoring the possibly changing value of assets over time, may have led to misclassification of socio-economic status. Some authors have suggested that the ranking of households is robust to the asset items included,  while others have suggested the opposite . However, the asset score showed surprisingly good discriminatory power to reveal inequalities in birth attendance and caesarean sections, and the changes in the distribution of wealth groups over time is consistent with the rapid economic growth in Bangladesh during this time. The inclusion of other important determinants of access to health care, in particular maternal education, in the model in conjunction with the asset scores, would be expected to give a reasonably accurate picture of inequalities within Bangladesh .