Researchers Share Findings and Recommendations for ensuring 24-hour normal delivery services in Union Health and Family Welfare Centres (UHFWCs) in Bangladesh.
The Population Council, an international, nonprofit, nongovernmental organization has released new research findings from its operations research study titled ‘Strengthening Health and Family Welfare Centers for Providing Round-the-Clock Normal Delivery Services’. This dissemination seminar was held in Spectra Convention Center, Gulshan, Dhaka and Mohammad Wahid Hossain, NDC, Director General, Directorate General of Family Planning (DGFP) was present in the event as the chief guest.
The Population Council team was led by Dr. Ubaidur Rob, Country Director and Mr. AKM Zafar Ullah Khan, Senior Policy Advisor described the implementation of the project and Md. Noorunnabi Talukder, Monitoring and Evaluation Advisor presented the research findings. Representatives from the government departments also spoke on the program.
Basically, in this study, the Population Council has provided technical assistance to the Directorate General of Family Planning (DGFP) to implement an Operations Research (OR) study in 24 Union Health and Family Welfare Centers (UHFWCs) of Chittagong and Munshiganj districts to test the effectiveness of a model to strengthen UHFWCs so that they can provide 24-hour normal delivery services.
Broadly, three interventions, namely, human resource strengthening, community participation, and referral linkage strengthening were implemented for 12 months. Six UHFWCs from Comilla district served as control sites.
KEY RESEARCH FINDINGS 1. Improved awareness of UHFWC’s 24/7 normal delivery services among women Chittagong: Pre-intervention 6%, Post-intervention 40% Munshiganj: Pre-intervention 0%, Post-intervention 31% Yet, two-thirds of the women remain ignorant of UHFWC’s 24/7 normal delivery services. 2. Seeking antenatal care (ANC) is almost universal in the intervention areas. In the intervention areas, of women who received ANC from government facilities, over 70 percent sought first ANC from local facilities (UHFWCs and Community Clinics) while 57 percent in the control district so reported. 3. Findings suggest a higher rate of institutional delivery in the intervention districts (Chittagong 72%, Munshiganj 79%) than the control district (53%). 4. A stark difference exists between two intervention districts in terms of types of delivery. Women in Chittagong were more likely to undergo normal deliveries (77%), while cesarean deliveries were more widespread in Munshiganj (58%). The higher rate of cesarean deliveries in Munshiganj reveals weaknesses in the clinical monitoring mechanism of the government. 5. Private-sector contribution to institutional deliveries is highest in the control district (81%). Between intervention districts, private-sector contribution to institutional deliveries is much higher in Munshiganj (70%) than Chittagong (36%) Client preference for private facilities: Despite the cost of receiving cesarean deliveries at private facilities is two times that at public facilities (BDT 23,485 vs. BDT 12,772), women in Munshiganj were more likely to use private facilities than public facilities, which suggests the better environment and quality of services at the private facilities. Qualitative findings explain the reasons for client preference for private facilities. People choose private hospitals over public hospitals as: • Physical amenities, e.g., infrastructure, environment, cleanliness, equipment, supplies, and attendant accommodation, are better in private facilities. • The unavailability of cesarean delivery provision at the UHFWCs and many upazila-level government facilities is the key supply-side problem that prompts women to go to private clinics. • Enhanced economic condition of the people is largely accounted for client’s preference for private facilities. 6. The utilization of postnatal care (PNC) increased remarkably (Chittagong: 54-75%, Munshiganj: 46-78%, Comilla: 26-54%). The improvement in the utilization of PNC within two days after birth is encouraging which indicates that provider utilized the opportunity to perform postnatal check-ups immediately after birth. Among the public-sector facilities, low use of UHFWCs for PNC (Chittagong: 34%, Munshiganj: 14%, Comilla: 14%) and non-use of Community Clinics indicate that bringing services to the proximity of women’s home is not adequate to ensure their utilization by community people. 7. In order to increase the efficiency of the model, UHFWC Management Committees were reactivated in 18 unions so that community monitoring and resource mobilization through active community participation can be ensured. Reactivation of UHFWC Management Committee with active involvement of local government representatives was considered the most effective activity. Outcomes of reactivation of UHFWC Management Committees: • Improved physical readiness of UHFWCs for 24/7 normal delivery services • Community fund created and used for facility improvement 8. Monitoring and supervision has increased during the intervention period. In addition to conducting regular monthly visit to UHFWCs, the medical officer (MO-MCH) enquires of the number of deliveries and whether UHFWC providers (i.e., family welfare visitors or FWVs) face any problems to conduct deliveries. FWVs receive skill-development lessons/coaching during the supervisory visit. Particularly, they learn from MO-MCH how to treat delivery complications and when to refer a pregnant woman. 9. Of the two intervention districts, Chittagong witnessed greater improvement in the utilization of maternal health services from the UHFWCs. 10. In Munshiganj, the project had limited impact in increasing the UHFWC utilization for normal delivery services due to a combined effect of: • Geographic proximity to the government tertiary level hospital (Mitford hospital) with good road communication • Availability of private clinics at the union level • Affordability of households to seek expensive care at private facilities KEY CHALLENGES • Absence of provision of delivery complications management is the key deficiency in the clinical readiness for providing delivery services • Preference for private facilities. Physical amenities are better in private facilities than public facilities WHAT NEEDED • A clear-cut policy guidelines to dispel fear and subsequent reluctance of local government representatives to raise and spend money • Capacity building of UHFWC providers (FWVs) on delivery complications management • A rigorous, clinical monitoring system for evaluating high rate of C-section at private facilities • Intensive awareness promotion activities in the community so that every pregnant woman can be informed about UHFWC’s 24/7 normal delivery services and community contribution to improve the physical facilities of the UHFWC
1. Improved awareness of UHFWC’s 24/7 normal delivery services among women Chittagong: Pre-intervention 6%, Post-intervention 40% Munshiganj: Pre-intervention 0%, Post-intervention 31% Yet, two-thirds of the women remain ignorant of UHFWC’s 24/7 normal delivery services.
2. Seeking antenatal care (ANC) is almost universal in the intervention areas. In the intervention areas, of women who received ANC from government facilities, over 70 percent sought first ANC from local facilities (UHFWCs and Community Clinics) while 57 percent in the control district so reported.
3. Findings suggest a higher rate of institutional delivery in the intervention districts (Chittagong 72%, Munshiganj 79%) than the control district (53%).
4. A stark difference exists between two intervention districts in terms of types of delivery. Women in Chittagong were more likely to undergo normal deliveries (77%), while cesarean deliveries were more widespread in Munshiganj (58%). The higher rate of cesarean deliveries in Munshiganj reveals weaknesses in the clinical monitoring mechanism of the government.
5. Private-sector contribution to institutional deliveries is highest in the control district (81%). Between intervention districts, private-sector contribution to institutional deliveries is much higher in Munshiganj (70%) than Chittagong (36%)
Client preference for private facilities: Despite the cost of receiving cesarean deliveries at private facilities is two times that at public facilities (BDT 23,485 vs. BDT 12,772), women in Munshiganj were more likely to use private facilities than public facilities, which suggests the better environment and quality of services at the private facilities.
Qualitative findings explain the reasons for client preference for private facilities. People choose private hospitals over public hospitals as: • Physical amenities, e.g., infrastructure, environment, cleanliness, equipment, supplies, and attendant accommodation, are better in private facilities. • The unavailability of cesarean delivery provision at the UHFWCs and many upazila-level government facilities is the key supply-side problem that prompts women to go to private clinics. • Enhanced economic condition of the people is largely accounted for client’s preference for private facilities.
6. The utilization of postnatal care (PNC) increased remarkably (Chittagong: 54-75%, Munshiganj: 46-78%, Comilla: 26-54%). The improvement in the utilization of PNC within two days after birth is encouraging which indicates that provider utilized the opportunity to perform postnatal check-ups immediately after birth.
Among the public-sector facilities, low use of UHFWCs for PNC (Chittagong: 34%, Munshiganj: 14%, Comilla: 14%) and non-use of Community Clinics indicate that bringing services to the proximity of women’s home is not adequate to ensure their utilization by community people.
7. In order to increase the efficiency of the model, UHFWC Management Committees were reactivated in 18 unions so that community monitoring and resource mobilization through active community participation can be ensured. Reactivation of UHFWC Management Committee with active involvement of local government representatives was considered the most effective activity. Outcomes of reactivation of UHFWC Management Committees: • Improved physical readiness of UHFWCs for 24/7 normal delivery services • Community fund created and used for facility improvement
8. Monitoring and supervision has increased during the intervention period. In addition to conducting regular monthly visit to UHFWCs, the medical officer (MO-MCH) enquires of the number of deliveries and whether UHFWC providers (i.e., family welfare visitors or FWVs) face any problems to conduct deliveries. FWVs receive skill-development lessons/coaching during the supervisory visit. Particularly, they learn from MO-MCH how to treat delivery complications and when to refer a pregnant woman.
9. Of the two intervention districts, Chittagong witnessed greater improvement in the utilization of maternal health services from the UHFWCs.
10. In Munshiganj, the project had limited impact in increasing the UHFWC utilization for normal delivery services due to a combined effect of: • Geographic proximity to the government tertiary level hospital (Mitford hospital) with good road communication • Availability of private clinics at the union level • Affordability of households to seek expensive care at private facilities
• Absence of provision of delivery complications management is the key deficiency in the clinical readiness for providing delivery services • Preference for private facilities. Physical amenities are better in private facilities than public facilities
• A clear-cut policy guidelines to dispel fear and subsequent reluctance of local government representatives to raise and spend money • Capacity building of UHFWC providers (FWVs) on delivery complications management • A rigorous, clinical monitoring system for evaluating high rate of C-section at private facilities • Intensive awareness promotion activities in the community so that every pregnant woman can be informed about UHFWC’s 24/7 normal delivery services and community contribution to improve the physical facilities of the UHFWC
It has been highlighted in today’s the discussion that Bangladesh needs such sound evidence to guide policies and programs on strengthening the capacity of UHFWCs. Also, speakers and experts argued that this study would serve as a key part of understanding how to best support UHFWCs to provide 24/7 normal delivery services and reduce maternal mortality & morbidity in Bangladesh.
