Effect of an integrated maternal and neonatal health intervention on maternal healthcare utilisation addressing inequity in Rural Bangladesh

Archives of Public Health Ahmed et al. Archives of Public Health (2023) 81:153 https://doi.org/10.1186/s13690-023-01155-7 Open Access RESEARCH Effect of an integrated maternal and neonatal health intervention on maternal healthcare utilisation addressing inequity in Rural Bangladesh Anisuddin Ahmed1,2*, Fariya Rahman2, Abu Sayeed2, Tania Sultana Tanwi2, Abu Bakkar Siddique2, Aniqa Tasnim Hossain2, Saraban Tahura Ether2, Ema Akter2, Tazeen Tahsina2, Syed Moshfiqur Rahman1, Shams El Arifeen2 and Ahmed Ehsanur Rahman2 Abstract Background Although Bangladesh has made significant improvements in maternal, neonatal, and child health, the disparity between rich and poor remains a matter of concern. Objective The study aimed to increase coverage of skilled maternal healthcare services while minimising the inequity gap among mothers in different socioeconomic groups. Methods We implemented an integrated maternal and neonatal health (MNH) intervention between 2009 and 2012, in Shahjadpur sub-district of Sirajganj district, Bangladesh. The study was quasi-experimental in design for the evaluation. Socioeconomic status was derived from household assets using principal component analysis. Inequity in maternal healthcare utilisation was calculated using rich-poor ratio and concentration index to determine the changes in inequity between the baseline and the endline time period. Result The baseline and endline surveys included 3,158 (mean age 23.5 years) and 3,540 (mean age 24.3 years) recently delivered mothers respectively. Reduction in the rich-poor ratio was observed in the utilisation of skilled 4+ antenatal care (ANC) (2.4:1 to 1.1:1) and related concentration index decreased from 0.220 to 0.013 (p < 0.001). The rich-poor ratio for skilled childbirth reduced from 1.7:1 to 1.0:1 and the related concentration index declined from 0.161 to -0.021 (p < 0.001). A similar reduction was also observed in the utilisation of skilled postnatal care (PNC); where the rich-poor gap decreased from 2.5:1 to 1.0:1 and the related concentration index declined from 0.197 to -0.004 (p < 0.001). Conclusion The MNH intervention was successful in reducing inequity in receiving skilled 4+ ANC, delivery, and PNC in rural Bangladesh. Keywords Maternal health, Neonatal Health, Skilled ANC visit, 4+ ANC check-up, Skilled delivery, Skilled PNC, Skilled Healthcare Provider, Bangladesh *Correspondence: Anisuddin Ahmed 1 Department of Women’s and Children’s Health, Uppsala University, Uppsala 75205, Sweden 2 International Centre for Diarrheal Disease Research, Bangladesh, Shaheed Tajuddin Ahmed Sarani, 1212 Mohakhali, Dhaka, Bangladesh © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ahmed et al. Archives of Public Health (2023) 81:153 Text box 1. Contributions to the literature • Socioeconomic disparity in availing essential MNCH services is a major challenge globally and nationally in Bangladesh. • The intervention tested substantially contributed to reducing the rich-poor gaps in accessing skilled maternal healthcare services such as antepartum, intrapartum, and postpartum care from medically trained providers. • Strengthening the health system through refresher training on MNCH services to the skilled health workforce and creating community awareness of MNCH services by involving community people would help in reducing the existing inequity and achieving the universal health coverage of SDG target 3 for Bangladesh. Introduction Universal Health Coverage (UHC) is a global agenda aiming to ensure health services at a reasonable cost as per individual requirements [1]. Three Maternal, Neonatal, and Child Health (MNCH) services covered under a UHC package are antenatal care (ANC), skilled delivery, and postnatal care (PNC) [2]. These are considered effective means to mitigate pregnancy, delivery, and postnatal complications and thus are beneficial to reduce maternal and neonatal mortality [3–5]. Despite having a UHC scheme, many countries around the world are still struggling to bridge the MNCH service gap between rich and poor communities [6]. In 2015, the State of Inequity report comprised data on MNCH inequity-prone lowand middle- income countries [6]. Among the 86 countries, the report showed that the richest women benefit from skilled delivery more than the poorest women by more than 80% and almost half of the countries showed a 25% difference among the richest and the poorest women in ANC uptake [6]. Therefore, the global drive to reduce maternal mortality and other adverse maternal health outcomes is not inclusive of achieving equity. It is important to ensure access to essential maternal, neonatal, and child healthcare services, irrespective of household socioeconomic status in order to fully achieve the Sustainable Development Goal (SDG) targets [7]. With persisting socioeconomic differences, the inequity scenario in Bangladesh is similar to this global finding. Bangladesh Demographic and Health Survey (BDHS) 2017-18 measured that the skilled ANC seeking between the richest and the poorest quintile differs by 34% (97.2% vs. 63.6%) (8). Likewise, the health facility delivery is higher among the women of the highest wealth quintile in comparison to the lowest wealth quintile (77.9% vs. 26.3%) and a similar rich-poor gap is also observed in PNC coverage as well (8). According to BDHS 201718, almost 71.5% of the mothers from the lowest wealth quintile do not avail PNC services at all but for the highest wealth quintile this figure is 17.9% (8). Page 2 of 12 To act upon service gaps and improve MNCH status, several governmental and non-governmental programmes have operated in Bangladesh since 2000. Programmes include the Maternal Health Voucher Scheme (MHVS), Emergency Obstetrical Care Services (EmOC) and Government’s nationwide training programmes for community skilled birth attendants (CSBAs) and midwives, in order to increase coverage of skilled healthcare provider’s care (...truncated)