Overall, we found that maternal CoC increased about two-fold from 13 percent in 2012-13 to 25 percent in 2019. Similarly, about 58 percent of the women received any optimum ANC or SBA or PNC in 2012-13, which increased to 78 percent in 2019. Nevertheless, women in Bangladesh still lack the CoC with persistent inequality, despite Bangladesh’s significant progress in expanding key maternal health services [6, 21]. The maternal CoC rate observed in this study was nearly similar to Pakistan (27 percent) [25] and lower than that reported in other South Asian nations, including India (45 percent) [26], Nepal (41 percent) [27]. The rate was also lower than other developing countries such as Ethiopia (47 percent) [28], Cambodia (60 percent) [29], and higher than Ghana (8 percent) [30]. Although, there are marked differences among these studies about methods and definitions of maternal health services. The Bangladesh Maternal Mortality Survey reported that complete maternal CoC has been consistently increasing from 5 percent in 2001, to 19 percent in 2010, and to 43 percent in 2016 [6]. However, the survey included at least one ANC in complete maternal CoC analysis, while WHO and Government of Bangladesh recommend at least 4 ANC [31].
The initial stage, ANC, was found to have largest gap in low utilisation CoC, followed by use of SBA and PNC in both surveys. Similar dropout trend was also observed in Pakistan [25]. Another recent study in Bangladesh suggested higher dropout between antenatal period and delivery than between delivery and postnatal period, and reported low completion rate of CoC [14]. This low utilisation of CoC could be explained by the inadequate readiness of health facilities to provide ANC and PNC services coupled with delivery by unskilled birth attendant [32]. In Bangladesh, delivery by SBA is mainly driven by facility delivery. Only 19 percent of the deliveries at home were attended by skilled health personnel in 2013, which decreased to 12 percent in 2019 [21, 22]. Besides, about half of the delivery in Bangladesh happens at home [6, 21], which result in low utilisation of PNC. Furthermore, our study observed more utilisation of PNC among the women who had SBA during delivery, which is coherent with BDHS 2017 [6]. Therefore, our findings imply that increasing the use of SBA assisted delivery might lead to increased PNC usage and improve the maternal CoC in Bangladesh. However, the low CoC rate of all the maternal health services found in this study indicates a greater risk of maternal and newborn health, as many women might not receive vital intervention from the prenatal to the postnatal period.
We found education, religion, use of media, number of children ever born, living area, and wealth as consistent correlates of maternal CoC in Bangladesh across the 2013 and 2019 surveys. Educated mothers and mothers who belong to a family with an educated household head were more likely to receive maternal CoC. A similar finding was also reported in other studies conducted in Nepal [27], Pakistan [25], and Nigeria [33]. Educated women might have increased female autonomy to make decisions about care-seeking from prenatal to postnatal period and awareness of the benefits of maternal healthcare [34]. The mother's educational attainment also moderates the media exposure and various maternal healthcare services [35]. Similarly, in our study, women's use of media such as television, radio, and the newspaper was a significant predictor of maternal CoC, which is coherent with similar studies in Bangladesh [14], Pakistan [25], Nepal [27], and Nigeria [33]. Therefore, these results indicate that women’s education may interplay a positive role to increase media exposure and awareness about the advantages of maternal healthcare.
Household head’s educational attainment was also found to be significant to increase maternal CoC in our study. Nearly all the household in our study was male headed and the result suggests that household head’s education, or lack of knowledge may be a barrier to the use of maternal healthcare in Bangladesh, reinforcing the need to enhance education among male household heads. Household head plays a key role in decision making of seeking maternal healthcare especially seeking skilled birth attendant, and their education plays an enabling factor [36]. However, it is unclear if higher male education is related to better maternal healthcare seeking behaviours by giving women more access to information and more control over when and where they seek health care. Further studies are recommended to understand in-depth the role of men’s education to increase the maternal health seeking behaviour in Bangladesh.
Besides, our study observed that women who belonged to non-Muslim families were more like to receive maternal CoC than those in Muslim families. Muslim women's need for privacy and the issue of their dependency on husband and family when it comes to decision-making for maternal healthcare has been reported to be a barrier to maternal healthcare utilisation [37, 38]. Moreover, our analysis also revealed that parity has a negative effect on maternal CoC, which is consisted with other studies [25, 27, 39]. High parity women have a reduced perceived risk of pregnancy on their health than primipara women [39]. Therefore, high-parity women may lack willingness to receive maternal healthcare. More study is needed to explore further the relationship between parity and women's willingness to seek maternal healthcare.
The study identified persistent and significant socioeconomic disparities in the utilisation of maternal CoC in Bangladesh. Women from wealthier households were more likely to receive maternal CoC than women from poorer households in both the 2013 and 2019 surveys. These disparities are also coupled with low utilisation of maternal CoC in rural areas compared to urban areas in Bangladesh. Other studies in Bangladesh [20] and other Asian countries [25–27] also reported low utilisation of maternal healthcare among women from poorer households and rural areas. About 70 percent of the people in poverty live in a rural areas in Bangladesh [40]. In Bangladesh, the poor and rural people confront demand and supply-side healthcare hurdles. On the demand side, it faces a high cost of healthcare, a lack of information about available services and cultural beliefs, and on the supply side, it faces inadequate services and quality care [41]. To deal with these problems, many community-based programs have been initiated in Bangladesh for poor and vulnerable women to improve access to maternal healthcare, such as Upazila Health Complex, Union Health and Family Welfare Centre, Rural Dispensaries, Community Clinic, SBA, and outreach services [42]. Despite these efforts, this study observed a persistent inequality in utilising different maternal healthcare across different wealth quintiles in Bangladesh. The distance to the nearest health facility centre has been identified as one of the most significant barriers to rural women's receiving maternal services in Bangladesh [43]. Besides, lower utilisation of ANC and PNC by a medically trained provider, higher home delivery by the unskilled provider, lack of awareness about maternal health services among poor and rural people could be a reason for this inequality [20–22]. We recommend implementing a balance of demand and supply-side intervention by increasing community awareness and skilled health providers.
The use of two similar survey data gives us a clear picture of the change in maternal CoC over the 6 years, and the reduction in inequity in Bangladesh. Besides, we applied concentration index, rather than bar graph, since it is useful to provide summery measure of seriocomic inequality and allow comparison across demographic group [23]. Two rounds of MICS survey, included in the study, did not have uniformity in terms of skilled providers for delivery. Besides, there were no data on the number of ANC variables in the MICS 2006. As a result, the study was confined to the two most recent MICS from 2013 to 2019. The analysis has other limitations that are attributable to the study design. Firstly, no causal associations can be drawn because of the survey's cross-sectional nature. Secondly, the survey's data are self-reported, which may include recall and social desirability bias. Finally, we did not consider maternal health service availability or relevant programmes affecting maternal and child healthcare utilisation.