Accounts of severe acute obstetric complications in rural Bangladesh.
BACKGROUND
As maternal deaths have decreased worldwide, increasing attention has been placed on the study of severe obstetric complications, such as hemorrhage, eclampsia, and obstructed labor, to identify where improvements can be made in maternal health. Though access to medical care is considered to be life-saving during obstetric emergencies, data on the factors associated with health care decision-making during obstetric emergencies are lacking. We aim to describe the health care decision-making process during severe acute obstetric complications among women and their families in rural Bangladesh.


METHODS
Using the pregnancy surveillance infrastructure from a large community trial in northwest rural Bangladesh, we nested a qualitative study to document barriers to timely receipt of medical care for severe obstetric complications. We conducted 40 semi-structured, in-depth interviews with women reporting severe acute obstetric complications and purposively selected for conditions representing the top five most common obstetric complications. The interviews were transcribed and coded to highlight common themes and to develop an overall conceptual model.


RESULTS
Women attributed their life-threatening experiences to societal and socioeconomic factors that led to delays in seeking timely medical care by decision makers, usually husbands or other male relatives. Despite the dominance of male relatives and husbands in the decision-making process, women who underwent induced abortions made their own decisions about their health care and relied on female relatives for advice. The study shows that non-certified providers such as village doctors and untrained birth attendants were the first-line providers for women in all categories of severe complications. Coordination of transportation and finances was often arranged through mobile phones, and referrals were likely to be provided by village doctors.


CONCLUSIONS
Strategies to increase timely and appropriate care seeking for severe obstetric complications may consider targeting of non-certified providers for strengthening of referral linkages between patients and certified facility-based providers. Future research may characterize the treatments and appropriateness of emergency care provided by ubiquitous village doctors and other non-certified treatment providers in rural South Asian settings. In addition, future studies may explore the use of mobile phones in decreasing delays to certified medical care during obstetric emergencies.
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Shegufta S
SS
Sikder
Alain B
AB
Labrique
Barkat
B
Ullah
Hasmot
H
Ali
Mahbubur
M
Rashid
Sucheta
S
Mehra
Nusrat
N
Jahan
Abu A
AA
Shamim
Keith P
KP
West
Parul
P
Christian
D000293:Adolescent; D000328:Adult; D001459:Bangladesh / Q000453:epidemiology; D004632:Emergency Medical Services; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008427:Maternal Health Services; D007744:Obstetric Labor Complications / Q000453:epidemiology* / Q000401:mortality / Q000517:prevention & control; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D019035:Rural Health Services; D012424:Rural Population; D011795:Surveys and Questionnaires; D055815:Young Adult