The health of women around the time of delivery remains a major concern in Bangladesh where the ratio of maternal mortality is over 322 per 100,000 (1). Skilled attendance at delivery has been promoted as the single most effective means of successfully reducing rates of maternal mortality in poorer countries (2). Yet, in Bangladesh, the majority of mothers do not use skilled delivery care due to a combination of sociocultural barriers (3) and issues associated with the availability, quality, and cost of services (4,5). While 91% of deliveries take place at home, a trained health worker is present in only 13% of cases, with most deliveries being attended either by relatives or by a traditional birth attendant (TBA) (6).
Financial cost plays an important part in the demand for healthcare in general (7) and for maternity care in particular (8-10)). A number of studies have estimated the household costs of antenatal (11,12) and obstetric care (13-14). These studies have focused mainly on the medical costs incurred within facilities and, in some cases, transport costs. Little has been reported about costs incurred by those delivering at home. Comparing costs of facility and home-based professional care is particularly relevant in settings, such as Bangladesh, where birth at home with a skilled attendant forms an essential part of the national safe-motherhood strategy (16). Furthermore, little is known about the equity implications or affordability of such cases. The cost--both financial and time--incurred by companions accompanying delivering mothers to a health facility is a further component of cost that has received minimal attention.
Generally, seeking care in a facility requires women to be accompanied by a family member, particularly in societies where restrictions are placed on female mobility. Lastly, the studies to date have considered the cost of specific services, e.g. antenatal or delivery care, without estimating the total costs incurred during pregnancy, delivery, and the postpartum period. Despite the lack of studies in this area, the cumulative cost of pregnancy, delivery, and postpartum care is potentially significant.
Against this background, we conducted a household survey in rural Bangladesh to estimate the overall costs incurred during pregnancy, delivery, and the postpartum period by place of delivery (at home or in a health facility) and by wealth group.
MATERIALS AND METHODS
Since 1966, ICDDR,B has maintained a registration of all births, deaths, and migrations in Matlab, a rural area of Bangladesh. Facilities within the area are funded, staffed, and maintained by ICDDR,B and provided free of charge.
Within this area, deliveries at home with skilled attendants, who were either midwives or paramedics, were advocated from 1987 to 1996, and from 1996 onwards, maternity care in basic obstetric facilities was gradually phased in. To this end, four existing health centres were upgraded with a delivery room, and the same healthcare workers, who had been working in homes, shifted to facility-based care, catering mostly for uncomplicated deliveries. A basic essential obstetric care (BEOC) hospital was also set in place. These facilities are within three kilometres of most households.
Complicated deliveries can be managed at comprehensive essential obstetric care (CEOC) facilities either at the government district hospital in Chandpur or at private hospitals, of which there are a growing number. These facilities provide, and charge for, essential obstetric care, conduct caesarean sections, and perform assisted deliveries by forceps and vacuum. A free ambulance service takes women from the BEOC facility to the CEOC facility.
Identification of costs
Two questionnaires were designed--one for each place of delivery (home and health facility)--to collect information on all monetary expenditure made by household members to access and receive antenatal care, delivery, and postnatal care. …