The crisis facing the maternal health workforce in Bangladesh

By Nazifa Ullah | 5th Year Medical Student, UCL | MAA Academic Officer

The crisis facing the maternal health workforce in Bangladesh

The crisis facing the maternal health workforce in Bangladesh

By Nazifa Ullah
 

It is no secret that there is a critical shortage of health care workers worldwide. A critical shortage is defined as a country with a density of less than 2.3 health care providers (e.g. doctors, nurses and midwives) per 1000 population [1]. Bangladesh is one of 57 countries that fall under this category with an estimated 3.05 physicians and 1.07 nurses per 10,000 population [2].  In fact, the WHO estimates that by 2030, there will be a projected shortfall of 18 million workers and unsurprisingly, most of these shortages will be found in low and middle income countries (LMIC) [1].

The reasons for such deficiencies in the work force are multifactorial. Insufficient funding, inadequate training programmes, negative work environments and increasing migration of health workers from source countries, are just but a handful of factors that contribute to the problem of shortages. The impact of such shortcomings are dire. A functional health system is dependent on having an adequate, available and accessible workforce [3]. Without this, health services simply cannot be delivered to a population with adequate coverage in an equitable manner.  

This shortage is particularly significant in the context of the maternal health workforce, comprising of midwives, nurses, doctors and community health workers with specialised skillsets and practise in diverse settings. Each have their own valuable role to play in the care of a pregnant women and thus having the appropriate mix of health professionals involved in maternal health provisions is equally as important as having the right number of providers. However, of the projected 17 million health care worker shortage estimated by WHO, 9 million of these workers are nurses and midwives, and this figure is likely to increase to 15 million by 2030 [3].

The consequences of such shortages and inappropriate skill mix have a significant impact on the quality of maternal healthcare that can be provided. For example, shortages of trained obstetricians and anaesthetics reduces the number of facilities equipped to offer emergency obstetric care when complications arise during childbirth, which in turn contributes to maternal death [4]. The lack of nurses and midwives’ results in reduced antenatal and postnatal care services that can be provided within a community. In fact, research suggests that by increasing the coverage of midwifery services by 10% in low income countries, maternal mortality could potentially reduce by 27% [5].   Bangladesh in particular has a substantial shortage of midwives, with the profession only being introduced to the country as recently as 2013, eventually leading to the first diploma level qualified midwives, becoming licensed to work in 2016 [6].

However, the problem is not just in the number and type of workers available but also in the distribution of human resources. In Bangladesh, there is an overwhelming level of health workers that are concentrated in urban settings, despite the fact that 70% of the population reside in rural areas [7]. It is unsurprising therefore, that geographical limitations contribute to the disparities seen in the maternal morality between rural and urban locations [7].

Fortunately, there are solutions to this problem. The strategy of task shifting is a well-known method that has been implemented in many countries worldwide. Task shifting involves delegating responsibilities to “existing or new cadres with less training or narrowly tailored training” [8]. This was implemented in Bangladesh with the launch of a Government programme in 2004 that aimed to create a new cadre of skilled birth attendants that were trained in essential midwifery skills [8]. Although such a strategy may help in improving access to maternal services, it is not a sustainable solution if it is not supported by a strong healthcare system. Fundamentally, to improve both quality and access to maternal health workers, better strategic governance at the governmental level is needed. In order create a more efficient and effective health system that has the capacity to fund and administer the appropriate supervision and opportunities needed to train the next generation of health workers [9]. Policies need to be put in place that aim to improve worker conditions and pay, consequently retaining more professionals in the country. Work also needs to be done to improve the infrastructure of the country and thus improve the access to workers and consequently reduce the disparities between urban and rural maternal deaths. For indeed without such actions, the maternal health workforce crisis in Bangladesh and worldwide, will not be adequately addressed.  

References:

  1. Naicker S, Eastwood J, Plange-Rhule J, Tutt R. Shortage of healthcare workers in sub-Saharan Africa: a nephrological perspective. Clinical Nephrology. 2011;
  2. Global Health Workforce Alliance. WHO | Bangladesh [Internet]. Who.int. 2021 [cited 30 January 2021]. Available from: https://www.who.int/workforcealliance/countries/bgd/en/#:~:text=Bangladesh%20suffers%20from%20both%20a,based%20on%20MoHFW%20HRD%202011).
  3. Maternal Health Taskforce. Global Maternal Health Workforce [Internet]. Maternal Health Task Force. 2021 [cited 30 January 2021]. Available from: https://www.mhtf.org/topics/global-maternal-health-workforce/
  4. Gerein N, Green A, Pearson S. The Implications of Shortages of Health Professionals for Maternal Health in Sub-Saharan Africa. Reproductive Health Matters. 2006;14(27):40-50.
  5. Homer C, Friberg I, Dias M, ten Hoope-Bender P, Sandall J, Speciale A et al. The projected effect of scaling up midwifery. The Lancet. 2014;384(9948):1146-1157.
  6. Bogren M, Erlandsson K, Byrskog U. What prevents midwifery quality care in Bangladesh? A focus group enquiry with midwifery students. BMC Health Services Research. 2018;18(1).
  7. Kamal N, Curtis S, Hasan M, Jamil K. Trends in equity in use of maternal health services in urban and rural Bangladesh. International Journal for Equity in Health. 2016;15(1).
  8. Fulton B, Scheffler R, Sparkes S, Auh E, Vujicic M, Soucat A. Health workforce skill mix and task shifting in low income countries: a review of recent evidence. Human Resources for Health. 2011;9(1).
  9. Saha M, Odjidja E. Access to a Skilled Birth Attendant in Bangladesh: What We Know and what Health System Framework can Teach Us. Health Systems and Policy Research. 2017;04(04).

 

The crisis facing the maternal health workforce in Bangladesh

By Nazifa Ullah
 

It is no secret that there is a critical shortage of health care workers worldwide. A critical shortage is defined as a country with a density of less than 2.3 health care providers (e.g. doctors, nurses and midwives) per 1000 population [1]. Bangladesh is one of 57 countries that fall under this category with an estimated 3.05 physicians and 1.07 nurses per 10,000 population [2].  In fact, the WHO estimates that by 2030, there will be a projected shortfall of 18 million workers and unsurprisingly, most of these shortages will be found in low and middle income countries (LMIC) [1].

The reasons for such deficiencies in the work force are multifactorial. Insufficient funding, inadequate training programmes, negative work environments and increasing migration of health workers from source countries, are just but a handful of factors that contribute to the problem of shortages. The impact of such shortcomings are dire. A functional health system is dependent on having an adequate, available and accessible workforce [3]. Without this, health services simply cannot be delivered to a population with adequate coverage in an equitable manner.  

This shortage is particularly significant in the context of the maternal health workforce, comprising of midwives, nurses, doctors and community health workers with specialised skillsets and practise in diverse settings. Each have their own valuable role to play in the care of a pregnant women and thus having the appropriate mix of health professionals involved in maternal health provisions is equally as important as having the right number of providers. However, of the projected 17 million health care worker shortage estimated by WHO, 9 million of these workers are nurses and midwives, and this figure is likely to increase to 15 million by 2030 [3].

The consequences of such shortages and inappropriate skill mix have a significant impact on the quality of maternal healthcare that can be provided. For example, shortages of trained obstetricians and anaesthetics reduces the number of facilities equipped to offer emergency obstetric care when complications arise during childbirth, which in turn contributes to maternal death [4]. The lack of nurses and midwives’ results in reduced antenatal and postnatal care services that can be provided within a community. In fact, research suggests that by increasing the coverage of midwifery services by 10% in low income countries, maternal mortality could potentially reduce by 27% [5].   Bangladesh in particular has a substantial shortage of midwives, with the profession only being introduced to the country as recently as 2013, eventually leading to the first diploma level qualified midwives, becoming licensed to work in 2016 [6].

However, the problem is not just in the number and type of workers available but also in the distribution of human resources. In Bangladesh, there is an overwhelming level of health workers that are concentrated in urban settings, despite the fact that 70% of the population reside in rural areas [7]. It is unsurprising therefore, that geographical limitations contribute to the disparities seen in the maternal morality between rural and urban locations [7].

Fortunately, there are solutions to this problem. The strategy of task shifting is a well-known method that has been implemented in many countries worldwide. Task shifting involves delegating responsibilities to “existing or new cadres with less training or narrowly tailored training” [8]. This was implemented in Bangladesh with the launch of a Government programme in 2004 that aimed to create a new cadre of skilled birth attendants that were trained in essential midwifery skills [8]. Although such a strategy may help in improving access to maternal services, it is not a sustainable solution if it is not supported by a strong healthcare system. Fundamentally, to improve both quality and access to maternal health workers, better strategic governance at the governmental level is needed. In order create a more efficient and effective health system that has the capacity to fund and administer the appropriate supervision and opportunities needed to train the next generation of health workers [9]. Policies need to be put in place that aim to improve worker conditions and pay, consequently retaining more professionals in the country. Work also needs to be done to improve the infrastructure of the country and thus improve the access to workers and consequently reduce the disparities between urban and rural maternal deaths. For indeed without such actions, the maternal health workforce crisis in Bangladesh and worldwide, will not be adequately addressed.  

References:

  1. Naicker S, Eastwood J, Plange-Rhule J, Tutt R. Shortage of healthcare workers in sub-Saharan Africa: a nephrological perspective. Clinical Nephrology. 2011;
  2. Global Health Workforce Alliance. WHO | Bangladesh [Internet]. Who.int. 2021 [cited 30 January 2021]. Available from: https://www.who.int/workforcealliance/countries/bgd/en/#:~:text=Bangladesh%20suffers%20from%20both%20a,based%20on%20MoHFW%20HRD%202011).
  3. Maternal Health Taskforce. Global Maternal Health Workforce [Internet]. Maternal Health Task Force. 2021 [cited 30 January 2021]. Available from: https://www.mhtf.org/topics/global-maternal-health-workforce/
  4. Gerein N, Green A, Pearson S. The Implications of Shortages of Health Professionals for Maternal Health in Sub-Saharan Africa. Reproductive Health Matters. 2006;14(27):40-50.
  5. Homer C, Friberg I, Dias M, ten Hoope-Bender P, Sandall J, Speciale A et al. The projected effect of scaling up midwifery. The Lancet. 2014;384(9948):1146-1157.
  6. Bogren M, Erlandsson K, Byrskog U. What prevents midwifery quality care in Bangladesh? A focus group enquiry with midwifery students. BMC Health Services Research. 2018;18(1).
  7. Kamal N, Curtis S, Hasan M, Jamil K. Trends in equity in use of maternal health services in urban and rural Bangladesh. International Journal for Equity in Health. 2016;15(1).
  8. Fulton B, Scheffler R, Sparkes S, Auh E, Vujicic M, Soucat A. Health workforce skill mix and task shifting in low income countries: a review of recent evidence. Human Resources for Health. 2011;9(1).
  9. Saha M, Odjidja E. Access to a Skilled Birth Attendant in Bangladesh: What We Know and what Health System Framework can Teach Us. Health Systems and Policy Research. 2017;04(04).

 

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