The aim of this study was to investigate the impact of health facility level factors on hospitalized normal delivery. Our findings indicate that the likelihood of hospitalized normal delivery increased with higher scores in health facility management and infrastructure systems at the nearest healthcare facility to the mother's home, as well as with greater availability and readiness of the nearest healthcare facility to provide hospitalized normal delivery services. In contrast, the distance between the mother's home and the nearest healthcare facility was found to have a negative association with hospitalized normal delivery, with a 20% decrease in likelihood observed for every kilometer increase in distance. These findings are the first of their kind in Bangladesh and other LMICs, and are robust. As such, they have important implications for policymakers seeking to develop evidence-based policies and programs aimed at increasing skilled, supervised deliveries, as targeted by the SDGs for achievement by 2030.
In this study, we found that nearly one in every four deliveries occurred in a healthcare facility, excluding those who underwent CS delivery. This rate is lower than the global and national targets for ensuring skilled supervised delivery, whether in homes or hospitals [42, 43]. Skilled supervised delivery is mainly available in hospitals in Bangladesh due to the limited availability of midwifery at the community level. There are many reasons for the limited access to normal delivery services in hospitals, but the most significant reason is women's preference for home delivery due to lower awareness about the importance of skilled supervised delivery [44–47]. Furthermore, the CS delivery rate has been rising significantly in Bangladesh over the years, and currently, more than 80% of maternal women admitted to hospitals for delivery undergo CS operations [48]. A majority of these procedures are unnecessary and performed only for financial gain, either due to in-patient demand or healthcare providers' malpractice [49]. Fear of unnecessary CS delivery may also increase non-skilled delivery at home among poor women due to the potential financial burden [50]. Policies and programs to ensure skilled healthcare personnel at the community level can play an effective role in increasing skilled supervised delivery. However, several challenges restrict the country's ability to ensure skilled healthcare personnel at the community level, including a limited number of midwives and high turnover rates in midwifery jobs. The tendency of healthcare personnel to move to urbanized areas is another reason for the limited availability of skilled supervised delivery healthcare services in rural areas. Private healthcare facilities are playing a significant role in providing healthcare services, mostly for CS deliveries [48]. However, their role in providing normal delivery healthcare services is still insignificant, leading to an increased risk of unskilled supervised or home delivery in Bangladesh.
We found that the number of normal deliveries in hospitals increased with the improvement of healthcare facilities, as measured by management and infrastructure scores, as well as the availability and readiness of normal delivery care services. However, we could not validate our findings due to the lack of literature in Bangladesh and other LMICs. Nevertheless, several similar studies in Bangladesh reported that healthcare facility level factors play important roles in preventing unintended pregnancies, under-five mortality, and increasing modern contraception use [40, 51, 52]. There are several possible explanations for these findings. Improved management and infrastructure of hospitals could serve as good proxy measures for higher availability of normal delivery healthcare services at the hospitals, thereby increasing the use of such services. Additionally, the availability of normal delivery healthcare services at the healthcare facility and their readiness can play an effective role in ensuring skilled and supervised delivery in various ways. For instance, women in Bangladesh traditionally prefer female healthcare providers for delivery [53–55], so it is important to ensure the availability of female healthcare personnel and their readiness to provide services for skilled and supervised delivery. Moreover, making the community aware that skilled and supervised delivery healthcare services are available at nearby hospitals with proper privacy and are available 24/7 is important to increase their utilization. Presently, government healthcare facilities are mostly busy and prefer to provide complex care rather than skilled and supervised delivery healthcare services, and delivery care services are mostly available during the daytime. In addition, filling the ongoing shortage of healthcare personnel at hospitals, especially those in rural and semi-urban areas, is crucial [54, 55].
We found that hospitalized normal delivery decreased by 20% for every kilometer increase in the distance from the mother's home to the nearest healthcare facility. This finding is consistent with available research conducted in several LMICs, including Bangladesh and Ethiopia [56]. Several reasons could be linked to this finding, including poor road conditions and lack of transportation [50, 56]. These challenges make it difficult for women to access healthcare facilities to receive delivery healthcare services. Moreover, transportation costs can also play an important role in reducing skilled supervised delivery at hospitals. The problem is even more severe in remote and hard-to-reach areas as well as rural areas [57, 58]. Importantly, socio-demographic factors of the respondents can also play a crucial role here, along with cost. For instance, when costs are a significant issue, older women, uneducated women, and women with increased parity may ignore the importance of accessing skilled supervised delivery healthcare services due to their lack of awareness about the benefits of such services and their dependency on prior pregnancy experiences. We reported a similar direction of association in this study, and consistent findings have been reported in other studies conducted in LMICs, including Bangladesh [53–55].
This study has several strengths and a few limitations. The first strength is the use of nationally representative household and healthcare facility data, which enabled us to draw findings on the effects of healthcare facility level factors on hospitalized normal delivery, adjusting for a range of individual-, household-, and community level factors that were selected based on a comprehensive review of available literature. Sophisticated and advanced analysis techniques were employed, and the hierarchical structure of the survey was considered in our analysis, resulting in robust findings. These findings should be applied for evidence-based policy and program making in Bangladesh and other LMICs to increase hospitalized normal delivery.
However, the major limitation of this study is the use of cross-sectional data, meaning that the findings reported are correlational rather than causal. Additionally, to protect the privacy of the respondents, BDHS displaced clusters’ locations up to 0–5 km for rural areas and 0–2 km for urban areas. This displacement may have resulted in calculated average distances to the nearest health facility that differ slightly from the actual distance. However, the BDHS ensured that the new perturbed locations fell within the designated administrative boundaries, and errors from displacement are likely to be random and minimal. Furthermore, the data were based on participants' self-reporting, with no opportunity for validation by interviewers, which may have resulted in reporting errors. Lastly, data on the last delivery method were collected retrospectively for births occurring three years before the survey, which may have introduced recall bias. However, any such biases are likely to be random and could not have affected the results of this study. Therefore, the findings remain valid.