Getting women to hospital is not enough: a qualitative study of access to emergency obstetric care in Bangladesh

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Abstract
Objective: To explore what happened to poor women in Bangladesh once they reached a hospital providing comprehensive emergency obstetric care (EmOC) and to identify support mechanisms. Design: Mixed methods qualitative study. Setting: Large government medical college hospital in Bangladesh. Sample: Providers and users of EmOC. Methods: Ethnographic observation in obstetrics unit including interviews with staff and women using the unit and their carers. Results: Women had to mobilise significant financial and social resources to fund out of pocket expenses. Poorer women faced greater challenges in receiving treatment as relatives were less able to raise the necessary cash. The official financial support mechanism was bureaucratic and largely unsuitable in emergency situations. Doctors operated a less formal "poor fund'' system to help the poorest women. There was no formal assessment of poverty; rather, doctors made "adjudications'' of women's need for support based on severity of condition and presence of friends and relatives. Limited resources led to a "wait and see'' policy that meant women's condition could deteriorate before help was provided. Conclusions: Greater consideration must be given to what happens at health facilities to ensure that ( 1) using EmOC does not further impoverish families; and ( 2) the ability to pay does not influence treatment. Developing alternative finance mechanisms to reduce the burden of out of pocket expenses is crucial but challenging. Increased investment in EmOC must be accompanied by an increased focus on equity.