Maternal-child health and family planning: user perspectives and service constraints in rural Bangladesh

Abstract

This article presents a microanalysis of interactions between female fieldworkers and women in rural Bangladesh, and a discussion of the broader organizational constraints that hamper service delivery. It is argued that the fieldworker, herself a rural woman, is faced with considerable demand for both maternal-child health (MCH) and reproductive health care services, but that operational constraints prevent her from realizing her potential in both of these areas. Qualitative data show that, in the eyes of rural women, contraceptive use and health care are intricately intertwined, and that this association often raises a range of questions that the worker cannot address competently. A number of specific operational barriers--worker densities, staff motivation, supervision, technical competence, supplies--are identified. These barriers reflect a general institutional weakness in the Ministry of Health bureaucracy that prevents it from organizing itself to deliver user-oriented health and family planning services while maintaining adequate and appropriate standards of care.

PIP: A microanalysis of interactions between female field workers and women in rural Bangladesh is presented. Broader organizational constraints that hinder service delivery are discussed. The field worker, a rural woman herself, is faced with much demand for both maternal-child health (MCH) and reproductive health care services, but operational constraints keep her from realizing her potential in both of these areas. Contraceptive use and health care are intertwined in the view of rural women. Qualitative data based on observations of the exchanges between female workers and rural women during the workers' regular household visits were collected. 65 encounters between 22 workers and rural women of reproductive age were observed. Some of the workers had received special training from the Extension Project. The association between contraceptive use and health care poses many questions which the worker cannot answer completely. The female worker (FWA) in Bangladesh has duties in both areas: MCH and family planning (FP). When the interactions between field workers and rural women were observed in the mid 1980s, each FWA covered an average of 7500 people. Since then the size has decreased to about 4000, due to recruitment of more female workers. In the FP area, the FWA is responsible for information, education, distribution of contraceptives, motivation, and referral for clinic methods. Her MCH jobs include distributing oral rehydration salts (ORS), referral for immunization, education, and for prenatal, perinatal, and postnatal care, and vitamin A distribution. The FWA is supervised by local government and staff of the rural health center at the level of the subdistrict. Technical support to the FWA is the responsibility of a female paramedic who works at a rural subcenter. Rural women in Bangladesh are worried about health consequences of contraceptive use. Family planning is a major health issue. MCH and family planning tasks compete with each other. Workers sometimes see MCH care as something apart from their work. Constraints on FWA's delivery of FP and MCH services include: 1) staffing density and work motivation; worker's technical competence and MCH supplies; supervision; availability and quality of care at subcenters. These problems defy simple solutions.