FIRST of all. a question: Do you believe that in Bangladesh maternal mortality is 150 times higher than that in developed countries?'. Yes it is. The reports of BIRPERT (1996) and BDHS (1996-97) are the source of my information. One does not have to look far to find sad stories of maternal deaths. Any group of women in rural or urban settings can tell stories of friends or family members or neighbours who have suffered agonizing deaths while giving birth. The magnitude of reproductive health problem of Bangladeshi women is reflected in the high maternal mortality ratio of nearly five per 1000 live births. It is an important public health problem not only because of the large number of such mortalities but also because of the traumatic effect of such an event on the family and community as a whole.

Giving birth at home is preferred by the vast majority of women and their families. According to Bangladesh Demographic and Health Survey (1996-97) almost all births (95 Eer cent) in Bangladesh occur at ome. The only exceptions to this high level of home deliveries are births to urban women. 23 per cent of which occur in health facilities. Though there is growing recognition that home deliveries have risks, giving birth at home is yet preferred. During a USAID customer appraisal, couples were asked their source of child delivery. Though there was general agreement that home deliveries were most appropriate, both men and women spoke of complications. In many cases, even when problems are recognised during the delivery those responsible for helping the women delay taking her to a facility. There are several identified reasons for this delay, such as — ignorance, fear, financial crisis, distance of health care centre, past negative experience etc.

Let us first discuss about ignorance. Ignorance i.e. lack of knowledge and information, not only delays treatment for a woman in distress but also makes her home the place of delivery. There is considerable ignorance about where facilities are and what services can be provided. In urban Dhaka slums 31 per cent of women did not know where a delivery facility was located (Franczak. 1995). Delay is compounded by ignorance of seriousness of situation also. In a study which probed both urban and rural respondents (women, husbands, mothers-in-law and community leaders) for knowledge of obstetric complications.

"...unprompted knowledge across the categories of respondents was below 50 per cent" (Barkat et aL 1995). The study identifies husbands and moth-ers-ih-laws as the principal decision makers at a time of maternal crisis. They are also identified as having the least knowledge about obstetric complications. Thus here I may advocate the extension of maternal care education to family members, including the motivation of men in the promotion of pre-natal care.

Families fear the institutional delivery because they will be unable to control the situation, as they can at home. The woman may be seen by a male doctors which may cause shame for the family and the woman herself. It should be noted that the number of female doctor in our country is not sufficient enough. In addition to this, the female doctors like to perform their duty in the city or town rather than the rural area.

The family members further worry that they would be asked to pay more than they are able to for the required treatment. A USAID publication (1995) states that women preferred to have their babies delivered by a known and trusted female

member of their family or community. They generally hesitate to give birth in a hospital. because according to the publication, "paying for normal deliveries was beyond the means of many Bangladeshis let alone paying between Tk 10.000 and Tk 20.000 for a cesarean section". In addition to this, greater number of people are of the belief that the doctors try to find the scope of operating upon the pregnant woman so that they (doctors) may earn a lot.

Both in rural and urban Bangladesh, there is a scarcity of healthcare centres or hospitals. So by the time people reach a facility which has the services they require, it can be too late (Blanchet. 1991). And thus the distance of healthcare centre is one of the identified reasons for the delaying taking to a facility. Thus the upgrading of health facilities, specially rural health facilities, is a must.

Past negative experiences with health facilities is a contributing factor to not seeking help on an emergency basis. When they cannot get routine services they require in an appropriate and timely manner, now could they be expected to turn these services in times of

distress?

Almost all disadvantaged people face a number of problems at the health care centres, among them — lack of competent doctors, absence of doctors and staff, private practice conducted in public facilities, long waiting time, lack of privacy, shortages of medicine and the sale of medicines outside the centre, are important. It is an undenying fact that a lot of Thana Health Complex doctors dp not reside at their, working places, they often do their jobs from the district headquarters.

According to BDHS (1996-97) 65 per cent of births In Bangladesh are assisted by traditional birth attendants (daO. with 8 per cent being assisted by trained dais and 57 per cent by untrained dais. Another onefourth of births are assisted by relatives and friends. Moreover it is possible that some women may have reported traditional birth attendants as their friends', since the distinction between 'friend' and 'dai' Is slight. So the percentage of traditional birth attendants may be higher. Less than 10 per cent of births are assisted by medically trained personnel — either doctors (5 yer cent) or nurses, family welfare visitors (3 per cent).

There has been little change over time in the proportion of births assisted by medical personnel. But very surprisingly and unfortunately even this change is not towards development but towards risk motherhood. Data from the 1993-94 BDHS show that about 10 per cent of births were assisted at deliveiy by a doctor, nurse or midwile. According to 1996-97 BDHS. the analogous figure is about 8 per cent. As might be expected, births In urban areas are more likely to be assisted by medical personnel (doctors, nurses or trained midwife) than In rural areas. It is nearly 35 per cent in urban areas and only 6 per cent in rural areas.

Beyond all doubt the majority of Bangladeshi women will continue to give birth at home with the assistance of dai for a long time to come. Thus the training of TBA's is obviously Important. Though the training programme has already been started, there is great controversy over such training of TBA's. No doubt. TBA's are not the substitute of the trained medical personnel. But it is not possible to change the present practice within a short period, so it is better to train the TBA's. Above all. considerable emphasis must be placed on the education of the community and the family members to encourage them so that they may give up the present practices.