Improving Health for Women in the Netrakona Region in Bangladesh

Background

SUS is a local NGO established in 1986 by Rokeya Begum. The organization is located in the outskirts of Netrakona district. SUS works with underprivileged and marginalized women, children, adolescents and the disabled through a holistic and participatory approach based on the needs of the community, with a prime focus on livelihood development. SUS is committed to bringing about positive changes in the quality of life by making available education, comprehensive health services, micro credit as well as other social services that enable the women to exercise their socio-economic rights. The organization believes that the quality of women's lives is enhanced by emphasising an inclusive gender approach, community participation and collaboration with governmental and other relevant organizations. SUS has been working in the health sector since 1998 and been financially supported by ID/DNJ/FOKUS since 2002.

Purpose/objective

The purpose of the midterm evaluation of the Health Project was to find out if SUS reaches its goals, performs the activities as planned, reaches the target group, delivers good quality health care and has worked with the recommendations given at the final evaluation of 2005. In addition, the evaluators looked at the organization and administration of the Health Project, its place within SUS and the gender issues within the Health Project and SUS. Finally, the team wanted to assess how the two Bangladeshi midwifes who, as part of an FK exchange programme, had settled back into work at the Health Project in Netrakona after nine months in Norway.

Methodology

The evaluation is based on interviews with a variety of different health workers, observations of health promoting activities and a TBA (traditional birth attendants) workshop and investigation of various reports and records kept by SUS.

Key findings

SUS has many numerical goals. It was impossible to evaluate whether all the numerical goals are going to be reached. Even though it is good to have numerical goals, it is easy to get distracted by them. The content of the activities is as important, if not more important. It appears that SUS will not reach their own goals regarding the teaching of TBA's and the teaching of their own staff.

Statistics provided by SUS are difficult to interpret and impossible to compare to national statistics. SUS has stopped the recording of details from the eligible couples. Instead they now collect information from the TBA's. At the time of the evaluation visit, no calculation had been done with the data gathered from the TBA's. Reliable methods for finding out maternal and perinatal mortality do exist. However, it requires specific expertise which SUS does not have and probably doesn't need.

The quality of the care given by the midwives has improved greatly. The number of antenatal visits per women was reduced in accordance with WHO's recommendation.
Going through the doctors register (in which all patients he sees are recorded on a daily basis), it is clear that many pregnant women are referred to the doctor. When the midwives were questioned about this, they mostly answered that this is the women's wish. From the women's records it was obvious that most women didn't have a medical reason for seeing the doctor. A doctor has a much higher status as a health worker than a midwife. However, as the present doctor is not specialised in gynaecology and obstetrics it could be argued that the midwives in effect are more qualified and have more experience in caring for pregnant women than the doctor.

In the counselling room we observed a film being shown to pregnant women and their relatives (usually mother-in-law). It was a locally produced film which seemed very relevant. So far no action plan/guidelines have been made to help midwives cope with complicated pregnancies. The quality of taking a history from the pregnant women can still be improved.

Recommendations

Regarding child delivery, the following recommendations are made:
1) Better records need to be kept. It was impossible to find out whether the woman in labour was a primiparous (giving birth for the first time) or multiparous. This is important information in labour. All babies were recorded with a weight of 2,5 kg. But the babies are not weighed and this is just an estimate. Maybe a correct Apgar Score and a note about the size of the baby (small, normal, big) are more relevant?
2) More restricted use of antibiotics. Several women received antibiotics after a perfectly normal delivery. The unnecessary use of antibiotics creates resistance, which is becoming a worldwide problem in the provision of health care.
3) The midwife needs to be aware of the fact that she acts as a role model while giving care at home. She needs to think carefully about the action she takes as deeds speak louder than words. Several women received an intravenous drip of oxytocin which stimulates contractions. Others received a drip of "strengthening Gluc 5% and IV vitamins". If the TBA's get the impression that such is needed to attain a spontaneous vaginal delivery, they will adjust their practice accordingly.
4) The midwives should make an effort to attend more deliveries in order to gain experience.

The Health Care Project is doing a valuable and important work. The quality of the activities is improving. In order to reach the target group of the extreme poor, SUS needs to look at the fees they charge and the geographical location they provide care at. The midwives should be given still more responsibility in the teaching of the TBA's. For the health care project to move on and develop, it is necessary to appoint a project director as well as a project manager, both of them should preferably be women. All the staff regularly needs to be offered ongoing teaching and training, both to ensure the quality of their work and to encourage interest and commitment to their work. Starting a maternity unit would require a lot more financial support, new and more qualified staff, its own project leader and close follow-up.