Recommendations to improve maternal mortality among Rohingya women in Bangladeshi refugee camps

Abstract

Despite current humanitarian efforts, The Rohingya in Bangladesh’s refugee camps have among the highest maternal mortality worldwide. The authors review maternal mortality within Rohingya refugee populations in Bangladesh, citing the camp conditions and cultural norms that affect the Maternal Mortality Ratio (MMR). Next, the authors review current humanitarian efforts made by the UNFPA toward improving reproductive health. Finally, the authors recommend a three-pronged approach to reducing maternal mortality among the Rohingya in Bangladeshi refugee camps. We suggest using Maternity Waiting Homes, Mama Rickshaws, and Traditional Birth Attendants to improve maternal health. These solutions address the three-delays model and place ownership into the community. Ultimately, the authors address a much-needed gap in the literature addressing Rohingya maternal mortality.

In the last two decades, conflict and instability in various countries have generated more than 70 million displaced people worldwide (United Nations High Commissioner for Refugees, 2021). Refugee communities are more likely to be discriminated against during antenatal care (Rustad et al., 2021) and more likely to deliver at home without access to secondary education, antenatal care, and motor vehicles, among other factors (Kim et al., 2020). As a result, as of 2017, conflict-affected countries have the worst maternal mortality ratio per 100,000 live births (World Health Organization, 2019).

Healthier maternal outcomes are heavily associated with, but not solely determined by, healthier neonatal and community outcomes (Lassi et al., 2013; Pirjani et al., 2021), which necessitates better research and intervention planning. A population most impacted by conflict with one of the highest maternal mortality rates is the Rohingya, a marginalized community in Myanmar who live in refugee camps in Bangladesh, Indonesia, Malaysia, and Thailand (Jaishankar & Manikandan, 2019). In this article, we have done the following:

1. Review maternal mortality, the Three Delays Model, and associated factors among Rohingya refugees in Bangladesh;

2. Outline humanitarian efforts to address maternal mortality; and

3. Propose evidence-based recommendations for culturally relevant interventions that will positively impact maternal outcomes for Rohingya women.

The authors provide a practical contribution to the global literature on maternal health outcomes for refugee populations. This paper is intended for an interdisciplinary audience and includes cultural and gender norms, culturally relevant health care professionals, NGOs, and public health measures in its practical solution.

Methods

With support from a health sciences librarian who is experienced in comprehensive searches, researchers searched PubMed and BLINDED UNIVERSITY’S Health Sciences Library System Database. The date of the last search was March 2023 in which researchers looked for articles that described (1) the current Rohingya refugee conflict in Bangladesh, (2) the state of maternal health in the Bangladeshi Rohingya refugee camps, (3) UN maternal health interventions in Bangladeshi Rohingya refugee camps, and (4) UN maternal health interventions in similar refugee contexts that have been successful. Researchers used the following canned searches: Rohingya, cultural competency, maternal mortality, humanitarian, reproductive health, interventions, infrastructure, refugees, camps, three delays framework, Traditional Birth Attendants (TBAs).

Bibliographies of relevant articles were examined by the health sciences librarian (HVV) for studies not found through database search engines. EndNote (Clarivate) was used to store all citations found in the search process and to check for duplicates. Search strategies and results were tracked using an Excel workbook. Data were collected and processed using an Excel workbook.

Background

Refugee maternal mortality

The global maternal mortality rate (MMR) has declined by 38% from 342 maternal deaths per 100,000 live births in 2000 to 211 deaths in 2017. While significant, this is less than half of the reduction needed to achieve the Sustainable Development Goal Target 3.1 of 70 maternal deaths per 100,000 live births (UNICEF DATA, 2022).

As of 2015, 61% of maternal deaths occurred in countries affected by humanitarian crises or fragile conditions, amounting to an MMR of 417 maternal deaths per 100,000 live births (United Nations Population Fund, 2015a).

As of 2018, there were more than 30,000 pregnant women among the Rohingya in Bangladesh (UNFPA, 2019). The Rohingya face an MMR of 400 per 100,000 live births, double that of other citizens in Myanmar (Parmar et al., 2019), and more than double Bangladesh’s MMR of 173 per 100,000 live births in 2017 (World Bank, 2019). The high MMR can be attributed to two major factors: camp conditions and gender norms. Most of the camps are overcrowded, which has resulted in inadequate sanitary services, creating difficulties in obtaining fresh and clean drinking water and lack of access to toilets and bathrooms (Chowdhury & Mostafa, 2020; Jaishankar & Manikandan, 2019). Additionally, poor sanitary services have generated a breeding ground for diseases like diphtheria, measles, and cholera, which exacerbate maternal health issues (Chowdhury & Mostafa, 2020).

Gender and cultural norms further complicate these matters. Most women are expected to follow purdah, in which women and girls are expected to stay at home and not interact with male strangers; most women agree with this belief (Parmar et al., 2019). Additionally, women have limited decision-making power and typically do not seek health care services without being accompanied by a male relative. Lack of literacy and female leadership limit opportunities for public communication with women on reproductive health (Parmar et al., 2019). Adolescent girls are also at risk for sexual exploitation, and most sex traffickers are often Rohingya women (Jaishankar & Manikandan, 2019; Rogers et al., 2020).

Results

Three delays model

Rohingya maternal mortality can be explained through the three delays framework, which was created by researchers from Columbia, Ghana, Nigeria, and Sierra Leone. This model aggregates factors that delay obstetric treatment and contribute to maternal mortality into three major broader delays: (1) the delay in the decision to seek care, (2) the delay in reaching care, and (3) the delay in receiving appropriate care, which is framed by socioeconomic and cultural factors along with accessibility of facilities (Thaddeus & Maine, 1994). The model’s holistic approach targets patients and providers while focusing research on maternal health care in Low- and Middle-Income Countries (LMICs) (Actis Danna et al., 2020).

The first delay contributes to most maternal deaths of Rohingya women (Amsalu et al., 2022; Jaishankar & Manikandan, 2019; UNFPA, 2021). Many women have negative experiences with reproductive health care in Myanmar. The government-sponsored population control enforced a two-child policy on Rohingya women and even encouraged authorities to force women to use birth control. Hence, many Rohingya women avoid medical care citing being denied by Bangladeshi doctors, the lack of beds at the hospital, and extortion as plausible reasons (Jaishankar & Manikandan, 2019). Similarly, broken trust between women and providers has contributed to the first delay in sub-Saharan Africa, and subsequently, women’s rationalizations during non-emergency settings to avoid care in the future (Binder et al., 2012). One study reported that a third of Forcibly Displaced Myanmar National (FDMN) women in Bangladesh received no antenatal care visit and 85% of births took place at home, 78.9% of which were assisted by a traditional birth attendant (TBA) (Rawal et al., 2021). One-third of these home births involved pregnancy and childbirth related complications. Bangladesh also has a culture of home deliveries, with a relatively high MMR of 173 per 100,000 live births. In other conflict-driven settings, traditional beliefs and practices through the guidance of traditional healers have also contributed to the first delay, leading to a decrease in health seeking behavior (Whitaker et al., 2021).

The second delay is primarily caused by insufficient infrastructure and distance to medical facilities (Thaddeus & Maine, 1994). Ambulances cannot reach most camps as they are inaccessible by road, and the slippery, muddy terrain makes vehicles more prone to accidents (Parmar et al., 2019). Women also lack legal status as refugees, so they face limited mobility outside the camp and access to the hospital (Jaishankar & Manikandan, 2019). Insufficient infrastructure is commonly cited as the second delay in several similar contexts, and as Emergency Medical Services is not available, this makes the second delay even more relevant (Whitaker et al., 2021).

Lastly, the third delay is made difficult due to discrimination toward the Rohingya from Bangladeshi health care workers and the lack of refugee employment in medical occupations (Jaishankar & Manikandan, 2019). Furthermore, pregnant Rohingya women seeking care tend to solely trust women health care providers and TBAs because of established trust and tend not to access facilities even when they are close in proximity. Hence, most Rohingya are uncomfortable receiving treatment at health care facilities due to the fear of being mistreated and the lack of Rohingya presence, such as TBAs and interpreters (Parmar et al., 2019). Similarly, language barriers are commonly cited as a third delay among populations that have moved to a new setting (Binder et al., 2012). Additionally, gaps in staff coverage, gaps in staff skills, and delays in the referral system are also components that contribute to the third delay, but in the case of the Rohingya refugees, discrimination tends to play a larger role (Alobo et al., 2021).

Humanitarian efforts

The UN Millennium Development Goals aimed to reduce the maternal mortality ratio by three quarters and achieve universal access to reproductive health by 2015 (United Nations, 2000). In the UN’s Sustainable Development Goals, universal access to reproductive health continues to be a target along with a global maternal mortality ratio of <70 per 100,000 live births by 2030 (The Global Goals, 2022).

The UNFPA is the lead agency operating in the camps. As of August 2018, it disseminated the Minimum Initial Service Package (MISP) for reproductive health in partnership with the Bangladeshi Ministry of Health and Sports, and it has also partnered with local organizations like the Hope Foundation to train and deploy midwives (Parmar et al., 2019; UNFPA, 2019). The Hope Foundation is a prominent local organization that responds to Rohingya needs through the establishment of the Hope Field Hospital for Women, nine reproductive health centers, an emergency care center, a primary health clinic, and maternal health centers (HOPE Foundation, n.d.). UNFPA also provides women with contraceptives, which are becoming increasingly popular in the camps, and delivery kits with clean sheets, towels, and sterilized equipment as most women choose to give birth at home (Jaishankar & Manikandan, 2019). Given the current Rohingya MMR of 400 per 100,000 live births (Parmar et al., 2019), it will be difficult to achieve the UN SDG of 70 per 100,000 live births by 2030; however, we have proposed the following recommendations to work toward this target.

Recommendations and cultural relevance

We recommend using a three-pronged approach to reduce maternal mortality among the Rohingya in Bangladeshi refugee camps: housing high-risk mothers in Maternity Waiting Homes (MWH) staffed by trained TBAs, increasing TBA attendance at community births, and implementing prenatal visits in the MHWs and community.

Maternity waiting homes and mama rickshaws

MWHs are safe spaces located near health facilities with obstetric care where high-risk mothers reside during the last month of their pregnancy and finally deliver their babies (Wild & Kurji, 2021). MWHs have increased institutional deliveries in Southwest Ethiopia by 61.4% in 140 cases (Hailu et al., 2021), increased MWH facility delivery in Zambia by 7.57% (Perosky et al., 2019), reduced maternal death by 80% in Ethiopia (Dadi et al., 2018), and nurtured a cost-effective intervention in rural Liberia (Buser et al., 2019). They have also been used in conflict-ridden settings, such as Afghanistan (Das et al., 2018) and Timor-Leste (Wayte et al., 2008). In displacement camps in Mogadishu, Somalia, which are also Muslim camps, MWHs have been deemed a “big success” by the UNFPA, which provided care to expectant mothers at all stages of pregnancy through 30,000 health consultations, 17,000 births, and identification and monitoring of 1,300 pregnancy and childbirth complications (UNFPA, 2015b). Given that MWHs have been used in previously similar contexts, we believe that Maternity Waiting Homes will help reduce maternal death among Rohingya camps in Bangladesh. Though Rohingya women are expected to follow traditional norms about remaining in their homes, especially during pregnancy, the success of MWHs in other low-resourced, conservative, and conflict-affected communities suggests that MWHs can effectively address high maternal mortality among the Rohingya in Bangladesh (Parmar et al., 2019; Translators without Borders, 2021). If staffed by Rohingya women and health care professionals, MWHs will address the third delay, which is the discrimination Rohingya face in Bangladeshi health care facilities. Consequently, this will address the first delay, distrust between patients and providers, as the Rohingya will be more likely to trust health care professionals from the same community.

We also propose implementing Mama Rickshaws, which are built for congested camp environments and transport expectant mothers from the community to MWHs and from MWHs to the local hospital in emergencies. Ride-hailing platforms have been successfully piloted in refugee and low-resource settings to improve maternal mortality outcomes, such as the Chopela Mama service in Mozambique (UNFPA Mozambique, 2021) and the Vodafone Foundation’s m-mama ambulance taxis (Vodafone Foundation News, n.d.).

Though Rohingya women are expected to follow traditional norms about remaining in their homes, especially during pregnancy, the success of MWHs in other low-resourced, conservative, and conflict-affected communities suggests that MWHs can effectively address high maternal mortality among the Rohingya in Bangladesh (Parmar et al., 2019; Translators without Borders, 2021).

Traditional birth attendants in humanitarian efforts

TBAs are known to be experienced and among the most trusted authority figures for Rohingya women (Translators without Borders, 2021). Due to their cultural and social acceptability within the community, TBAs are critical for health education, serving as a positive link for women and families to preexisting health care structures (WHO, 2004), and providing a sense of comfort regarding disseminating accurate health information and culturally sensitive care (Miller & Smith, 2017). However, TBAs also pose several challenges: the lack of ability to recognize delivery complications, the lack of formal education leading to various methods that may not be the best practice, and the lack of ancillary and continuing education to be well-informed on the latest practices and treatments (Amutah-Onukagha et al., 2017; Flaherty, 2008). Nonetheless, TBAs effectively garner trust among women in their communities (Miller & Smith, 2017), and given the discrimination the Rohingya face in Bangladeshi health care facilities, cultivating trust in health care facilities among the Rohingya is critical. Therefore, we propose deploying trained TBAs to deliver babies both in homes and the Maternity Waiting Homes, conduct prenatal and postnatal checkups, and identify and encourage high-risk mothers to use the MWHs. Staffing MWHs with TBAs will ensure continuous monitoring and promote facility-based birth culture. The WHO has recommended utilizing trained TBAs where service gaps exist to health care workers in low-resource settings (WHO, 1970), efforts that have been successfully executed in Eastern Burma (Mullany et al., 2008), Burundi (Chi & Urdal, 2018), and along the Thai-Myanmar border (White et al., 2016). A study conducted among Rohingya refugees in Cox’s Bazaar has shown that educating TBAs about the signs of high-risk pregnancy and motivating them to make early referrals can improve maternal outcomes (Sarker et al., 2020).

Discussion

Addressing the three delays

Our recommendations address each of the three delays in a feasible and culturally sound manner. Mama Rickshaws addressed the second delay by providing transport to the MWHs and health care facilities. The third delay is addressed by staffing the community and MWHs with TBAs, whom the community trust and revere. Finally, the first delay, the decision to seek care, will be addressed over time as second and third delays decline. Mothers are more likely to seek care because of the trust in institutional births established through TBA staffing and the success of the waiting home facilities.

Sustainability through community-owned resources

Our recommendations are sustainable if existing resources within the camps are capitalized. TBAs are an established workforce and training them builds on their skill sets and breadth of knowledge. A successful intervention will partner with a local hospital, such as the Hope Field Hospital, to allow for easy transfer of management of the waiting homes. This builds on the existing infrastructure of the hospital, places ownership into the community, and ensures that the homes remain sustainable. Finally, these recommendations allow for male community members to seek employment opportunities as rickshaw drivers and security guards for the MWHs.

Conclusion

Maternal mortality is one of the health outcomes targeted by the Sustainable Development Goals and humanitarian organizations like the WHO and the United Nations. The Rohingya are a vulnerable population impacted by high maternal mortality due to gender discrimination, inadequate sanitary services, and government hostility toward cultural practices. The authors have presented evidence-based recommendations for a streamlined, culturally sensitive approach to reduce maternal mortality among Bangladeshi refugee populations by addressing the three delays model. Addressing maternal health in refugee settings is of the utmost importance as healthy mothers, babies, and families promote overall community health and well-being.

Acknowledgments

We would like to thank Dr. Helena VonVille, Elaine Linn, Dr. Cynthia Salter, and the Global Studies Center from the University of Pittsburgh for their continuous support and organization of the University of Pittsburgh’s Global Health Case Competition.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The authors report that the Global Studies Center at the University of Pittsburgh hassupported the publication of this study.