The Tremendous Cost of Seeking Hospital Obstetric Care in Bangladesh

Abstract

In Bangladesh, maternal mortality is estimated to be 320 per 100,000 live births, among the highest in the world, and most deliveries in rural areas occur at home. Women with obstetric complications fear to seek hospital care for various reasons; one of which is the tremendous cost. This paper shows how cost impedes rural, poor women's access to emergency obstetric care. The data are from a larger ethnographic study of childbirth practices in 2000–01 in Apurbabari village, the adjacent sub-district health complex and more distant tertiary hospitals at district level. Families had to spend what for them added up to a fortune for a caesarean section and other surgery, medicines, laboratory investigations, blood transfusion, food, travel and other expenses. Corruption in the form of demands for under-the-table payments to obtain these aspects of essential care is rife. Adequate resources should be allocated to the different health facilities, including for emergency obstetric treatment. Thana health complexes (sub-district hospitals) should be upgraded to provide comprehensive obstetric care. The system for prescribing drugs should be reformed and the causes of corruption investigated and addressed. Hospital care should not be allowed to further impoverish the poor. Addressing these issues will help to encourage rural, poor women to seek skilled delivery and post-partum care, particularly in emergency situations.

Résumé

Au Bangladesh, la mortalité maternelle est estimée à 320 pour 100 000 naissances vivantes, l'une des plus élevées du monde ; la plupart des accouchements dans les régions rurales se déroulent à domicile. Les femmes présentant des complications obstétriques craignent de demander des soins hospitaliers, pour plusieurs raisons dont leur coût exorbitant. L'article montre comment le coût empêche les femmes rurales pauvres d'accéder aux soins obstétrique d'urgence. Les données sont tirées d'une vaste étude ethnographique sur les pratiques obstétriques en 2000-2001 dans le village d'Apurbabari, le complexe de santé de sous-district adjacent et les hôpitaux tertiaires de district plus éloignés. Les familles doivent dépenser ce qui représente pour elles une fortune pour des césariennes et d'autres interventions, des médicaments, des analyses, des transfusions sanguines, des frais de voyage, d'alimentation et autres. La corruption, sous la forme de ≪ dessous de table ≫ exigés pour obtenir ces soins essentiels, est très répandue. Il convient d'allouer des ressources appropriées aux centres de santé, notamment pour un traitement obstétrique d'urgence. Les centres de santé de sous-district doivent être aménagés pour fournir des soins obstétriques complets. Il faut réformer le système de prescription des médicaments et les causes de la corruption doivent faire l'objet d'enquêtes et être éliminées. Les soins hospitaliers ne sauraient appauvrir encore les démunis. Ces mesures encourageront les femmes rurales pauvres à rechercher des soins qualifiés pendant et après l'accouchement, particulièrement dans des situations d'urgence.

Resumen

En Bangladesh, la tasa de mortalidad materna es de aproximadamente 320 por cada 100,000 nacidos vivos, una de las más altas del mundo. La mayorı́a de las mujeres en las zonas rurales dan a luz en su hogar. Aquéllas que presentan complicaciones obstétricas temen acudir al hospital por varias razones, entre ellas el alto costo. En este artı́culo se muestra cómo el costo impede el acceso de las mujeres pobres rurales a la atención obstétrica de emergencia. Los datos provienen de un amplio estudio etnográfico sobre la atención de partos en del perı́odo 2000-01 en el poblado de Apurbabari, en el establecimiento de salud del subdistrito cercano y en los hospitales distritales de tercer nivel de atención más distantes. Las familias gastaron una fortuna para cubrir las cesáreas y otros procedimientos quirúrgicos, medicamentos, exámenes de laboratorio, transfusiones sanguı́neas, alimentación, transporte y otros gastos. La corrupción o exigencias de pagos por debajo de la mesa para obtener estos aspectos básicos de la atención médica es la norma. Se deben distribuir los recursos adecuados a los establecimientos de salud, incluso el tratamiento obstétrico de emergencia. Asimismo, se deben actualizar los establecimientos de salud de los subdistritos para capacitarlos en la atención obstétrica integral. Debe reformarse el sistema de formulación de medicamentos y se deben investigar y eliminar las causas de la corrupción. El tratar estos aspectos ayudará a motivar a las mujeres pobres rurales a acudir a los prestadores calificados de atención obstétrica y posparto, particularmente en situaciones de urgencia.

Key Words:

• childbirth
• rural poor women
• emergency obstetric care
• out-of-pocket payments for health care
• Bangladesh

Bangladesh is primarily an agrarian society with an annual GDP per capita of US$370, and a very slow economic growth of over 5%.^{1 2} At least 47 million people live in extreme poverty, of whom women are the most disadvantaged. The resources allocated for public health sectors are not more than 5% of the total national budget.³ Government expenditure for health is about US$3 per person per year, yet an estimated US$12 is required to provide a minimum level of health care.⁴ In Bangladesh, maternal mortality is among the highest in the world, 320 per 100,000 live births.⁵ Each year approximately four million women become pregnant and 600,000 develop complications.⁶ Although some 15% of pregnant women require life-saving obstetric services, only about 8% of total births take place in medical facilities and only 2.23% undergo caesarean sections in Bangladesh.⁷ Thus, a high proportion of women do not receive essential obstetric services even in life-threatening situations.

Various Safe Motherhood initiatives, long before the Millennium Development Goals, influenced the government of Bangladesh to offer essential obstetric care services throughout the country.^{8 9} Government-run health facilities are hierarchically distributed through different governmental administrative units. There are union health and family welfare centres, thana health complexes (sub-district hospitals), district hospitals and medical college hospitals. At union health and family welfare centres, basic services include first-aid, e.g. injectable oxytocin (ergometrine), antibiotics and anticonvulsants; at thana health complexes, manual removal of placenta, assisted vaginal delivery and vacuum aspiration are provided. Comprehensive obstetric services, including caesarean section and blood transfusion, are available at district hospitals and medical college hospitals.

Despite the government's policy to provide free health care, the budgetary constraints have given rise to poor financial health resources allocation. The cost of hospital obstetric treatment is estimated to be high in Bangladesh. A study done in Dhaka city reported that the total cost for normal childbirth at the hospital was BDT 1,275 (US$31.90), and for caesarean sections BDT 4,703 (US$117.50).¹⁰ For rural, poor families, these costs are very high and may impede their access to hospital care. In this paper, I shall examine how expenses related to obstetric treatment impede rural, poor women's access to hospital obstetric care even if they are in a critical condition.

Participants and methods

I used ethnographic methods for data collection, primarily in-depth interviews supported by participant observation and informal discussion. I spent ten months from December 2000 to September 2001 in a village called Apurbabari and in two adjacent hospitals. I chose this village because of previous acquaintance, familiarity with the local dialect, the close proximity to hospitals and good road communications. The two hospitals were the 31-bed thana health complex, as rural women firstly sought care there, and the 636-bed tertiary-level medical college hospital, which gave only comprehensive obstetric care and managed complicated obstetric cases. Six beds in the former and 80 beds in the latter were allocated for obstetric patients. I collected data in the hospitals to validate interview data by observing hospital situations and listening to the experiences of women and other respondents.

In my research, the total number of participants was 170. In the village, primary selection of respondents was made from among women who had given birth in the previous five years, whose names and addresses were taken from the register of a local NGO paraprofessional. I categorised them into four groups: (a) experienced childbirth both at home and hospital; (b) gave birth only at home; (c) delivered only at hospital; and (d) were currently pregnant. All were selected purposively depending on their willingness to participate, experience and ability to reflect on it. I met and included some of the women during the course of interviewing other participants.

In the village, I interviewed 14 women, of whom four had given birth at home and at hospital, seven only at home and three only at hospital. They were aged 18–35. Twelve of the women came from the poorer section of the village, with eight having had no formal school education, three completed five years of schooling and one ten years of schooling. Two women were from well-off families and had completed 12 years of schooling; one of them was a schoolteacher. I interviewed them each for 2–3 hours over 2–3 days. Moreover, I observed birth events of five pregnant women at their homes and interviewed them. I began to talk with them during their pregnancies, observed the births and followed them till their seventh day post-partum. These women were 20–30 years old from poor families, with four having no formal education and one five years of schooling. Six husbands, three mothers, two fathers, two mothers-in-law, two fathers-in-law and six dainis (traditional birth attendants) were also interviewed.

In the medical college hospital, 21 women were purposively selected. Four women were selected during admission at the emergency room, three women at the antenatal examination room right after admission, two at antenatal wards, five in the labour room and the rest in post-natal wards. They were aged 18–35. I observed and interviewed four rural, poor women, two of whom had caesarean sections and the other two serious complications (post-partum haemorrhage and ruptured uterus). I observed them for five to seven days and interviewed them and their families for 2–3 hours each. One of the four went to primary school; the others had no formal education. I also observed assisted normal vaginal deliveries of 15 women and interviewed them and their family members. Three of them came from affluent families and had more than 10 years' schooling; the rest were poor, five having no education and seven with more than five years of schooling. I also interviewed for 3–4 hours each two well-off women who had undergone caesarean sections, aged 25–30, and had completed 14 years of schooling.

I interviewed two senior female obstetricians at professor level, one male obstetrician, three clinical assistants and six interns in the medical college hospital for their views on hospital birth practices. Among the nurses, one senior nurse, four mid-level nurses and four student nurses were interviewed, and the latter two groups were observed as well. One senior hospital administrator, four medical representatives, one dietician, one ward supervisor, four ayahs (helpers) and two cleaners were also interviewed.

In the thana health complex, I observed assisted normal vaginal deliveries of eight women, and followed two of them back home. They were selected purposively right after admission. They all came from a poor background and were aged 18–20. Three of them had completed five years of schooling and the rest had no formal education. I also interviewed the family members of the eight women, one thana health administrator, two medical officers, four nurses, two ayahs and one female cleaner about their experience of hospital birthing practices.

The principal research questions were why rural, poor women adhere to indigenous birth practices and practitioners and resist seeking hospital, obstetric care; what factors impeded and influenced them to seek hospital care; the merits and demerits of home birth vs. hospital birth; and the role of different actors at home birth and in the hospitals. Information on hospital costs and the associated hidden costs were extracted from interviews with birthing women, husbands, family members, health professionals at hospitals and other hospital staff. This information was strengthened by my own observations in the hospitals.

My research assistant helped record and transcribe the interviews and observational field notes in the village. In the hospitals, doctors and nurses refused to be recorded on audiotape so we took notes. I generated themes out of the research texts, and the data were eventually presented as narratives with verbatim comments, to enhance the authenticity of the individual voice.^{11 12} The quotes presented here are typical of the women interviewed; their names have been changed to maintain confidentiality.

Getting to the hospital

When a problem occurred with a delivery, rural women and their families ran from one place to the other in their journey from home to hospital. As the thana health complex was located near the village, the majority first tried to seek care there. The first disappointment they faced was when they had to be referred on to the medical college hospital.

“We took the rickshaw to go to the thana hospital. They kept us waiting for two hours and then, as they couldn't treat my problem, told us to go to the big hospital. Later on, we took a bus to reach the district hospital. The doctors tried to deliver the baby. We were there for six hours. They couldn't deliver my wife. From there we hired an ambulance to come to this big hospital. It took three hours to reach. We spent more than 24 hours before reaching the big hospital.” (Romila and her husband)

“We went to the thana hospital on my brother-in-law's rickshaw van. From there, my husband took me to the bus station on a rickshaw. We arrived in town by bus and hired a rickshaw to reach the doctor's chamber and afterwards came to the hospital. My husband estimated that more than BDT 1000 was spent on our travel and our relatives.” (Rownak)

Women and their husbands and families spent from BDT 1000 to 3000 on travel to and from the hospitals where they were sent.

Experiences on arriving and admission to hospital

Getting into the medical college hospital was difficult for poor families, despite their having a hospital pass. The gatekeepers usually refused them entry and commonly demanded BDT 10–20 to allow family members access, which family members told me about and I observed myself.

“I paid BDT 20 at the main entrance and BDT 10 at two other gates. Each day I usually pay the gatekeeper BDT 10.” (Romila's husband)

At the Medical College Hospital emergency room, during admission all the women I observed and interviewed were charged BDT 10, when the standard fee was BDT 7.50 and they received a receipt for BDT 7.50. I heard from nurses and senior doctors that the money was shared among the staff responsible for admission to the emergency room.

Then, as soon as the women were admitted, they faced hospital-aides, ward boys and special ayahs who came forward to offer to push the trolley and transfer them to the antenatal room. The women and their families sought this assistance due to their unfamiliarity with the hospital and to reach the antenatal ward quickly. The hospital-aides demanded cash for this service, about BDT 200. The majority of the patients and their companions did not anticipate paying for this, as they assumed these were paid staff. In fact, the ward boys were on the payroll but special ayahs were not. I observed in most cases that the attendants tried to bargain with them; the majority paid BDT 150–200 and a few only BDT 100. In some instances, the ward boys and ayahs became annoyed if the payment was less than what they demanded.

“I told them, we are poor. We can't pay the amount you ask, but we won't make you unhappy.” (Shahana's mother)

“We help patients. But, when the question of payment is raised, they refuse to pay us the due amount.” (Ayah)

In most cases, the payment was made one to two days later or when patients left.

Treatment-related expenses

Medicines

Expenses incurred in hospital treatment of obstetric patients were very high. The rural, poor patients were usually brought to the medical college hospital in a critical condition. After an examination, junior doctors at the medical college hospital and nurses at the thana health complex would give the patients' families a list of medicines. The medicines were not available at the medical college hospital and not easily obtained. However, doctors often put pressure on the families to get the medicines quickly without considering their financial situation.

The cost of the first prescriptions for caesarean section was BDT 2500–3000 whereas for normal vaginal delivery it was BDT 250–300 in the thana health complex and BDT 350-400 in the medical college hospital. When emergency surgical procedures such as caesarean sections were required, the urgency put poor villagers under tremendous stress to secure the money. Families would arrive at the hospital with some cash, but the amount of money required was beyond their imagination. Most did not know where to turn or where to buy the medicines, which led to delays, and because of the cost they often bought less than the required amount. All the interns interviewed believed that the villagers were trying to trick them by saying they were unable to buy medicine, and got annoyed and frustrated. They put further pressure on the families, though some of them also tried to arrange some medications from their own medicines boxes, kept for emergency situations. The families usually went back to their villages to raise more money. The senior obstetricians interviewed were observed to understand the situation, and one of the three tried to arrange medications herself from a pharmaceutical company or from her own purse.

Many generic medicines were in fact available in the central drugstore of the medical college hospital but the majority of interns and junior doctors were observed to prescribe non-generic brands of the drugs. As a result, families thought they had to buy the branded drugs instead of those given free to some patients. Most interns and junior doctors were not always aware of trade vs. generic drug names, or their cost or availability in the hospital. One day, a patient's husband drew my attention to this matter. He showed me the drug list prescribed for his wife. As I believed some of the drugs were available in the hospital, I checked with the nurse:

“Yes, medicines such as muscle relaxants used with anaesthesia, antibiotics and intravenous saline are available in the hospital drugstore. I received this drug requisition form after I had sent today's requisition to the drugstore. I will be able to send the form tomorrow morning, and then the patient will receive the medicine from the hospital. The interns always make the same mistakes. They prescribe medicine under a different trade name, but these are all available in our drugstore. However, if I send the requisition form with the trade names written by the interns, the drugstore will not dispense the drugs.” (Nurse, medical college hospital)

On one occasion, I observed that an intern rushed to give a drug list to a patient who was supposed to have dilation and curettage (D&C) under general anaesthesia that day. The nurse was not aware that this operation was booked as the pre-operative treatment order had not been written in the patient's file the previous night. The doctor also seemed to be careless about prescribing the medication in time. The patient was taken to the operating theatre. The family member went to the drugstore to buy the medicines. The nurse said:

“If the doctor had written the pre-operative order last evening, we would have managed to give medicine to this patient by sending a requisition to the drugstore in the morning.”

The relationship between nurses and interns was not very congenial. The nurses were more experienced and more acquainted with hospital situations than the interns. But the interns felt superior to the nurses and usually did not communicate with them for fear of exposing their lack of knowledge. The nurses also did not come forward to help the interns with prescriptions either. These conflicts and lack of communication caused suffering for poor patients and raised the burden of costs.

In the medical college hospital, the pharmaceutical representatives were observed to influence the doctors to prescribe brand-name drugs. During my 30-minute stay in one doctor's duty room, I met five drug representatives who fondly described the importance of their drugs and gave a small gift (pen or notebook) and drug sample to the doctor. In hospital wards, some representatives were seen to read patients' files to check whether their own brands were being ordered. They also accessed hospital registers where drugs prescribed to patients were recorded, without nurses' permission.

Furthermore, drugs were being stolen from the hospital before, during and after being dispensed. In the hospital, there were posters saying: “Be careful of stealing! Keep your medicine safe and do not give medicines to strangers.” However, I myself witnessed a fake doctor wearing a white-coat taking drugs from a patient on the ward and disappearing. In spite of written and verbal notices to give medicines to nurses on duty only, these situations occurred.

“The problem starts from the very beginning when the government calls for a tender from the agent. Three to four agents usually get the contract to supply drugs to the hospital and sell drugs at very high prices. No one says anything because high officials are involved in it.” (Doctor)

“The serious crime happens in the central drugstore. Most drugs get stolen before their arrival in the hospital. Drugs are also stolen from the hospital drugstore and in dispensing. The ward boys who bring the drugs from the store also steal some. Hospital drugs are seen available in the market.” (Doctor)

Blood transfusions

The urgent need for blood transfusion of obstetric patients made interns and patients' families run from the wards to the Blood Bank. The Blood Bank is supposed to sell blood to in-patients at BDT 200 per bag. Collecting blood on time was a common problem despite immediate payment, and most patients had to pay additional money.

“The staff at the Blood Bank said, we don't have any blood right now. But the doctor asked for blood immediately. I didn't know what to do. Then they demanded some money from me. I had to pay BDT 100 extra.” (Rownak's husband)

“Selling blood is an opportunity for the criminal. Staff at the Blood Bank hide blood and sell it at a higher price. In emergency situations, a bag of blood can be sold at BDT 1000.” (Senior doctor)

I observed that for caesarean sections during morning and evening hours, blood was sold at the normal price. On the other hand, a patient with post-partum haemorrhage late at night required 18 bags of blood and paid more than BDT 5000. Sometimes, for very poor patients, the senior doctors arranged for the hospital to provide blood. A very poor woman admitted with septic abortion received one bag of blood at BDT 100, and the rest was borne by the same senior obstetrician mentioned earlier.

Investigations and tests

Laboratory investigations are supposed to be done free in the hospital. Despite their availability, many patients were sent to private laboratories.

“When we went there for blood tests, they told us the reagents required were not available in the hospital.” (Marina)

Private laboratories were located near the hospital, and hospital pathologists and technicians also worked in them part-time.

Rownak's husband said it cost at least BDT 500 for blood tests and a chest X-ray. Rahima, who developed complications due to septic abortion and later required a hysterectomy, said that they spent BDT 2000 for laboratory tests.

“It is a big profit-making business. These labs make lots of money as the patients are referred from hospital. The doctors and technicians get involved in business ventures by referring patients to private laboratories.” (Doctor)

Food-related expenses

The supply of meals was inadequate for the number of in-patients, especially in the medical college hospital. I observed that many nurses tried to distribute meals based on their assessment of the economic status of patients and geographic distance of their residence, but were not always successful.

“I cry when I see poor patients sitting with their plates and waiting for meals. Food is often given to patients who are related to hospital staff. When the issue was put before the Deputy Director of the hospital, he said that they were as poor as others. Yes, they are also poor, but do not live far. We can't make everything possible in spite of our willingness.” (Nurse)

Poor patients and their families were confused about how meals were allocated to patients. They dared not ask for fear of being insulted or scolded.

“I was getting bread and milk. One day I got milk, but the other day I did not. I was not sure what my meal was.” (Romila)

The hospital dietician explained why the number of meals was insufficient:

“Previously, the expenditures incurred in providing diet were met from the budget. The annual budget allocation for hospital meals was BDT 7,200,000, but the hospital spent an additional BDT 8,000,000. As the contractors were not paid, they refused to supply further meals to the hospital. Then, a decision was taken that additional meals would not be prepared.”

These constraints forced many patients to buy their own meals. I observed that most rural women were accompanied by 3–5 family members and their meals were bought locally.

“My husband had to spend so much money on meals. Everyday we spent about BDT 200 for our relatives coming from the village. I stayed three days in hospital and the meal costs exceeded BDT 1000.” (Rownak)

Other payments

One doctor admitted charging for assisting deliveries in the thana health complex, and also for seeing patients in the outpatient department in his work hours.

Women and their families were obliged to pay for other services as well. In the labour room, I observed that one or two ayahs would stand beside the birthing woman. One time, one held the woman's leg and assisted the doctor, and the second held the other leg and helped with the baby after it was born; then they did all the cleaning up of the woman and baby after removal of placenta. Later they demanded BDT 400 payment, but the patient's family refused to pay it. Four or five ayahs crowded round and started to quarrel with the family. Suddenly, the nurses were not able to locate the patient's file, which the ayahs had hidden. On bargaining, the two ayahs were paid BDT 300. This was a common occurrence in the medical college hospital and thana health complex. In the thana health complex labour room, the nurses were observed to demand BDT 200–400 from poor patients and became annoyed if they got less. In the village, three respondents stated that they ran away from the hospital to avoid the burden of such payments. For well-off families, paying money to ayahs, ward-boys, nurses and others was not a problem as they could afford it.

In the hospital wards, an ayah would charge BDT 80–100 per day for looking after a patient. Even if they were asked to do a small task by the patient, such as buy medicine from the drugstore, buy blood or collect lab results, BDT 30–100 was demanded plus another BDT 20 to hasten the process.

“I didn't even ask the ayah to do this. She forcibly took my daughter's clothes, washed them and demanded BDT 100.” (Rahimon's mother)

“My wife was in dire need of blood, but none of them was coming forward to do blood group and cross-matching tests. Then, I gave them BDT 20 to have a cup of tea. The task was done immediately.” (Hanufa's husband)

If they refused to pay, patients and their families were purposely misinformed of the location of the hospital drugstore, blood bank or labs by ward boys or ayahs.

The total burden of payments and costs

Table 1 shows estimates of total expenditure for normal births and caesarean sections based on information from patients and their families. Normal childbirth cost about BDT 800 at the thana health complex and BDT 1600 at the medical college hospital, and emergency caesarean section cost about BDT 13,000. With other complications, the estimated costs were BDT 20,000–25,000, a huge amount for poor, rural families.

Difficulties in putting together the money needed

Collecting the required money was difficult for poor villagers, who usually had no assets or savings. No one wanted to loan them money either. Some families borrowed money from moneylenders at very high interest rates, which tripled within six months. Some raised money by selling domestic birds, cattle or land or even a tin shed roof. Romila's husband spent their total savings of BDT 10,000, which he was saving for a homestead, on his wife's treatment and had to borrow BDT 10,000 from moneylenders as well. Raimon's parents sold their only piece of land for their daughter's care, and then she died.

Rural women interviewed in hospital and the village said that high hospital costs barred them from seeking hospital obstetric care. When Shaheron was referred to the Medical Hospital for pre-eclamptic toxaemia, she refused to go:

“If I die, I will die here. I don't want to sell my house and sleep with my family on the street.”

Discussion

This paper examines how costs incurred in obstetric treatment impede rural, poor women's access to hospital obstetric care. Data reveal that rural, poor families had to bear enormous costs, particularly for caesarean section and major surgery, and became poorer as a result.

Despite the Bangladeshi Government's policy to provide free health care, budgetary constraints limit resources in hospitals. The under-resourcing begins at national level where the defence budget (13%) is almost three times the health budget (5%).³ Furthermore, the current annual hospital budget is based on the number of hospital beds estimated to be needed in the early 1960s, which is one-third of the current patient volume. Moreover, the tendency to fund urban-based centres means far fewer financial resources are allocated to thana health complexes, which are geographically accessible to more than 80% of the population but can offer only a minimum level of services. Rising health care costs further limit provision.

Under-resourced hospitals and poorly paid staff, from doctors to ward boys, create space for corrupt practices such as unofficial fees and stealing of hospital supplies in Bangladesh.^{13 14 15 16 17 18 19} Rose-Ackerman argues that it is self-interest and greed that provoke individuals and groups to become involved in corruption.¹⁹ Poor, salaried staff are vulnerable and easily bribed, but corrupt practices also serve the interests of high-level officials,¹⁹ such as hospital administrators and doctors, who may not be directly involved. Kohli argues that middle- and lower-level staff imitate their seniors, and that it is senior staff who initiate corrupt practices.²⁰ In Bangladesh, the silence on these issues is due to senior political and personal interests, an analysis supported by Chowdhury's documentation of officials, including doctors, making money on medicines.²¹ Corruption is not always directly related to earning cash, but to fulfillment of personal interests, such as obtaining or maintaining a position or exercising power.²² Ahmed in this context claims, “Corruption, therefore, is not merely a financial transaction or some bending of rules but the very reproduction of the structure that goes on to make such a transaction or bending of rules possible.”²³

In Bangladesh, 62% of total medical expenditure is associated with the cost of drugs.¹⁰ Prescribing brand-name drugs is not only linked to pharmaceutical company influences but also to doctors' own beliefs about claims of the quality of those drugs.²³ Part of the reason for the cost explosion of modern treatment can be attributed to doctors' prescribing behaviour and high expenditures on drugs.^{21 24}

The costs incurred for a normal birth in the medical college hospital were close to the monthly income of some families in this study. The cost of a caesarean section is four to five times the monthly income–less than BDT 5,000–of 76% of households.²⁵ This is not unique to Bangladesh but is also the case in India.¹⁴ These hefty expenses, especially on surgery and treating other major complications, result in acute crises in poor families, and greater impoverishment. National and global efforts to improve maternal health thus have little meaning to poor women, whose families become the victims of modern, biomedical treatment.

Recommendations

Rural, poor women experience normal birth in their own homes with the support of family members and other women. For complications, they require medical intervention. However, the majority of people in Bangladesh cannot bear the expenses and refuse to seek hospital obstetric care. To encourage them to make use of that care, the Government of Bangladesh should consider how to minimise the expenses they incur, as follows:

• Equitable and increased resource allocation to health at national level and at different health facilities should be considered, with more going to sub-district level health facilities, which will increase accessibility for the rural, poor population. More resources should be allocated to patient treatment, which is now only 1% or less of the total budget of each hospital (Anonymous, personal communication). This may improve supply of drugs and other materials to hospitals and hence, to poor patients. Moreover, equity in providing services would ensure free, quality services for the most economically disadvantaged population and not just for the rich.

• The current health reforms suggest the need to upgrade all thana health complexes to reduce travel time and the costs that impede rural women from getting emergency obstetric care. Community-supported local transport should be emphasised to facilitate transfer to hospital in emergency situations.

• Mismanagement and corrupt practices at all levels in hospitals should immediately be stopped through quality assurance, effective supervision and punitive measures against those involved.

Addressing these issues may reduce the burden of costs for rural, poor women and their families, and remove their worries about expense when they need emergency obstetric care.

Acknowledgements

This paper is excerpted from my PhD thesis “Power, knowledge and childbirth practices: an ethnographic exploration in Bangladesh”, Edith Cowan University, Western Australia, 2004. I am grateful to Drs Lynne Hunt and Nancy Hudson-Rodd for guidance and supervision during the doctoral programme, and to BRAC for their assistance in my fieldwork. I am indebted to all the rural women and their families and hospital staff for their cooperation; without them, this paper would not have been possible.