Background: Midwives are essential providers of primary health care and can play a major role in the provision of health care that can save lives and improve sexual, reproductive, maternal, newborn and adolescent health outcomes. One way for midwives to deliver care is through midwife-led birth centres (MLBCs). Most of the evidence on MLBCs is from high-income countries but the opportunity for impact of MLBCs in low- and middle-income countries (LMICs) could be significant as this is where most maternal and newborn deaths occur. The aim of this study is to explore MLBCs in four low-to-middle income countries, specifically to understand what is needed for a successful MLBC. Methods: A descriptive case study design was employed in 4 sites in each of four countries: Bangladesh, Pakistan, South Africa and Uganda. We used an Appreciative Inquiry approach, informed by a network of care framework. Key informant interviews were conducted with 77 MLBC clients and 33 health service leaders and senior policymakers. Fifteen focus group discussions were used to collect data from 100 midwives and other MLBC staff. Results: Key enablers to a successful MLBC were: (i) having an effective financing model (ii) providing quality midwifery care that is recognised by the community (iii) having interdisciplinary and interfacility collaboration, coordination and functional referral systems, and (iv) ensuring supportive and enabling leadership and governance at all levels. Conclusion: The findings of this study have significant implications for improving maternal and neonatal health outcomes, strengthening healthcare systems, and promoting the role of midwives in LMICs. Understanding factors for success can contribute to inform policies and decision making as well as design tailored maternal and newborn health programmes that can more effectively support midwives and respond to population needs. At an international level, it can contribute to shape guidelines and strengthen the midwifery profession in different settings.

In Bangladesh, Midwife Led Birthing Centres (MLBCs) have been established to provide midwifery care and sexual and reproductive health services for the displaced Rohingya population in Cox’s Bazar. The aim of this study was to explore MLBCs in this humanitarian context from the perspectives of women, midwives, and other key stakeholders. A mixed-method case study was conducted at one of the MLBCs within the Rohingya refugee camps in Cox’s Bazar. The MLBC serves a population of approximately 8,500 people. Quantitative data were collected from the medical records and documents of the MLBC. Qualitative data included two key informant interviews (KIIs) with policy makers, one focus group discussion (FGD) with 7 midwives and ten in-depth interviews (IDIs) with Rohingya women who gave birth in this MLBC. Thematic analysis of qualitative data was performed. In 2022, 267 women gave birth at the MLBC, and 70 women with complications were transferred to higher-level facilities. Women chose the MLBC because of the respectful care provided by kind and skillful midwives, and the high-quality services. The MLBC was often recommended by community volunteers and relatives. Midwives provided a range of health services including antenatal, labour and birth, postnatal, family planning, mental health support and gender-based violence services. Challenges included language barriers, difficulty obtaining transport from home and back particularly at night in remote areas, security fears and weak cell phone coverage that affected communication for referral and follow-up. Recommendations included increased support and security staff, establishing a referral hospital nearer to the camp, refresher training for midwives and monitoring, and mentoring to improve service quality. The MLBC in the Rohingya camp shows that respectful midwifery care including management and referral of obstetric complications with wider sexual and reproductive health services can be provided in a humanitarian setting to optimize maternal and neonatal health outcomes.

The rise in the number of facility-based births in Bangladesh has been accompanied by a caesarean section (CS) epidemic. The current CS rate is 45% and while many are performed when medically unnecessary, there is still maternal mortality due to lack of access to CS. A significant contributor to the rising CS rates in Bangladesh is repeat CS. Evidence from high-income settings has shown that vaginal birth after caesarean section (VBAC) is safe and should be recommended for women with one previous CS, however, its practice in Bangladesh is low. VBAC has the potential to help reduce unnecessary CS in Bangladesh. As obstetricians play a significant role in birth decision-making, their opinions, and perspectives on barriers to VBAC need to be explored. This study will address a gap in the literature exploring barriers and enablers to promoting VBAC from the level of the obstetric decision-maker. This qualitative study was conducted in the Dhaka Division of Bangladesh in July 2023. Criterion sampling was used to select obstetricians for in-depth semi-structured interviews. Seven interviews were conducted in a private hospital in Dhaka city and five interviews were conducted in a non-governmental organisation (NGO) hospital outside Dhaka city. Ethical approval was received from the relevant organisations in both Liverpool and Bangladesh. The thematic analysis gave rise to three main themes: “policy awareness and national situation”, “reasons for practice decisions” and “ways to improve service delivery”. Despite good awareness of VBAC policies and appreciation of its benefits, obstetricians expressed a preference for repeat CS. From the perspective of obstetricians, the main barriers to VBAC practice are related to the structure and function of the health system. To create an environment that will enable safe practice of VBAC, health system improvement and community awareness of the benefits of normal vaginal birth are required.

Aims: This study aims to explore why and how difficult it is for obstetric fistula patients living in the underprivileged teagardens community of Bangladesh. Methods: It was a qualitative study conducted in 10 teagardens with approximately fifty thousand population. Five case studies followed by five Focus Group Discussions (FDG) were conducted in places where obstetric fistulas were identified. Results: The mean age of the women was 41 years and the mean duration of suffering was 19 years. All of them got married before the age of 15 and became pregnant in the following year. One woman was divorced, two were separated and two were living with their husband. Only one of them received treatment from a tertiary center but did not continue due to economic constraints; rest of them were never exposed to any treatment or care. They believed that it would be recovered over time. All of them were neglected in their society and were deprived from all social and religious activities in the community. FGDs findings represent that poverty, lack of knowledge and perception are the significant barriers. Conclusions: Underprivileged communities in the teagardens in Bangladesh are far behind in terms of access to quality health care services. Obstetric fistula is particularly still being under reported and undermined and focused intervention is required to eliminate fistula among them.

The information systems for the Maternal and Perinatal Death Surveillance and Response (MPDSR) program have been digitalized in Bangladesh since 2014. This study aimed to investigate the availability of information systems for measuring the status of an MPDSR program and the planning process and actions developed based on real-time information. This study explored innovative information systems designed to easily monitor and measure the impact of health programs. The study included both the primary and secondary data. Key informant interviews were conducted to explore the enablers and strengths of information systems. Secondary data were collected from government websites and approved MPDSR action plans. This study highlights the potential and challenges of governmental health information systems in notifying maternal and neonatal deaths. The study reveals that the existing death notification rates are not up to national standards. It is encouraging to see health managers develop action plans and address this issue. The MPDSR information system serves as an essential tool for health managers, enabling them to assess variations in maternal and perinatal mortality rates while facilitating the development of interventions tailored to local needs. However, several obstacles must be addressed, such as insufficient data, lack of monitoring, and irregularities in MPDSR review meetings. By finding ways to overcome these challenges, we can unlock the full potential of MPDSR and improve maternal and neonatal health outcomes. The success of an MPDSR program relies on how the information is utilized to take action and measure the outcome. Advanced information systems, such as health dashboards, scorecards, and administrative data, can play a vital role in measuring the progress and impact of a program. The primary challenge lies in capturing all deaths, including their causes, and having the capacity to analyze the data effectively to develop action plans for health managers.

The health sector in Bangladesh is thriving, and the Maternal and Perinatal Death Surveillance and Response (MPDSR) program has been in place to investigate the causes of maternal and perinatal death. This study aimed to investigate the availability of information systems for measuring the status of an MPDSR program and the planning process and actions developed based on real-time information. This study delved into innovative information systems that can be used to monitor and measure the impact of health programs. The study included both the primary and secondary data. A total of six key informant interviews were conducted to explore the enablers and strengths of information systems. Secondary data were collected from government websites and MPDSR action plans. This study highlights the potential and challenges of governmental health information systems in notifying maternal and neonatal deaths. While the current notification rates are not up to national standards, it is encouraging to see health managers develop action plans and address this issue. The MPDSR information system is a valuable tool to help health managers measure changes in maternal and perinatal mortality rates and design locally targeted interventions. However, several obstacles must be addressed, such as insufficient data, lack of monitoring, and irregularities in MPDSR review meetings. By finding ways to overcome these challenges, we can unlock the full potential of MPDSR and improve maternal and neonatal health outcomes. The success of an MPDSR program relies on how the information is utilized to take action and measure the outcome. Advanced information systems, such as health dashboards, scorecards, and administrative data, can play a vital role in measuring the progress and impact of a program. The primary challenge lies in capturing all deaths, including their causes, and having the capacity to analyze the data effectively to develop action plans for health managers.