But this picture is changing. By training up skilled birth attendants who visit pregnant women at home, monitor and care for them during pregnancy and assist at the delivery, more women in the most remote and hard-to-reach areas of Bangladesh can access the care they need to protect them and their baby. Not only is this giving mothers and babies a fighting chance, but it is also providing marginalised women with an opportunity to gain social and financial independence. If families, communities and businesses are to prosper under the new sustainable development agenda, enhancing lives and livelihoods through supporting frontline health workers is key.
Salma is one such woman on the frontline – we met her while on a recent trip to Sunamganj, which involved a three-hour drive along its only road, surrounded by water as far as the eye could see. A homemaker, Salma had harboured dreams of becoming a doctor or nurse. Through CARE International, she got the opportunity to do six months certified training that would enable her to become a private community-based skilled birth attendant. Now she loves the joy of helping a mother give birth safely and also has the chance to earn a living.
Skilled birth attendants like Salma are trained in maternal and child care and managing home deliveries. In rural regions such as Sunamganj, where women are giving birth without any support or with the aid of a traditional birth attendant, this is a lifeline. Since 2010, CARE International – with backing from GSK through its commitment to reinvest 20% of profits from least developed countries back into training health workers – has supported the training of 168 skilled birth attendants.
They have managed almost 9,000 deliveries and 80,000 ante-natal visits. More than 3,000 community health workers and volunteers have been trained on preparing for birth, essential newborn care and family planning. These volunteers provide a vital link between the community and the birth attendants, identifying pregnant mothers and explaining to them how women like Salma can help.
Importantly, skilled birth attendants are also given business training and can earn a living by charging a small fee for their services. These tariffs are set by the government in consultation with the local community. If someone cannot afford to pay, the birth attendant might help them for free or a local community support group or local government may help out by paying, or enabling the patient to cover the costs over time. Average monthly earnings of skilled birth attendants have been rising – generating an average monthly income of £33. This is a not insignificant sum for someone living in rural Bangladesh.
There are challenges to this model, where private skilled birth attendants charge for their services. Arguably it is preferable for health workers to be salaried by the government. But in many developing and emerging economies, health workers are paid too little or nothing at all, meaning they have little incentive to stay in the role. The WHO estimates the world is short of 7 million health workers. These frontline staff are the backbone of resilient health systems and thriving societies; they empower people to seek healthcare, which in turn helps people live healthier lives, sustaining communities and businesses. Without these workers, mothers are left alone during pregnancy and childbirth – and communities are left vulnerable to both everyday illnesses such as malaria and unexpected crises.
If we are to swell the ranks of frontline health workers, new and innovative models are needed. Enabling health workers to charge small fees and sell healthcare products could be one solution. In Sunamganj, skilled birth attendants keep a connection to the formal system through working with different providers of government health services. Only 6% of these community midwives have dropped out. The goal is for the programmes to become self-sustaining – by enabling health workers to forge a livelihood and communities to create viable payment mechanisms; and creating an evidence base for investing in health workers, catalysing support from governments and other quarters.
So far, evidence suggests that investing in health workers does deliver a great return. The number of births attended by a skilled health worker now stands at 50% in the Sunamganj programme area - meaning the region has met an important Millennium Development Goal target on maternal health. Half of those births were managed by CARE-trained birth attendants. This has given us confidence to expand the programme to cover the whole of Sunamganj – doubling the population covered to three million. A collaboration like this between a corporate and NGO might seem unlikely. But through innovative partnerships, by taking a leap and testing out different models, we can give more women, mothers and children the chance to survive and thrive.