Barriers and Facilitators to Accessing and Using Maternal Healthcare Services by Women Living in Rural Bangladesh: A Theory-Guided Narrative Literature Review

Abstract

Objective:

To identify and synthesize the barriers and facilitators to accessing and using maternal healthcare (MHC) services by women living in rural Bangladesh.

Methods:

A structured literature search was conducted using six databases in 2024. Studies were synthesized using a thematic approach, underpinned by the Social-Ecological Model.

Results:

Searches returned 3,619 studies, of which 37 were included in this review. Findings related to barriers and facilitators were categorized into four themes: individual, family, social and community, and organizational levels. Key barriers to accessing and using MHC services included illiteracy, lack of family support, cultural taboo to pregnancy disclosure, distance to health facilities, and lack of quality services. Key facilitators to accessing and using MHC services were higher literacy levels, family support, NGO support and mass media exposure, and free healthcare services.

Conclusion:

Based on the findings of the review, to improve Bangladeshi women’s access to and use of MHC services, improvements in women’s literacy levels, village roads, family support, and service-related skills of healthcare providers are necessary.

Introduction

The United Nations Sustainable Development Goal 3 (SDG3) aims to ensure healthy lives and promote wellbeing for all by 2030 [1]. Strengthening maternal healthcare (MHC) services for women, including antenatal care (ANC), childbirth, and postnatal care (PNC), are considered essential components to achieving the SDG3 targets [2].

Bangladesh made notable advancements in maternal health through MHC services in response to the call of the Millennium Development Goals, and is currently working toward the newly agreed SDGs to be achieved by 2030 [3–5]. The newly agreed SDG3 related to maternal health includes reducing the maternal mortality rate (MMR) to 70 or less per 100,000 live births, ensuring universal access to sexual and reproductive healthcare services, achieving universal health coverage, etc. [1]. However, the Sustainable Development Report (SDR) 2024, with an aim to provide updated information to track performance on the SDGs, shows a moderate improvement in the MHC situation in Bangladesh [6]. The SDR Report classifies Bangladesh inside the moderate progress category, as its current SDG performance score is 64.3, exceeding the 50% threshold of the required growth rate but falling short of the 70% necessary to attain the SDG by 2030 [6]. Therefore, Bangladesh is only partially on track to meet SDG3-related targets. Moreover, several socioeconomic issues, such as poverty, lack of healthcare infrastructure, etc., remain challenges in terms of progress toward meeting the SDG3 targets [6]. Access to and utilization of MHC services remains difficult for some population groups within Bangladesh, for example, married women who reside in remote rural regions of Bangladesh [5]. Women residing in rural areas in Bangladesh account for 35% of the female population and are less likely than urban women (57%) to have made the World Health Organization (WHO) recommended four or more ANC visits in 2022 [7]. Although the target of the Government of Bangladesh was to reach 50% coverage of four or more ANC visits by 2023, the percentage of women living in rural Bangladesh attending four or more ANC visits declined from 43% in 2017/18%–35% in 2022 [3, 7].

In relation to facility-based childbirth, whilst more than half (68%) of urban-dwelling childbirths in Bangladesh were attended by qualified doctors, nurses or other healthcare staff in Bangladesh, this rate is almost half for mothers residing in rural Bangladesh (51%) [7]. Moreover, Bangladesh is one of the largest contributors to the global burden of maternal death, with an estimated 123 MMR per 100,000 in 2020 compared to the UK, where the MMR rate is only 10 per 100,000 during the same period [5, 8].

Maternal deaths in Bangladesh are reported in the first 2 days after childbirth, and as a result, prompt PNC is important for the mother to identify and treat any complications arising from childbirth. The percentage of non-institutional childbirth that occurs predominantly in rural areas, for which the mother received PNC from a medically trained provider within 2 days of childbirth, was reported only to be 13% in 2022 [7].

Several challenges to access and use of MHC services include inadequate budget allocation resulting in reduced facilities, increased out-of-pocket costs [9, 10], lack of information and education about services, superstitions, and fear of losing family status [10], which negatively impact the availability and quality of maternity services, especially in rural Bangladesh. In addition, healthcare services-related challenges exist and include a lack of quality services, insufficient drug supplies [10, 11], and a shortage and absenteeism of physicians, as they prefer not to go to rural areas because of a lack of training opportunities, huge work pressure, and a preference to treat the urban educated class [9, 12, 13].

Therefore, to promote the overall health and wellbeing of Bangladeshi women and to make strides in achieving the SDG3 goal [1], it is important to understand the barriers and facilitators experienced by women in accessing and using MHC services in rural Bangladesh. To date, three reviews [14–16] have been undertaken related to healthcare services provision in Bangladesh. Two of the identified reviews have focused on noncommunicable diseases [15] and adolescents’ MHC services [16]. Only one review was relevant to the women’s MHC services [14], which was undertaken in 2011, and thus somewhat outdated. The review undertaken in 2011 reported that several barriers, including long distance between households and healthcare centers, poor income, unfriendly attitudes of healthcare providers, and the sex of providers, made women’s access and use of MHC services in rural Bangladesh acute [14]. The review is expected to be outdated, as the Government of Bangladesh has been actively engaged in the health sector since 2015, focusing on SDGs and initiating the digitalization process, resulting in numerous enhancements in MHC services. Furthermore, during the past decade since 2011, numerous research papers have been published that have not undergone review. Therefore, this narrative literature review intends to update the research literature in the MHC area using a theory-based approach.

The Social-Ecological Model (SEM) can be used to understand healthcare access and utilization of individuals [5, 17], as it considers the dynamic interactions between individuals and their environments as determinants of health-related behavior [18]. The SEM shows that individuals’ healthcare access behavior is shaped through five hierarchical levels: intrapersonal, interpersonal, institutional, community, and policy levels [17] (Figure 1).

FIGURE 1

Therefore, this review aimed to identify and critically synthesize published studies examining barriers and facilitators to accessing and utilizing MHC services by women living in rural Bangladesh using the SEM.

Methods

A narrative literature review [19] was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [20] as the step-by-step process for reporting on the review. A narrative literature review [19] was considered the most appropriate design to gain a better understanding of the barriers and facilitators to MHC services from the heterogeneous nature of the literature rather than summarizing results in response to a narrow research question, undertaken for a conventional systematic review [21]. To guide the review process, the SEM framework was adopted to provide a more holistic understanding of access to and utilization of MHC services by women residing in rural Bangladesh.

Search Strategies

A systematic search was conducted with six electronic databases, including MEDLINE, PubMed, Web of Science, Scopus, ProQuest Sociological Abstract, and ProQuest Dissertation and Theses, to identify studies for inclusion in the review. For the MEDLINE database search, the Ovid interface was used, and for the PubMed database search, as PubMed includes all MEDLINE records, only resources apart from MEDLINE (e.g., PubMed Central articles) were used. All databases encompass published manuscripts in health and biomedical sciences, social sciences, public health, and nursing, offering relevant insights into the specific topic of interest [5]. The search with electronic databases was first undertaken in November 2019 and then updated in June 2024. To identify additional literature, first conducted in 2019 and then repeated in June 2024, Google Scholar, Google, and Leeds University Library were accessed using keywords (Table 1). The search included medical subject headings (MeSH) and text words for barriers and facilitators, maternal healthcare access, and maternal healthcare utilization. The Population, Intervention, Comparison, and Outcome (PICO) model (see an example in Table 1) was used to develop the search terms from the research question: What are the barriers and facilitators to accessing and using MHC services by rural Bangladeshi women? An example of search terms in MEDLINE (Ovid) has been included in Supplementary Material S1. Study titles and abstracts were screened first, and then full-text versions of potential citations were retrieved for detailed examination based on the eligibility criteria below.

Eligibility Criteria

Studies were included in the review if they: (i) incorporated access to and use of MHC services by women aged 16–49; (ii) were full-type peer-reviewed studies published in the English language; (iii) were conducted in Bangladesh; and (iv) were published after 2000. This review examined changes in MHC services in Bangladesh over the past two decades as the nation’s healthcare system has undergone changes during that time [5]. For example, in 1998, community clinics were built to provide MHC services to women residing in rural Bangladesh [22]. As a result, studies pertaining to these services were not published before 2000.

Studies were excluded when they included texts not available in full and primary data, such as conference abstracts, commentaries, editorials, and opinion papers.

Study Selection

A total of 3,619 publications were identified from electronic databases and manual searches. 1903 publications from the electronic databases were removed because of duplication, and the remaining 1706 abstracts were screened. Duplicate detection of studies was executed using EndNote software and a manual process where each individual study was checked. Of these, 1,045 publications were excluded based on the exclusion criteria. The full texts of the remaining 565 studies were examined in detail, and 538 studies were further excluded. Therefore, 27 studies were included from the database search. Additionally, 10 studies were identified from a manual search of the reference lists of the studies included, and they were all included after assessment. Finally, 37 studies were considered eligible and included in this review. A PRISMA flowchart was used to enhance the transparency and reporting of the literature search and selection process, as summarized in Figure 2.

FIGURE 2

Assessing Quality of the Included Studies

The selected studies were assessed to determine their level of quality. As the review encompassed multiple study designs, three different appraisal checklists were used to assess qualitative, quantitative, and mixed methods (MM) studies (Supplementary Material S2), as recommended in the literature [23] and found in practice [24]. For this assessment process, cohort and randomized control trial (RCT) studies were assessed using the Critical Appraisal Skills Programme (CASP) checklists [25, 26], and cross-sectional quantitative studies using the critical appraisal checklist for cross-sectional studies that was adapted from Combie [27]. Additionally, the CASP checklist [28] was used to appraise qualitative studies, and the mixed methods appraisal tool (MMAT) version 2018 [29] for MM studies. Appraisals included a minimum of 10 and a maximum of 17 questions with possible answers of “Yes,” “No,” or “Can’t tell.” Each question contains one score.

To classify the quality of studies included in this review, a scoring procedure used in another review [24] was adopted for all the appraisals: (i) the individual score for each study was calculated based on the appraisal questions in each row of the Table (Supplementary Material S2); (ii) the score achieved was divided by the total score, and then converted into a percentage; and (iii) finally, three categories based on the percentage and range were made to classify the quality of the studies: 80%–100% = high, 60%–79% = medium, and <60% = low. Descriptive responses were not counted for scoring, and explanations were provided for each question.

Data Synthesis

Thematic synthesis [30] was used for data synthesis as this review included heterogeneous study designs, and is recommended by the literature [30, 31]. There are trends in the use of thematic synthesis for narrative review in healthcare research where there is heterogeneity in studies [32, 33]. Thematic synthesis is considered an adaptation of thematic analysis to synthesize the research studies and offers a range of established methods and techniques for the identification and development of analytic themes in first-hand data [30]. Thematic synthesis [30] based on the SEM [17] was undertaken. Based on the SEM levels of influence, the extracted data were inductively coded, and themes and subthemes were then identified (Supplementary Material S3).

The characteristics and key findings were extracted and tabulated according to the Ma et al. [18] guidelines. The main characteristics include: (i) author(s) and year of publication, (ii) region where the study was conducted, (iii) aims of the study, (iv) study design, (v) sampling method and participants, (vi) types of healthcare services, and (vii) main findings, including barriers and facilitators. Initially, the studies were grouped and summarized separately on the basis of quantitative or qualitative design. Likewise, data obtained from the quantitative and qualitative components of the MM studies were included in the relevant group. The characteristics and key findings of these studies are summarized and categorized in Table 2.

Results

Study Characteristics

Table 2 presents a summary of the characteristics of the studies included in this review. Studies were published between 2001 and 2023. The majority of studies were published between 2011 and 2018 (n = 23; 62%). Most of the included studies (n = 29; 78%) in this review were considered of high quality, and the remaining eight were of medium quality (Table 2). The review included 37 studies, of which 24 were quantitative, 10 were qualitative, and three were MM studies. Fourteen studies were carried out in rural locations, and the remaining 23 studies focused on both rural and urban locations.

Description of Themes

Four key themes related to accessing and using MHC services by rural Bangladeshi women emerged from the thematic analysis of the studies, using the SEM as the guiding framework: (i) individual-level barriers and facilitators; (ii) family-level barriers and facilitators; (iii) community and social-level barriers and facilitators; and (iv) organizational-level barriers and facilitators.

Theme 1: Individual-Level Barriers and Facilitators to Accessing and Using MHC Services

This theme included two sub-themes, including demographic barriers and facilitators and lack of self-confidence in treatment.

Demographic Barriers and Facilitators

Fifteen quantitative [34–48], two MM studies [49, 50], and one qualitative [51] out of the 37 studies focused on demographic barriers to women accessing MHC services. Women and their husbands with lower levels of education [34, 35, 37–41, 43–49, 51, 52] reported having less access to MHC services. Educated mothers were approximately 16 times more likely to receive ANC compared to illiterate mothers, and 14 times more likely to obtain the components of ANC content visits, such as counselling regarding danger signs [35].

Another barrier is related to the early age of being married and being a mother of women. Women living in rural Bangladesh reported that early age of marriage [35, 36, 38, 43, 49] and early age of being a mother [36, 38–41, 43, 45, 46] impeded them from accessing and using MHC services. Women aged 30–49 in rural Bangladesh reported that they had twice as many facility-based deliveries compared to the younger group [36]. In addition, higher parity (the number of children a woman has had) [34, 36–41, 44, 46], mothers’ involvement with no income-generating activities [34, 36, 38, 43, 46], unintended pregnancy [38, 45], and lack of ANC checkup [48] were also identified as barriers to accessing and using MHC services for women living in rural Bangladesh.

Positive associations between demographic facilitators and access to and use of MHC services were identified in 16 quantitative studies [34, 36–41, 43–48, 52–54] and one MM [50]. Four facilitators were found to be associated with access to and use of MHC services by women: higher literacy level enabled women to be aware of the MHC services [38, 40, 41, 43–48, 52–54]; low parity [35–37, 40, 44]; having income made women capable of affording the cost associated with services [46, 50, 53]; and the mother being older showed greater experience of seeking services [36, 38]. For example, ANC visits were found to be three times higher among mothers with a higher level of education compared to mothers with no education [35].

Lack of Women’s Self-Confidence in MHC Treatment

Ten studies, five qualitative [55–59] and five quantitative [34, 38, 52, 54, 60], reported on the lack of self-confidence in MHC treatment among women living in rural Bangladesh. This lack of self-confidence was based on a number of factors. Misconceptions or limited knowledge of MHC services [54–57, 59, 60] were reported as the reason for women’s self-confidence in treatment. In most cases, women living in rural areas of Bangladesh were not informed about the reasons for their physical examinations [55, 59], taking medicines [57], and menstrual regulation (MR) services [56, 59], which led to misconceptions among them. Additionally, fear in using MHC services [55–60] was identified as being linked with women’s lack of self-confidence. Fear was mostly reported to be associated with pain, increased blood pressure after childbirth, etc. [55, 59, 60]. Finally, low decision-making ability [34, 38, 52] was identified as a barrier to women residing in rural Bangladesh in seeking treatment.

Theme 2: Family-Level Barriers and Facilitators to Accessing and Using MHC Services

Thirteen studies, six qualitative [55, 57–59, 61, 62], five quantitative [43, 47, 63–65], and two MM [49, 66], reported on family issues that were reported to hinder women in accessing and using MHC services. As reported in several studies, delays in decision-making when seeking MHC services were identified as a family-level barrier, as women from rural Bangladeshi families relied on family members, including husbands and mothers-in-law, for seeking advice to travel outside that is often delayed [43, 49, 55, 57, 59, 61, 65]. Moreover, absence of husbands’ participation in maternity care due to their shyness and family culture [62], intimate partner violence (IPV) [63], family financial constraints to afford the expense related to using MHC services [47, 58, 64], and a culture of home childbirth [64, 66] were commonly reported as family-level barriers to women accessing and using MHC services.

However, 15 studies, 13 quantitative [34–40, 43, 44, 52, 54, 64, 65], one qualitative [58] and one MM [50], highlighted how the family supported women’s access to MHC services. Husbands in a patriarchal society like Bangladesh generally have a key household decision-making role. Husbands who had a higher level of education [34, 35, 37, 40, 52], occupational involvement [36, 37, 43, 50], wealth status [35–39, 44, 52, 64, 65], positive attitudes toward care [58, 59], and shared their mobile phones with women to access mHealth services [54] were found to be positively related to women’s access to and use of MHC services.

Theme 3: Community and Social-Level Barriers and Facilitators to Accessing and Using MHC Services

Three subthemes were identified under this theme: sociocultural barriers, geographical barriers, and Non-Governmental Organization (NGO) and microcredit support and mass media exposure.

Sociocultural Barriers

Several sociocultural barriers were highlighted in six studies, which include four qualitative [55, 57, 58, 62], one quantitative [54], and one MM [66]. Traditional attitudes and beliefs about pregnancy and childbirth [55, 57, 58, 62, 66] were identified as a sociocultural barrier for women living in rural Bangladesh to access and use MHC services. For example, there was a belief that pregnancy disclosure could lead to unwanted spiritual complications and that pregnant women going outdoors during certain times of the day and week was considered to be harmful to the fetus [57]. Additionally, gender inequality in mobile phone ownership affected women, as they were unable to make a call to a doctor if needed [54]. Finally, religious rituals such as setting up a separate room outside of the household for childbirth and seclusion [58, 66] were reported to adversely affect women residing in rural Bangladesh in accessing and using facility-based delivery care.

Geographical Barriers

Geographical barriers were reported in 14 studies, which included 10 quantitative [35, 36, 39, 40, 44, 45, 47, 52, 53, 67], three MM [49, 50, 66], and one qualitative [61]. Geographical barriers included residing in rural areas, which reduced women’s access to MHC due to limited and remote healthcare facilities [35, 36, 39, 40, 44, 45, 47]. For example, urban women, as a result of having available healthcare facilities, were 1.4 times more likely to receive ANC services compared with their rural sisters (OR = 1.351; 95% CI: 1.104–1.496) [35]. Another geographical barrier included long travel distances to healthcare points, which prevented women from seeking care, as it involved physical risks to pregnant women [50, 52, 66]. Moreover, having inadequate transportation [49, 50, 61] and living in a flood-prone area [53, 67] were all found to be associated with a delay in seeking MHC services among women living in rural Bangladesh.

NGO and Microcredit Support and Mass Media Exposure

Seven studies, five quantitative [35–37, 42, 44] and two MM [49, 50], reported on NGO and microcredit support and/or mass media exposure. Three studies [35, 42, 50] reported that NGO and microcredit involvement among Bangladeshi women empowered them to access and use MHC services. For example, utilization of MHC services was found to be twice as high among mothers who visited NGO health facilities as compared to those who did not use the facilities [35]. Additionally, six studies reported that exposure to mass media (television and radio) messages [35–37, 42, 44, 49] was helpful for women in accessing healthcare services. For example, awareness-raising messages, such as timely using ANC services at the nearest community clinic and risks of early conception, through television or radio programs have been found to be effective by expectant mothers who reside in rural Bangladesh [36, 37].

Theme 4: Organizational-Level Barriers and Facilitators to Accessing and Using MHC Services

Eight studies, five qualitative [55, 56, 58, 59, 61], two quantitative [48, 68] and one MM [66], focused on organizational barriers to access and utilization of MHC services by women living in rural Bangladesh. A wide range of organizational-related barriers were identified. An important organizational barrier included lack of quality healthcare services [55, 66], which affected women using satisfactory services. Patients in rural Bangladesh reportedly received poorer quality of MHC services for the following reasons: shortages of qualified personnel, lack of training of health staff, and limitations of diagnosis [55, 66]. Experiencing mistreatment, including use of vulgar words, from healthcare providers [48, 55, 58, 59] was also reported to be another important organizational barrier to assessing and using MHC services for women living in rural Bangladesh. Moreover, the gender of the healthcare personnel [59, 66] was reported to be an issue when women felt discomfort seeking care from male doctors. Another barrier included service costs related to medication and investigation fees [56, 58, 61, 66], discriminatory service provision [66], and uncleanliness and lack of privacy [68].

Organizational facilitators were the factors that helped women to access and use of MHC services in public and private facilities, identified in four qualitative [51, 57, 59, 69] and three quantitative [54, 60, 70] studies. Key facilitators to increasing access and use of MHC services by women in public facilities included: (i) health center-based support, including free services to users [57, 60, 69, 70]; (ii) incentives to healthcare providers [70]; and (iii) technology support, including mHealth such as calling doctors from the home or online services such as emergency blood management [51, 54, 69] to reduce the cultural gap between the patient and doctor to the use of services. Additionally, one quantitative [68] and two qualitative [56, 59] studies reported on some private health center-based facilitators, that included convenient opening hours, privacy, cleanliness, caregiving, and normal childbirth management skills. Women were reported to be more satisfied with private facilities compared to public facilities.

Discussion

This narrative literature review aimed to identify and critically synthesize published studies examining barriers and facilitators to women living in rural Bangladesh in accessing and using MHC services. This review has identified a number of barriers and facilitators influencing the access to and the utilization of MHC services by women residing in rural Bangladesh. These findings have been categorized using the SEM as individual, family, community and social, and organizational levels of health influence, as it is recognized that human behavior is influenced and shaped by multiple, interrelated factors [17, 18].

This narrative review has identified that at the individual-level, education and literacy levels, among both women and their husbands, were found to be the most identified factor related to access and utilization of ANC services among women residing in rural areas in Bangladesh. For instance, women and their partners are more likely to access and use of MHC services when their education and literacy levels are satisfactory, as compared to individuals with lower levels of these factors. This supports previous research in the area that suggested an increase in knowledge and health literacy among women residing in rural areas [71–73]. Although improving knowledge remains an effective intervention in rural settings to increase access and utilization of MHC services by women residing in rural settings, it is also important to consider the husbands’ knowledge levels in this area [72].

The findings also suggested that women’s lack of self-confidence in their treatment, due to a lack of health literacy, fear of treatment, etc., was a further barrier to accessing and using MHC services. This finding presents a new issue, as it was not highlighted in the previous review [14] in the MHC field in Bangladesh. This finding corroborates and builds on previous research [74], where it was identified that women did not access the facility-based childbirth as a result of a lack of awareness. Therefore, educational interventions need to include increasing knowledge and health literacy skills regarding the need for access and use of MHC services through raising awareness programs for both women and their husbands.

At the family-level, decision-making to seek MHC care was found to be an influencing factor in both access and use of MHC services is crucial, as women’s healthcare was dependent on timely decision-making. However, this review identified that for women living in rural Bangladesh, healthcare decision-making was mainly found to be based on family members’ views, which can lead to delays in seeking care. This finding builds on the findings of studies published in Bangladesh [75, 76] and Pakistan [77], where senior and/or male family members were mostly reported to decide family issues, including healthcare. In a patriarchal society like Bangladesh, husbands play a dominant decision-making role in all family aspects, including healthcare expenditure, purchasing household items, etc., as they are mostly the income earners [76]. Additionally, the findings from this review identified that some husbands, who lived in rural areas in Bangladesh, had less participation in women’s maternity care, which has added a new finding, and it was not reflected in the previous review [14]. Two factors were identified in the review literature that were related to men’s low participation in women’s MHC services: (i) negative perceptions of a patriarchal society and (ii) restrictions on men’s access to maternity clinics [78–80]. WHO [81] recommends that the participation of men as an intervention during maternity care can enable women to make decisions about their healthcare and that of their newborns. Also, women who were physically and sexually abused by their partner were reported to be less likely to have visited a qualified ANC provider. This is possibly as a result of women’s stress after experiencing abuse, which could lead to a lack of motivation in pursuing appropriate care [63]. Therefore, increasing women’s decision-making power and involving their partners in MHC services could increase accessing and using MHC services by women in rural Bangladesh, which are also suggested in other studies [75–77].

The narrative review identified some negative social and cultural practices, such as traditional attitudes and beliefs about pregnancy and childbirth, which were revealed as barriers to women both accessing and using MHC services at the community and societal-level. This supports previous research in the area conducted in South Asia [82, 83] that suggested pregnant South Asian women who resided in rural areas preferred home delivery over facility-based delivery due to privacy concerns and an unwillingness to divulge their pregnancy [84, 85]. However, these concerns could contribute to an increase in high maternal mortality and other maternal complications [85]. Therefore, developing culturally sensitive interventions with women around increasing awareness of the importance of facility-based delivery are needed to increase access and use of MHC services by women living in rural Bangladesh. Another, the distance needed to travel to health center facilities by women living in rural Bangladesh, is often reported a as barrier identified in the review and seen in previous research studies [77, 82, 84]. Constructing village roads and strengthening mHealth services can be the solution to reduce the distance barrier.

Rural dwelling Bangladeshi women’s connection with NGOs and microcredit connections was found to increase their empowerment levels around informed decision-making, being more likely to access health information and healthcare services than those without such connections. This may be due, in part, to the fact that NGOs have their own health centers for their clients, and that the services are less costly and more easily accessible. This supports previous research in the area conducted in African and South Asian countries for women seeking access and use of ANC services [86, 87]. This narrative literature review adds this new information, which is different from the previous review undertaken on MHC services in 2011 [14]. These studies also identified that, when women received loans from NGOs and microcredit organizations, they utilized that money to get out of poverty, which ultimately increased their capability of accessing MHC services. Additionally, women’s wider social networks beyond their family were identified as being supportive and a useful resource for women with regard to receiving health-related information from organizations or neighbors. Thus, the connection with NGOs and microcredit organizations was found to be helpful for women living in rural Bangladesh to become more independent in accessing and using MHC services.

The narrative review found that, at the organizational-level, there was a reported lack in the quality-of-service provision, which was identified as a major barrier for both access and use of MHC services. Although most women in the reviewed studies were found to frequently visit government-run health centers, these studies also highlighted that women were more satisfied with privately-run services. Women’s dissatisfaction with government facilities was found to be due to its poor service provision such as a lack of quality healthcare services, which supports previous studies in the area [88, 89]. The review also identified that women also experienced and/or reported mistreatment, including rude behavior, late surgery appointments, and physical abuse by doctors and/or nurses whilst using MHC services. Such mistreatment does not coincide with the National Health Policy of Bangladesh [90] and the United Kingdom National Institute for Health and Care Excellence (NICE) guidelines [91], which emphasize that advice and information should be provided to women about specific treatments and care options. Although, based on this review, women’s experience of existing MHC services was found to be mixed, undesired experiences were more evident at each stage of receiving services. Therefore, MHC staff need further education and training to support them in improving women’s access and use of MHC services by the provision of satisfactory services. This recommendation is supported by previous research in the area that was conducted in Asia and Africa, which found that health workers needed adequate MHC service provision-related education and training to provide satisfactory services to women living in rural Bangladesh [92, 93].

A supportive organizational culture such as free service, mostly in public health centers, was identified as a facilitator for women accessing and using MHC services, and is supported by previous research in the area [77]. However, clinical investigations are not free and sometimes unavailable, making them costly outside. Therefore, to improve MHC services use, the number of items, including medicines, beds, and investigation items, should be covered under free or reduced-price services, especially for the women residing in rural Bangladesh.

Strengths and Limitations

Although one review on access to healthcare services by women in rural Bangladesh [14] has been published, it was conducted more than a decade ago. This is the first known narrative literature review with a systematic search and updated study to identify access to and use of MHC services by women in rural Bangladesh. This review’s strength lies in its application of the SEM model to synthesize findings spanning more than 20 years of literature on the barriers and facilitators to accessing and utilizing MHC services by women in rural Bangladesh.

However, there are some limitations to this narrative literature review. There are not many studies on health-related topics published in Bengali, and most of them lack peer review, so their potential impact is likely to be minimal. Therefore, the review only included peer-reviewed studies and those published in English due to limited resources, which may have narrowed the scope of this review. It is likely that studies in other languages, particularly Bengali, may have provided further contributions. In addition, the wide variety of study methods precluded the possibility of conducting a meta-analysis, which can be used to identify the common effect [5].

Conclusions

Accessing and using MHC services for women residing in rural Bangladesh is a complex issue involving a wide range of barriers and facilitators at the individual, family, community and social, and organizational levels. By using the SEM framework to guide this review, the influence of multiple, interrelated factors in shaping behavior to access and use MHC services by women living in rural Bangladesh has been highlighted. More studies focusing on the barriers than the facilitators were identified in this review. Significant barriers to accessing and using MHC services encompass low levels of women’s literacy, insufficient self-confidence regarding treatment, delays in decision-making processes, absence of male support, a preference for home childbirth, restrictions on disclosing pregnancy, distance to healthcare facilities, and inadequate quality of care. Conversely, key facilitators, such as high literacy rates of women and their spouses, support from NGOs and microcredit programs, media exposure, and the availability of free services, enhance women’s access to and use of MHC services in rural areas. To attain SDG3, policymakers and healthcare professionals need to focus on these barriers and facilitators and develop interventions that can increase access and use of MHC services by women residing in rural Bangladesh. Researchers can use these findings to help make plans for how to enable more women in low- and middle-income countries like Bangladesh to access and use MHC services. Further studies, including meta-analyses are needed to understand the causal relationship and actual magnitude of the barriers and facilitators to MHC services.

References

• 1.

  United Nations. Sustainable Development Goals (Sdgs) (2015). Available online at: https://www.un.org/sustainabledevelopment/sustainable-development-goals/ (Accessed January 3, 2020).

  • Google Scholar

• 2.

  WHO. Maternal Health: Fact Sheet on Sustainable Development Goals (SDGs)dghealth tarHets. (2021).

  • Google Scholar

• 3.

  Niport ICF . Bangladesh Demographic and Health Survey 2017-18: Key Indicators. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT and ICF (2019).

  • Google Scholar

• 4.

  MOHFW. Bangladesh National Strategy for Maternal Health 2019-2030. Dhaka: DGHS and DGFP (2019).

  • Google Scholar

• 5.

  Chanda SK . Needs, Experiences, Barriers and Facilitators to Primary and Maternal Healthcare Accessibility and Utilisation Among Women in Rural Bangladesh. In: A Mixed Methods Study. United Kingdom: White Rose Libraries, University of Leeds (2022). Available online at: https://etheses.whiterose.ac.uk/id/eprint/32543/.

  • Google Scholar

• 6.

  Sachs JD Lafortune G Fuller G . The Sdgs and the UN Summit of the Future. In: Sustainable Development Report 2024. Paris: SDSN, Dublin: Dublin University Press (2024).

  • Google Scholar

• 7.

  NIPORT, ICF. Bangladesh Demographic and Health Survey 2022: Key Indicators Report. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT and ICF (2023).

  • Google Scholar

• 8.

  WHO, UNICEF, UNFPA, World Bank Group, UNDESA/Population Division. Trends in Maternal Mortality 2000 to 2020. Geneva: World Health Organization (2023).

  • Google Scholar

• 9.

  UNICEF. Uncertainty in Aid Commitments Threatens Bangladesh's Progress in Maternal Health – UNICEF. Bangladesh: UNICEF, UNFPA and WHO (2025).

  • Google Scholar

• 10.

  Rahman SA Parkhurst JO Normand C . Maternal Health Review Bangladesh. Policy Res Unit (Pru) MOHFW, Bangladesh (2003). Available online at: https://www.gov.uk/research-for-development-outputs/maternal-health-review-bangladesh.

  • Google Scholar

• 11.

  UNICEF. Bangladesh Faces Critical Challenges in Maternal and Newborn Care, with over 100,000 Child Deaths and 63,000 Stillbirths Annually. (2025).

  • Google Scholar

• 12.

  Islam MR Angell B Naher N Islam BZ Khan MH McKee M et al Who Is Absent and Why? Factors Affecting Doctor Absenteeism in Bangladesh. PLOS Glob Public Health (2024) 4(4):e0003040. 10.1371/journal.pgph.0003040

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 13.

  Naher N Balabanova D McKee M Khan MH Roy P Ahmed SM et al Absenteeism Among Doctors in the Bangladesh Health System: What Are the Structural Drivers? SSM - Qual Res Health (2022) 2:100089. 10.1016/j.ssmqr.2022.100089

  • CrossRef
  • Google Scholar

• 14.

  Hossen MA Westhues A . Rural Women's Access to Health Care in Bangladesh: Swimming Against the Tide?Social Work Public Health (2011) 26(3):278–93. 10.1080/19371910903126747

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 15.

  Kabir A Karim MN Islam RM Romero L Billah B . Health System Readiness for Noncommunicable Diseases at the Primary Care Level: A Systematic Review. BMJ Open (2022) 12(2):e060387. 10.1136/bmjopen-2021-060387

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 16.

  Shahabuddin ASM Delvaux T Abouchadi S Sarker M De Brouwere V . Utilization of Maternal Health Services Among Adolescent Women in Bangladesh: A Scoping Review of the Literature. Trop Med and Int Health (2015) 20(7):822–9. 10.1111/tmi.12503

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 17.

  Sallis JF Owen N Fisher EB . Ecological Models of Health Behavior. In: GlanzKRimerBKViswanathK, editors. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco: Jossey-Bass (2008). p. 465–85.

  • Google Scholar

• 18.

  Ma PHX Chan ZCY Loke AY . The Socio-Ecological Model Approach to Understanding Barriers and Facilitators to the Accessing of Health Services by Sex Workers: A Systematic Review. AIDS Behav (2017) 21(8):2412–38. 10.1007/s10461-017-1818-2

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 19.

  Ferrari R . Writing Narrative Style Literature Reviews. Med Writing (2015) 24(4):230–5. 10.1179/2047480615z.000000000329

  • CrossRef
  • Google Scholar

• 20.

  Page MJ McKenzie JE Bossuyt PM Boutron I Hoffmann TC Mulrow CD et al The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews. The PRISMA 2020 Statement: An Updated Guideline Reporting Systematic Reviews (2021) 372:n71. 10.1136/bmj.n71

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 21.

  Greenhalgh T Thorne S Malterud K . Time to Challenge the Spurious Hierarchy of Systematic over Narrative Reviews?Eur J Clin Invest (2018) 48(6):e12931. 10.1111/eci.12931

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 22.

  Community Clinic Health Support Trust. History of Community Clinic: A Public Health System MOHFW (2025). Available online at: https://communityclinic.portal.gov.bd/ (Accessed March 18, 2025).

  • Google Scholar

• 23.

  Univesity of Maryland. Evidence Synthesis Service: Critical Appraisal of Studies Health Sciences and Human Services Library. Baltimore, United States: Health Sciences and Human Services Library, Univesity of Maryland (2025). Available online at: https://guides.hshsl.umaryland.edu/EvidenceSynthesis/appraisal (Accessed November 12, 2025).

  • Google Scholar

• 24.

  Chanda SK Kabir MR Roy T Shohel TA Howlader MH Razu SR . Sociocultural Costs of the Long-Term COVID-19 Outbreak in Bangladesh: A Systematic Review. Sage Open (2022) 12(4):21582440221143298. 10.1177/21582440221143298

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 25.

  CASP. CASP Cohort Study Checklist Online (2018). Available online at: https://casp-uk.net/casp-tools-checklists/ (Accessed January 12, 2019).

  • Google Scholar

• 26.

  CASP. CASP Randomised Control Trial Checklist (2018). Available online at: https://casp-uk.net/casp-tools-checklists/ (Accessed January 12, 2019).

  • Google Scholar

• 27.

  CEBM. Critical Appraisal Questions for a Cross-Sectional Study Online (2014). Available online at: https://www.cebma.org/ (Accessed January 12, 2019).

  • Google Scholar

• 28.

  CASP. CASP Qualitative Checklist Online (2018). Available online at: https://casp-uk.net/casp-tools-checklists/ (Accessed January 12, 2019).

  • Google Scholar

• 29.

  Hong QN Pluye P Fàbregues S Bartlett G Boardman F Cargo M et al Mixed Methods Apprisal Tool (MMAT), Version 2018. Can Intellect Property Off (2018). Available online at: https://www.nccmt.ca/knowledge-repositories/search/232.

  • Google Scholar

• 30.

  Thomas J Harden A . Methods for the Thematic Synthesis of Qualitative Research in Systematic Reviews. BMC Medical Research Methodology (2008) 8(1):45. 10.1186/1471-2288-8-45

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 31.

  Sandelowski M Barroso J . Handbook for Synthesising Qualitative Research. New York: Springer (2007).

  • Google Scholar

• 32.

  Ryan C Hesselgreaves H Wu O Paul J Dixon-Hughes J Moss JGJSR . Protocol for a Systematic Review and Thematic Synthesis of Patient Experiences of Central Venous Access Devices in Anti-cancer Treatment. Syst Rev (2018) 7(1):61. 10.1186/s13643-018-0721-x

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 33.

  Nagata JM Hernandez-Ramos I Kurup AS Albrecht D Vivas-Torrealba C Franco-Paredes C . Social Determinants of Health and Seasonal Influenza Vaccination in Adults >= 65 Years: A Systematic Review of Qualitative and Quantitative Data. BMC Public Health (2013) 13(1):388. 10.1186/1471-2458-13-388

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 34.

  Huda TM Hayes A Dibley MJ . Examining Horizontal Inequity and Social Determinants of Inequality in Facility Delivery Services in Three South Asian Countries. J Glob Health (2018) 8(1):010416. 10.7189/jogh.08.010416

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 35.

  Islam MM Masud MS . Determinants of Frequency and Contents of Antenatal Care Visits in Bangladesh: Assessing the Extent of Compliance with the WHO Recommendations. PLOS ONE (2018) 13(9):e0204752. 10.1371/journal.pone.0204752

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 36.

  Rahman MM Haider MR Moinuddin M Rahman AE Ahmed S Khan MM . Determinants of Caesarean Section in Bangladesh: Cross-Sectional Analysis of Bangladesh Demographic and Health Survey 2014 Data. PLoS ONE (2018) 13(9):e0202879. 10.1371/journal.pone.0202879

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 37.

  Saha S Mubarak M Jarl J . What Socioeconomic Factors Are Associated with Different Levels of Antenatal Care Visits in Bangladesh? A Behavioral Model. Health Care Women Int (2017) 38(1):2–16. 10.1080/07399332.2016.1217864

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 38.

  Rahman MM Rahman MM Tareque MI Ferdos J Jesmin SS . Maternal Pregnancy Intention and Professional Antenatal Care Utilization in Bangladesh: A Nationwide Population-based Survey. PLoS ONE (2016) 11(6):e0157760. 10.1371/journal.pone.0157760

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 39.

  Kamal SM Hassan CH Islam MN . Factors Associated with the Timing of Antenatal Care Seeking in Bangladesh. Asia Pac J Public Health (2015) 27(2):NP1467–80. 10.1177/1010539513485786

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 40.

  Rai RK . Utilization of Maternal health-care Services by Muslim Women in India, Bangladesh, and Pakistan, 2005–2007. J Public Health (2015) 23(1):37–48. 10.1007/s10389-014-0651-6

  • CrossRef
  • Google Scholar

• 41.

  Sarker MA Harun-Or-Rashid M Reyer JA Hirosawa T Yoshida Y Islam MM et al Associations of Socioeconomic Determinants with Community Clinic Awareness and Visitation Among Women: Evidence from Bangladesh Demographic and Health Survey-2011. BMC Res Notes (2015) 8:590. 10.1186/s13104-015-1374-7

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 42.

  Rahman KMM . Determinants of Maternal Health Care Utilization in Bangladesh. Res J Appl Sci (2009) 4(3):113–9. Available online at: https://www.makhillpublications.co/files/published-files/mak-rjas/2009/3-113-119.pdf.

  • Google Scholar

• 43.

  Chakraborty N Islam MA Chowdhury RI Bari W Akhter HH . Determinants of the Use of Maternal Health Services in Rural Bangladesh. Health Promotion Int (2003) 18(4):327–37. 10.1093/heapro/dag414

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 44.

  Akter E Hossain AT Rahman AE Ahmed A Tahsina T Tanwi TS et al Levels and Determinants of Quality Antenatal Care in Bangladesh: Evidence from the Bangladesh Demographic and Health Survey. PLoS ONE (2023) 18(5):e0269767. 10.1371/journal.pone.0269767

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 45.

  Islam MH Jubayer A Nayan MM Nowar A Islam S . Maternal Pregnancy Intention and Antenatal Care Seeking Behaviors in Bangladesh: Evidence from Bangladesh Demographic and Health Survey, 2018. Int J Public Health (2023) 68:1605944. 10.3389/ijph.2023.1605944

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 46.

  Nizum MWR Shaun MMA Faruk MO Shuvo MA Fayeza F Alam MF et al Factors Associated with Utilization of Antenatal Care Among Rural Women in Bangladesh: A Community-based cross-sectional Study. Clin Epidemiol Glob Health (2023) 20:101262. 10.1016/j.cegh.2023.101262

  • CrossRef
  • Google Scholar

• 47.

  Hajizadeh M Alam N Nandi A . Social Inequalities in the Utilization of Maternal Care in Bangladesh: Have They Widened or Narrowed in Recent Years?Int J Equity Health (2014) 13(1):120. 10.1186/s12939-014-0120-4

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 48.

  Paul BK Rumsey DJ . Utilization of Health Facilities and Trained Birth Attendants for Childbirth in Rural Bangladesh: An Empirical Study. Social Sci and Med (2002) 54(12):1755–65. 10.1016/s0277-9536(01)00148-4

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 49.

  Edmonds JK Paul M Sibley L . Determinants of Place of Birth Decisions in Uncomplicated Childbirth in Bangladesh: An Empirical Study. Midwifery (2012) 28(5):554–60. 10.1016/j.midw.2011.12.004

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 50.

  Islam MR Odland JO . Determinants of Antenatal and Postnatal Care Visits Among Indigenous People in Bangladesh: A Study of the Mru Community. Rural and Remote Health (2011) 11(1672):1672. 10.22605/rrh1672

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 51.

  Khatun F Heywood AE Ray PK Bhuiya A Liaw ST . Community Readiness for Adopting Mhealth in Rural Bangladesh: A Qualitative Exploration. Int J Med Inform (2016) 93:49–56. 10.1016/j.ijmedinf.2016.05.010

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 52.

  Khanam R Creanga AA Koffi AK Mitra DK Mahmud A Begum N et al Patterns and Determinants of Care-Seeking for Antepartum and Intrapartum Complications in Rural Bangladesh: Results from a Cohort Study. PLoS ONE (2016) 11(12):e0167814. 10.1371/journal.pone.0167814

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 53.

  Begum A Hamid SA . Maternal Healthcare Utilization in Rural Bangladesh: A Comparative Analysis Between High and Low Disaster-Prone Areas. PLOS Glob Public Health (2023) 3(7):e0001409. 10.1371/journal.pgph.0001409

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 54.

  Khatun F Heywood AE Hanifi SMA Rahman MS Ray PK Liaw ST et al Gender Differentials in Readiness and Use of Mhealth Services in a Rural Area of Bangladesh. BMC Health Serv Res (2017) 17:573. 10.1186/s12913-017-2523-6

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 55.

  Begum T Ellis C Sarker M Rostoker JF Rahman A Anwar I et al A Qualitative Study to Explore the Attitudes of Women and Obstetricians Towards Caesarean Delivery in Rural Bangladesh. BMC Pregnancy Childbirth (2018) 18:368. 10.1186/s12884-018-1993-9

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 56.

  Hossain A Moseson H Raifman S Gerdts C Biswas KK Foster DG . How Shall We Survive: A Qualitative Study of Women's Experiences Following Denial of Menstrual Regulation (MR) Services in Bangladesh. Reprod Health (2016) 13(1):86. 10.1186/s12978-016-0199-8

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 57.

  Alam A Rasheed S Khan NU Sharmin T Huda TM Arifeen SE et al How Can Formative Research Inform the Design of an Iron-Folic Acid Supplementation Intervention Starting in First Trimester of Pregnancy in Bangladesh? BMC Public Health (2015) 15(1):374. 10.1186/s12889-015-1697-2

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 58.

  Choudhury N Ahmed SM . Maternal Care Practices Among the Ultra Poor Households in Rural Bangladesh: A Qualitative Exploratory Study. BMC Pregnancy Childbirth (2011) 11:15. 10.1186/1471-2393-11-15

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 59.

  Afsana K Rashid SF . The Challenges of Meeting Rural Bangladeshi Women's Needs in Delivery Care. Reprod Health Matters (2001) 9(18):79–89. 10.1016/s0968-8080(01)90094-1

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 60.

  Gazi R Kabir H Saha NC . Changes in the Selected Reproductive Health Indicators Among Married Women of Reproductive Age in Low Performing Areas of Bangladesh: Findings from an Evaluation Study. BMC Public Health (2014) 14:478. 10.1186/1471-2458-14-478

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 61.

  Sikder SS Labrique AB Ullah B Ali H Rashid M Mehra S et al Accounts of Severe Acute Obstetric Complications in Rural Bangladesh. BMC Pregnancy Childbirth (2011) 11:76. 10.1186/1471-2393-11-76

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 62.

  Shahjahan M Kabir M . Why Males in Bangladesh Do Not Participate in Reproductive Health: Lessons Learned from Focus Group Discussion. Int'l Q Community Health Education (2006) 26(1):45–59. 10.2190/9623-6736-6154-7547

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 63.

  Rahman M Nakamura K Seino K Kizuki M . Intimate Partner Violence and Use of Reproductive Health Services Among Married Women: Evidence from a National Bangladeshi Sample. BMC Public Health (2012) 12:913. 10.1186/1471-2458-12-913

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 64.

  Aziz S Basit A Sultana S Homer CSE Vogel JP . Inequalities in Women’s Utilization of Postnatal Care Services in Bangladesh from 2004 to 2017. Scientific Rep (2022) 12(1):2747. 10.1038/s41598-022-06672-z

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 65.

  Amin R Shah NM Becker S . Socioeconomic Factors Differentiating Maternal and Child Health-Seeking Behavior in Rural Bangladesh: A Cross-Sectional Analysis. Int J Equity Health (2010) 9(1):9. 10.1186/1475-9276-9-9

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 66.

  Banik BK . Barriers to Access in Maternal Healthcare Services in the Northern Bangladesh. South East Asia J Public Health (2017) 6(2):23–36. 10.3329/seajph.v6i2.31832

  • CrossRef
  • Google Scholar

• 67.

  Orderud H Härkönen J Hårsaker CT Bogren M . Floods and Maternal Healthcare Utilisation in Bangladesh. Popul Environ (2022) 44(3):193–225. 10.1007/s11111-022-00410-3

  • CrossRef
  • Google Scholar

• 68.

  Adhikary G Shawon MSR Ali MW Shamsuzzaman M Ahmed S Shackelford KA et al Factors Influencing Patients' Satisfaction at Different Levels of Health Facilities in Bangladesh: Results from Patient Exit Interviews. PLoS ONE (2018) 13(5):e0196643. 10.1371/journal.pone.0196643

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 69.

  Akhter S Anwar I Akter R Kumkum FA Nisha MK Ashraf F et al Barriers to Timely and Safe Blood Transfusion for PPH Patients: Evidence from a Qualitative Study in Dhaka, Bangladesh. PLoS ONE. (2016) 11(12):e0167399. 10.1371/journal.pone.0167399

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 70.

  Rob U Alam MM . Performance-Based Incentive for Improving Quality of Maternal Health Services in Bangladesh. Int Q Community Health Education (2013) 34(4):303–12. 10.2190/IQ.34.4.b

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 71.

  Alam ATMS Alam S Mobasshira K Anik SMN Hasan MN Chowdhury MAB et al Exploring Urban-Rural Inequalities of Maternal Healthcare Utilization in Bangladesh. Heliyon (2025) 11(2):e41945. 10.1016/j.heliyon.2025.e41945

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 72.

  Dimbuene ZT Amo-Adjei J Amugsi D Mumah J Izugbara CO Beguy D . Women's Education and Utilization of Maternal Health Services in Africa: A Multi-Country and Socioeconomic Status Analysis. J Biosoc Sci (2018) 50(6):725–48. 10.1017/s0021932017000505

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 73.

  Islam and Odland. Determinants of Antenatal and Postnatl Care (2011).

  • Google Scholar

• 74.

  Gamble J Creedy DK McCourt C Weaver J Beake S . A Critique of the Literature on Women’s Request for Cesarean Section. Birth (2007) 34(4):331–40. 10.1111/j.1523-536X.2007.00193.x

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 75.

  Mustafiz RB Chowdhury SSA Kundu S Munaf NB Sharif AB . Determinants of Healthcare Decision-Making Autonomy Among Bangladeshi Women: Mixed-Effect Logistic Regression Analysis. BMC Women's Health (2025) 25(1):192. 10.1186/s12905-025-03666-7

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 76.

  Story WT Burgard SA . Couples' Reports of Household Decision-Making and the Utilization of Maternal Health Services in Bangladesh. Soc Sci Med (2012) 75(12):2403–11. 10.1016/j.socscimed.2012.09.017

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 77.

  Nisar YB Aurangzeb B Dibley MJ Alam A . Qualitative Exploration of Facilitating Factors and Barriers to Use of Antenatal Care Services by Pregnant Women in Urban and Rural Settings in Pakistan. BMC Pregnancy Childbirth (2016) 16:42. 10.1186/s12884-016-0829-8

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 78.

  Davis J Vyankandondera J Luchters S Simon D Holmes W . Male Involvement in Reproductive, Maternal and Child Health: A Qualitative Study of Policymaker and Practitioner Perspectives in the Pacific. Reproductive Health (2016) 13(1):81. 10.1186/s12978-016-0184-2

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 79.

  Kaye DK Kakaire O Nakimuli A Osinde MO Mbalinda SN Kakande N . Male Involvement During Pregnancy and Childbirth: Men's Perceptions, Practices and Experiences During the Care for Women Who Developed Childbirth Complications in Mulago Hospital, Uganda. BMC Pregnancy Childbirth (2014) 14(1):54. 10.1186/1471-2393-14-54

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 80.

  Sharma S Kc B Khatri A . Factors Influencing Male Participation in Reproductive Health: A Qualitative Study. J Multidiscip Healthc (2018) 11:601–8. 10.2147/JMDH.S176267

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 81.

  WHO. WHO Recommendation on Male Involvement Interventions for Maternal and Neonatal Health. WHO Reproductive Health Library. Geneva: World Health Organization (2015).

  • Google Scholar

• 82.

  Singh S Rajak R . Barriers in Utilization and Provisioning of Obstetric Care Services (OCS) in India: A Mixed-Methods Systematic Review. BMC Pregnancy Childbirth (2024) 24(1):16. 10.1186/s12884-023-06189-x

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 83.

  Kaphle S Hancock H Newman LA . Childbirth Traditions and Cultural Perceptions of Safety in Nepal: Critical Spaces to Ensure the Survival of Mothers and Newborns in Remote Mountain Villages. Midwifery (2013) 29(10):1173–81. 10.1016/j.midw.2013.06.002

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 84.

  Sarkar A Kharmujai OM Lynrah W Suokhrie NU . Factors Influencing the Place of Delivery in Rural Meghalaya, India: A Qualitative Study. J Fam Med Prim Care (2018) 7(1):98–103. 10.4103/jfmpc.jfmpc_45_17

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 85.

  Tarafder T . Reproductive Health Care Services of Rural Women in Bangladesh: A Case Study of Belief and Attitude. Canberra, Australia: University of Canberra Research Portal (2013).

  • Google Scholar

• 86.

  Kyei NNA Chansa C Gabrysch S . Quality of Antenatal Care in Zambia: A National Assessment. BMC Pregnancy Childbirth (2012) 12(1):151. 10.1186/1471-2393-12-151

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 87.

  Rani M Bonu S Harvey S . Differentials in the Quality of Antenatal Care in India. Int J Qual Health Care (2008) 20(1):62–71. 10.1093/intqhc/mzm052

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 88.

  Sikder SS Labrique AB Ali H Hanif AM Klemm RDW Mehra S et al Availability of Emergency Obstetric Care (Emoc) Among Public and Private Health Facilities in Rural Northwest Bangladesh. BMC Public Health (2015) 15(1):36. 10.1186/s12889-015-1405-2

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 89.

  Aminu M Utz B Halim A van den Broek N . Reasons for Performing a Caesarean Section in Public Hospitals in Rural Bangladesh. BMC Pregnancy Childbirth (2014) 14(1):130. 10.1186/1471-2393-14-130

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 90.

  MOHFW. National Health Policy 2011. Mohfw, Governmnet of Bangladesh. (2011).

  • Google Scholar

• 91.

  Gholitabar M Ullman R James D Griffiths M , Guideline Development Group of the National Institute for Health and Clinical Excellence. Caesarean Section: Summary of Updated NICE Guidance. BMJ (2011) 343:d7108. 10.1136/bmj.d7108

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 92.

  Lacerte P Pradipasen M Temcharoen P Imamee N Vorapongsathorn T . Determinants of Adherence to Iron/Folate Supplementation During Pregnancy in Two Provinces in Cambodia. Asia-Pacific J Public Health (2011) 23(3):315–23. 10.1177/1010539511403133

  • Pubmed Abstract
  • CrossRef
  • Google Scholar

• 93.

  Tita ATN Selwyn BJ Waller DK Kapadia AS Dongmo S . Evidence-Based Reproductive Health Care in Cameroon: Population-Based Study of Awareness, Use and Barriers. Bull WHO (2005) 83(12):895–903.

  • Pubmed Abstract
  • Google Scholar