The maternal mortality ratio (MMR) is high in Bangladesh. The presence of skilled birth attendants (SBAs) during delivery may reduce this high MMR. To meet the MMR target of the United Nations’ Sustainable Development Goals (SDGs) it is important to increase the number of deliveries attended by SBAs. This study was conducted to examine the factors associated with deliveries attended by SBAs.

Cross-sectional secondary, and generalizable data from the Bangladesh Demographic and Health Survey (2014 BDHS) were analyzed. Factors were selected based on published reports and available data.

The factors that were found to be positively associated with deliveries attended by SBAs included known pregnancy complications higher education level of women, receiving antenatal care (ANC) by a skilled provider during the pregnancy period, and higher wealth quintile. Conversely, the factors that were inversely associated with deliveries attended by SBAs included living in rural areas and divisions other than Khulna.

A survey was recommended to investigate the associations of factors not explored in this study but that were validated in previous studies. The government should focus more on rural areas along with divisions with a low presence of SBAs during delivery. It was also recommended to focus on potential factors (e.g., ANC visit by a skilled provider and identifying pregnancy complications) to improve the number of deliveries attended by SBAs.

Despite a substantial reduction of the estimated maternal mortality ratio (MMR) in Bangladesh from 550 per 100,000 live births in 1990 to 176 per 100,000 live births in 2015 the MMR is higher than most other countries [1]. Reduction of the MMR was a target of the United Nations’ (UN) Millennium Development Goals (MDGs), and it is also stated as one of the Health Goals (Goal 3) of the UN’s Sustainable Development Goals (SDGs) SDG 3.1 aims to reduce MMR to less than 70 per 100,000 live births by 2030 [2]. The estimated annual reduction of MMR in Bangladesh from 1990 to 2015 was 5% and to achieve the targets of the SDGs this progress needs to be accelerated [3].

According to the World Health Organization (WHO) skilled birth attendants (SBAs) are accredited health professionals (such as midwives, doctors, or nurses) who have been educated and trained to proficiently manage normal (i.e., uncomplicated) pregnancies, childbirths and the immediate postnatal period, as well as handle the identification, management and referral of complications in women and newborns [3]. The presence of SBAs can significantly reduce maternal and neonatal mortality by preventing or managing most obstetric complications [4, 5] including stillbirths [6]. In addition to the high MMR, Bangladesh has a high neonatal mortality rate with an estimated 23 per thousand live-births in 2015 [7].

The latest 2014 Bangladesh Demographic and Health Survey (2014 BDHS) revealed that the percentage of deliveries attended by SBAs in Bangladesh increased from 16% in 2004 to 42% in 2014 [8]. This rate is below the targeted level (50%) of the Health Population and Nutrition Sector Development Program (HPNSDP) set by the Ministry of the Health and Family Welfare (MOHFW) of the Government of Bangladesh [9]. To increase the number of deliveries attended by SBAs in Bangladesh and to achieve the target of the HPNSDP, a clear, focused, and evidence-based approach is needed. The identification of the factors that affect deliveries attended by SBAs is important in this approach. There are few recent studies in Bangladesh that have examined the factors associated with the presence of SBAs during deliveries, which ultimately limits our understanding of this problem and indicates that this issue has been underestimated in Bangladesh. Therefore, further comprehensive studies are required.

Previous studies found that factors of different levels such as individual household or socioeconomic conditions simultaneously affect the decision of delivery attended by SBAs [10–14]. In Bangladesh, there is inequality in rural and urban areas, and inequality according to region and division. A population-based and nationally representative study may reveal the overall state of the SBA attended deliveries, which would be beneficial for the planning of health programs. It is better to address the modifiable factors and the areas or regions requiring intervention to increase the number of deliveries attended by SBAs. We attempted to identify and fill these existing gaps of knowledge to inform the policymakers and researchers to take a risk-specific intervention approach. We examined the factors that affect the decision of an SBA attended delivery by analyzing a nationally representative dataset from Bangladesh.

The age group (of study women and their husbands) was not a significant predictor of the deliveries attended by SBAs (p >0.05). The women with a gap of three or more years between subsequent deliveries were 1.5 times more likely to be delivered by SBAs compared to women with a birth interval of less than two years. The higher education level of women (AOR: 1.7 95% CI: 1.2-2.3) and their husbands (AOR: 1.8 95% CI: 1.3-2.4) was a significant predictor. The women from higher wealth quintiles were more likely to be delivered by SBAs in both the unadjusted (COR: 11.6 95% CI: 8.9-15.1) and adjusted analyses (AOR: 3.4 95% CI: 2.5-4.7). Though exposure to mass media (i.e. reading newspapers, listening to radio or watching television) was a significant predictor in the unadjusted level (p <0.05), exposure to television did not remain significant after adjusting for other factors. The mothers who received a follow-up from an SBA during the pregnancy period increased the likelihood to be delivered by an SBA in comparison to the women who did not receive a follow up from an SBA (AOR: 1.5 95% CI: 1.1-2.1). The likelihood of a delivery attended by SBAs was significantly lower in all six divisions compared to Khulna. Religion was not significantly associated with deliveries attended by SBAs.

Our analyses revealed that known pregnancy complications higher education level of women, receiving ANC by a skilled provider during the pregnancy period, and higher wealth quintiles were positively associated with the deliveries attended by SBAs in Bangladesh. On the other hand, living in rural areas and divisions other than Khulna were inversely associated with the likelihood to be delivered by SBAs within the country. We did not find any association of deliveries attended by SBAs with age, history of child death, sex of the head of the household, exposure to mass media, and religion.

The education level of the husbands was positively associated with deliveries attended by SBAs in our study and this finding is supported by other studies [10–12]. This may be the result of greater knowledge and awareness of the importance of SBAs in deliveries. The association of education level may also be linked to the wealth quintile, as educated people have more opportunities to work and get well-paying jobs. Moreover, education was the strongest and most consistent predictor of health status [15]. As reported in other studies in Bangladesh, there was a significant association between women with an occupation outside of the home and deliveries by SBAs [10, 11]. However, we found the opposite there was a negative association between women working outside of the home and deliveries attended by skilled attendants. A study in Nepal found a similar association [13].

Similar to other studies we found that women from higher wealth quintiles were more likely to be delivered by skilled attendants compared to less privileged women [10, 12, 16, 17]. This may be due to the costs of SBAs during deliveries, which is difficult to manage for families with lower income. Improving the socio-economic status is difficult and a long-term process however a review of the BRAC-ICDDR,B Joint Research Project Working Paper Series in Bangladesh suggested that microcredit programs may improve maternal and child health conditions within the targeted program areas [18]. The application of improvement programs is a potential area for policymakers in the country to get involved.

We found that women living in rural areas were less likely to be delivered by SBAs. Mothers living in rural areas have less access to antenatal obstetric, and postnatal care services compared to their urban counterparts consequently women in rural areas do not utilize family planning, antenatal and other services as much as women in urban areas [8]. Less access and use of health services is closely linked to the lower socioeconomic conditions of rural people and inadequate health care services in rural areas of the country. In Bangladesh, there are vast differences between rural and urban utilization of health services there are also differences between rural and urban health-related outcomes including the neonatal and infant mortality rate and the maternal mortality ratio [8]. This inequality is required to be fulfilled by community-based programs. Moreover, more than 65% of the people of Bangladesh live in rural areas the people in rural areas should be prioritized to achieve desired health outcomes [19].

Women living in divisions other than Khulna were less likely to be delivered by SBAs. Moreover in all other divisions, less than one-third of the pregnant women were delivered by SBAs. Specifically, Sylhet had the lowest number of deliveries attended by SBAs in comparison to the other six divisions. Khulna is one of the best performing divisions for all health indicators in Bangladesh and was able to meet the governmental target for SBA attendance during childbirth compared to most of the other divisions Khulna had the highest proportion of women delivered in health facilities and the highest proportion of women receiving antenatal and postnatal care [8]. The differences in the regional use of health services contributed to the gap in health indicators and the increased number of deliveries attended by SBAs. The government should increase awareness programs in the other six divisions and intervene to increase the likelihood of being delivered by SBAs.

Receiving ANC by a skilled health care provider during pregnancy and prolonged intervals between subsequent births were positively associated with deliveries attended by SBAs and this is corroborated by the findings from other studies of Bangladesh [10–12, 14]. A prolonged birth interval is also associated with increased awareness among women. Receiving counseling and information from the SBAs during pregnancy may increase the likelihood of being delivered by SBAs [20, 21] the pregnancy period is the most suitable opportunity for intervention. Moreover antenatal counseling is one of the four pillars of the Safe Motherhood Initiative based on its effectiveness [22].

A study in Nepal found an association between the autonomy of women and deliveries attended by SBAs [23]. However we did not find any association between head of household and deliveries attended by SBAs.

We considered that women who have been exposed to mass media (i.e. radio, television, and newspaper) were more likely to use SBAs during delivery. A study in Uganda found an association between exposure to mass media and birth preparedness [24] therefore we considered that women may become more aware of SBAs by advertisements or exposure to awareness programs. Moreover, one study in Bangladesh found a positive association between the use of contraceptives and television exposure [25]. Television exposure appeared to be a significant predictor in the calculated CORs however television exposure did not remain significant when we adjusted for other factors. This suggests that women were either not informed of a delivery by SBAs due to the absence of awareness programs or if exposed, women were reluctant to adopt it. We were unable to investigate whether women were exposed to an awareness program through mass media due to unavailable data.

One limitation of our study is that we were unable to examine certain factors that were revealed in other studies. Several studies found the following associations with deliveries attended by SBAs: complications related to delivery distance to the nearest hospital, transportation issues to reach health facilities, presence of SBAs in the geographic area, and cost of SBAs [10–12, 16, 26–30]. These factors were also validated by studies in other countries [31–33]. We were unable to examine these factors due to unavailable data. Another limitation of this study is that we only analyzed the data of women who survived, and we were unable to investigate the determinants of the most affected group. The data were collected retrospectively, and the data were cross-sectional. Causality cannot be established fully as the condition may have changed after childbirth.

The main strength of this study is that the analysis is generalizable for Bangladesh as there was a large sample size accounting for the population across the entire country. To our knowledge, no other studies in Bangladesh were able to identify the divisions with fewer deliveries attended by SBAs. The response rate of the survey was high (approximately 99%), and there was little missing data. Furthermore, the possibility of a recall bias was minimized by interviewing only women with a history of childbirth within the last five years.

The analysis of the 2014 BDHS data revealed that individual, fertility, and contextual variables had a significant effect on the number of deliveries attended by SBAs. A delivery by skilled personnel is required for all women in Bangladesh regardless of age, location or socioeconomic condition. From a program planning perspective, to achieve the maternal mortality target of the United Nations’ Sustainable Development Goals (SDGs) and to achieve the target of 50% of deliveries attended by SBAs of the Government of Bangladesh, it is important to consider the modifiable factors that affect the presence of SBAs during childbirth. To increase the number of deliveries attended by SBAs at the population level, community-based programs should focus on the positive factors such as ANC visits by a skilled provider and surveillance for complications during pregnancy; based on priority, health programs should include these components to increase awareness in rural areas and the divisions with a lower presence of SBAs during childbirth. Effective collaboration with stakeholders should be ensured, and further studies should be conducted to reveal unexamined factors associated with the presence of SBAs during childbirth.