Changing perspective of CSBA: Opportunities and challenges

Background: Bangladesh's commitment to its citizens and the international community necessitate a solution to the high maternal mortality ratio, which is driven by inequitable access to skilled and facility-based childbirth services. In addressing this problem, CARE Bangladesh, in 2013, promoted and invested in a proven and tailored model – the Skilled Health Entrepreneur (SHE) model – in hard-to-reach areas.

Under the SHE model, women are identified and selected from within the communities they serve, and subsequently trained and accredited as skilled birth attendants (SBAs) by the Bangladesh Nursing and Midwifery Council. As SBAs, they promote birth preparedness planning, provide antenatal care (ANC) and provide skilled assistance to pregnant women to ensure institution-based childbirth.

CARE Bangladesh in association with The Daily Star organised a roundtable titled "Changing perspective of CSBA: Opportunities and challenges" on January 12, 2022. Here we publish a summary of the discussion.

Dr Halida Hanum, Reproductive health epidemiologist, Johns Hopkins University

We have achieved a lot in terms of reducing the maternal mortality rate in Bangladesh. However, we have a long way to go. As per our SDG commitment, Bangladesh wants to reduce its maternal mortality rate from 170 to 70 by 2030. By 2025, we want to increase institutional delivery from 47 to 70. We also have many other important targets in this field. Today, we will discuss how we can achieve these targets, and what role CSBA can play in this endeavour. We will also discuss what lessons we can take from GSK-CHWI/SHE model.

Professor Dr Syed Mudassar Ali, President, Community Based Health Care

I must congratulate CARE Bangladesh for providing training to community-based skilled birth attendants (CSBAs). Now, the challenge is to properly utilise this human resource. We need adequate budget to give it a more permanent shape. Unfortunately, we can't absorb them into our existing community clinic structure. We can't pay them regular salary. However, the Local Government Ministry has a budget for health which often remains unutilised. If they can bear the yearly expenditure of the trained human resource, we, from CBHC, can provide all other required support.

Daryl Burnaby, Director, Global Health, GlaxoSmithKline (GSK)

GSK reinvested 20 percent of the profit generated in Bangladesh to develop the health infrastructure in partnership with CARE and the Government of Bangladesh. As an organisation that develops vaccines and medicines, we realise that we need to go further to help build and support the infrastructure that needs vaccines and medicines most. Working with an expert organisation like CARE which has been working in Bangladesh for a long time and in partnership with government of Bangladesh, means that any solution we develop will be locally appropriate and sustainable. We have trained 400 skilled health entrepreneurs and more than 4000 community health workers. We have also provided support to community groups to make sure people in the community have access to expert healthcare for infectious disease, nutrition, hygiene, sanitation, and maternal neonatal and child health problems. In the maternal, newborn and child health space, as a result of our work, newborn and under-five child mortality and morbidity has declined. Our work has increased access to antenatal and post-natal care and there is now much better understanding about potential complications during pregnancy and childbirth. We are really proud to support the programme. We hope that the Government of Bangladesh, CARE and other stakeholders carry it forward.

Bidhan Krishna Sarkar, Assistant Scientist, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)

Hard-to-reach areas such as Sunamganj and Netrokona remain underwater for almost six months every year. It is really difficult for the people of these areas to get proper healthcare support, particularly the services of skilled birth attendants. Keeping this in mind, the initiative of creating private CSBAs by training local people began. They were trained as per the protocol of the Bangladesh Nursing Council. 400 CSBAs have been trained through this process. We got extensive support from the local government bodies and community clinics.

This programme was launched in 2012. It was carried out in 11 Upazilas in Sunamganj and five Upazilas in Netrokona, covering around four million people. It was an ideal example of public-private partnership. We have developed a business model so that the private CSBAs can continue their activities even after completion of the project. The service price was determined by the local government authorities. 

The trained CSBAs have participated in 50,000 safe deliveries and referred to institutional facilities for another 50,000 deliveries. Earlier, only 13 percent of deliveries were attended by skilled birth attendants. Our intervention has increased the rate to 37 percent. The work of CSBAs has helped to reduce the mortality rate of mothers and children significantly in these areas. In addition to attending deliveries, CSBAs have also been providing health-related services for non-communicable diseases such as diabetes. 

Private CSBAs serve the marginal and poor sections of the population. They are already familiar with the government health structure since they provide support during delivery at the government facilities. Considering the contribution of private CSBAs, the government should invest in this human resource and bring them into mainstream health facilities. Those who will not be integrated into health facilities can still refer patients to institutional delivery facilities. They can be recognised as professional referrals. They can be of great help in successfully implementing the government's plan to provide 24/7 delivery services.

Mahmuda Akhter, Private CSBA & Secretary, Suseba Network, Netrokona

I, along with 110 other private CSBAs, have been working in the remote areas of Netrokona since 2020. We got training from CARE Bangladesh. After completing training, we began working as skilled birth attendants at both home and institutional facilities such as community clinics and family welfare centres. However, we do not get a salary for providing these services. We serve the ultra-poor communities in these areas, but our own families are also dependent on us financially. I hope that we will soon be provided with some form of compensation for the service we provide. There should be some sort of seating arrangement for us at institutional health facilities.

Marzia Begum, Private CSBA, Sunamganj

We have been providing delivery services in 13 Upazilas of Sunamganj since 2013. Besides attending deliveries, we also provide antenatal and postnatal care services. We are involved in the COVID-19 vaccination programme. Some of us are affiliated with government health facilities. We get very little compensation from the local government body for our service. I would request the government to seriously consider providing us an emolument. 

Dr Md Shamsul Haque, Line Director, Maternal newborn child and adolescent health (MNC & AH), Directorate General of Health Services (DGHS)

The CSBAs have played an essential role in carrying out the COVID-19 vaccination programme in hard-to-reach areas such as Netrokona and Sunamganj. To ensure their future services, we must support them. Local government bodies can play an important role in this regard. We can involve these CSBAs in our upcoming operation plan for the community clinic programme in hard-to-reach areas. 

Dr Masud Reza Kabir, Line Director, Community Based Health Care, Community Clinic Health Support Trust

If we want to achieve the SDGs, we need to increase the number of CSBAs in the country. They have been playing a significant role in reducing maternal and child mortality. CSBAs, who are affiliated with local government health facilities, have facilitated around 85,000 normal deliveries without any casualties. We have a shortage of community health workers, and CSBAs are potential healthcare providers for a range of services outside of birth delivery. That is why we should provide additional training to CSBAs and facilitate their activities by providing various kinds of institutional support.

Professor Dr Ferdousi Begum, Obstetrical and Gynaecological Society of Bangladesh

At one point of time, the rate of maternal mortality was very high in the country. Now, we have curbed this rate with the help of CSBAs. However, there is still a lot of work to be done. We cannot allow for the number of CSBAs in the country to fall. That is why, it is important to incentivise these CSBAs to continue to serve the country. Alongside incentives such as child delivery fees and financial assistance, they should also be provided with training so they can work in other sectors of health as well.

Dr Afsana Karim, Senior Technical Advisor, Maternal and Newborn Health, Save the Children

While working in the area of maternal health, we realised that there are some hard-to-reach areas in the country where childbirth services are not available. At the same time, the local institutional facilities are also inadequate at times. In these areas, the CSBA programme can be beneficial.

The hardest challenge is to find women who fit the criteria necessary to be a CSBA. Ideally, when selecting CSBAs, we should take women who have studied till the 10th grade. At the same time, they should be from the local community so that there is no risk of them moving elsewhere.

Once the CSBAs have been provided with training, the local government should act as a liaison between the CSBAs and the local community. Additionally, the government should set the fees that will be paid to the CSBAs so that they can continue to provide services without facing a financial burden.

Dr Iqbal Anwar, Former Scientist, icddr,b

Skilled Birth Attendants (SBAs) include doctors, nurses and midwives. In Bangladesh, there is a severe lack of SBAs. Despite providing various forms of skills training, the number of SBAs in the country has not increased.

While there are Trained Birth Attendants (TBAs) throughout the country, they cannot provide the same services as an SBA. That is why we have to work to increase the number of SBAs. TBAs and institutional delivery cannot reduce the maternal mortality rate alone. The services provided by the SBAs or CSBAs can help save the lives of many pregnant women, and that is why we need to encourage more women to take on the role of a CSBA.

Farida Begum, Programme Analyst, Midwifery, United Nations Population Fund (UNFPA)

If we want to utilise CSBAs properly, then we must engage them in institutional delivery. They can work at the community clinics or recommend nearby facilities to pregnant women in the case of complications.

We should consider increasing the number of midwives in community clinics in areas with a high maternal mortality rate. If we can ensure financial support for CSBAs, they can act as agents for the local government. This will help increase the number of institutional deliveries, thus reducing the maternal mortality rate.

Dr Ashutosh Das, Ex-Civil Surgeon, Sunamganj     

If we want our country to move forward, we must empower motherhood. We have to value mothers as, without a healthy mother, there cannot be a healthy child. And if we don't have healthy children, we cannot ensure a healthy nation.

Dr Mozammel Haque, Deputy Director Family Planning, Faridpur 

In recent years, CSBAs have played an integral role in the overall family planning vision of the Bangladesh government. They are providing support in various roles outside of traditional CSBA duties. They have acted as substitutes for Family Welfare Visitors (FWVs) in districts with a shortage of FWVs. Alongside this, they have helped provide antenatal care and also worked in the community clinics.

First and foremost, we need to ensure that CSBAs are provided with a fee for every birth delivery they make. Additionally, we need to incorporate them into the Local Governance Support Project (LGSP).

Finally, the local administration should establish a micro-loan facility for CSBAs, so that they can engage in income-generating activities by themselves.

Dr Tajul Islam, Ex-Civil Surgeon, Netrokona

CSBAs have very few demands. They want to receive some form of financial support and want to be able to work at their community clinics. They are not asking for much, and we should allocate specific rooms for CSBAs at the local community clinics. Giving them such a small form of recognition can encourage even more women to come forward to work as CSBAs in their communities.

Dr Md Anisur Rahman, Deputy Director Family Planning, Netrokona

In the Netrokona district, there was hardly any Family Welfare Assistant (FWA) or FWV when I first joined. In Kalmakanda, we had seven postings for FWVs, but only two were hired. But now, the scenario is different due to the help of CSBAs. Our CSBAs work at 18 community clinics and nine Family Welfare Centres (FWCs) in Netrokona. We need to continue all the training programmes for CSBAs as they can help fill the gap for FWAs and FWVs.

Tulashi Ranjan Saha, Managing Director (Additional Secretary), Community Clinic Health Support Trust

As per our commitment to the SDGs, our target is to reduce maternal mortality to 70 deaths per 100,000 live births by 2030. In Bangladesh, the number is currently at 169 per 100,000 live births. It will be a great challenge to reduce this number by 100 in the next eight years, and this cannot be achieved without the support of CSBAs.

Currently, we have over 14,000 community clinics in the country. However, not all of these clinics have birth delivery services. In these areas, having a CSBA who is adequately trained can save the lives of many pregnant women.

CSBAs are not only trained in childbirth but also in other health-related areas such as inoculation, food, nutrition, etc. That is why it would be beneficial to link existing CSBAs with local government institutions for a variety of health-related services.

Niranjan Bandhu Dham, Deputy Director Family Planning, Sunamganj

In Sunamganj, the rate of at-home birth deliveries is approximately 60 percent. We want to increase the percentage of institutional delivery, but it's a challenge to do that in areas with communications issues. Having CSBAs in such areas ensures a minimum level of support for pregnant mothers during childbirth at home. Alongside this, CSBAs can also help by recommending pregnant women to nearby institutions in case of complications. When they refer other medical institutions, they should receive a referral fee, and the government should make this referral fee mandatory.

Dr Riad Mahmud, Policy and Technical Advisor, USAID

My first recommendation would be that CSBAs, both private and public, are available at community clinics, especially in hard-to-reach areas. The second recommendation is to ensure that all CSBAs are brought under some framework. While CARE-GSK has done a great job training their CSBAs, other agencies are also working here. We need to ensure that all CSBAs in the country are following standard procedure and ensure a certain quality of service. The local government should enlist the CSBAs in the health and family planning department so that they can be monitored properly.

Mahbub Elahi Chowdhury, Scientist, icddr,b

We have two types of CSBAs: government-employed CSBA and private CSBA. Today we are focusing on private CSBAs. We need to find out how this role can be made more sustainable. Without some form of income-generating activity, CSBAs cannot continue to provide the necessary services.

Dr Zoshim Uddin, UH&FPO

The local government has the necessary funds, but we must ensure that it reaches the community clinic level. Currently, CSBAs receive around six months of training and nine months of practical experience. If we add another six months to the training programme, then the training would meet international standards for SBAs. The government should allocate a portion of the budget from health and family planning towards SBAs in the upcoming National Budget.

Dr Halida Hanum

Every year 2.6 million children are born in Bangladesh. Currently, 53 percent of deliveries take place at home of which only 3 percent are attended by SBAs. We need to seriously think about this 50 percent of mothers who are giving birth at home without any support from SBAs. Besides safe delivery, we should provide proper care to women during the pregnancy and postpartum periods.

Every woman has the right to safe motherhood. Political commitment is needed towards ensuring this right. 

We need to engage local government bodies and other local organisations in our effort. We should also try to mobilise various local funds for training and provision of emolument for CSBAs. The private sector should also come forward to support these initiatives.

Shahana Parvin, National Coordinator, Community Clinic Health Support Trust

Awareness is more important than money. We must create mass awareness about safe motherhood.

I want to actively engage community groups and support groups in all the health-related programmes in Bangladesh. I am seeking active support from all the relevant stakeholders to achieve this goal.

Professor Dr Syed Mudassar Ali

We are increasing space in community clinics. There will be a provision to add another floor. It will enable us to provide seating facilities to CSBAs.

If we properly develop the referral system, we will be able to reduce maternal mortality significantly. We have to diagnose symptoms properly and in a timely manner.

I promise you that you will get full support from community clinics. We will sign MoUs with different organisations including CARE to build strong partnerships and reduce maternal mortality.

Dr Ikhtiar Uddin Khandaker, Director - Health, CARE Bangladesh

I want to express my sincere gratitude to all the participants of today's roundtable. It was a fruitful discussion. We have received several important recommendations which will make our intervention more impactful. Finally, I request all to join hands and work together to achieve the goal of safe motherhood for women in Bangladesh.

Recommendations

• Private community-based skilled birth attendants (CSBAs) should be formally integrated into the government health sector. The government should invest towards maintaining this human resource. 
• Local government bodies can play an important role in supporting CSBAs.
• CSBAs should be provided with a fee for every birth delivery they perform and a referral fee whenever they recommend a nearby medical institute.
• Provide additional training to CSBAs so that they can provide services beyond attending deliveries.
• Allocate and reserve space for CSBAs at local health facilities such as community clinics and family welfare centres.
• Bring all CSBAs under one framework so that they can be monitored properly.
• Ensure that training for CSBAs meets international standards.
• A portion of the upcoming National Budget should be allocated for CSBAs.
• The private sector should be encouraged to support training and employment of CSBAs.