Abstract
Background
This study explores receiving maternal health care (MHC) and associated factors among the Rohingya refugee women living in the camps in Cox’s Bazar, Bangladesh, amidst a backdrop of severe challenges, including high maternal mortality rates and limited healthcare access.
Methods
A cross-sectional study was conducted among 415 refugee women in Camp-4, located in the Kutupalong Mega area in Cox’s Bazar. Data were collected using a structured, pretested, and facilitator-administered questionnaire.
Results
Of the Rohingya refugee women, 297 (71.57%) had at least four antenatal care (ANC) visits, 247 (59.5%) gave birth to the last baby in a place with an adequate facility, and 288 (69.4%) reported that the skilled birth attendants (SBAs) were present during the previous delivery. Moreover, 331 (79.8%) received postnatal care (PNC), while 314 (28.7%) had a PNC visit with a doctor or healthcare provider. Above all, half of them (51%) received adequate maternal health care (MHC), such as medical facilities during delivery, postnatal visit, etc. Bivariate analysis shows that the status is highly significant in all aspects of the Rohingya refugee women’s receiving ANC, pregnancy, and PNC through exposure to maternal health information and services. Nagelkerke R2 value shows that the Rohingya women’s exposure to maternal health information and services appeared as stronger predictors than socioeconomic variables for receiving MHC. The result of multivariate logistic regression depicts that younger age among refugee women (AOR = 0.93, 95% CI: 0.88–0.98), having greater land ownership in Myanmar (AOR = 1.07, 95% CI: 1.01–1.13), receiving consultation with a skilled health care provider about maternal, sexual, and reproductive health (MSRH) (AOR = 5.22, 95% CI: 2.18-12.), participating in an awareness program about MSRH (AOR = 1.98, 95% CI: 1.08–3.61), and understanding MSRH messages (AOR = 5.31, 95% CI: 2.63–10.69) had a significantly higher association with receiving MHC.
Conclusion
Maternal health information and services have a significant influence on receiving maternal health care. Accordingly, this study highlights the importance of strengthening maternal health interventions, as it is challenging to alter their socioeconomic status within existing settings.
Keywords: Rohingya, Refugee, Inequality, Access to health care, Maternal health care
Introduction
Almost 750,000 Rohingya refugees have crossed the border into Cox’s Bazar, Bangladesh, in the wake of violence and widespread human rights abuses in Myanmar’s Rakhine state starting in October 2016; the vast majority arriving since the latest round of violence began in August 2017 [1, 2]. Approximately 60% of new arrivals are women and girls [3]. Estimates suggest that around twenty-four thousand pregnant and lactating Rohingya women require maternal healthcare support [2]. Life-saving emergency obstetric care is not available for a majority of residents, and access to transportation to health facilities is limited [4]. As a result, Rohingya women are at acute risk of maternal mortalities and morbidities. According to the Inter-Sector Coordination Group (ISCG) [4], 63% of Rohingyas in Bangladesh are women. Of these, 13% are adolescents, and 21% are pregnant and lactating.
Pregnant women living in the camps suffering from malnutrition are likely to give birth to underweight babies, which makes matters even worse [5]. Besides, a number of women died there from complications linked to teenage pregnancy in previous years and inadequate spacing between two births [6]. Consequently, 179 mothers die from preventable causes related to pregnancy and childbirth for every 100,000 live births in Rohingya camps [7]—nearly two-and-a-half times the global maternal mortality goal of under 70 per 100,000 live births [8]. Bangladesh’s national maternal mortality ratio is 115 per 100,000 live births [9], which means that Rohingya women are much more likely to die during childbirth than the national average.
According to UNICEF, more than 60 babies are born every day in 34 refugee camps in Teknaf and Ukhia Upazilas [10]. At the same time, family planning is a sensitive subject for persecuted Rohingya communities, and many of the refugees do not believe in using contraception [11, 12]. The numerous family planning initiatives among refugees will likely clash with more traditional cultural and religious beliefs. Moreover, contraceptives among Rohingyas are unpopular, mainly due to a lack of education and family planning awareness [6]. In addition, child marriage is prevalent in society, leading to inadequate maternity and child health [6, 11].
Moreover, refugees are more susceptible to health issues, various hardships that impact their well-being, including food scarcity, absence of drinking water, risk of detention, and sexual assault [13]. The situation of the Rohingya has worsened at the camps due to the dearth of drinking water, adequate food, and sanitary latrines. Accordingly, apart from various health problems, local as well as international NGOs, along with the government, are working to address the reproductive and maternal health issues of the Rohingyas through communication campaigns, awareness programs, and different health services [6]. However, the effectiveness of exposure to maternal health information and services has not been evaluated yet. This study explores receiving maternal health care and associated factors among the Rohingya refugee women living in the camps in Cox’s Bazar, Bangladesh. In particular, the study focused on pregnancy-related components of maternal health care among Rohingya refugee women, explicitly focusing on antenatal care (ANC), delivery services, and postnatal care (PNC). The importance of the present study lies in providing information that the government of Bangladesh and NGOs can use to support their ongoing health services and to develop appropriate health interventions for improving the maternal health status of the Rohingya refugee women.
Methods
Study design and study setting
This study is a camp-based cross-sectional study conducted at Rohingya Refugee Camp-4 located at Kutupalong Mega area in Cox’s Bazar, a district in Chittagong division of Bangladesh. This camp was chosen as the study site because it is one of the largest, with 24 international and national organizations providing assistance to Rohingya refugees. This diversity of services ensured logistical feasibility, greater variation in health service exposure, and access to a dense health communication environment for participants. Camp 4 was selected for this study based on logistical convenience. This camp was more accessible in terms of transportation, and members of the research team, including facilitators, had prior familiarity with the site’s administrative setup and community structure.
Study population and sampling
The target population consisted of married Rohingya women aged 15–49 residing in Camp 4. According to a UNHCR report, as of September 30, 2019, Camp-4 had a total population of approximately 32,389, of which around 51% were female and 49% were male—including an estimated 7,683 adult women aged 18 to 59 [14]. Because choosing a suitable selection strategy was problematic, given the humanitarian context and limited funds, participants in the sample were selected using a convenience sampling approach. We acknowledge that this sampling method may limit the generalizability of findings. The sample size was 384, which was determined using a single population proportion formula considering the following assumption: p = 50%, significance level 5% (α = 0.05), Z 
= 1.96, margin of error 5% (d = 0.05). Assuming 5% nonresponse rate, the sample size was: n = n + 10% = 384 + 38 = 422. Finally, a total of 415 refugee women were included as the study participants, and the response rate was 98.34%.
Regarding the region of residence in Myanmar of the respondents, 182 (43.9%) were from Buthidong sub-district, followed by Mongdu (124, 29.9%), and Racidong (109, 26.3%). The mean age of the respondents was 25.52 (SD ± 6.32) years. As regards the educational status of the Rohingya refugee women, more than half (218, 52.5%) of them had no formal education, and the remaining 197 (47.5%) had at least a primary level of education. Most of the respondents, 327 (78.8%), were homemakers, and the rest of them (88, 21.2%) were involved in different professions. The mean amount of land the respondents owned in Myanmar was 5.24 (± 6.22) acres. The mean number of children of the study participants was almost 4 (3.96, SD ± 2.58).
Data collection methods
Data collection started on September 10, 2019, and ended on January 10, 2020. Data were collected using a pretested, structured, and facilitator-administered questionnaire. Ten female facilitators were selected to guide and administer the survey based on prior data gathering experience. Researchers were escorted by recognized community leaders when visiting participants’ homes to prevent being perceived as outsiders. Many of the Rohingya women who were involved had previously worked with their community. Ahmed et al. [15] also recommend involving community members in the research process. The facilitators were fluent in Rakhine/Arakanese and spoke it fluently and had worked in the Rohingya camp for many years. Data collectors who have worked in NGOs and industries other than the health sector have been hired to minimize bias in data gathering.
Variables
Receiving maternal health was measured by five items, while each item of the outcome variable was dichotomous using answer options ‘yes = 1’ and ‘no = 0’. Afterward, the total score of five items was then calculated and dichotomized using a mean of 3.56 as a cut-off value. Then, a score below the mean value was coded as ‘0’, reporting inadequate maternal health care, and the above mean value was coded as ‘1’, indicating adequate maternal health care. Adequate maternal health care implies that the respondents received at least four maternal health services out of five.
In this study, enough diet denotes the consumption of three or more nutritious meals daily during pregnancy. Adequate rest is characterized by having a minimum of eight hours of sleep or rest daily during pregnancy. An adequate facility refers to a location equipped with basic infrastructure and the presence of at least one skilled birth attendant, such as a nurse, midwife, or physician.
Data analysis
The collected data were processed using SPSS version 29.0 (IBM Corp.). As receiving maternal health care is a dichotomous variable, chi-square (χ2) analysis and Spearman’s correlation were used to examine the relationship between independent and main outcome variables. Then, variables with a p < .05 in the bivariate analysis were included in the multivariate logistic regression model to assess the contribution of each of these predictor variables. Most of the variables were fitted to the logistic regression. In total, three models were fitted to predict the determinants of three outcome variables in logistic regression (Table 4). Step 1 assessed the determinants of receiving adequate maternal health care concerning sociodemographic variables. Step 2 explored the association between sociodemographic variables and the source of MHC knowledge-related variables. Step 3 (final model) examined the effect of sociodemographic variables, the source of MHC knowledge, and exposure to maternal health information and services-related variables. The Omnibus Tests of Model Coefficients gives an overall indication of the ‘goodness of fit test’. Each variable coefficient in the final model produces the odds ratios and 95% confidence intervals (CI). Variables having a p-value <.05 in the multivariate analysis were taken as significant predictors. Adjusted Odds ratios (AOR) with their 95% confidence intervals were used to report the strength of the relationship between explanatory variables and the outcome variable.
Table 4.
Logistic regression predicting the Rohingya women’s receiving maternal health care
| Characteristics (N = 415) | Model 1 | Model 2 | Model 3 |
|---|---|---|---|
| AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | |
| Rachidong Region in Myanmar | |||
| No (ref.) | 1 | 1 | 1 |
| Yes | 1.82 (1.07–3.11)a | 1.64 (0.95–2.83) | 1.49 (0.82–2.73) |
| Respondents’ education | |||
| No (ref.) | 1 | 1 | 1 |
| Yes | 1.70 (1.08–2.67)a | 1.65 (1.04–2.60)a | 1.52 (0.87–2.67) |
| Age of Respondents | 0.96 (0.92–0.99)a | 0.96 (0.92–1.01) | 0.93 (0.88–0.98)b |
| Amount of Land in Myanmar | 1.07 (1.03–1.12)b | 1.08 (1.03–1.14)b | 1.07 (1.01–1.13)a |
| Number of children | 0.86 (0.77–0.96)b | 0.86 (0.78–0.96)b | 0.89 (0.79–1.02) |
| Access to a reliable source of MSRH knowledge | |||
| No (ref.) | 1 | 1 | |
| Yes | 2.19 (1.36–3.53)b | 1.02 (0.57–1.81) | |
| Received consultation with a skilled health care provider about MSRH issues | |||
| No (ref.) | 1 | ||
| Yes | 5.22 (2.18–12.49)c | ||
| Home visit from a health/field worker about MSRH | |||
| No (ref.) | 1 | ||
| Yes | 1.27 (0.59–2.72) | ||
| Participated in an awareness program about MSRH | |||
| No (ref.) | 1 | ||
| Yes | 1.98 (1.08–3.61)a | ||
| Exposed to MSRH posters/banners | |||
| No (ref.) | 1 | ||
| Yes | 0.48 (0.25–0.92) | ||
| Understood MSRH messages | |||
| No (ref.) | 1 | ||
| Yes | 5.31 (2.63–10.69)c | ||
| Model Chi-square | 67.30c | 77.90c | 174.51c |
| Nagelkerke R2 | .20 | .23 | .47 |
| Classification† | 69.9% | 71.6% | 77.8% |
Note: Model 1 adjusted for the study participants’ sociodemographic variables (Region in Myanmar, amount of land in Myanmar, age); Model 2 adjusted for sociodemographic and source of MHC knowledge-related variables; Model 3 adjusted for sociodemographic, source of MHC knowledge, and exposure to maternal health information and services-related variables
AOR = Adjusted Odds Ratio; CI: Confidence Interval; MHC = Mother Health Care; MSRH = Maternal Sexual Reproductive Health
ap < .05, bp < 0.01, cp < 0.001
† Step 0 = 61.9%
Results
Receiving maternal health care (MHC) among the Rohingya refugee women
Figure 1 illustrates that of the study participants, 297 (71.6%) received at least four antenatal care (ANC) visits, 307 (74%) consumed adequate food, and 259 (62.4%) took sufficient rest during the last pregnancy. Additionally, 247 (59.5%) of refugee women gave birth to their last baby in a place with an adequate facility predominantly managed by GoB, NGOs, and INGOs, employing skilled birth attendants (SBAs) and community health workers (CHWs). In contrast, approximately 40% of deliveries happened at home, facilitated by relatives or unskilled attendants. Additionally, 288 (69.4%) reported that the skilled birth attendants (SBAs) were present during the previous delivery. It is noteworthy that doctors were often engaged primarily in cases with complications or referrals, although regular postnatal care was predominantly administered by SBAs. Moreover, 331 (79.8%) received postnatal care (PNC), while 119 (75.7%) had a postnatal visit with a skilled health care provider. Most PNC services were reported to have been received within 48 h after delivery, either at home or at nearby health facilities, depending on availability. Furthermore, 386 (93%) reported that their last child received all recommended immunization doses. Above all, Table 1 depicts that 257 (62%) received adequate maternal health care.
Fig. 1.
Receiving maternal health care of the study participants
Table 1.
Bivariate analysis of receiving maternal health care by the Rohingya women’s exposure to maternal health information and services health services
| Exposure to Maternal Health Information and Services | |||||
|---|---|---|---|---|---|
| Variable (N = 415) | n | Low (%) | High (%) | χ2 | p |
| Received adequate maternal health care | 71.74 | <.001 | |||
| No | 158 | 108 (68.4) | 50 (31.6) | ||
| Yes | 257 | 67 (26.1) | 190 (73.9) | ||
| Received at least four antenatal care visits | 38.73 | <.001 | |||
| No | 118 | 78 (66.1) | 40 (33.9) | ||
| Yes | 297 | 97 (32.7) | 200 (67.3) | ||
| Consumed sufficient food during the last pregnancy | 21.48 | <.001 | |||
| No | 108 | 66 (37.7) | 42 (17.5) | ||
| Yes | 307 | 109 (62.3) | 198 (82.5) | ||
| Took adequate rest during the last pregnancy | 33.53 | <.001 | |||
| No | 156 | 94 (53.7) | 62 (25.8) | ||
| Yes | 259 | 81 (46.3) | 178 (74.2) | ||
| The delivery place had adequate facilities | 115.88 | <.001 | |||
| No | 168 | 124 (70.9) | 45 (18.3) | ||
| Yes | 247 | 51 (29.1) | 196 (81.7) | ||
| Skilled birth attendant present during the last delivery | 40.34 | <.001 | |||
| No | 127 | 83 (65.4) | 44 (34.6) | ||
| Yes | 288 | 92 (31.9) | 196 (68.1) | ||
| Received postpartum care | 13.01 | <.001 | |||
| No | 84 | 50 (59.5) | 34 (40.5) | ||
| Yes | 331 | 125 (37.8) | 206 (62.2) | ||
| Visited a skilled health care provider for postnatal care | 63.53 | <.001 | |||
| No | 101 | 77 (76.2) | 24 (23.8) | ||
| Yes | 314 | 98 (31.2) | 216 (68.8) | ||
Note. Columns against the categories of characteristics of each group sum to 100%. Chi-square (χ2) test was performed to depict the difference
Difference in receiving MHC by inequality of exposure to maternal health information and services
Table 1 shows that the refugee women who had more exposure to maternal health information and services had a higher likelihood to have adequate maternal health care (χ2 = 71.74, p < .001), received at least four antenatal care visits (χ2 = 38.73, p < .001), consumed sufficient food during previous pregnancy (χ2 = 21.48, p < .001), took adequate rest during previous pregnancy (χ2 = 33.53, p < .001), last delivery took place in a health facility (χ2 = 115.88, p < .001), a skilled birth attendant was present during the previous delivery (χ2 = 40.34, p < .001), received postpartum care (χ2 = 13.01, p < .001) and visited a skilled health care provider for postnatal care (χ2 = 63.53, p < .001).
Table 2.
Spearman’s correlation between receiving adequate maternal health care and exposure to maternal health information and services
| Variables | 1 | 2 | 3 | 4 | 5 | 6 |
|---|---|---|---|---|---|---|
| Received Adequate Maternal Care | 1 | |||||
| Received consultation with a skilled health care provider | .45** | 1 | ||||
| Received a home visit from a field/health worker | .41** | .68** | 1 | |||
| Participated in a maternal health awareness program | .34 ** | .47** | .48** | 1 | ||
| Exposed to the MSRH poster/banner | .22** | .44** | .40** | .44** | 1 | |
| Comprehended key messages related to MSRH | .48** | .49** | .54** | .39** | .33** | 1 |
**. Correlation is significant at the p < .001 level (2-tailed)
Association between ANC visits and safe delivery care
Figures 2 and 3 report a significant positive association between receiving antenatal care (ANC) visits and two key indicators of maternal health service quality. According to the findings of Fig. 2, women who had at least four ANC visits were significantly more likely to deliver in a facility with adequate conditions: 76.8% of those who received ANC delivered in adequately equipped facilities, compared to only 16.1% of those who did not receive ANC (χ² = 128.99, p < .001). Similarly, Fig. 3 shows that the presence of a skilled birth attendant (SBA) during delivery was much more common among women who had received at least four ANC visits (83.8%) than those who had not (33.1%), and this association was also statistically significant (χ² = 102.57, p < .001).
Fig. 2.
Association between ANC visits and adequate facility during delivery (χ² = 128.99, p < .001)
Fig. 3.
Association between ANC visits and presence of skilled birth attendant during delivery (χ² = 102.57, p < .001)
Correlation between receiving adequate MHC and exposure to maternal health information and services
We ran zero-order correlations (Table 2) to examine the relationship between Rohingya refugee women’s receipt of adequate maternal health care and their exposure to maternal health information and services. These services included both interpersonal and media-based interventions targeting maternal, sexual, and reproductive health (MSRH). Our analysis revealed significant positive correlations between receiving adequate maternal health care and consulting a doctor, nurse, or midwife about MSRH issues (r = .45, p < .001), receiving a home visit from a health or field worker about MSRH (r = .41, p < .001), participating in awareness-raising programs (r = .34, p < .001), viewing posters related to MSRH (r = .22, p < .001), and understanding MSRH -related messages (r = .48, p < .001). Figure 4 also illustrates strong relationships between these independent variables and the likelihood of receiving adequate maternal health care.
Fig. 4.
Relationship map between dependent and independent variables
Bivariate relationship between Rohingya women’s receiving adequate MHC and explanatory variables
Table 3 reports on the bivariate relationship between the study participants’ receipt of adequate MHC and explanatory variables. Findings reveal that respondents’ Rachidong region in Myanmar (χ2 = 9.62, p = .002), younger age of the respondents (r = -.27, p < .001), at least primary education (χ2 = 21.69, p < .001), professional status (χ2 = 9.56, p = .002), greater land ownership in Myanmar (r = .12, p = .014), having fewer children (r = .30, p < .001), having an access to a reliable source of MSRH knowledge (χ2 = 17.11, p < .001), receiving consultation with a skilled health care provider about the MSRH issue (χ2 = 82.13, p < .001), receiving door visit from a health/field worker (χ2 = 68.77, p < .001), participation in a MSRH awareness program (χ2 = 47.53, p < .001), exposure to a MSRH poster or a banner (χ2 = 20.25, p < .001), and understanding MSRH message (χ2 = 93.60, p < .001) are reported as significant factor for receiving adequate MHC in the bivariate analyses.
Table 3.
Sociodemographic, access to information source and exposure to maternal health information and services-related predictors of receiving adequate maternal health care in bivariate analysis
| Variable (N = 415) | Received Adequate Maternal Care | |||
|---|---|---|---|---|
| No (%) | Yes (%) | χ2/r | p | |
| Region of residence in Myanmar | 9.62 | .002 | ||
| Racidong | 28 (25.7) | 71 (74.3) | ||
| Mongdu/Buthidong | 130 (42.5) | 176 (57.5) | ||
| Age † | - .27 | < .001 | ||
| Education (at least primary) | 21.69 | < .001 | ||
| Yes | 52 (26.4) | 145 (73.6) | ||
| No | 106 (48.6) | 112 (51.4) | ||
| Occupation | 9.56 | .002 | ||
| Professional | 137 (41.9) | 190 (58.1) | ||
| Housewife | 21 (23.9) | 67 (76.1) | ||
| Amount of land in Myanmar † | .12 | .001 | ||
| Current number of children † | - .30 | < .001 | ||
| Access to a reliable source of MSRH knowledge | 17.11 | < .001 | ||
| Yes | 41 (25.6) | 119 (74.4) | ||
| No | 117 (45.9) | 138 (54.1) | ||
| Received consultation with a skilled health care provider about MSRH issues | 82.13 | < .001 | ||
| Yes | 90 (27.2) | 241 (72.8) | ||
| No | 68 (81.0) | 16 (19.0) | ||
| Received a home visit from a field/health worker about MSRH | 68.77 | < .001 | ||
| Yes | 70 (24.6) | 214 (75.4) | ||
| No | 88 (67.2) | 43 (32.8) | ||
| Participated in a maternal health awareness program | 47.53 | < .001 | ||
| Yes | 66 (25.4) | 194 (74.6) | ||
| No | 92 (59.4) | 63 (40.6) | ||
| Exposed to MSRH posters/banners | 20.25 | < .001 | ||
| Yes | 60 (27.8) | 156 (72.2) | ||
| No | 98 (49.2) | 101 (50.8) | ||
| Comprehended key messages related to MSRH | 93.60 | < .001 | ||
| Yes | 79 (25.1) | 236 (74.9) | ||
| No | 79 (79.0) | 21 (21.0) | ||
†Spearman’s rho correlation
Multivariate logistic regression analyses examining the determinants of receiving adequate MHC
The result of multivariate logistic regression models (Table 4) revealed in Model 1 that the study participants’ Rachidong region in Myanmar (AOR = 1.82, 95% CI: 1.07–3.11), having at least primary level of education (AOR = 1.70, 95% CI: 1.08–2.67), study participants’ younger age (AOR = 0.96, 95% CI: 0.92–0.99), greater land ownership in Myanmar (AOR = 1.07, 95% CI: 1.03–1.12) and having fewer children (AOR = 0.86, 95% CI: 0.77–0.96) had a significant association with respondents’ receiving adequate maternal health care. Moreover, in Model 2, the study participants’ having at least primary level of education (AOR = 1.65, 95% CI: 1.04–2.60), having greater land ownership in Myanmar (AOR = 1.08, 95% CI: 1.03–1.14), having fewere children (AOR = 0.86, 95% CI: 0.78–0.96), and having a reliable source of MSRH knowledge (AOR = 2.19, 95% CI: 1.36–3.53) had a positive and significant association with respondents ‘receiving adequate maternal health care.
The results of Model 3 indicate that respondents’ younger age (AOR = 0.93, 95% CI: 0.88–0.98), having greater land ownership in Myanmar (AOR = 1.07, 95% CI: 1.01–1.13), receiving consultation with a skilled health care provider about MSRH (AOR = 5.22, 95% CI: 2.18-12.), participating in an awareness program about MSRH (AOR = 1.98, 95% CI: 1.08–3.61), and understanding MSRH messages (AOR = 5.31, 95% CI: 2.63–10.69) had a significantly higher chance of getting adequate maternal health care.
For model 1, sociodemographic variables were statistically significant predictors, χ2 (5) = 67.30, p < .001, Nagelkerke R2 = .20. For model 2, after controlling for the demographic covariates, MCH knowledge source was positively predictive of receiving MHC, χ2 (6) = 77.90, p < .001, Nagelkerke R2 = .23. For model 3, after controlling for the demographic covariates and source of MSRH knowledge-related variables, exposure to maternal health information and services were significantly predictive of receiving MHC, χ2 (10) = 174.51, p < .001, Nagelkerke R2 = .47.
Discussion
Maternal health care remains a critical issue globally, particularly in marginalized populations such as refugees [16]. Our study provides an overview of the utilization of maternal health care (MHC) information and services among Rohingya refugee women, shedding light on various factors influencing access and uptake. The demographic profile of the participants reflects the challenges faced by this population, with a majority having no formal education and a mean number of children close to four. Despite these challenges, the study found that over half of the women had received high-quality maternal care during their last childbirth, indicating a considerable level of engagement with MHC services within the Rohingya refugee community.
Compared to national averages in Bangladesh, maternal health care utilization among Rohingya refugee women in our study presents a somewhat encouraging picture. For instance, nearly 80% of respondents reported receiving postnatal care (PNC), and about 60% had institutional deliveries. According to the Bangladesh Demographic and Health Survey (BDHS) 2022, although nearly two-thirds of Bangladeshi mothers (65%) deliver at a health facility, only 78% of them receive postnatal care (PNC) from a medically trained provider within two days of delivery, highlighting a critical gap in follow-up care even in institutional settings [17]. The present findings suggest that targeted health interventions by humanitarian organizations in the refugee camps—such as community-based outreach, free service provision, and intensive mobilization—may have contributed to better-than-expected outcomes. This finding highlights a critical insight: with coordinated efforts and dedicated resources, even marginalized populations in highly constrained environments can achieve significant gains in maternal healthcare. Lessons from the Rohingya response, including the deployment of trained birth attendants, mobile clinics, and integrated community health workers, may offer a replicable model for improving maternal health access in other underserved regions of Bangladesh.
Our study explored significant associations between maternal health information and service utilization and specific components of maternal health care, such as antenatal care (ANC) visits, delivery in a health facility, presence of a SBA during delivery, and receiving postnatal care (PNC). Women who utilized more health services were more likely to have access to these essential components of maternal health care, highlighting the role of healthcare access in facilitating access to comprehensive maternal health services. It emphasizes the importance of comprehensive healthcare access in ensuring optimal maternal health outcomes among refugee women. While 59.5% of Rohingya refugee women in our study gave birth in places with adequate facilities, only 69.4%% reported the presence of skilled birth attendants during delivery, underscoring the need for targeted interventions to improve the availability of skilled birth attendants in refugee settings.
Moreover, our findings reveal significant disparities between women who received and did not receive adequate maternal care. Among those who did not attend the recommended four ANC visits, a substantial proportion (83.9%) delivered in facilities lacking sufficient infrastructure, and only 16.1% of them had access to such facilities. Similarly, only 33.1% of women in this group had the presence of a skilled birth attendant (SBA) during delivery. These figures indicate a considerable service gap, particularly in professional care and facility preparedness, emphasizing the need for increased availability of trained doctors and nurses.
Additionally, multivariate logistic regression analyses identified several key determinants of MHC utilization, including having at least a primary education level, land ownership, being younger, having fewer children, access to reliable SRH knowledge, and engagement with healthcare providers and awareness programs. Education has been identified as a substantial determinant of maternal healthcare utilization [18–20]. Our study also revealed that education was a significant predictor of maternal health service utilization. Specifically, women who had attained at least primary education were more likely to access maternal health care services than those with no formal education.
Our study revealed that land ownership in Myanmar was positively associated with maternal care utilization among Rohingya refugee women. While current income was not assessed due to restrictions on economic activities in the camps and participants’ reluctance to disclose financial information, land ownership prior to displacement may serve as a proxy for previous socioeconomic status and social standing. Refugees with such assets may retain symbolic capital within the community, influencing both their own health-seeking behavior and access to maternal care through networks and information pathways. This finding is consistent with prior studies suggesting that refugees’ pre-displacement social and economic capital continues to shape their health behavior even in displacement settings [21, 22].
In the bivariate analysis, the age of the respondents also showed a significant negative association with receiving adequate care (p < .001), suggesting that younger women were more likely to receive adequate maternal care. The number of children was negatively associated with MHC utilization, indicating that the odds of utilizing MHC services decrease as the number of children increases. It aligns with existing literature highlighting that women who had three or more children were notably less inclined to receive postnatal care in comparison to women with one or two children [23]. In a study, researchers observed a negative correlation between the number of children and the utilization of institutional delivery and antenatal care (ANC) services. Specifically, they observed that as the number of children increased, there was a decrease in the utilization of both institutional delivery and ANC [24]. Furthermore, the inverse relationship between the number of children and maternal healthcare utilization highlights the competing demands on women’s time and resources in caring for larger families. This finding underscores the significance of family planning services and the integration of reproductive health education into maternal health programs, enabling women to make informed decisions about their reproductive health [21, 22, 25].
Furthermore, access to a reliable information source emerged as a critical determinant of maternal healthcare utilization among Rohingya refugee women. Women who had access to reliable sources of sexual and reproductive health knowledge were more likely to seek maternal health care services. Consultation with a skilled health care provider, on maternal health care (MHC) and participation in awareness programs on MHC were also significant predictors of maternal health care utilization [26].
Policy implications
The findings of this study have significant and far-reaching policy implications. For example, the factors reported as important in predicting better reproductive and maternal health status deserve the attention of the authorities of national and international NGOs. Examining the status of the reproductive and maternal health awareness, perceptions, and behaviors among the Rohingya women added to our knowledge as well as to policymakers and administrators; it will ease the design of appropriate health communication programs and campaigns and the development of effective communication materials to ameliorate this exposed community’s reproductive and maternal health status.
Limitations of the study
However, its findings must be interpreted in light of some caveats that should be taken into account in future research on this subject. First, social desirability bias is probable, meaning that participants may have provided replies they believed were expected or seen favorably by the interviewer, such as understating their use of skilled maternal health care or participating in health programs.
Second, since this was a purely quantitative study, it couldn’t capture the depth, context, and complexity of the participants’ experiences, beliefs, and sociocultural barriers related to maternal healthcare.
Third, although family planning (FP) is a crucial aspect of reproductive health, this study did not gather specific data regarding FP utilization among Rohingya women. Consequently, interpretations relating to FP are outside of the scope of the current findings and should not be presumed.
Finally, the challenges were exacerbated by the distances between separate blocks, where data collection was taking place simultaneously. Due to a shortage of funds, the study data were only obtained from one camp. As a result, concerns may be raised as to whether the various camps, in terms of facility and NGOs’ access, could cast doubt on the study’s assertion of the wholeness of the refugee women, even though study participants from various backgrounds were included as study samples.
Future research
To mitigate the social desirability bias, a qualitative study is necessary to provide in-depth insights into the efficacy of health communication interventions addressing reproductive and maternal health issues among Rohingya refugees, and to inform policy research in this area. Empirical research should be conducted to learn more about the demographic characteristics, culture, needs, and demands of the refugee people.
Conclusion
This study finds that education, land ownership in Myanmar, the current number of children, access to a reliable source of MSRH knowledge, consulting skilled healthcare providers, and participation in awareness programs are among the most significant factors influencing the frequency of maternal healthcare use among Rohingya refugee women. Given the socioeconomic constraints of refugee life, this study recommends prioritizing midwifery and community-based care models over increasing the number of physicians [27, 28]. Findings revealed that women who lacked access to consultations with doctors or midwives, had low health literacy, or did not participate in maternal health awareness activities were significantly less likely to receive adequate maternal health care. These barriers highlight gaps in both service provision and health communication outreach, underscoring the need for more skilled personnel and improved community engagement strategies.
Acknowledgements
We thank all the participants for their support during data collection.
Abbreviations
- ANC
Antenatal Care
- AOR
Adjusted Odds Ratio
- CI
Confidence Interval
- GoB
Government of Bangladesh
- IAWG
Inter-Agency Working Group
- IBM
International Business Machines
- ISCG
Inter Sector Coordination Group
- MHC
Maternal Health Care
- MSRH
Maternal Sexual and Reproductive Health
- NGOs
Non-governmental Organizations
- PNC
Postnatal Care
- SD
Standard Deviation
- SPSS
Statistical Package for Social Sciences
- UNHCR
United Nations High Commissioner for Refugees
- UNICEF
United Nations Children’s Fund
- UN Women
United Nations Women
- WHO
World Health Organization
Author contributions
All authors were responsible for the structure of this paper. MZ, AKA, and AZ were involved in the study design and conceptualization; MZ and AKA supervised the data collection; MZ and MRM performed the data extraction and analysis; MZ, MRM, AKA, NKB, and MN drafted the manuscript; NKB, MN, FC, and AZ reviewed and edited the manuscript; FC and AZ supervised the study. All authors have critically read and approved the final manuscript.
Funding
This work was partially funded by the Planning and Development Office of the University of Chittagong, Bangladesh [246(17)/POU/7–37(8)/2ND-2019], and partially supported by the Tsinghua BRIGHT Program.
Data availability
All of the primary data have been included in the results. Additional materials with details may be obtained from the corresponding author if required.
Declarations
Ethics approval and consent to participate
The study was reviewed and approved by the Research and Publication Office of the University of Chittagong, Bangladesh. The present study was approved by the Ethics Review Committee of the University of Chittagong (Reference No. CU SOC-21-0003). The study was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all the study participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All of the primary data have been included in the results. Additional materials with details may be obtained from the corresponding author if required.