In the isolated char villages of northern Bangladesh, a young woman’s life slipped away during childbirth. Her brother, Abu Bakar (pseudonym), a madrasa teacher, still carries the weight of that loss: “Twelve years ago, I lost my younger sister during childbirth, I had to bury her with my own two hands. The pain of that day never left me. But now, seeing this hospital (Primary Health Care (PHC)) centre here, where our mothers, sisters, and daughters can get the care they need -- it feels like a new beginning.”
Abu Bakar’s story is not unique. Across Bangladesh’s chars, haors, and hill tracts, thousands of families share similar grief -- a grief compounded by a harsh truth: our progress in saving mothers and children has stalled, not for lack of effort, but for lack of equity. As we continue our collective efforts to strengthen maternal healthcare, it is vital that we reflect on how far we have come in protecting mothers’ lives — and how far we still have to go.
The stagnation crisis: A tale of two Bangladeshes
Bangladesh’s maternal and child health achievements once inspired the world. Between 2000 and 2015, maternal mortality dropped by 40 per cent, and child deaths halved. How did we get here? The success was driven by grassroots innovations and bold policy commitments.
Community healthcare expanded dramatically: the government revitalised thousands of community clinics and deployed an army of frontline health workers to provide antenatal check-ups, iron supplements, and health education -- even in remote villages.
For every urban mother who can access a qualified doctor, there is a mother in Kurigram’s chars who risks her life simply because she lacks access to a functional facility.
But not everyone could access them. Not equally, and not everywhere.
Since 2017, these gains have flatlined. Today, one in three mothers in char areas still gives birth without a skilled birth attendant, and one in five child deaths stems from preventable causes such as diarrhoea and pneumonia. These numbers are not just statistics -- they reflect a systemic failure to reach the last mile.
The problem is not a lack of hospitals or clinics. It is a mismatch of priorities. Public facilities in hard-to-reach areas remain chronically under-resourced: a 2023 survey found that rural health centres often lack basics like antibiotics, medical equipment, consumables, and even trained providers such as midwives. This is the everyday reality for around 10 million people living across 109 coastal and river chars in Bangladesh.
Meanwhile, the private sector -- now providing nearly 70 per cent of healthcare nationwide -- is clustered in cities, leaving rural populations dependent on unregulated and often exploitative informal sectors. For every urban mother who can access a qualified doctor, there is a mother in Kurigram’s chars who risks her life simply because she lacks access to a functional facility.
When she feels the first signs of labour, she has two choices: travel along crumbling dirt roads and make a risky boat journey to a distant facility -- raising the chance of complications -- or stay home and deliver without trained help, following decade-old norms and practices.
Hope in the chars: How community-led models are breaking the cycle
Some places are rewriting the narrative. Today, Abu Bakar’s hope stems from something new: a community-based health model that is bringing care to the chars.
In Narayanpur Char, Nageshwari upazila, a new BRAC Primary Healthcare (PHC) centre -- ‘Shushastho’ -- is providing emergency obstetric care, neonatal support, and family planning services to over 38,000 people across 24 chars. But what makes it unique is its network of Community Health Workers (CHWs).
These trained local women now trek through monsoon floods and dry-season dust storms to deliver ante- and postnatal check-ups, educate families on nutrition, and refer high-risk pregnancies to the PHC. By the end of this year, the project aims to reduce home births from 95 per cent to under 50 per cent.
This model is attempting to bridge the fatal gap between access and availability. Unlike distant urban hospitals, BRAC’s PHC is staffed by locals who understand the community’s needs and prioritise care over cost. It is also a model that strengthens the broader health system.
The path forward: Scale equity, not just infrastructure
But we must go further. If we want every mother to have a fair shot at survival, we need to shift how we think about care. Bangladesh cannot afford to view healthcare as a numbers game.
Building hospitals is not enough if mothers cannot reach them. Training doctors is not enough if they won’t work in hard-to-reach areas. A one-size-fits-all approach may work in the plains, but not in chars, where transportation is seasonal, staff turnover is high, and the nearest emergency facility is hours away.
To reignite progress, we must invest in hybrid models like BRAC’s PHC-CHW approach, blending fixed facilities with mobile care. We must regulate the private sector to incentivise rural service expansion, not just urban saturation. And we must empower local women as CHWs, whose knowledge of the local context makes them more than caregivers -- they are trusted community anchors. And we also need to develop policies that incentivise skilled providers to serve in marginalised, hard-to-reach areas.
Lastly, community engagement and awareness efforts to promote behaviour change must be amplified. The era of simply urging women to go to hospitals is over. Awareness efforts must go beyond messaging. Telling a woman to seek care is not enough if the nearest facility is three hours away. We need to bring empathetic, culturally appropriate care to her doorstep. That includes outreach through community health workers who can identify danger signs in pregnancy and facilitate timely referrals. Families and local leaders must be part of this solution too.
Let us remember that maternal health is not a privilege -- it is a right. We cannot allow progress to stall while mothers in the margins are left behind. Abu Bakar’s sister deserved better. So do the 4,200 mothers Bangladesh still loses every year. When we meet communities where they are, hope follows. Our journey continues until every birth is a safe birth -- and motherhood is a time of joy, not a test of survival.
Let us keep the promise we made. Let us walk the last mile together.
* Dr. Imran Ahmed Chowdhury is the Head of Health System Transformation and Innovation
at the BRAC Health Programme. Email: imran.ac@brac.net