Context: Skilled attendance at delivery is a critical intervention, yet the median national coverage rate among low-income countries is only 70%. In Bangladesh, the governmental authorized private community skilled birth attendants (PCSBAs) to increase access in remote rural areas. The objective of this study is to assess the sustainability of the PCSBA model in three districts supported by the MaMoni Health Systems Strengthening Program, a USAID-funded program focused on maternal and child health.

Methods: PCSBAs in three districts were surveyed regarding their activities, health systems and community supports they receive, their income, and their satisfaction with their work. Routine register data submitted by PCSBAs to program managers were analyzed to describe service provision levels over 14 months. Additionally, qualitative interviewers were conducted with a subsample of high- and low-activity PCSBAs and with program managers to explore barriers and facilitators for the PCSBAs’ work.

Results: All 79 trained PCSBAs completed the survey and 22 participated in in-depth interviews. Only 10 (13%) of PCSAs trained between 2007 and 2016 reported that they had stopped working as PCSBAs in June 2017—seven stopped within their first four months working. On average, a PCSBA performed 12 antenatal care visits (range: 0 to 157) and 1.3 deliveries (range: 0 to 19) per month over the 14-month period from May 2016 to June 2017. The average monthly income among 69 active PCSBAs was 268 Bangladeshi taka (~3.5 USD; range: 3 to 2,158 taka). Half of all PCSBAs were “not at all satisfied” with their income while one-third were “mostly” or “completely” satisfied. PCSBAs reported that many families are too poor or unwilling to pay the community-set rate for services. PCSBAs also expressed a desire for enhanced clinical skills to meet community demand for services (e.g., repairing perineal tears). Support from families and communities were important for facilitating PCSBAs’ work.

Conclusions: Some PCSBAs established very active practices in their community, earning significant income and improving access to care. Programs to develop PCSBAs’ clinical and business skills, and encourage community and family support, would enhance the sustainability of this model.