Kanta Jamil USAID, Bangladesh

3 May 2012

700
600

574

500
400 300 200 100

MDG 5 Target

143

0 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015

Estimate of Maternal Mortality Ratio

2001 Bangladesh Maternal Mortality and Health Use Survey

Sample size ~100,000 nationally representative

2010 Bangladesh Maternal Mortality and Health Use Survey

Sample size ~175,000 nationally representative Provided MMR estimate for 3 years before the survey Information was collected on all deaths in the households in the three years before the survey For deaths of women under 50 years questions were asked on whether death occurred during pregnancy, delivery or after delivery Verbal autopsy was conducted on all deaths of women in the reproductive age group to determine causes of deaths

700
600

574

500
400 300 200 100

322
2001 BMMS

MDG 5 Target

194
2010 BMMS

143

0 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015

Maternal Mortality Decline Contextual Factors

Government of Bangladeshs sustained and consistent commitment

Excellent Government, NGO and Development Partner collaboration

Basic MCH Service delivery structure in place since the late 1970s

hospitals at district and sub district levels static clinics at union level providing ANC/PNC satellite clinics at the community level providing ANC/PNC Fieldworkers at community/household levels mobilizing communities with behavior change and communication messages

Maternal Mortality Decline Contextual Factors

Intensive Family Planning Program since late 1970s GOB programs offering Menstrual Regulation Services
Trained 42,000 traditional birth attendants (1980-2000) Broader social development Investment in female education from the 1990s Female empowerment through micro-credit program since 1980s Development in Communications

Facilities upgraded (1990-2001) to provide comprehensive EmOC

59 District Hospitals (out of 64) 60 Maternal and Child Welfare Centers (out of 98) 3 Upazila Health Complexes (out of 417)

facility

non-facility

10

6 4 1993 BDHS

4 5 1996 BDHS

13 4 9

12 3 9

1999 BDHS

2001 BMMS

Decline in infections related to child birth

Tetanus Toxoid immunization during pregnancy increased Use of antibiotics became more widespread Training of traditional birth attendants improved some practices that reduced infections
1989 2001

At least 1 TT

85

26

Source: 1989 BFS; 2004 BDHS

Decline in unsafe abortions

Increase in contraceptive use from 32% to 54% (19892001)reduced unintended pregnancy Access to Menstrual Regulation provided alternative to unsafe abortion

Fertility declined by 26% from 4.3 to 3.2 births per woman

Reduced higher risk births. Fertility fell by 41% among women age 35+ ; 24% among women age <30 Maternal mortality risk is 5-6 times higher for women age 35+ compared to those age <30

Obstructed or Prolonged Labor 7%

Hemorrhage 31%

Other Direct 5%

Abortion 1%

Indirect 35%

Undetermined 1%

Hemorrhage
35%

Eclampsia
50%

Obstructed Abortion
85%

26%

2001

2010

Other Direct
57%

Indirect
Undetermined 0 25 50 75 100

Maternal Mortality Ratio

Interventions

133 Upazila Health Complexes (UHC) upgraded to provide comprehensive EmOC

~6,000 Community Skilled Birth Attendants trained (starting in 2003) Introduction of demand side finance (DSF) in phases starting in 2006

2 pilot Upazila in 2006

~33 Upazilas under DSF by 2010 , 53 Upazilas by 2012

Strengthening health systems for MNH in selected Districts (starting 2007)

The reasons for the fall are several:

Medical Socio-economic

Demographic

Percent of births three years before the survey 35

Non-facility 30
25 20 % 15 10

Facility

Doubled+

3
9

23

5
0

2001 BMMS

2010 BMMS

facility

non-facility

2.0% per year (2001-2011) 27

0.3% per year (1993-2001) 13 10 6 4
1993 BDHS

32 3

21 16 12 3 9
2001 BMMS

4 29 23 17

9
4 5
1996 BDHS

4 12
2004 BDHS 2007 BDHS 2010 BMMS

4
9
1999 BDHS

2011 BDHS

25 2 20

1.4 percentage points increase

8.6 percentage points increase

15
% 10 1

11

3
5 6 0 2001 BMMS 2010 BMMS 10

4.2 percentage points increase

Public

Private

NGO

20

15

10 12.2

2.6
0 2001 BMMS 2010 BMMS

20

15

10 17.2
5

12.2

2.6
0 2001 BMMS 2010 BMMS 2011 BDHS

80 60
%

40

71 52 35 All Facilities
23.4%

20 0

30 Private Sector
11.3%

Public Sector
10.0%

NGO Sector
2.0%

Sought Any Treatment

75

50

68 25 53

0 2001 BMMS 2010 BMMS

Sought Any Treatment

75

Sought treatment from health facilities 75

50

50

68 25 53 25 29 16

0 2001 BMMS 2010 BMMS

0 2001 BMMS 2010 BMMS

Additional facilities upgraded

Growth of private sector facilities offering maternal health services

Availability of mobile phones improved communication

Percent of households owning mobile phones increased from 3% to 63% Qualitative study indicates families used mobile phone for --Accessing health providers --Accessing information --Arranging funds, blood, getting medicine

1993

2001

2010

58

44
23 15 26

45

No Education

At least Some Secondary

From 3.2 to 2.5 births per woman--22% decline

Fertility fell more among older women who have relatively high-risk births
-- Fertility fell by 52% among women age 35+ and 18% among women age <30 --Maternal mortality risk is 5-6 times higher for women 35+ compared to those age < 30

MMR: 322/100,000 LB
Number of births: 3.7 million

18000

Annual Maternal Deaths, 2001

12000

Maternal deaths: 12,000 annually

6000

12000

2001

# of women of reproductive age (WRA) increased by 29%.

18000

Annual Maternal Deaths, 2001 and 2010 (expected)

12000

If TFR and MMR remained at the 2001 levels there would be 15,800 maternal deaths in 2010 (due to increase in WRA)

15800 6000 12000

0 2001 2010

Maternal Deaths declined: 25% due to TFR decline

18000

15800
3990
25% due to TFR decline 4% due to fertility pattern change 24% due to MMR decline

12000

40% decline

650 3870

6000

12000 7300
Current maternal deaths per year

0 2001 2010

The l a s t h u n d r e d m e t e r s

576
194

322

Focus on ensuring provision good quality and reliable basic EmOC services at UHCs and strategically-located UHFWCs/CCs backed up by effective referral systems Service quality is still a concern, particularly with staffing, staff attendance, logistics (medicines, blood), and skills

Integrated interventions to prevent PPH and Eclampsia deaths across the continuum community to referral facility
Private sector is responding to the demand for maternal health services, but it is too expensive for the poor and the very high rates of C-sections is a concern

Care-seekers are still spending time inefficiently on ineffective home treatments They are often going to inappropriate or ill-equipped facilities

Education levels will continue to rise two-thirds of older teenage girls now have some secondary schooling

Family Planning services must be supported and strengthened to bring down high risk births

Congratulations on this very impressive achievement

The momentum for further progress is in place

In both cases - the mother and baby survived Let us not forget. Improving maternal health is not only about preventing deaths
Every woman has the right to have an enjoyable, rewarding and affordable experience in giving birth