Jamil_Bangladesh Defying All Barriers Makes Impressive Progress on Saving Mothers' Lives
Transcript of Jamil_Bangladesh Defying All Barriers Makes Impressive Progress on Saving Mothers' Lives
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Kanta Jamil
USAID, Bangladesh
3 May 2012
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574
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700
1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
MDG 5
Target
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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 inthe three years before the survey
For deaths of women under 50 years questions were asked
on whether death occurred during pregnancy, delivery orafter delivery
Verbal autopsy was conducted on all deaths of women inthe reproductive age group to determine causes of deaths
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574
143
322
194
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100
200
300
400
500
600
700
1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
2010 BMMS
MDG 5
Target2001 BMMS
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Maternal Mortality DeclineContextual Factors
Government of Bangladeshs sustained and
consistent commitment
Excellent Government, NGO and DevelopmentPartner collaboration
Basic MCH Service delivery structure in place sincethe 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 mobilizingcommunities with behavior change and communication
messages
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Maternal Mortality DeclineContextual 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
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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)
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4 5 9 96 4
4 3
1993 BDHS 1996 BDHS 1999 BDHS 2001 BMMS
facility non-facility
10 913 12
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Decline in infections related to child birth
Tetanus Toxoid immunization
during pregnancy increased
Use of antibiotics becamemore widespread
Training of traditional birth
attendants improved some
practices that reduced infections
26
1989 2001
85At least 1 TT
Source: 1989 BFS; 2004 BDHS
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Decline in unsafe abortions
Increase in contraceptive use from 32% to 54% (1989-2001)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
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Hemorrhage31%
Indirect35%
Other Direct 5%
Abortion1%
Obstructed orProlonged Labor
7%
Undetermined1%
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0 25 50 75 100
Hemorrhage
Eclampsia
Obstructed
Abortion
Other Direct
Indirect
Undetermined
Maternal Mortality Ratio
2001 2010
35%
50%
85%
57%
26%
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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)
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The reasons for the fall are several:
Medical
Socio-economic
Demographic
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Percent of births three years before the survey
9
233
4
0
5
10
15
20
25
30
35
2001 BMMS 2010 BMMS
%
Non-facility Facility
Doubled+
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4 59 9
1217
2329
6 44 3
4
4
4
3
1993
BDHS
1996
BDHS
1999
BDHS
2001
BMMS
2004
BDHS
2007
BDHS
2010
BMMS
2011
BDHS
facility non-facility
10
21
27
2.0% per year
(2001-2011)
9
1312
0.3% per year(1993-2001)
32
16
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6
10
3
11
1
2
0
5
10
15
20
25
2001 BMMS 2010 BMMS
%
Public Private NGO
4.2 percentagepoints increase
8.6 percentagepoints increase
1.4 percentage
points increase
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2.6
12.2
0
5
10
15
20
2001 BMMS 2010 BMMS
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2.6
12.2
17.2
0
5
10
15
20
2001 BMMS 2010 BMMS 2011 BDHS
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52
35
71
30
0
20
40
60
80
All
Facilities
Public
Sector
Private
Sector
NGO
Sector
10.0% 11.3% 2.0%23.4%
%
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Sought Any Treatment
53
68
0
25
50
75
2001 BMMS 2010 BMMS
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16
29
0
25
50
75
2001 BMMS 2010 BMMS
Sought Any Treatment Sought treatment from health
facilities
53
68
0
25
50
75
2001 BMMS 2010 BMMS
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Additional facilities upgraded
Growth of private sector facilities offering
maternal health services
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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
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58
15
44
2623
45
No Education At least Some Secondary
1993 2001 2010
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From 3.2 to 2.5 births per woman--22% decline
Fertility fell more among older womenwho have relatively high-risk births
-- Fertility fell by 52% among women age 35+
and 18% among women age
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12000
0
6000
12000
18000
2001
MMR:322/100,000 LB
Number of
births:3.7 million
Maternaldeaths:
12,000 annually
Annual Maternal Deaths, 2001
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12000
15800
0
6000
12000
18000
2001 2010
# of women ofreproductive age
(WRA) increased by
29%.
If TFR and MMR
remained at the 2001
levelsthere would
be 15,800 maternal
deaths in 2010 (due
to increase in WRA)
Annual Maternal Deaths, 2001 and2010 (expected)
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12000
7300
3870
650
3990
0
6000
12000
18000
2001 2010
Maternal Deaths declined: 25% due to TFR decline
25% due to TFR decline
4% due to fertility patternchange24% due to MMR decline
Current maternal deathsper year
40%
decline
15800
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576
322
194
The
l a s t h u n d r e d m e t e r s
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Focus on ensuring provision good quality and reliable basic
EmOC services at UHCs and strategically-located
UHFWCs/CCsbacked 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 continuumcommunity 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
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Care-seekers are still spending time inefficiently onineffective home treatments They are often going toinappropriate 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
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Congratulations on this
very impressive achievement
The momentum for
further progress is in place
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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 affordableexperience in giving birth