Maternal Mortality in Bangladesh

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Maternal Mortality in Bangladesh

• Learning From The Past, Moving Towards The Future
• Özge Tunçalp, MD MPH
• Johns Hopkins Bloomberg School of Public Health

April 30th, 2009 Istanbul, Turkey
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OUTLINE

• Background
• Methods
• Unraveling The Decline in Mortality
• Where Do We Go From Here?

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Background

• MDG-5
• Delivery at home universal (90)
• TBA attended birth (75)
• Postpartum hemorrhage leading cause
• YET
• Declining trends in maternal mortality
• National data BMMS-2001
• Matlab data - 2005

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Projection of MMR in Bangladesh 1976-2015
Per 1,000 live births
Projected declining rate 3.2 annually
Required declining rate 5.1 annually
(Koblinsky, 2008)
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Methods

• Key-informant interviews in Bangladesh
• Government, international and non-governmental
  organization officials and researchers
• Government reports and documents
• Agency reports and unpublished drafts
• Facility observation

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Unraveling The Decline in Maternal Mortality
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Government services are meant to be free, but
shortages of supplies and staff make only certain
parts free.

• Rich get better services at government services.
  Its human psychology.

Quotes from government officials
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Government Programs

• STRENGTHS
• Political Commitment
• Sector-wide approach
• Government-owned, donor-funded, internationally
  assisted programs
• Facility-based initiatives
• Maternal Vouchers
• Menstrual Regulation and Family Planning

• WEAKNESSES
• Discrepancy between urban vs. rural
• Coverage of the population
• Cost main deterrent
• No real monitoring over private sector
• Lack of evaluation
• Political situation()

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TBAs are not literate, but accepted in the
community. Doctors are knowledgeable and can
manage problems, but their availability is hard
to find, and they are facility-based, they dont
go to the community. We need somebody in between
with both plusses. In this case, it is community
skilled birth attendants for Bangladesh.
A practicing ob/gyn and a consultant on safe
motherhood

• Absenteeism is a big problem in government
  clinics.
• Officer at an international
  organization

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Skilled Attendance at Birth

• Community-Based
• Traditional Birth Attendants
• Skilled Birth Attendants
• Future Integration of SBAs to the facility care

• Facility-Based
• Capacity building for health care staff
• Lack of anesthesiologists
• Private practice
• Urban vs. rural

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Bangladesh is mobilized and on the move.
Officer from an international
organization

• Maternal mortality has not declined because of
  better facilities or better staff. It has
  decreased because of the social development.
  Unless people come and participate, facilities
  cannot do much.
• Member of National Consultant Professional
  Organization

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Social Development

• Right now
• Education (scholarships)
• Decreasing TFR
• Delayed marriage and childbirth
• Communication Infrastructure (cell phones, media,
  roads)
• Microcredit and womens empowerment

• Whats missing?
• Very hard to differentiate the effects
• Harder to study
• An amalgam?

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In Summary
Skilled Attendance at Birth (Community /
Facility)
Social Development
Staffing
SBA

• Education
• Delayed marriage,
• and childbirth
• Infrastructure
• Communication
• Increasing GDP
• Decreased TFR
• Microcredit

Deciding to Seek Care
Reaching the Medical Facility
Receiving adequate care
Infrastructure and Capacity Building
Maternal Voucher
Government Programs
Family Planning Menstrual Regulation
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Where Do We Go From Here?
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Community Based Misoprostol

• FOR
• PPH 1 killer
• Delivery practices
• Proven in other resource-poor settings
• User-friendly
• Studies in Bangladesh

• AGAINST
• Possible adverse effects
• Slow update on already existing protocols
• Mixed messages

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Considering the home delivery to be the
universal norm, the majority of deliveries being
assisted by traditional birth attendants in
resource-poor areas, and womens lack of
decision-making power for their health makes the
community-based misoprostol intervention both an
effective and empowering strategy in improving
womens lives in Bangladesh.
RECOMMENDATION
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Intrapartum Health Center Care

• FOR
• Not-so-successful previous strategies
• Cost-effectiveness analysis in Bangladesh
• SBAs are not sufficient

• AGAINST
• Too many rural births
• (3,2 million/year)
• Lack of infrastructure
• Lack of staff
• Cultural preferences

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The ongoing improvements in the healthcare
infrastructure and capacity building for health
care professionals are promising steps toward a
facility based intrapartum care strategy. However
in the short term, switching the policies and the
programs completely is not feasible.
RECOMMENDATION

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THANK YOU!otuncalp_at_jhsph.edu

• Bangladesh
• Marge Koblinsky
• ICDDR,B RH Unit
• JHSPH
• Michael Koenig
• Michelle Hindin
• Ron Gray

Funded by Global Field Experience Award
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MDG-5 Updated