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Stalled maternal mortality rate indicates attaining SDG-3 would be difficult

Dhiraj Kumar Nath
Stalled maternal mortality rate indicates attaining SDG-3 would be difficult

Bangladesh Maternal Mortality  and Health Care Survey 2016 conducted by NIPORT with the support of Measure Evaluation, icddr,b, USAID, DFID has presented recently some striking strengths and weaknesses of the health care delivery system in Bangladesh in their preliminary findings that generated sensation in the health  and family welfare sector as a whole. The findings appeared as challenge to the claims of government in attainting successes in the health and family welfare sector for which DGHS has instantly contradicted some observations and findings as old ones. He expressed his firm conviction that Bangladesh might achieve the targets of SDG -2030 within coming years. State Minister of Health and Family Welfare highlighting government achievements in Health and Family Welfare sector remarked that devil is not as black as painted. He wanted to indicate that findings of the Survey are not so dismal to get frustrated. His optimism encouraged the program managers with visionary guidelines that could have been more transparent and well conceived.   

The BMMS 2016 sample size was designed to the estimate obtained in the 2010 BMMS, assuming that the MDG targets of 143 per 100,00 live births had been met . The survey used a multistage sampling procedure, using sampling frames derived from 2011 census. A total of 1922 urban and 2826 rural clusters were selected for a total of 4,748 clusters overall of which 4,739 were successfully interviewed .Total sample was 298,284 households and total ever married women (13-49 years) responded to the survey were 321,214. By any consideration, the survey size represents the national character consistent with prevailing situation.

The maternal mortality rate stalled during last few years arriving at 196 per thousand live births in 2016, almost identical to the estimate of BMMS 2010.  Between BMMS 2001 and BMMS 2010, MMR declined from 322 to 194 per thousand live births indicating a significant progress whereas this findings of 2016 Survey indicates a challenge to achieve the target of 105 per thousand live birth by 2022 as planned  by 4th HPNSP (2017-2022)  and SDG goal of reducing the MMR  to 70 per 100,00 live births by 2030.  

It is well- neigh impossible to bring down the MMR from 196 to 70 per thousand live births by 2030 within next 13 years.

 The survey indicates that 31 Lakhs of births take place in a year of which 10 Lakhs are caesarean and out of the same 7.50 Lakhs caesarean are done by private sector owned facilities and 43,000 are by Non-Government organizations and rest by the public sector. The delivery by C-Section increased dramatically from 12 percent in 2010 to 31 percent in 2016 indicating a drive and competition to earn money and profit with the facilities offering the opportunities for maternal care. Cesarean is becoming a common practice in private clinics accounting for 83 percent of the delivery whereas in Government facilities it is 35 percent only. At the same time, facility based –care for maternal complications has increased from 29 per cent in 2010 to 46 percent in 2016. Most of the public and private facilities are not fully ready to provide quality maternity care.  Almost one in five maternal deaths occurs in transit, indicating delays in decision making and absence of a functional referral system.          

The survey also indicated that median expenditure related to normal deliveries at home is less than Tk. 1000 whereas it is four times higher in any facility. C-section delivery in private clinic is on average Tk. 20,000 and it is around Tk. 12,000 in government facilities.  Although family fund is the common source  to cover the expenditure  but survey revealed that about 20 % had to take loan   and  2 % percent sold or mortgaged properties to the meet the expenses.                                                                                                                                                                                                                                                                                                                                           

With this dismal scenario, one very encouraging finding is the remarkable increase of the medically trained service providers attending 50 percent of births in 2016 in comparison to 27 percent in 2010. At the same time, the percentage of women receiving the complete continuum of maternity care (PNC, ANC, delivery care) has increased significantly from 19 percent in 2010 to 43 percent in 43 in 2016. These are considered as significant achievements in service delivery system.  

 It indicates a better quality of care being delivered in comparison to preceding six years that is fundamental to improve maternal health outcomes. But Bangladesh Health Facilities Survey of 2014 showed substantial deficiencies in the readiness of both public   and private health facilities to provide high quality maternity care that contributed much to make the MMR stalled. The facilities survey findings indicated that only 39% of the facilities providing normal delivery care had a delivery care provider on call or on site round the clock and only 3 per cent of the facilities had service readiness to provide quality of normal delivery services. The study indicated that only 46 percent of Upazila and higher level public facilities and 20 percent of private hospitals had at least one staff member who ever received training on emergency obstetric care (EmOC).

Service readiness for maternal care is poorer in private facilities compared to district and Upazila level public facilities. In the Urban areas, some readiness of maternity care is available but so costly that goes beyond the reach of poor segment of the society and slum dwellers.

The survey also made analysis MMR of other 37 countries in sub –Saharan Africa and South and South East Asia and found a weak association between the MMR and the percentage of delivery occurring in health facility. It derived from such analysis that a higher level of facility delivery is important but not sufficient to lower MMR across countries. In some countries, the apparent stall in MMR occurred despite increases in coverage of medically trained providers and available health facilities. It was observed that Bangladesh is not the only country to experience stalling of MMR with increase in use of maternal health services.

 In conclusion, the preliminary findings observed, “The findings serve as a timely reminder that decreasing maternal mortality requires attention to both demand and supply side factors; maternal death will only  be prevented if women go to facilities  and facilities are fully prepared to handle obstetric emergencies when they occur.”  With this scenario, it might be very much challenging to achieve the SDG – goal: 3 to ensure healthy lives and promote well-being for at all ages with 9 targets to attain by 2030. This study in fact has indicated a signal to the Government to review its strategy and get prepared much well ahead of time to achieve the targets of SDG-3 by 2030 as 4 targets attained during the Millennium Development Goals by 2015 and Bangladesh earned its reputation worldwide.   

The writer is former Director General, Directorate of Family Planning and Adviser to a caretaker government



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Editor : M. Shamsur Rahman
Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

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