Bangladesh

Disclaimer: Some of the MDG data presented in this website have been adjusted by the responsible specialized agencies to ensure international comparability, in compliance with their shared mandate to assess progress towards the MDGs at the regional and global levels.^[1]

 

Indicators (United Nations)

 

5.1 Maternal mortality ratio (MMR):

a.    2000: 380^[2]

b.    2005: 570^[3]

c.    After 2005:

A maternal death is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes.”^[4] According to the 2005 WHO/UNICEF/UNFPA maternal mortality estimates, most of the countries in the Asian region have not reduced the maternal mortality by three quarters as stated in the MDG Goal.^[5] 

The WHO/UNICEF/UNFPA estimates of maternal mortality for Bangladesh remain at 570 per 100,000 live births in 2005^[6].

 

The Bangladesh Maternal Health Services and Maternal Mortality Survey (BMMS) 2001, estimates the maternal mortality figures for Bangladesh at 322. This survey too is not a fully satisfactory estimate of overall level of adult female mortality. According to The Lancet, Volume 371, Issue 9615, p 811, published in March 2008 , the response from Kenneth Hill and collegues (who carried out a review of worldwide maternal mortality ratios), notes the the BMMS survey report justified the similarity of overall maternal mortality rates in Bangladesh to those reported for Matlab( a small area where maternal mortality survey was carried out) Health and Demographic Health Surveillance System, and this cannot be regarded as a nationally represented MMR estimate for Bangladesh.

 

Whatever the estimates, women in Bangladesh do die from preventable maternal deaths and this aspect needs to be addressed.

 

 

Critical indicators to comprehensively monitor maternal mortality

 

5.1.1 Lifetime Risk of Maternal Death

The concept of adult lifetime risk of maternal death measured as the probability of dying from a maternal cause during a woman’s reproductive lifespan^[7], is more holistic in comparison to maternal mortality ratio (MM Ratio) and maternal mortality rate (MM Rate). Whereas the MMRatio and the MMRate are measures of the frequency of maternal death in relation to the number of live births or to the female population of reproductive age, the lifetime risk of maternal mortality describes the cumulative loss of human life due to maternal death over the female life course. Because it is expressed in terms of the female life course, the lifetime risk is often preferred to the MMRatio or MMRate as a summary measure of the impact of maternal mortality^[8].

 

The lifetime risk of maternal death is 1 in 51, as compared to 1 in 1 300 in China, which shows the extent of risk to the life and well being of Bangladeshi women in reproductive age group, which is indicative of inequity.

 

5.1.2 Maternal deaths due to unsafe abortion

 

Unsafe abortion continues to be a major factor in maternal deaths in the region. Mortality due to unsafe abortion, in South Asia, is estimated at 13%.^[9]  

 

In Bangladesh, abortion contributes to 8% of maternal deaths.^[10] However, another study has found that between 1996-1997, nearly 26% of all maternal deaths were estimated to be a result of abortion-related complications. At this time, almost half of the reported abortions resulting in complications were performed by untrained birth attendants through the insertion of a foreign object into the uterus, most commonly a root or stick. If services had been available for women to obtain a medically approved abortion from a trained provider, nearly 84% of the deaths would probably have been prevented.^[11] The impact of menstrual regulation services on reducing maternal mortality and abortion related deaths has been significant in Bangladesh, although determining and understanding the extent of this impact has been difficult due to the scarcity of data on abortions.  Despite the safety and increased availability of MR procedures, women in Bangladesh still lack access to these services based on differences such as location and financial status, and many women, despite access, still seek a traditional provider because of the convenience.  Additionally, as many as 33% of women seeking a MR are rejected—most often the result of a late gestational age.  Most of these rejected women will still obtain an abortion even if the abortion is not achieved through a medically approved procedure. These women are at a greater risk of complications that could result in death; yet, the magnitude of this risk remains undocumented.^[12]  

It is important to understand that providing access to safe abortion services is a critical intervention to reduce maternal deaths in these contexts.

 

Voices from the ground:

News/Magazines articles:

a.    Educating girls and women is a key factor for reducing maternal deaths. This is because women being educated leads to them making better choices and being more active in making family planning choices. Read the article here 

b.    This article is based on the maternal mortality status of Bangladesh. It mentions what the government is doing to reduce MMR, e.g. training community-based skilled birth attendants and strengthening of EOC services. Bangladesh has made remarkable progress in dealing with this issue. Read the article here

 

Videos

a.    This photo essay gives statistics of the number of women dying due to childbirth and the number experiencing life threatening complications in Bangladesh. it also mentions the fact that partnerships between NGO’s and local governments have been essential in the improvement of the well being of mothers and babies. Watch the video here

b.    Alastair Lawson from BBC reports on the battle to improve maternal health in Bangladesh and assess if Bangladesh is on track to meet the Millennium Development Goals (MDGs) by the year 2015. The situation in Bangladesh is so much better currently than it was a few years back. However, it also talks about other complications and other statistics for MMR that are worse in some slums in Bangladesh. Watch the video here 

 

5.2 Proportion of births attended by skilled health personnel:

a.    2000: 12.1^[13]

b.    2006: 20.1^[14]

c.    After 2005: 18.0^[15]

A skilled attendant, according to WHO, refers to “an accredited health professional-such as a midwife, doctor or nurse- who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.” Traditional Birth attendants (TBA) either trained or untrained are excluded from the category of skilled health workers.

Skilled attendants at birth in 2006 in Bangladesh was reported to be 20.1 per cent^[16].

According to the Bangladesh Demographic Health Survey 2007, 63 percent of women were delivered by untrained birth assistants

                                                                                   

Critical indicators to comprehensively monitor skilled health attendance would include not just skilled birth attendants but also access to basic and comprehensive emergency obstetric care services and post-partum care 

The quality of care provided by skilled attendants at birth is crucial. Particularly when complications occur, skilled personnel need access to essential drugs, supplies, equipment and emergency obstetric care. They should receive training on required competencies. And they need supervision that helps ensure high standards of care, which is vitally important^[17].

Global and country studies on skilled attendants showed that the overall effectiveness of skilled attendants depends on their access to a functioning health system with a basic and comprehensive level of obstetric care, including surgery and blood transfusions  in case of complications. The key to maternal death reduction is universal access to  emergency obstetric care which is a major challenge in most of the Asian countries.

It is therefore critical to not just look at skilled attendants at birth, but also look at a) access to emergency obstetric care services and b) postpartum care so as to reduce maternal deaths meaningfully.

5.2.1 Access to emergency obstetric care

Of the 710 facilities surveyed in Bangladesh, in 1999, 35% had five EmOC facilities per 500,000 population, including both private and public facilities. In Matlab, Bangladesh, it was concluded in a study by Ronsmans,,(1997), that when emergency obstetric services are close (less than 2 hrs travel time), maternal mortality was reduced to the same degree as in programme areas with midwives posted in health centres with transport to EmOC care.

 

 

5.2.2 Post partum care

 

A large proportion of maternal deaths occur during the 24 hours after delivery and hence postnatal care constitutes a critical safe pregnancy intervention. The first two days following delivery are critical for monitoring complications arising from the delivery.

 

The single most common cause of maternal mortality is obstetric haemorrhage, generally occurring postpartum and accounting for 25—33% of all maternal deaths. The rate of death due to post partum haemorrhage (PPH) varies widely in the developing world. PPH-related mortality rates based on hospital studies are estimated to be 25—30% in India, and 43% in Indonesia. However, women who come to a hospital for care do not represent the general population of women. Because haemorrhage is more apt to occur and more difficult to treat in the community, studies have suggested higher rates of PPH-related mortality in these areas, but there is comparatively little data available outside of a hospital setting.^[18]

Data from the DHS show that in Bangladesh, a mere 21% of women received postpartum care  within 2 days  and had a non-institutional live birth in the five years preceding the survey.^[19]

 

5.3 Adolescent birth rate (per 1000 women):

a.    2000: 134.0^[20]

b.    2005: 133.0^[21]

c.    After 2005:

The adolescent birth rate measures the annual number of births to women 15 to 19 years of age per 1,000 women in that age group. It represents the risk of childbearing among adolescent women 15 to 19 years of age. It is also referred to as the age-specific fertility rate for women aged 15-19^[22].

The adolescent birth rate in Bangladesh remained almost stagnant in 2005 at a very high 133 per 1000 women.

 

According to the Bangladesh Demographic Health Survey 2007, one-third of adolescents age 15-19 have begun childbearing. Twenty-seven percent of teenagers in Bangladesh have given birth, and another 6 percent are pregnant with their first child. Early childbearing among teenagers is more common in rural than urban areas. Delayed childbearing is strongly related to education among women age 15-19. Childbearing begins earlier in the lowest wealth quintile, 42 percent of adolescents in this group have begun childbearing, compared with only 20 percent of adolescents in the highest wealth quintile.

 

Teenage fertility and pregnancies are a major health concern because teenage mothers and their children are at high risk of reproductive morbidity and mortality. Early childbearing also impedes the overall development of teenage girls and their access to education and labour force participation.

 

 

Critical indicators to comprehensively monitor adolescent birth rate would look at the median age at marriage,  the legal age at marriage and access to sex and sexuality education

 

5.3.1 Median age at marriage

The median age for marriage for women aged (25-49) in Bangladesh is 15.

 

According to the Bangladesh Demographic Health Survey 2007, “Marriage occurs early for women in Bangladesh among women age 20-49, 78 percent are married by age 18, and 88 percent are married by age 20.”

 

5.3.2 Legal age of marriage 

The legal age of marriage in Bangladesh is 18 for women and 21 for men.

In Bangladesh, one in three adolescents has already begun child-bearing.^[23] This is despite the Child Marriage Restraint Act 1929 which states that girls cannot be married until the age of 18 and boys, 21. These differing legal ages of marriage are superficially discriminatory as large numbers of girls are married before the legal age.^[24] Additionally, it appears that even this discriminatory law has had little impact on the prevalence of early marriage in Bangladesh as it is estimated that half of women there are younger than 18 when they marry. The lack of birth registration and lack of awareness of  the detrimental effects of early marriage make enforcement of this law difficult.^[25]

 

5.3.3 Sex and sexuality education

Sex education is defined as the basic education about reproductive processes, puberty and sexual behaviour. Sex education may include other information, for example about contraception, protection from sexually transmitted infections and parenthood.^[26] Sexuality education is defined as education about all matters relating to sexuality and its expression. Sexuality education covers the same topics as sex education but also includes issues such as relationships, attitudes towards sexuality, sexual roles, gender relations and the social pressures to be sexually active, and it provides information about SRH services. It may also include training in communication and decision-making skills.^[27] 

Bangladesh has not started providing comprehensive sex education in schools as part of the school curriculum. In Bangladesh, sex education is not taught by teachers in schools although some basic reproductive health topics are included in the school curriculum.

5.3.4 Access to reproductive health services for adolescents within the public health system

Data is not easily available, but evidence suggests that married adolescents, compared to unmarried adolescents, have easier access through the public health systems. 

 

5.4 Contraceptive prevalence rate (Current contraceptive use among married women 15-49 yrs old any method%:

a.    2000: 53.8^[28]

b.    2004: 58.1^[29]

c.    2007: 55.8^[30]

CPR was 53.8 in 2000, increased to 58.1 in 2004, but fell to 55.8 in 2007.

Critical indicators to comprehensively monitor contraceptive prevalence rate would include looking at range of methods available including access to modern methods and provision of informed choice.

Beyond the numbers for CPR it is essential to look at access to a range of contraceptive services.

 

5.4.1 Range of contraceptive methods available 

In Bangladesh, in the 2007 BDHS, pill users form more than 50% of all contraceptive users and a preponderence of one method often demonstrates provider bias/ service provision bias.

 

5.4.2 Provision of informed choice service provision.

Informed choice of family planning methods is an important rights indicator. However it has not been commonly regarded as an important aspect of the service provided with the contraception method. Informed choice includes: information on the full range of methods including traditional and male methods; information on side-effects of all methods and the appropriate course of action; and information on the efficacy of each of the methods.^[31] However, data is not readily available for Bangladesh for this indicator.

 

5.5 Unmet Need for contraception:

 

a.    2000: 15.3^[32]

b.    2005: 11.3^[33]

c.    After 2005: 17.1^[34]

Unmet need dropped from 15.3 (2000) to 11.3 (2005) and increased to 17.1 (2007).

In Bangladesh, “unmet need is lowest among women with the most education and does not vary much among those with lower levels of education. Differentials by wealth show a similar pattern—the unmet need is lowest among the wealthiest women.”^[35]

Generally women with lower education or are uneducated, who are poor, who live in remote areas and rural areas face the greatest challenge in controlling their own fertility. Socio-economic inequities are closely inter-linked with higher rates of unintended births and it is important to ensure access to contraception to all groups of women.^[36]

The accepted definition of “[u]nmet need for contraception is the percentage of fertile, married women of reproductive age who do not want to become pregnant and are not using contraception.”^[37] The concept of unmet need is an important one because it assesses the ‘need’ for contraception based on whether and when a woman wants a child or another one rather than focusing on government limits on family size. The limitation, currently, is that the DHS calculates unmet need based on a sample of married, heterosexual women and not single, unmarried women and this does not accurately capture the extent of unmet need in a country. Another limitation is that it assumes all users as having their need ‘met’ including women with infertility and secondary infertility. But many women may be using a contraceptive method not of their choice due to provider bias or government policy as earlier discussed and this constitutes an ‘unmet need’ too. It is also important to keep in mind that contraception is primarily focused on pregnancy prevention. There is also an urgent unmet need for disease/infection prevention which is not being considered.^[38]

 

Critical indicators to comprehensively monitor unmet need would take into account differences between total and wanted fertility rates and reasons for non-use of contraception.

5.5.1 Total and Wanted Fertility Rates

    Wanted fertility rates compared to TFR

 

a.    Total Fertility Rate (2005): 2.7^[39]

b.    Wanted Fertility Rate (2005): 1.9^[40]

c.    % difference: 42^[41]

 

It is important to look at Wanted Fertility Rates and Total Fertility Rates to also establish unmet need.

In the BDHS 2007, the TFR was 2.7 and the WFR was actually 1.9; this means women were having 42% more children than they actually wanted and this constitutes an unmet need.^[42]

 

5.5.2 Reasons for non-use of contraception

One of the most common reasons given by married women with an unmet need for not using contraception is associated with the supply of methods and services and within this category, concerns about the side effects, health consequences and inconvenience of methods were the most prominent reasons. The prevalence of these concerns is particularly high in South Asia.^[43]

Apart from the fertility-related reasons, method-related reasons and health concerns, a major reason for non-use of contraception in Bangladesh is ‘fatalism’ (14.6%) i.e. fertility is still seen as something ‘fate’ deals out rather than a matter of exercising choice. In addition, opposition to use (both own and spousal) constitute 8.3% and religious prohibition constitutes 3.8% all of which are not being considered in discussing unmet need.^[44]

 

5.6 Antenatal care coverage :

a.    At least one visit (%):

Ø  2000: 33.3^[45]

Ø  2004: 48.7^[46]

Ø  After 2005: 51.2^[47]

b.    At least four visits(%):

Ø  2000: 10.5^[48]

Ø  2004: 15.9^[49]

Ø  After 2005: 20.6^[50]