Safe Motherhood: Achievements and Challenges

Brigadier General (Retd.) Shahedul Anam Khan, Editor, Op-Ed & Strategic Issues, The Daily Star
We need healthy and robust mothers. So we have to care for our mothers when they conceive, when they deliver and after they have delivered; these are very important stages of motherhood. Safe motherhood is important, not only for our wives and mothers but also for our children's health. Only, a healthy child can be a good citizen.

I think today's programme will identify the challenges of safe motherhood along with celebrating our achievements. We, The Daily Star, always support such causes and connect our efforts to make people aware of what is happening and also what can be done to keep us on our feet everyday to do what is right for women of Bangladesh.

Arthur Erken, UNFPA Representative, Bangladesh
Bangladesh has made tremendous progress with regards to maternal mortality. That said, still more than 7,000 pregnant women die each year. By the time we end this roundtable, another two women would have lost their lives in Bangladesh during the delivery of their baby. For these two women, motherhood, which should be unique, will turn out to be tragic. So the real issue for policy makers and health practitioners is to reflect whether they are you doing the right thing for the women of Bangladesh? Are we delivering the services that pregnant women need and that are acceptable to them? We cannot allow more than 7,000 women to die of causes that for 90 per cent are entirely preventable. That is the real tragedy. Pregnant women do not die of diseases we cannot treat; they die simply because we have not made their health and their well-being a priority. Unless we do that, unless we invest in maternal health, it will remain a problem. So far we have invested in reducing fertility rate, now it's time to invest in safe delivery and post-natal care. Now is the time to focus on further reducing maternal mortality. That is message of today's roundtable.

Dr. Hasina Begum, Assistant Representative ,UNFPA
The maternal mortality ratio (MMR) has declined 40% within 9 years, which is really an excellent performance. The risk of a maternal death has come down to 1 in 500 births, which is very significant. We are on track in fulfilling our MDG target. Still, the proportion of births attended by a skilled health worker is very low. The current status shows that the rate is 32 per cent (according to DHS-2011). Ante-natal care coverage of at least one visit is far behind the target. We are now at 68 percent, whereas our target is 100 per cent. So we are not on track in this area. Ante-natal care coverage for more visits is also not on track, because we are now at 26 per cent, whereas our target is 50 per cent by 2015. That said, we do have lots of achievements that we have to celebrate as well.

We have to look into the details to find out why we have achieved such a remarkable reduction in MMR. There are two specific factors behind the reduction. One is behavioural change in seeking health care services and second is the sustainable increase in facility deliveries, skilled attendants during delivery and treatment seeking behaviour when complications arise. And all this could happen because of increased access to health services and the increased number of facilities offering emergency obstetric care (EOC).

We have seen a significant growth in the number of facilities from the 1990s onwards; we have established district hospitals, MCWCs, Upazilla health complexes and Union health and family welfare centres. All 59 district hospitals and 70 MCWCs (out of 90 MCWCs) have been upgraded to provide comprehensive EOC services. Some 132 Upazilla health complexes have been upgraded to provide emergency obstetric care services. Improvement of road and transport facilities and wide increase of mobile usage have helped access to health care services. Other than that the income at the national and household level has also increased, even among poor households. Another underlying factor is the increase in the number of higher educated young women. International evidence shows that when women are educated then the maternal mortality rate goes down because their care seeking behaviour significantly improves.

Besides all these, the 2010 Bangladesh Maternal Mortality Survey (BMMS) also revealed that there is a significant increase of awareness about the maternal health care services and it also increased among the uneducated women. Moreover, the facility delivery increased significantly from 2004 till 2010. The most impressive increase is in the private sector, which has increased by 400 per cent. Bangladesh also saw a 28 per cent increase in health seeking behavior, which means that women are asking for services at the home level and also visiting health facilities.

We still have lots of challenges. The main challenge is that every day 20 women are dying, which is still very high. Another challenge is that many women are dying right after delivery. Hemorrhage and eclampsia are two preventable diseases, which contribute to half of the maternal mortality. Treatment of both requires the availability of skilled health providers at higher-level health facilities.

Social inequality is still a very serious concern. There is inequality with regards to geographical locations. There are pockets at the Upazilla level, which are very poor in terms of all the maternal facility indicators. Most of these pockets are located in the North-East, South-East and Southern areas, which means that we need special attention to these areas.

Caesarian sections have increased 5 times in the last 9 years. But it has significantly increased in the private sector, which is worrisome. Some 71 per cent of all deliveries in the private sector are done by caesarian section, whereas the figure is 35 per cent in the public sector and 30 per cent in NGO facilities.

When we come to complete maternal care, which means care provided by a skilled health worker, the percentage is very low at 19 per cent of all deliveries. Though the number has increased from 4.5 per cent to 19 per cent, still some 40 per cent of the women do not have any access to maternal care.

We have to further reduce the maternal mortality ratio by 25 per cent to reach the MDG-5 target by 2015. This will still be a huge challenge. This is the last mile of the race. We still have to focus on family planning, to increase the number of skilled health care attendants and providing health care facilities to the poor people. We have to raise awareness among the people, because still one third of the pregnant women do not discuss about birth preparedness. We have to really reach those women. Surveys show that in case of complications, women are visiting different places because they are not clearly referred to places which are properly equipped, thereby losing valuable time to receive life-saving treatment. So we have to improve these facilities. The last thing we have address social inequality as well as geographical inequality.

Dr. Ahmed Al Kabir, President, RTM International
We have a very young population in Bangladesh that has to be recognised. Some 34% of the population are below 14 years of age, 65% are below 30 years and 80% are below 45 years. If we consider fertile population specially women from 15 to 45 that means we have 40% of our people within that age bracket. This fact needs to be recognised in any programming or any planning. If we take proper care of this population only then can we enjoy the demographic dividend of this large number of young population.

Next, I want to focus on health which includes primary healthcare, secondary healthcare and tertiary healthcare. I will focus on the secondary healthcare system where we have very good infrastructure at the Upazilla level. But there is a major challenge. We need adequate number of gynecologists and anesthetists in the Upazilla health care centres. To provide primary care we need good nurses and midwives too. In Nepal the government provides six months training to anesthetists which proves to be very successful. This is feasible for Bangladesh. In terms of primary healthcare we have to train professional midwives which is the most important part of the whole process, but remain neglected due pressure from professional groups. This time our prime minister pledged at the UN that at least 3,000 midwives would be trained, but so far the outcome is lagging behind. We have achieved only 200 trained midwives so far. But we have enough resources to train 3,000 midwives within a year. After fighting for 4 years we have recently got a policy guideline, so we can do it, there is no excuse for not reaching this target.

Dr. Bushra Ahmed, Senior Health Specialist, World Bank
Talking about maternal health, some issues are medical issues and some are beyond medical issues. These are the socio economic determinants. Among these socio economic determinants first of all comes the access to education in which Bangladesh is doing quite well and in Primary school the gender parity has been achieved. In the secondary level, I want to congratulate government for providing stipends which help keep girls in college. If the girl is more educated then she has the decision making power.

The other one is life expectancy. Life expectancy has increased which has impact on overall maternal health issues. Participation of women in income earning activities is another factor which has very positive impact on reducing maternal mortality rate. That also gives them economic empowerment. Once the women are economically empowered they have decision making power in their households and that improves their health seeking behaviour. Difference in wage is also important. In Bangladesh for every dollar a man earns, a woman gets only 20 cents. We should really look into this issue. Another important area is legislation. There are countries who have ratified CEDAW and we are one of them. But if you really look into them how the legislation is being made effective there is a gap between implementation and legislation. If you look into domestic violence still it is very high.

Another important thing is political participation of women. In Bangladesh the rate is 19% among the political parties. We have to involve them in the political process not only in the highest offices. How much decision making power women have in the rural areas?

Now come into the issues of medical areas. We have to look into skill birth attendant. It is only 32% which really have to go up. It can not only go up with midwives, but with all the cadres of skilled birth attendants. I want to congratulate UNFPA for initiating community based skilled birth attendants programme, which really proves to be successful. We should focus on the FWAs as well. They are the ones who work in the field.

The bifurcation of family planning and health is another serious issue. The structure of referral is also very important. We have a very good NGO sector. If they could send the women to proper health facilities then we could have addressed the maternal mortality issue much better. We the H4+ (World Bank, along UNFPA, UNICEF, WHO and UNAIDS) have discussed with the government that if 80% of the 132 Upazillas could be prepared for EOC services then we can achieve a lot. The government has taken the initiative which will bear very good results in the future. There are some really hard to reach areas in Bangladesh and we should have very specific design or targeted intervention for these areas. And keeping doctors, nurses and other birth attendants ready at that point is very important.

Professor K.M Nurun Nabi, Department of Population Science, University of Dhaka
Our young population structure gives rise to a larger proportion of women in the reproductive age span. And also a larger proportion of contribution is made by the adolescents in the total fertility rate (TFR). We know that 25% of maternal mortality reduction is due to increase in TFR. If we want to sustain the reduction in TFR we must look at these two demographic factors. Another factor is family planning which is integrated with safe motherhood. Here we need to take care of providing the appropriate contraceptive method mix. If we plan and design the method mix taking into consideration the life cycle of women, that would ultimately give better results.

We are talking about permanent methods but it needs the creation of demand, which needs a very strong campaign for changing the harmful practices like early marriage, early pregnancy, dropout, etc. Therefore, we have to create social norm changing campaign, which includes all the stake holders, to campaign against harmful practices which should be a community participatory programme.

Another point is the health of the mother. The nutrition status of the mothers is very poor. If you provide all types of facilities but the mother's health remains poor then she will still have many complication during her motherhood. In our national development plan there is a nutrition segment but that is not taken seriously at the implementation level. Stunting, low birth weight and wastage are three indicators which show the precarious condition of our mothers and children.

Poverty is the umbrella of all inequalities and without eradicating poverty we would not get satisfactory results.

Dr. Morsheda Chowdhury, Senior Programme Manager, BRAC
I want to put emphasis on the solution side.

First one is referral system. In Bangladesh we have a good infrastructure. We have to use 100% of that. It is possible when there is demand among the population and they know how to use it. It is possible when there is people in the community who know what services are available, how to get it and when and how to reach there.

It is possible when the community participates actively. We have tried that system in many of the northern areas of Bangladesh and we found that in 2011 around 1, 80,000 women came to the facility and took care for their pregnancy related complications. That is huge number. They came at their own cost. Maternal mortality rate came down in those areas which prove the effort's success. In Nilphamari, the maternal mortality rate came down to 154 in 2011. I think it is an achievement.

The health information system has been developed in Bangladesh which should be utilised to strengthen our delivery, monitoring and dissemination system.

Another thing is family planning. Our modern method use rate is 52%. Among these modern methods, 85% is short term. Discontinuation rate is very high there. One in 3 women discontinues the method within a year. That leaves them vulnerable to become pregnant. This happens due to lack of information and awareness. This is the sector where we need public-private-NGO partnership because here we need interpersonal communication for example they face problems all time in using pills so there have to be one who will give them solution in time of complication. Only coordination among public, private and NGO organisations can only provide us that large number of root level health workers.

Dr. Momena Khatun, Health Adviser, CIDA
My first point is skilled birth attendants. Did we do justice to them? We gave them training. The female health assistant and FWA go to attend births, but they have hundred other activities to do as well. Did we provide them the technical level supervision so that they can have confidence of conducting delivery at home? Training follow up is one issue and post training follow up is another issue. We did not do the post training follow up.

We did not make aware the community of the need to demand the first hand services. We did not do much to help them continue their education after the secondary level. We have to do these jobs seriously.

In 2001 the national maternal health strategy was taken, and we were supposed to use the already have infrastructure as we were not going to recruit any new people. UNFPA first started implementation of the national strategy and they started community based training. So far we have trained more than 6,000 C-SBAs, and we have to add more.

We know that 50% of pregnant women die due to direct obstetric causes, but we do not know the reasons behind the 35% of women who die of indirect causes. We have to know the indirect causes. One survey once showed that 14% of maternal mortality was caused due to violence which I do not think viable. Still we do not have any survey or data about the indirect cause. We have to do work on this issue.

Kaosar Afsana, Director, Health, BRAC
Evidence from BDHS and BMMS shows that direct causes have been reduced but indirect causes still remain. Low birth weight is one of the causes which give rise to complexities like diabetes, cardiovascular diseases, hypertension which cause maternal death. Because there is no scope of treatment of these complexities in our country so the 35% remains stuck at the same point for the last 10 years. So we have to connect this issue with the life cycle of a mother because motherhood is not only about mothers, but also the whole process of the health of our population.

In the hospital we have to think about the quality of care which creates fear among the women who go to hospital. We have to respect every patient with proper care irrespective of his or her social status.

Another important point is FWC. We have been neglecting this fine structure which should not be done. We can include community through FWCs and can easily solve the problem like hemorrhage where the community people can provide blood to the patient and save the mother.

Another important issue is task sharing and task shifting. Our nurses are doing so many jobs in the hospital but that is not properly recognized by our government. Our professional associations of doctors are very restrictive about allowing them to perform tasks they could easily do. We should sit with the professional associations and bring them on board to shift some of the duties to lower level health cadres.

Another important matter is promoting C-SBAs, because the birth outcome is much better than that of other health providers working in the community. We have to include them in our health system so that they can provide better services. This is really important otherwise it will remain only a training programme.

Dr. Mohammad Sharif, Director, LD, MCARH & Director (MCH-S), DGFP
We have not been sleeping. On the contrary, from January we started normal delivery at FWCs. Out of 3725, FWCs 1500 have been upgraded. They now have well-equipped delivery rooms. These institutions are doing 3,000 to 4,000 deliveries every month! Now 500 FWCs are working for normal delivery. We still lack supervision and monitoring. And we have also shortage of manpower. There are 1400 doctor posts but at present only 550 doctors are serving. We have to recruit adequate manpower immediately.

Dr. AKM Mahbubur Rahman, Line Director-CCSD, DGFP
Early child bearing is the major cause of death for the adolescent mothers. We need to address this issue seriously. For this we need community participation.

Another important thing is registration of pregnant mothers. We do not have data how many mothers are pregnant at this time. Through registering them we can easily chalk out programmes to cover them properly.

We are trying to reduce frequent pregnancy of the mothers through long term contraceptive method to newly wedded couples like implant. It will help to reduce early pregnancy and adolescent pregnancy.

Tania Sultana, C4D Specialist, Unicef
I want to address demand side issues. In Bangladesh lot of people do not understand the importance of seeking services from facilities. In the rural areas, most of the women prefer to have their delivery at home. Even the time of pregnancy is taken as usual as normal, because the seniors of the family think she should follow the same path which they have already taken. Pregnant women need special care and support, which is part of safe motherhood. Unicef is working to create an enabling environment so that women can understand the need of seeking services so that she can get support from the family members. So we are creating social network so that we can speak in a same language which is very important.

Dr. Ubaidur Rob, Country Director, Population Council
Right now we have 7000 maternal deaths, which needs to come down to 4000 if we want to achieve the MDG-5 target. To do that you need targeted interventions to identify high risk mothers who should go to the facility for delivery and those who are relatively safe they can have their delivery at home assisted by a skilled birth attendant, without crowding in the facilities.

We have been talking about NGOs' successes. But let's look at the 2011 BDHS; their so-called 'success' in contraceptive implementation is less than 5%, even though many have been working in the country for the last 35 years! Their market share has gone down in recent years.

Fertility level is going down due to the inherent willingness of our women to have fewer children. In Bangladesh a typical woman these days finishes child bearing by age 24 which means that they get married at age16 and have 2 children by 24. She therefore has to be protected from unwanted or unplanned pregnancies by family planning methods for the next 20 years. That is the question we have to discuss how we will do that and that is the period when the maternal mortality will be occurring more significantly than what occurring for intended or wanted pregnancies. For your information 50% birth in the US are unintended which is only 33% in Bangladesh. So, unintended fertility is high globally.

We are not exception in contraceptive discontinuation. How can we reduce it? Pay-for-performance is a model which we have tested in 12 upazillas and it has significantly increased the performance of the delivery institutions. I am not prescribing that the institution delivery will significantly loose the number of maternal mortality but it is the way to reach it. Look at the example of Cambodia; with 66% institutional delivery they have the same maternal mortality like us with 33% institutional delivery. So, institutional delivery is not the only solution. Definitely we have to identify high risk mothers who will come to the facility and we would provide them services as they need. So investing 10 million for the next few years in the payment performance project you can significantly reduce the number of maternal mortality. Mind it; it is behaviour change once you change it you do not have to do that again.

We have attained gender parity at the secondary school, but what does it mean? At the age of 15 one finishes secondary school. So they are getting married at age 16 or 17. So, finishing secondary school is not going to give any dent to our adolescent fertility. You need to give them some sort of skill so that they can earn some for their own otherwise parent will get married them immediately after passing the secondary school.

Dr. Mahammad Hussain Chowdhury, GM Services, Marie Stopes
If you look at the success of family planning the publicity and ads contribute significantly. So we have to chalk out effective information dissemination strategy to reach to the grassroots level so that they can learn about the facilities and come to the utilise them.

Dr. Tekendra Karki, WHO, Bangladesh
WHO is providing six months competency training to registered nurses. Already we have trained 100 nurses and they are doing midwifery successfully. In Bangladesh I have seen that there is acute crisis of anesthetists. In Nepal anesthetists are paid extra allowances so that people get interest in that profession. There are incentives for the doctors who work in the remote areas. During the MBBS study students who are given stipends are supposed to serve in the remote areas for two years. These practices have done a lot to reduce the human resource shortage in grass root areas.

Dr. SM Ashraful Islam, Additional Secretary,Ministry of Health and Welfare
Economic development of a country can gradually remove the maternal mortality. The ministry of health and welfare has a goal achieving the MDG Goal 4 and 5. Our strategy is strengthening the health system. We have 8,000 facilities which provide maternal and neonatal services. Are these facilities accessible for the mothers? One hindrance is our cultural norms. Do the mother-in-laws allow their in-laws to go to these facilities? In the educated family it is yes, but in the lower strata it is no. So here education is very important.

Ministry of health is suffering serious shortage of resources. In the human resource area we have problem of production, supply and retention, especially rural retention is a big problem in this country. I have only 130 anesthetists in the public sector, and I have more than 400 posts of anesthetists vacant. If you ask people to take the profession of anesthetist they are not willing to do. Going to the rural area is culturally declined by our work force, especially doctors. But nurses are working in the Upazillas. Family welfare workers and family welfare visitors are also working in the rural area but not the doctors. Doctors have natural bias to better living because they can afford. So we are going to develop midwives and our target is 3,000. Now, we have Midwifery Strategy, draft Bangladesh Nursing Council Act that is to change it to Bangladesh Nursing and Midwifery Council and draft Nursing and Midwifery Regulation. We need standards and indicators for CSBS. In total, we have 32 human resource plans to strengthen our health sector.

This country did a crime for a long time neglecting the nurses. Now the situation has been changed. Last year we had unprecedented number of application for nursing colleges and nursing institutions. For increasing the production capacity we have already started partnership with private sectors. Two of the private sector partnership we have already approved. One is GP Grant Public School from BRAC and another Glaxo Smith Klein with the condition that they should be accredited by the Nursing Council. So we are trying to rationalize our health work force.

We cannot merge the DG Health and DG Family planning, but at the field level we can provide integrated services. Where government has constraints we ask NGOs to fill up the gap. Our development model is partnership model. I will invite all the stake holders to board on a same platform to fight maternal mortality. I will especially invite media like The Daily Star to cover the maternal mortality issue seriously and aware people about taking services from our existing facilities.

Arthur Erken
It is clear from today's discussion that if we want to further reduce the maternal mortality we have to strengthen the delivery system. Facilities should be equipped, especially with human resources. Bangladesh has huge problem with delivering the adequate number of providers. There are huge vacancies and huge retention issue in this country, particularly in the rural areas. That needs to be addressed because the real reduction will come from that.

We need to work on skilled care providers at all levels. From community-based skilled birth attendants, to midwives, to nurse and doctors, the whole spectrum, have to be equipped with skilled human resources and they have to work together. This requires a well-functioning referral system. That is the big challenge we have to address. This country has many facilities, many health cadres and money! The health sector programme has a budget of almost US$ 8 billion, which is one of the largest health sector programmes in the world. How these three components can work together is really a big matter.

In addition, we need to target our interventions in those geographical areas that are lagging behind. There are areas that need more support and investments than others. So we have to focus on these areas. In those areas, people have to be made aware about the facilities so that they can come to right place at the right moment.

Moreover, we need to better understand the indirect causes of maternal mortality. It can be malnutrition and other causes, but we need to know what is behind these indirect causes, so that we can better target our programmes in addressing those causes. So far, there has been very little research in this field.

On the demand side, the age of marriage is extremely important. The legal age of marriage is 18. But, 50% of our girls get married by the age of 16. That is simply unacceptable. We need to find a way of enforcing the law and to make sure that girls do not get married before the legal age of 18. We need to go beyond secondary school level, and promote gender parity in tertiary school levels as well. Equally important is providing our adolescents with quality vocational and skills training.

Another issue is that girls not only get married at a young age, but they are informed about family life, sexuality and family planning. The need for educating our girls and boys on reproductive health is very important so that when they get married they have basic understanding of family planning and reproductive health.

Mahfuz Anam, Editor and Publisher, The Daily Star
No mother should lose her life when giving life. This is the least a society can do for some who is giving life. The man never risks his life; he is very happy of the child who comes out of the marriage but unconscious of his partner who is risking her life to give birth. So there is a gender issue here. We, men, have to be far more conscious at the individual level as well as social level. We are doing right in all the indicators except the age of marriage. The early marriage of girls is very serious issue. This is a violation of law. We, The Daily Star, will do our best to focus on this issue and raise awareness as much as possible.

I am struck hearing the amount spent in the health sector which proves that we have enough money in the sector . But we have to ensure services, we have to reach to the women and build our structure so that people can find confidence and come to get the services on offer.

We can bring out editorials, Op-Eds focusing on this issue. I would like urge you to dictate as a partner so that we can carry out the effort throughout the year and concentrate our focus on the issue of maternal mortality .