Maternal mortality has not declined in Bangladesh. The 2016 Bangladesh Maternal Mortality Survey (BMMS), third of its kind, revealed the astounding fact that current maternal mortality ratio (MMR) is 196 per 100,000 live births which was 194 in 2010. MMR indicates not only the performance of health sector but also reflects how a society values its women.
The survey was led by the National Institute of Population Research and Training (NIPORT) under the MOH&FW with technical support from international agencies. The robust scientific survey collected data from 300,000 households all over the country. Unfortunately, since the public dissemination of the embarrassing results, actions of the MOH&FW officials were conspicuous only by denial of the fact of stalling; no substantive counter argument was presented.
Bangladesh’s recent progress in health indicators has been impressive. The child survival MDG4 goal has been achieved. Over the last seven years, delivery in health facilities and care seeking for maternal complications increased significantly. Unfortunately, these achievements have not translated into the reduction in maternal mortality leaving Bangladesh perplexed in a paradox.
Citing global lessons experts cautioned earlier that, business as usual and dependence on contextual factors only (like education, communication, foreign remittance etc.) would not work for the last mile and such a stalling effect could happen. MOH&FW did not heed the warning and consequentially 42,000 mothers died in the last seven years. These deaths are unacceptable because ninety percent of them were preventable.
Followings are plausible reasons to believe that our health systems grossly underperformed in at least four following areas that contributed to the current situation.
More than half of the maternal deaths are due to hemorrhage and eclampsia. Solutions are known and financial provisions are available in the health sector program. We simply failed to deliver. For example, every delivered woman need to consume two tablets of misoprostol within 10 minutes of delivery and that should substantially prevent postpartum hemorrhage.
Bangladesh is on target to become one of nine countries to dramatically reduce maternal mortality
Only 17 percent of the delivered women have received this so far. Despite having a large fleet of more than 150,000 GO-NGO frontline health workers the system failed to reach the mothers with tablets that would cost 24 takas only.
What is evident is the lack of prioritization, proper planning, insincerity of health workers and inefficiency of managers of different levels. This is just one of many similar examples.
Be it public or private, health facilities largely do not meet standards of quality. Only 3 percent of all facilities meet minimal standards of normal delivery care. Shortage of appropriately trained manpower, the absence of manuals and guidelines, lack of equipment and essential drugs hinder the quality.
Considering ‘available on-call’ only 39 percent of facilities have 24 hours availability of doctors to provide life-saving emergency obstetric care (EmOC). While a woman can die of hemorrhage within 2 hours, the huge health human resources are simply not available at the right time at the right place. Aspirations for reduction of maternal mortality thus remain elusive.
Fifty-three percent of our mothers deliver at home. It’s hard to provide them with standard care and support unless they are brought under high-quality facility-level care. Only 3 percent of those mothers receive skilled care at home leaving the vast majority with no one to help identify and make a decision should there be any complication. We have not yet been able to establish a functional referral system which is a key prerequisite to EmOC. As a result, maternal deaths taking place on the way to a hospital have risen to 19% from 13% in 2010.
In order to ensure referral level care, we need the round-the-clock presence of specialists to perform the emergency cesarean operation at the EmOC centers, many of which are now non-functional owing mainly to non-availability of anesthesiologists. While more than hundred countries in the world allow nurses to be trained to provide limited anesthesia, MOH&FW hasn’t done so in the face of opposition from our Anesthesiologists.
Mothers have died in thousands, still, they are, from preventable causes and yet no one is held accountable. It’s rare to find a health system that has near-zero accountability like ours. The ever-rising unnecessary cesarean operation is a perfect example. As opposed to a WHO recommended a maximum range of 15% our cesarean rate is now 31% of which three-fourths are unnecessary. Public or private, the health sector falls far short of being ‘regulated’.
Bits and pieces of maternal health interventions, best practices, skills, and strategies are available in the country. Absent is ambition, strategic thinking to connect the discrete dots and most importantly – action on-the-ground. It appears that the health leadership failed to understand the ‘business unusual’ needed for the last mile towards ending preventable maternal deaths by 2030 committed by nations of the world including us.
The article is written by Dr. Ishtiaq Mannan, a public health specialist working at Save the Children in Bangladesh as the Deputy Country Director.
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The opinion expressed in the article is entirely of the writer and not necessarily reflects as of the organization he works for.