93555 Knowledge Brief Health, Nutrition and Population Global Practice BANGLADESH: MATERNAL AND REPRODUCTIVE HEALTH AT A GLANCE Sameh El-Saharty, Naoko Ohno, Intissar Sarker, Federica Secci, and Bushra Binte Alam November 2014 KEY MESSAGES: Country Context • Bangladesh, a densely populated and low Bangladesh is among the most densely populated income country, has achieved several countries in the world. Its population (155 million) is the MDGs in education, health, and poverty world’s eighth largest and among the poorest in South reduction, and made remarkable progress Asia. Yet Bangladesh has sustained growth over 30 years in gender equality. Despite growth and and progressed in human development. Per capita GNI grew at a yearly compound rate of 4.9 percent from an progress in human development, poverty average of $25 in the 1980s to $913 by 2013. While GNI levels remain high. growth in the 1980s and 1990s was mostly from GDP growth, remittances in the past decade are a significant • MMR declined by 70 percent from 1990 to source of income. 1, 2 2013 and is now 170 deaths per 100,000 Poverty remains high: 43 percent of the population live births. subsists on less than US$1.25 per day (2010). Poverty • Fertility declined to 2.2, while contraceptive fell from nearly 63 million in 2000 to 47 million in 2010. 3 The main drivers were growth in labor income and prevalence rate increased to 61%. Fifty- dropping fertility rates. 4 The large youth population — 32 five percent of women sought ANC from a percent are under 15 — offers an opportunity to benefit qualified provider and nearly 32% of births from the demographic dividend. 1, 2 were attended by qualified providers. Bangladesh achieved several MDG targets in • While fertility and CPR are evenly education, health, and poverty reduction. Its progress in social sectors compares favorably to similar income distributed, wide gaps in access to level countries. Child mortality is the third lowest in South maternal health services remain. Asia: 41 for under-fives and 33 for infants per 1,000 live births in 2013. 1, 2 • Despite its decline, undernutrition still remains a challenge. Gender equality and women’s empowerment are important determinants of reproductive health. • Bangladesh would need to focus on Bangladesh’s progress in attaining gender parity is increasing political commitment to remarkable. It reached 110 in primary and secondary adolescent health; focusing interventions education. Over 7,000 NGOs are registered with the Ministry of Social Welfare. Some 400 NGOs work in on high-fertility and high MMR areas; maternal health, family planning, and microfinance. addressing human resources constraints; Bangladesh ranks 111 of 148 countries in the Gender and harnessing the use of technology. Inequality Index.6 Page 1 HNPGP Knowledge Brief  MDG Target 5a: Reduce the MMR by three-quarters, between 1990 and 2015 An increased contraceptive prevalence rate (CPR) has Bangladesh has made great progress over the past accompanied the fertility decline. The CPR (any two decades on maternal health. The MMR declined method) has increased from about 40 percent in 1991 to from 550 deaths per 100,000 live births in 1990 to 170 in 61 percent in 2011 (figure 2). 1 Modern methods are the 2013 (figure 1). According to the latest Interagency main choice of contraceptives and are used by 52.1 estimates, Bangladesh is “making progress” toward percent of currently married women. The pill (27 percent), achieving MDG5.i Maternal mortality declined 70 percent injectables (11 percent), male condoms (6 percent), and with an average annual decline of 5 percent between female sterilization (5 percent) are the most commonly 1990 and 2013. 6 used form of modern methods. Traditional methods are used by 9.2 percent of currently married women. There is still an unmet need of 13.5 percent. 7 Early childbearing affects maternal health outcomes. Among women age 20-49, the median age at first marriage is 15.8 years and the median age at first birth is 18.3 years. The share of women age 15-19 that have begun childbearing is 30.2 percent.7 The adolescent fertility rate is 80.6 births per 1,000 women age 15 –19.1 Pregnancy Outcomes Complete and timely antenatal care (ANC) is a necessary component for positive pregnancy outcomes. As of 2011, 54.6 percent of women sought ANC from a medically qualified provider, but only 25.5 percent of women received the recommended four or more ANC visits. Tetanus toxoid is a vaccination given as part of ANC: 41.7 percent of mothers received two or more injections during their last pregnancy and 89.9 Fertility percent had their last birth protected against neonatal Bangladesh has a long and well-established family tetanus. 7 planning program. Its current Population Policy (2009) aims to achieve replacement fertility by 2015.7 Fertility has been declining over the past 20 years. Between 1990 and 2012, the total fertility rate (TFR) fell by more than half from 4.6 to 2.2 (figure 2).1 Page 2 HNPGP Knowledge Brief  There is also a large gap between wealth quintiles in receiving ANC: 87.4 percent of women in the richest quintile received ANC from a qualified professional, but only 30.4 percent of women in the poorest quintile (figure 5). 7 Skilled birth attendance (SBA) is critical in reducing maternal deaths. SBA in Bangladesh by a medically trained provider increased from 9.5 percent in 1994 to 31.7 percent in 2011 (figure 3).1 The majority of births are delivered at home with institutional delivery accounting for only 28.8 percent of all births (15.1 percent in public sector facilities, 11.8 percent in private sector facilities, and 1.9 percent in NGO facilities).7 Postnatal care is another important component for maternal health especially for managing post-delivery complications. It is recommended that postnatal care for mothers occur within the first two days of delivery. In Bangladesh, only 27.1 percent of women sought this type of care from a qualified provider within the first two days of delivery. 7 MDG5 is being addressed through the Health, Similar disparities are also found in SBA: 53.7 percent Population and Nutrition Sector Development of urban women are assisted during delivery by a Program (HPNSDP). The HPNSDP covers 2011-2016 medically qualified professional but only 25.2 percent of and aims to deliver a package of quality and essential rural women (figure 6).7 health services.7 Equity in Access to Maternal Health Services Inequity in access to maternal health services is a barrier toward MDG 5. Some indicators show a more equitable distribution than others. In Bangladesh, CPR and TFR show a somewhat even distribution across residence (rural/urban) and wealth quintiles. While utilization of ANC has been increasing, wide disparities remain. Women in urban areas were more likely to seek antenatal care (74.3 percent) from a qualified professional than their rural counterparts (48.7 percent) (figure 4). 7 Page 3 HNPGP Knowledge Brief  Considerable variations in skilled birth attendance Key Strategies to Improve Maternal also exist amongst wealth quintiles. Women in the and Reproductive Health Outcomes richest quintile were five times more likely than women in the poorest quintile to have skilled birth attendance. Only Increasing political commitment to adolescent health by reviewing the current adolescent health programs run by the 11.5 percent of women in the poorest quintile received public and private sectors and update the strategy; and skilled birth attendance compared to 63.7 percent in the introducing a specific focus on adolescents’ nutrition in the richest quintile (figure 7). 7 updated Nutrition Policy and in the existing health related interventions. Focusing interventions on high-fertility and high MMR areas and reducing inequalities by promoting female education and intersectoral collaboration to increase age at marriage, including first child birth; developing effective IEC and BCC to increase birth spacing and the uptake of long term/semi-permanent or permanent methods; empowering women through income generation and livelihood programs; targeting interventions in rural, urban, and hard to reach areas; increasing coordination between MOLGRDC and MOHFW and strengthening it in urban areas scaling up CRVS to register every pregnancy, birth, and maternal death; and addressing the quality issues in DSF voucher program and then proceeding to scale up. Addressing the unavailability of human resources by increasing the number of skilled birth attendance, specially the Community SBAs with effective mentoring and supervision; strengthening the accreditation of training; addressing task shifting; Nutrition ensuring teams, e.g., OBG, Anesthetists and trained nurses at the Since the 1990s, undernutrition has declined gradually. Comprehensive Emergency Obstetric Centers work round the However, the pace of decline has not matched the rapid clock; and strengthening structures to provide EmONC services; strengthening the referral linkage and support to appropriate improvements in other development indicators such as facilities. economic growth, child and maternal mortality, education and rice production. The undernutrition situation remains Harnessing the use of technology by improving HMIS and serious: 41%, of children under five are stunted, 36% electronic record keeping; and using mobile phones for data collection and pregnancy related tracking. underweight and 16% wasted. Among women, 24% are underweight and 13% are of short stature, which increases the likelihood that their children will be stunted. References: 1 World Bank. World Development Indicators 2014: Accessed 19 May 2014 This situation reflects the underlying causes of 2 Bangladesh:Country Program Snapshot. March 2014, the World Bank undernutrition including sanitation and hand washing 3 World Bank 2013. Bangladesh Poverty Assessment Report practices, access to food and health care, child feeding 4 Jolliffe, Dean; Sharif, Iffath; Gimenez, Lea; Ahmed, Faizuddin. 2013. practices and the status of girls and women in the family Bangladesh - Poverty assessment: assessing a decade of progress in and society. Nutrition is inextricably linked to persisting reducing poverty, 2000-2010. Bangladesh development series ; paper no. 31. social norms embedded in gender inequity. A mother’s Washington DC; World Bank. age at marriage and first delivery has a significant effect http://documents.worldbank.org/curated/en/2013/06/17886000 bangladesh- on the birth weight and nutritional status of her children. poverty-assessment-assessing-decade-progress-reducing-poverty-2000- The high rate of child marriage in Bangladesh also leads 2010 to early abandonment of education. 5 UNDP. 2013 Human Development Report Gender Inequality Index 6 WHO, UNICEF, UNFPA and The World Bank. 2014. Trends in Maternal Mortality: 1990 to 2013: World Health Organization 7 National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ICF International. 2013. Bangladesh Demographic and Health Survey 2011. Dhaka, Bangladesh and Calverton, Maryland, USA: NIPORT, Mitra and Associates, and ICF International. For more information on this topic, go to: www.worldbank.org/health. Page 4