Bangladesh is a classic case of a low- and middle-income country achieving the unachievable which many others failed to. It reduced its maternal mortality by 66 per cent between 1990 and 2010; the reduction was 40 per cent between 2001 and 2010 alone.
These were achieved by lowering the maternal mortality rate (the number of maternal deaths per 100,000 live births) from 574 to 194 during the period 1990 to 2010. The reduction was substantial even in a short span of eight years (1990 to 1998) — 574 to 322 per 100,000 live births. As per the 2012 WHO estimates, the average annual rate of decrease was 5.9 per cent during the period 1990 to 2010, which is more than the Millennium Development Goal 5 target of 5.5 per cent or more.
What is more surprising is that the reduction in MMR (maternal deaths per 100,000 live births) was almost the same in both the urban and rural areas.
At the current rate of (MMR) reduction, Bangladesh is well on its way to reaching the MDG 5 target of 143 per 100,000 live births this year — a year ahead of schedule. India too reduced maternal mortality by 65 per cent from 569 to 190 per 100,000 live births between 1990 and 2013.
Yet, with only 4.5 per cent annual reduction in MMR, India is bound to miss the MDG 5 target of 5.5 per cent or more decrease rate before 2015.
So how did Bangladesh, one of the poorest countries in the world with the highest population density and where 75 per cent of the population lives in rural areas, achieve it? “It’s a difficult question to answer. Several different things happened and they were interlinked,” said Prof. Shams El Arifeen, Centre for Children and Adolescent Health, ICDDR, B, Shaheed Tajuddin Ahmed Sharani, Dhaka.
“If you were to highlight the factors, the status and value of women have improved. They are more educated and have access to finance. Discrimination against women has come down... there is quite a bit of evidence of that.” Education has in turn increased women’s willingness and ability to seek health care. “Education for women in the 15-24 years age group is particularly important... there is a revolution happening with 80 per cent literacy in women. It is the time when they are starting their reproductive life and having families and babies. A big factor is that the government is consistent in encouraging education regardless of which political party is in power,” he explained.
“In villages can see more girls are educated compared with boys.” One of the biggest benefits of education is seen in reduced fertility. Each individual is replacing himself. “Every couple produces no more than two children. I couldn’t have imagined this 20 years ago,” he pointed out. The family planning norm has changed. Couples used to have more children but that norm has changed. Most couples have 2 or less children. With increased use of contraceptives, fertility rate reduced by 0.7 child per women.
On average, the fertility is currently 2.3. “The desired fertility is 1.6. That gap can be reduced by reducing fertility,” he said. Besides reduced fertility, one third to one half of women who deliver are first time mothers. “Twenty years ago, each couple would have had five children,” Prof. Arifeen said.
It is known that mothers have a greater risk of dying when they have greater parity. “So we don’t see high risk deliveries happening now. There are fewer chances of maternal mortality.
There is a shift from high parity high risk to low risk low parity,” he noted. According to a paper published today (June 30) in The Lancet (Prof. Arifeen is the first author), the fertility reduction led to MMR reduction through two mechanisms. While there was 21 per cent deaths averted through reduction in the number of births, a shift towards more younger women (aged 20-34 years) and those with fewer children delivering babies contributed an additional seven per cent reduction in MMR.
It is a “valid, nationally-representative household survey-based statistical evidence of progress towards MDG 5,” the journal notes. This is just one of the many factors that differentiate Bangladesh from India. The first survey in 2001 included 100,000 households and the second in 2010 covered 174,000 households. Bangladesh witnessed a 40 per cent reduction in maternal mortality during the period the 2000 and 2010. A three-fold increase in deliveries by medically trained healthcare providers was one of the important factors; deliveries attended by midwifery were, however, low (3 per cent).
While there has been an improved access to and use of health facilities, most often people turn to the private sector. There has been only a fair bit of investment in the public health sector. “The private sector is more expensive,” Prof. Arifeen admits.
“The problem is that the ultra-poor don’t benefit. So have to worry [about] how to provide help to that stratum. We definitely need to provide affordable care to everybody.” He does see the Indian model of more public care spending as an advantage to the socioeconomically backward class. “There is a lot to learn from India’s experience,” he admitted. “We are talking about universal health coverage. Affordable service is a part of health coverage. We must provide some sort of safety net for the poor.”
(The Correspondent participated in the Partnership for Maternal, Newborn and Child Health Forum in Johannesburg at the invitation of the Global Health Strategies, New Delhi.)