Marked improvements in maternal and child health in Bangladesh
Bangladesh has witnessed marked improvements in maternal and child health over the last four decades. Women are having fewer children, and these children are increasingly likely to live longer and healthier lives than previous generations. Women are also receiving more skilled assistance during pregnancy and delivery than ever before. Further improvements would need effective public-private and NGO partnerships to improve access to and quality of services. Bangladesh also needs to be prepared to deal with the worrying rise in non-communicable illnesses, like hypertension and diabetes. These challenges, brought to light by the newly released 2011 Bangladesh Demographic and Health Survey (2011 BDHS), will require policy and program reform, more targeted and more innovative interventions, and long-term behavior change.
Fertility: In 1975, Bangladeshi couples on the average had 6.3 children, and now it has declined to 2.3. Behind this success story are regions and population groups with higher than average fertility. Nationwide, fertility is highest in Sylhet, where only 45 percent of women use family planning, compared to the national rate of 61 percent. The contraceptive method mix depends heavily on temporary methods, increasing costs and service delivery requirements for the government as well as the risk of contraceptive failure. Use of the more reliable and cost-effective long-term methods has not increased over the last decade. Teen-age fertility is declining more slowly than fertility among older women, and many young people are poorly informed about family planning.
Population groups most in need of family planning information and services are young women and men, and families in Sylhet and Chittagong. Both the public and private sector need to promote and provide family planning services appropriate to individual needs and explore more flexible approaches such as mobile clinics and enhanced community support. Family planning needs to assume a higher profile nationwide with comprehensive behavior change communication (BCC) programs reaching many more women through mass media, community health workers, and other innovative approaches. Adolescents both married and unmarried need better access to information on reproductive health.
Maternal Health: According to the 2011 BDHS, only 26 percent of women who had a child in the last three years received the recommended four or more antenatal care (ANC) visits; only 29 percent of recent births took place in a health care facility, and only 27 percent of recently delivered mothers received post-natal care (PNC). The poorest women are the least likely to receive care, and while the gap between the rich and the poor is narrowing, far too many disadvantaged women give birth with minimal support from the health care system. Bringing more women into contact with the public and private health care system early in pregnancy is critical to improving maternal and newborn health. Women who receive ANC are much more likely to deliver in a facility and to receive PNC than women who do not see skilled providers during pregnancy.
Increasing women’s access to and use of health care facilities will require major interventions including improving skills among lower cadres of health care providers, ensuring that skilled providers are in residence at union and lower levels of the health care system through various incentive schemes, and establishing and enforcing standards of quality of care. The ongoing effort to revise the National Maternal Health Strategy and development of Standard Operating Procedures are appropriate opportunities to address these high priority issues.
Child Health: Child survival is improving substantially in Bangladesh. Under-five mortality has dropped from 133 to 53 deaths per 1,000 live births in just 20 years, benefitting both urban and rural children alike. The causes of death have changed over time. Diarrhea, once responsible for 20 percent of all deaths is now being controlled by frequent use of oral rehydration salts, zinc, and support from health care providers. Increasing facility-based deliveries have contributed to reducing the prevalence of birth asphyxia.
To reduce early deaths even further Bangladesh must target the poorest populations where infant and child mortality has not declined at the same pace as the rest of the nation. Strategies are needed as well to tackle respiratory and other infections, especially in the neonatal period, through improved immediate newborn care practices and better management of illness. Encouraging parents to bring their sick children to trained providers, improving case management through rational use of antibiotics, and expanding vaccination against haemophilus influenza type b and pneumococcal illnesses will save many lives. More community interventions are also needed to prevent drowning, which now accounts for more than 40 percent of all deaths between ages one and five.
Nutrition: Malnutrition contributes both to child illness and death and also to impaired growth and mental development. Malnourished children suffer lifelong deficits. While nutrition has improved somewhat in the last 10 years, a greater proportion of Bangladesh’s children suffer from acute and chronic malnutrition than children in far poorer countries like Uganda and Nepal. Anemia is common among both women and children, contributing to more frequent illness and lost productivity. Among wealthier urban populations, overnutrition is on the rise. As the causes of malnutrition are complex, multisectoral approaches will be needed to bring about change.
Behavior change communication is needed to increase exclusive breastfeeding in the first six months of life, to improve diets for young children and adults, with a greater emphasis on lean protein vegetables, and fruits. Communities must be mobilized to enhance local hygiene and sanitation. The government must develop agricultural policies that promote growth of various healthy foods.
Non-communicable diseases: The 2011 BDHS is the first survey in Bangladesh to collect blood samples from a nationally representative sample to estimate the prevalence of high blood pressure and diabetes among men and women age 35 and older. The results are alarming. Overall, one in three older women and one in five older men have hypertension or high blood pressure. Many more are pre-hypertensive, or on the cusp of serious disease. In addition, one in nine women and men age 35 and older has diabetes and one in every four is pre-diabetic. This translates into 25 million people living with hypertension or pre-hypertension and 17 million with diabetes or pre-diabetes. These chronic conditions too often lead to serious heart disease, disability, and premature death and that place a staggering burden on the country’s health care system.
Preventing NCDs is safer, more effective, and much less expensive than treating them. The Government of Bangladesh has recognized the growing burden of chronic illness and has established guidelines for prevention and treatment. Most health care providers and facilities are not equipped to deal with chronic disease, however, and community awareness of prevention, symptoms, treatment, and complications is minimal. Immediate interventions are essential to improve health workers’ knowledge and skills, to establish screening systems in health care facilities and in the community, to supply appropriate drugs, and to educate the population.
The 2011 BDHS collected data from almost 18,000 households. Interviews were conducted with over 17,800 ever-married women age under age 50 and almost 4,000 ever-married men age 15-54. The survey was conducted under the authority of the National Institute for Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare and implemented by Mitra and Associates, a Bangladeshi research firm located in Dhaka. ICF International, a US-based company, provided technical assistance. The U.S. Agency for International Development (USAID) provided financial assistance.