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Safe Motherhood: Achievements and Challenges
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 2011.1 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 B D H S 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. ARM Mahbubur Rahman, Line
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.
Director-CCSD, DGFP
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 recentyears.
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 age 16 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 significandy 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 thesecondaryschool.
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 espe-
cially 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.