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“Be attentive to the adolescents”
Renowned population expert Professor Dr. AKM Nurunnabi talked to A.B.M Shamsud Doza of The Daily Star on the present situation of universal access to reproductive health in Bangladesh.
The Daily Star (TDS): What is the present status of universal access to reproductive health in Bangladesh?
A.K.M Nurunnabi (AKN): Universal access to reproductive health has improved a lot. Contraceptive prevalence has been improved and the current rate is 61%. That is quite an achievement. You can call Bangladesh a contraceptive society.
Having said that, we should also be aware of the drop out rate. In the last demographic health survey, we found that more than 50% of the users dropped the usage of methods in a year, which has reduced to 36%, according to BDHS 2011. That is an improvement, but 36% is also a very high number in terms of dropout of contraceptive method.
If we look at the total fertility rate, it is almost near replacement level. So, that is an achievement. But there are also gaps in terms of hard-to-reach areas, poor people, uneducated people, people living in slums. They have little access to reproductive health facilities. Their conception rate is low and TFR is very high.
Proper antenatal care needs four visits to complete a safe delivery process for a childbirth. But we find very few women go to the experts or the health clinic or any trained personnel to complete the four visits. Therefore, rate of antenatal care is very low. Postnatal care is also not that high in proportion, because we see that neonatal mortality is very high compared to the mortality under five and compared to the other mortality rates.
We have health infrastructures like community clinics, Union centres and centres, Upazilla health centers, and clinics where one can obtain reproductive health care services. But these are far from adequacate. These infrastructures lack facilities, services, trained personnel and awareness about accessing those facilities.
If you look at the unmet need for family planning, it is still 12% in Bangladesh. If we can meet that 12%, right now, the total fertility rate will come down to 1.8, which would reduce the population significantly.
If we can do that, especially for those who are less educated, ultra poor, living in chars and slum areas it will be a great achievement. The family size of these people is big and the complicacy related to reproductive health, i.e. maternal mortality rate, is higher than that of the educated and urban people.
In the urban areas, we do not have a concerted effort for reproductive health from the government side, although there are efforts from the non-government side through donor agencies. City corporations are conducting those programmes. However, that is not enough. Our urbanisation rate is growing so rapidly. There are 33-35% of people living in the urban area now. City corporation authorities do not have enough capacity to handle the situation there. So there are achievements as well as shortcomings.
Although in terms of overall mortality - maternal mortality and child mortality - we are progressing and have received UN award. We may receive another award for reducing maternal mortality.
We are lagging behind in terms of neonatal mortality, which happens due to the complicacy arising out of reproductive health problems, especially for the mothers who are under 18. This is a serious concern for Bangladesh. Our legal age of marriage is 18, but the girls are getting married at 15.6 years on average according to BDHS, 2011. It is child marriage. Child marriage is occurring for 66% girls in Bangladesh. Even if we have success, we cannot sustain that success because of this child marriage and early child bearing. This problem is further exacerbated by limited access of adolescent girls and mothers to reproductive health. 35% of the girls are becoming mothers by 19 years of age. So, with an immature reproductive system, a child is being forced to become a mother of a child. So, the health of mother and child are at risk, and both suffer from malnutrition and reproductive health complications.
TDS: On the whole, adolescents do not have that much access to universal reproductive health services. Why is it so? What should the government do to reach them?
AKN: The problem is with our perception about adolescents. They are regarded neither as adult nor as child. They are in no man's land situation, and the major changes that go through the body and mind of a person is at that age. In health facilities, we do not have adolescent friendly environment. Although the government is trying to focus on this, but when you visit a hospital or a clinic you do not see a place a room, or any facility that is only meant for the adolescents. It is because of the perception of the society as well as the lack of communication between the adolescents and the social network. They cannot express themselves to their parents or teachers; the only place they can express their needs and other queries is to their peers. Peers are also of their age they do not have the knowledge to substantiate the catering of the need of adolescents. We need to be very careful as well as attentive regarding this issue.
If we become attentive to the adolescent group, then the population rate of Bangladesh would be reduced drastically. For example, the adolescent fertility rate in Bangladesh is one of the highest in the world, 124/1000, which is not desirable. Adolescents are one fourth of the people of our country and they are not being addressed very seriously. So be attentive to the adolescents
TDS: What are the priority areas that we should emphasise on?
AKN: We should priorities on: (i) family planning; (ii) emergency obstructive care, (iii) maternal care and childcare, and (iv) provision of services.
We have enough policies in this nation; we need implementation and execution.
Both the government and NGOs should be attentive to urban health situation, not only the reproductive health but also the overall health situation. Dhaka is a mega city. Almost 38-40% people are living in slums of this mega city. Poor slum dwellers do not have access to reproductive health services. We should be particularly attentive to their need.
'Disadvantaged people,' it may be adibashis, small minority group in terms of region, in terms of profession, in terms of anthropological identification, should be prioritised and brought in the forefront.