Maternal mortality in Bangladesh: a Countdown to 2015 country case study

doi:10.1016/S0140-6736(14)60955-7

The Lancet

Volume 384, Issue 9951, 11–17 October 2014, Pages 1366-1374

https://doi.org/10.1016/S0140-6736(14)60955-7 Get rights and content

Summary

Background

Bangladesh is one of the only nine Countdown countries that are on track to achieve the primary target of Millennium Development Goal (MDG) 5 by 2015. It is also the only low-income or middle-income country with two large, nationally-representative, high-quality household surveys focused on the measurement of maternal mortality and service use.

Methods

We use data from the 2001 and 2010 Bangladesh Maternal Mortality Surveys to measure change in the maternal mortality ratio (MMR) and from these and six Bangladesh Demographic and Health Surveys to measure changes in factors potentially related to such change. We estimate the changes in risk of maternal death between the two surveys using Poisson regression.

Findings

The MMR fell from 322 deaths per 100 000 livebirths (95% CI 253–391) in 1998–2001 to 194 deaths per 100 000 livebirths (149–238) in 2007–10, an annual rate of decrease of 5·6%. This decrease rate is slightly higher than that required (5·5%) to achieve the MDG target between 1990 and 2015. The key contribution to this decrease was a drop in mortality risk mainly due to improved access to and use of health facilities. Additionally, a number of favourable changes occurred during this period: fertility decreased and the proportion of births associated with high risk to the mother fell; income per head increased sharply and the poverty rate fell; and the education levels of women of reproductive age improved substantially. We estimate that 52% of maternal deaths that would have occurred in 2010 in view of 2001 rates were averted because of decreases in fertility and risk of maternal death.

Interpretation

The decrease in MMR in Bangladesh seems to have been the result of factors both within and outside the health sector. This finding holds important lessons for other countries as the world discusses and decides on the post-MDG goals and strategies. For Bangladesh, this case study provides a strong rationale for the pursuit of a broader developmental agenda alongside increased and accelerated investments in improving access to and quality of public and private health-care facilities providing maternal health in Bangladesh.

Funding

United States Agency for International Development, UK Department for International Development, Bill & Melinda Gates Foundation.

Introduction

The Countdown to 2015 for maternal, newborn, and child survival in its 2012 cycle reports that only nine of the 75 Countdown countries are on track to achieve the Millennium Development Goal (MDG) 5 target to reduce the maternal mortality ratio (MMR, maternal deaths per 100 000 livebirths) by three-quarters between 1990 and 2015.¹ We reviewed the experience of Bangladesh, one of the nine countries on track, in the improvement of maternal health as part of a series of in-depth country case studies commissioned by Countdown.

Bangladesh has one of the highest population densities in the world, with a population of more than 150 million and a land size of 144 000 km². Situated at the top of the Bay of Bengal, it is largely surrounded by India. Administratively, the country is divided into divisions (seven), districts (64), Thanas and Upazilas (485) or Municipalities and City Corporations (324), and unions (4546).²

Recent economic growth in Bangladesh has been robust, averaging 6% annually between 2001 and 2012 despite periods of political turmoil and frequent natural disasters; income per head reached US$848 per year in 2012. Progress has also been rapid in the social sector with increasing educational levels, especially for women.³ However, Bangladesh remains one of the poorest countries in the world, with nearly a third (32%) of the population living below poverty and 29% underemployed.4, 5 Total health expenditure has remained low, representing only 3% of gross domestic product (GDP), with only a quarter of health spending coming from the public sector.⁶

Several factors influenced Countdown's decision to invite Bangladesh to undertake this in-depth analysis of the country's progress in improvement of maternal health. First, Bangladesh is one of the very few countries that are on track to achieve the MDG 5 target.⁷ Second, Bangladesh is unique among low-income and middle-income countries in having valid, nationally-representative household survey-based statistical evidence of progress towards MDG 5. Third, the reduction in maternal mortality has been accompanied by important changes in other indicators of maternal health and socioeconomic development. These factors render Bangladesh an ideal real-world setting for the study of the driving forces behind large changes in risk of maternal mortality at a population level.

We explored how Bangladesh achieved these reductions in maternal mortality. We focused on change between 1998–2001 and 2007–10, on the basis of the reference periods of the 2001 and 2010 Bangladesh Maternal Mortality Surveys (BMMS).

Section snippets

Data sources

We used data from two high-quality and highly comparable household surveys, the 2001 and 2010 BMMSs, for the primary analyses in this study. The BMMSs were designed to assess the situation of the country with respect to maternal health, and particularly to provide national estimates of MMR. Both surveys were large, covering about 100 000 households in 2001 and 174 000 households in 2010, and nationally representative, using a three-stage sampling design.8, 9 Deaths of women of reproductive age

Results

MMR in Bangladesh substantially decreased from 322 (95% CI 253–391) deaths per 100 000 livebirths in 1998–2001, to 194 (149–238) deaths per 100 000 livebirths in 2007–10. The implied average annual rate of decrease is 5·6%, slightly faster than the average annual reduction rate required (5·5%, based on the formula: P_t = P₀ × e^rt; for which P_t is the value at time t, P₀ is the initial value, r is the growth rate, and t is the time in years) between 1990 and 2015 to meet the MDG 5 target. The

Discussion

At the current rate of MMR reduction, Bangladesh would reach the MDG 5 target of 143 per 100 000 livebirths by 2014, a year ahead of schedule. This rate of reduction is very similar to that noted in the ICDDR,B Matlab Government Service Area (5·3%; appendix). In their 2010 modelled estimates of maternal mortality in 181 countries,²² Hogan and colleagues had reported an annual rate of decrease of 6·4% for Bangladesh for the period 2000–08.²² The 2012 WHO/UNFPA/UNICEF/WB model estimates arrive at

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ArticlesMaternal mortality in Bangladesh: a Countdown to 2015 country case study

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Data sources

Results

Discussion

Lancet

Lancet

Building a Future for Women and Children: The 2012 Report

Annual Report 2011-2012

Bangladesh Economic Review 2010

Report of the Household Income and Expenditure Survey 2010

Report on Monitoring of Employment Survey 2009

National Health Accounts 1997–2007

Trends in Maternal Mortality 1990-2010: WHO, UNICEF, UNFPA and The World Bank estimates

Bangladesh Maternal Health Services and Maternal Mortality Survey 2001