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 toreaching 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 among women in this age group...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.”
Besides the obvious benefits that come with
education, like greater employability and more resources in hand, education
among girls has led to reduced fertility. This has had a direct impact in
reducing both maternal mortality and child mortality.
As a result of reduced fertility, each individual is
only 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.
As a result of 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.
One more unique thing is, Bangladesh has 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 differentiateBangladesh 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, it is the private sector that people most often turn to.
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 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 is participating in the Partnership
for Maternal, Newborn and Child Health Forum in Johannesburg at
the invitation of the Global Health Strategies, New Delhi.)
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