Rezaul Haque

Achieving Millenium Development Goals on Maternal health

General information of Bangladesh• Peoples republic of Bangladesh is bordered by India on three sides

except for a small border with Myanmar (Burma) to the far southeast and by the Bay of Bengal to the south. The capital is Dhaka

• Total area of Bangladesh is 1,47,570 square kilometer.

• Total population is 15,25,18,015 out of that male is 7,63,50,518 (50.06%) and female is 7,61,67,497 (49.94%).

• Population Growth rate is 1.34%.

• Contraceptive prevalance rate is 61%.

• Life expentency for male and female are 65.7 and 68.3 years respectively.

• The population density is 1034 per square kilometer.

• MMR 194/100000 live birth.

• Malnutrition among women of reproductiveage group is 45%.

• Mean age at marriage (Female) 18.5 years.

Gonoshasthaya Kendra (GK) (People’s Health Center)

• GK started the journey during the liberation war in 1971 as Bangladesh Field Hospital.

• In 1972 it is registered as a public Charitable Trust with the vision that the fate of the country depends upon the fate of the poor and the development of the country depends upon the development of rural community particularly women, with basic health services including reproductive and child health care services through a cadre of village-based health workers, known as paramedics, mostly female to over one million population in 647 villages in 50 unions in 17 locations of Bangladesh till 2012.

• To access in the health care services GK introduced a social based heath insurance scheme for the benefit of the poorer section of the community in 1973.

Objectives of GK• Develop people oriented health management programs and make people

aware of health issues.

• Train paramedics, doctors and impart skills to women and men to make them self-reliant, thereby making GK a self-reliant organization.

• Enable women to improve their self-image and encourage them to assert themselves.

• Organize poor women, train them and provide them opportunities for income generation.

• Provide basic education, particularly to children and women of poor families.

• Play an advocacy role for the well being of poor people in national and international levels.

• Undertake relief and rehabilitation programs for natural disaster mitigation and also conduct preparedness programs.

• Promote the Bengali language and instill pride in the mother tongue.

• Create social awareness against fundamentalist, protect the interest of minorities and fight communal violence

Reproductive Health Care Services of GK • To provide comprehensive primary

health care GK adopted the holistic approach where women are brought in the center of planning and development.

• After the formal training the health workers are posted at GK‘s Union level Health centres they work together with the Traditional Birth Attendants under the supervision of a senior health worker worker to provide services to the families in village 15 to 18 days in a month and carry simple medicines with them.

• GK provides a wide range of reproductive and child health and family planning services in its programme villages.

Services of reproductive health care(i) In ANC services

i) checking of oedemaii) checking blood pressure, jaundice and anaemiaiii) Testing of urine for sugar and albuminiv) Examining eyes, ears and teethv) Examining abdomen for fundal height, foetal movement and

foetal heart soundvi) Cutting nailvii) Doing blood grouping and random blood sugar viii) Distribution of iron and calcium tablets amongst pregnant

womenix) Immunisation of pregnant women against tetanusx) Identification and regular follow-up of high risk mothers and

ensure their timely treatment including referral xi) Health awareness massages to pregnant women and their

families for additional 2 hours rest in noon and additional food even before the male members.

xii) Promotion and delivery of family planning services

(i) In PNC servicesi) Follow-up of the mothers and the newborns

ii) Immunisation of children under age one against eight deadly diseases: Diphtheria, Whooping Cough, Tetanus, Polio, Tuberculosis, Measles, hemofailas influenza and hepatitis-B

iii) Promotion of additional nutrients and a balanaced diet for lactating mothers and newborns with family members

iv) Promotion and delivery of family planning services

Gender equality and equity for women• In the training curriculum for the paramedics gender issues are incorporated.

• A crèche at GK is enabling women to work and study despite the demands of motherhood

• GK women are entitled to six months maternity leave, four months with full pay

• They are paid through a bank rather than in cash. It helps them to have some degree of autonomy within their families.

Figure 1 show a considerable reduction in Maternal mortality ratio (MMR) by 39.14%, from 178.76 per 100,000 live births during 2000-2004 to 108.79 per 100,000 live births during 2009-12 GK programme area.

Maternal mortality ratio (MMR) in GK program area 2000-2012

MMR, National and GK programme areafrom 1990-2011

MMR in GK area during 1992-93 is 36.54% lower than the national level (570)during 1990. MMR in GK area during 2001 – 2002 is 46.96% lower than that ofthe national level (320) in 2001. MMR in GK area during 2010-2011 GKachieved the Millennium Development Goal on MMR of 143 in 2015 and36.34%lower than that of the national level MMR 194.

MMR in GK programme area from April 2002 – April 2012

The figure shows the trend of Maternal Mortality Ratio in GK programmesarea. GK achieved the Millennium Development Goal on MMR in April 2008 toApril 2009 (1415 Bangla year).

Place of maternal death in GK programme area from April 2002- April 2012

Figure shows that most of the maternal death occurs in the hospital(108/238) 45.38% and (88/238) 36.97% in home and (42/238) 17.65% on the way tohospital

Distribution of birth, reproductive age and maternal deaths from April 2002-April 2012

The table presents all female, 15-49 years female age group death rate and

maternal mortality ratio in the GK area during April 2002 - April 2012.

Group Population Deaths Death rate (per 1000)

Female all ages 4875883 8062 1.65

Females aged 15-49 2475671 1637 0.66

Females with pregnancy termination 160523 238 1.48

Live births 149007 238 1.59

MMR by Life Span (duration) of GK Program Area from April, 2011- April, 2012

Life Span of GK program areas

Number of Villages

Maternal Death Live birth MMR (per 100,000 live births)

0 - 4 years 27 1 508 196.85

5 - 9 years 29 1 633 157.98

10 years and above 591 9 12055 74.66

Total 647 11 13196 83.36

The table shows that MMR is 62.07% and 52.74% lower than that villages of GK is working 10 years in comparing of that village 0-4 years and 5-9 years

Factors behind the succes

1.

2. Identification and Follow-up of ‘High Risk Mothers’

3. Social accountability

4. Skilled/Trained Traditional Birth Attendants (TTBAs)

5. Backup Hospital with motivated and committed staffs

1. Higher ANC Visit and Services

Maternal Mortality by direct Causes of Death from April 2002 - April 2012

Causes of Death Total % of direct causes % of all causes

Ante Partum Eclampsia 21 11.23 8.82

Ante Partum Haemorrhage 14 7.49 5.88

Antepartum Haemorrhage with Prolapse uterus 1 0.53 0.42

Obstructed Labour 22 11.76 9.24

Post Partum Eclampsia 28 14.97 11.76

Post Partum Haemorrhage with Retained Placenta 44 23.53 18.49

Post Partum Haemorrhage without Retained Placenta 44 23.53 18.49

Ruptured Uterus 7 3.74 2.94

Infection due to abortion 6 3.21 2.52

Total 187 100.00 78.57

Indirect Causes of Maternal Death from April 2002 - April 2012

Causes of Death Total % of indirect causes % of all causes

Cardiac Failure 16 31.37 6.72

Anaemia 7 13.73 2.94

Hepatic Failure 5 9.80 2.10

Snake bite 1 1.96 0.42

Acute Diarrhoea 1 1.96 0.42

Respiratory Failure 4 7.84 1.68

Renal failure/Kidney 4 7.84 1.68

Stroke 3 5.88 1.26

Hypertension 4 7.84 1.68

Traumatic injury 2 3.92 0.84

Anaesthesia 1 1.96 0.42

Fever unknown origin 1 1.96 0.42

Unknown 1 1.96 0.42

Murder 1 1.96 0.42

Total 51 100.00 21.43

Conclusion• Achieving MDGs in MMR is possible in rural areas

• Trained and committed workers, who are related to ANC and PNC services

• A backup hospital to support the referral cases