Maternal Health Programs in Bangladesh

Emergency Obstetric Care (EOC) Program To improve the maternal health situation targeting to achieve the Millennium Development Goal 5, the Government of Bangladesh in collaboration with UNICEF is conducting facility based Emergency Obstetric Care (EOC) Program in all the districts of Bangladesh. All the government medical college hospitals, district hospitals, upazila hospitals, and maternal and child welfare centers take part in providing EOC. A number of private clinics or hospitals and NGO providers also participate in the program. The service is provided in two forms, viz. Comprehensive Emergency Obstetric Care (CEmOC) and Basic Emergency Obstetric Care (BEOC). Currently all medical college hospitals, 2 district hospitals and 269 upazila health complexes provide CEmOC and 59 district hospitals and 132 upazila health complexes provide BEOC. NGO and private providers from a number of districts also provide similar services. Under a program jointly operated by Management Information Systems (MIS) of DGHS and UNICEF, data are collected from the EOC facilities. These data are then translated into a format called United Nations Process Indicators. Table-1 summarizes the source of EOC data we received for the year 2009.
Table-1. Number of hospitals and non-state providers which sent emergency obstetric care data to MIS-Health in 2009
Type of hospital Medical college hospitals District and general hospitals Upazila health complexes Districts from where NGO providers sent data Districts from where private providers sent data Total = No. 13 61 401 30 62 567 Percentage 2.3 10.8 70.7 5.3 10.9 100.0

Data show that there were 448,564 reported deliveries in the countrys EOC facilities in 2009 and there were 434,502 live births. The number of newborn deaths in these EOC facilities was 2,385 and that of maternal deaths was 1,307. Table-2 also shows the division-wise distribution.
Table-2. No. of total deliveries, live births, newborn deaths and maternal deaths in the emergency obstetric care facilities of Bangladesh by Division (Year 2009)
Un Process Indictor Total delivery (N) Live birth (N) Newborn death (N) Maternal death (N) National 448,564 434,502 2,385 1,307 Barisal 20,165 19,310 426 115 Chittagong 65,791 63,224 458 179 Dhaka 150,201 146,237 563 365 Khulna 60,372 59,052 126 112 Rajshahi 128,292 124,651 520 402 Sylhet 23,743 22,028 292 134

Figure-1 shows the rates of newborn and maternal deaths as percentage of total live births and total deliveries respectively in 2009. These death rates are only at the EOC facilities and should not be drawn as reflections of the whole community. Nationally the newborn death rate as percentage of total live births was 0.5%, which was 2.2% and 1.3% in the Barisal and Sylhet divisions respectively; but varied between 0.2% and 0.7% in other four divisions (Khulna, Dhaka, Rajshahi and Chittagong) of Bangladesh. The maternal death rate at facilities as percentage of
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total deliveries was 0.3% nationally. The rate was 0.6% in each of Barisal and Sylhet divisions. The rate varied between 0.2% and 0.3% in other four divisions (Khulna, Dhaka, Rajshahi and Chittagong).

Table-3 shows the detail figures of the process indicators summarized for each division. The reported institutional delivery rates varied between 10.3% and 17.7% with average for the whole country being 15.0%. The met need for emergency obstetric care varied between 37.5% and 59.3% (average: 47.2%). Cesarean section rate was between 4.1% and 8.4% (average: 6.4%). The case fatality rate was between 0.4% and 0.9% (average: 0.6%).
Table-3. Division Summary of data received from the emergency obstetric care facilities in 2009 and translated into process indicators
Process Indictor Expected birth (N) Expected complication (N) ANC service (N) Admission (N) Complication treated (N) Normal delivery (N) Forceps delivery (N) Vaginal breech delivery (N) Cesarean section (N) Total delivery (N) Live birth (N) Still birth (N) Other operation (N) Referred out (N) PNC service (N) Maternal death (N) Newborn death (N) Proportion (%) of all births in EOC facilities Met need of EOC (%) Cesarean section as % of all births Case fatality rate (%) Barisal 196,600 29,499 34,089 31,636 12,706 9,844 49 56 10,216 20,165 19,310 1,087 669 1,811 12,490 115 426 10.3 43.1 5.2 0.9 Chittagong 581,727 87,259 133,524 87,405 32,709 38,812 863 971 25,145 65,791 63,224 3,097 4,477 4,133 49,921 179 458 11.3 37.5 4.3 0.5 Dhaka 940,306 141,046 406,735 202,558 77,945 68,863 1,195 836 79,307 150,201 146,237 4,589 6,569 8,447 185,218 365 563 16.0 55.3 8.4 0.5 Khulna 352,246 52,837 160,536 83,972 25,336 33,392 336 239 26,405 60,372 59,052 1,546 2,048 2,906 57,036 112 126 17.1 48.0 7.5 0.4 Rajshahi 725,691 108,854 217,590 171,368 46,025 82,545 1,333 942 43,472 128,292 124,651 4,552 5,231 9,702 90,173 402 520 17.7 42.3 6.0 0.9 Sylhet 190,456 28,568 46,053 36,558 16,930 14,881 579 398 7,885 23,743 22,028 1,812 2,624 2,302 18,689 134 292 12.5 59.3 4.1 0.8 Country 2,987,086 448,063 998,527 613,497 211,651 248,337 4,355 3,442 192,430 448,564 434,502 16,683 21,618 29,301 413,527 1,307 2,385 15.0 47.2 6.4 0.6

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Table-4 shows the distribution of EOC services provided by the medical college hospitals, district hospitals, upazila health complexes, NGO facilities and the private clinics/hospitals. Out of the 448,564 reported deliveries, 67,999 were took place in medical college hospitals, 71,958 in district hospitals, 135,185 in upazila hospitals, 17,543 in NGO facilities and 155,879 in private clinics/hospitals. It stands at 275,142 (61.3%) deliveries in public facilities and 173,422 (38.7%) deliveries in NGO and private facilities. Of the total public facility deliveries, 24.7% took place in medical college hospitals, 26.2% in district hospitals and the largest proportion (49.1%) took place in upazila health complexes. Of the total deliveries in NGO and private facilities, 10.1% were done by NGO facilities and 89.9% were done by private clinics/hospitals. Table-4.4 reveals that there were 192,430 cesarean sections in 2009, of which public hospitals performed 80,561 (41.9%) and NGO and private facilities performed 111,869 (58.1%) cesarean sections. Of the total public facility cesarean sections (n=80,561), 43.4% were done in medical college hospitals (n=34,960), 32.5% in district hospitals (n=26,181) and 24.1% in upazila health complexes (n=19,420). Of the total cesarean sections done by NGO and private facilities (n=111,869), 5.8% were done by NGO facilities and 94.2% were done by private clinics and hospitals.
Table-4. Summary of data received from the emergency obstetric care facilities in 2009 and translated into process indicators
Process Indictor ANC services (N) Admission (N) Complications treated (N) Normal delivery (N) Forceps delivery (N) Vaginal breech delivery (N) Cesarean section (N) Total delivery (N) Live births (N) Still births (N) Other operations (N) Referred out (N) PNC services (N) Maternal death (N) Newborn deaths (N) Case fatality rate (%) Medical College Hospitals (n=13) 94,426 100,252 41,232 31,314 984 741 34,960 67,999 63,617 4,836 4,473 614 32,255 716 1,428 1.7 District Hospitals (n=61) 104,104 129,359 55,427 44,751 327 699 26,181 71,958 68,144 4,481 9,216 4,080 59,499 400 193 0.7 Upazila Health Complexes (n=401) 431,637 192,866 52,655 113,342 1,789 634 19,420 135,185 131,402 4,709 5,755 21,417 168,829 87 285 0.2 NGO facilities (n=30) 95,910 19,752 2,553 10,403 290 335 6,515 17,543 17,258 341 86 770 25,412 11 112 0.4 Private clinics/ hospitals (n=62) 272,450 171,268 59,784 48,527 965 1,033 105,354 155,879 154,081 2,316 2,088 2,420 127,532 93 367 0.2 Total (n=567) 998,527 613,497 211,651 248,337 4,355 3,442 192,430 448,564 434,502 16,683 21,618 29,301 413,527 1,307 2,385 0.6

Demand side financing (DSF) through maternal health voucher scheme The Ministry of Health and Family Welfare conducts an innovative program to encourage the pregnant women seek antenatal, intra-natal and postnatal cares from the skilled medical personnel. This program is popularly known as Demand Side Financing (DSF). Introduced in 2006 and continuing until now, the program provides a pregnant mother a reimbursable maternal health voucher, if she takes any or other form of pregnancy related health care from skilled medical personnel or health facilities in the program area. The maternal health care includes a package of three antenatal check-ups, safe delivery, a postnatal care within 6 weeks of delivery, and services for obstetric complications. The woman receives a financial benefit worth Tk. 750 for normal delivery. The breakdown of this Tk. 750 is as follows: registration fee:
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Tk. 10 + lab tests for 3 ANCs for 2 blood tests and 2 urine tests: Tk. 140 + consultation fee for 3 ANCs and 1 PNC: Tk. 200 + safe delivery: Tk. 300 + medicine: 100. If there is a complication, such as, forceps delivery, manual removal of placenta, dilatation and curettage, or vacuum extraction of baby, she receives another amount of Tk. 1,000. For management of eclampsia, there is provision for Tk. 1,000. For a case requiring cesarean section, an amount worth up to Tk. 6,000 is given. She may get Tk. 500 to bear costs for travel to the health facility, and another amount of Tk. 500 for referral to the district hospital. A cash amount worth Tk. 2,000 is given as incentives for institutional delivery. After the baby is born in the health facility, the mother receives hygienic toiletries and the newborn toys. In 2009, DSF covered 33 upazilas of Bangladesh, which has been expanded to 53 upazilas.

Maternal and neonatal health (MNH) program With the assistance of UNFPA, UNICEF and WHO and funded by EC and DFID, the Director of Primary Health Care of the Directorate General of Health Services started to implement a Maternal and Newborn Health program is four districts of Bangladesh. The districts are Thakurgaon, Jamalpur, Narail and Moulavi bazar. All the upazilas under these four districts are included in the program. The program focuses on saving maternal and newborn lives through creating need based demand and priority-based actions. The broad principle of this program is Local Level Planning (LLP) and decentralization. The offices of the Civil Surgeon and the Deputy Director of Family Planning serve as the two principal locations for the project. The three UN agencies help ensuring inclusion of the three added values, viz. participation of civil society organization, direct disbursement of funds to agreed cost centers, and reaching the difficult-toreach populations. National level authorities deal with major procurement, training, partnership arrangements with NGOs and national communication campaigns. The project plans to allocate a fixed ceiling of fund to each district based on needs, defined by its poverty level, population and number of upazilas. The fund is in addition to ministrys routine
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allocation. It is proposed that over the lifetime of the project at least 30% of resources at the district level must be devoted to demand side interventions and involving both state and nonstate agencies. There is a coordination mechanism to ensure that local level planning fits to the national MNH policies, strategies and guidelines. The project is designed for implementation for five years in two phases. The first phase is a start-up phase covering a period of 18 months and includes four districts. After 18 months of operation, a review will be conducted. If this is satisfactory, agreement will be reached for expansion and covering an additional 16 districts (implementation for 42 months). If after review it is decided not to move to scale-up, then this project will remain only in 4 districts and end after a further 18 months. The project has a number of novel and innovative approaches, based on global best practices, to accelerate progress towards achievement of MDGs 4 and 5, having the following elements: (i) a districtfocused approach with direct resource allocation to identified cost centres and the application of WHO problem-solving techniques to develop, monitor and implement the plans; (ii) continuum of care that links the mother and newborn and addresses the three delays model; (iii) rights-based equitable approach in planning, monitoring, implementation and supervision through involvement of consumer groups and public health watch groups to ensure accountability to women, families and communities; (iv) piloting initiatives such as contracting of private practitioners to provide specialized services, in an attempt to improve human resources for MNH at the district and upazila levels; (v) pilot testing of demand-side financing schemes (vouchers and other means) targeting the vulnerable and marginalized households to address equity; (vi) pilot testing of ARH community-based and clinic-based youth-friendly services and Voluntary Confidential Counselling and Testing (VCCT) centres in selected districts with high risks of HIV and STIs. Training of manpower for improving maternal health One of major barriers to improve the maternal health is the shortage of skilled manpower in the remote areas to extend obstetric care. To tackle the problem, the Ministry of Health and Family Welfare undertook a short term measure to produce trained manpower with a view to fulfill the gap in the interim period. Young medical doctors were given 6 months training on obstetric and anesthesiology. Number of doctors receiving training in the former discipline was 160 and in the later discipline was 155. The family health visitors (49,522 Nos.) under the Directorate General of Family Planning received training on operation theater management and nursing care. The family welfare visitors (1,475 Nos.) received training on midwifery. The family welfare assistants and female health assistants (5,179 Nos.) received Community Skilled Birth Attendant (CSBA) training. Cervical and breast cancer screening program Cervical and breast cancers are important causes of mortality and morbidity of women in Bangladesh. Early detection may significantly reduce the morbidity and mortality related to these two diseases. The Government of Bangladesh has taken the initiatives to develop a cervical and breast cancer screening program. VIA (Visual Inspection of Cervix with Acetic Acid) test through application of 5% acetic acid identifies the existence of the precancerous condition of the cervix and early cancer. A pilot program assessed the feasibility of this method for cervical cancer screening within the existing government infrastructure of 16 out of 64 districts
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with the support of UNFPA and Bangabandhu Sheikh Mujib Medical University (BSMMU). After completion of the pilot program, the cervical cancer screening program was introduced in all the districts. The government also conducted a pilot program on breast cancer screening in 2007 in the same 16 districts. Currently both cervical and breast cancer training and services are in operation under a combined program. BSMMU is playing important role by providing technical assistant for training, developing referral centers, quality control and management of positive cases. Table-4.5 shows the distribution of health personnel who have been given training on VIA by the project.
Table-5. Distribution of health personnel who have been given training from 2004 to 2010 on VIA (Visual Inspection of Cervix with Acetic Acid)
Year Pilot Program (2004-2005) 2006 2007 2008 2009 2010 (Till June) Designation Doctor Nurse/ FWV Doctor Nurse/ FWV Doctor Nurse/ FWV Doctor Nurse/ FWV Doctor Nurse/ FWV Doctor Nurse/ FWV Total = Medical college hospital/ District hospital /Upazila health complex 31 21 13 21 20 47 24 59 11 66 3 10 326 Maternal and child welfare center 17 32 10 12 13 30 14 27 8 38 5 5 211 Union health and family welfare center 0 12 0 20 0 0 0 0 0 0 0 5 37 Total in each category 48 65 23 53 33 77 38 86 19 104 8 20 574 Total

113 100 134 154 153 28 574

At present this program is continuing in all the 64 districts and screening positive women are referred to the referral hospitals for colposcopic evaluation and management. To serve as the referral hospitals, 79 postgraduate gynecologists from various medical colleges and institutes have been given training on colposcopy. Table-6 shows the referral hospitals with number of trained personnel.
Table-6. Referral hospitals for colposcopy with number of trained health personnel (2006-2010)
Name of referral hospitals Bangabandhu Sheikh Mujib Medical University (BSMMU) Dhaka Medical College Hospital (DMCH) Sir Salimullah Medical College & Mitford Hospital (SSMC & MH) Khulna Medical College Hospital (KMCH) Rajshahi Medical College Hospital (RajMCH) Chittagong Medical College Hospital (CMCH) MAG Osmani Medical College Hospital (SMAGOMCH), Sylhet Rangpur Medical College Hospital (RpMCH) Mymensingh Medical College Hospital (MMCH) Comilla Medical College Hospital (CoMCH) Faridpur Medical College Hospital (FMCH) Bogra Medical College Hospital (SZMCH) Dinajpur Medical College Hospital (DinajMCH) Sher-E-Bangla Medical College Hospital (SBMCH), Barisal Institutes of Mother and Child Health (ICMH), Matuail, Dhaka Total = No. of Colposcopists 23 5 4 6 6 7 3 6 6 5 3 2 1 1 1 79

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From January 2005 to December 2009, VIA test was done in 220,161 women in 56 districts of which 10,224 (4.64%) women were found VIA+ve (Figure-3). About half of the VIA+ve cases (n=4,607; 45.06%) attended the referral center of BSMMU and rest to other medical college hospitals. However, 12% of the positive women did not attend for colposcopy.

The condition of the cervix of the referred VIA+ve cases which have been examined by colposcopy at BSMMU is shown in (Figure-4). In each referral hospital, the women with precancerous condition of the cervix received treatment (LEEP or Cryotherapy) and the women with cervical cancer received treatment.

From January 2007 to December 2009, 146,871 women had Clinical Breast Examination (CBE) tests at the service points of 56 districts. Among them, 3,432 (2.33%) were CBE+ve, who were referred to the referral centers. As of now most of the districts of Bangladesh have at least two centers for cervical and breast cancer screening. It is opined that awareness creation, utilization
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of facilities, and further scaling up will have noticeable impact on improvement of womens health and prevention of cancer. Tetanus toxoid (TT) for women of child bearing age Bangladesh is maintaining maternal and neonatal tetanus free status since 2008. EPI Bangladesh aims to immunize the women of child bearing age with tetanus toxoid vaccine (TT) before the age of 18. A period of 2 years and 7 months is required to complete all the 5 doses of TT vaccines. If a woman starts it at the age of 15, and maintains the exact interval, she would be able to complete all the doses before she reaches the age of marriage a protection for her entire reproductive life. Figure-4.10 shows the TT valid vaccination status of the country. Although the crude TT vaccination coverage (TT vaccination doses without maintaining exact interval) is relatively higher, it is assumed that coverage of TT4 and TT5 doses go down in the country. Attention is needed to improve the situation particularly in this regard.
5.

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