The preliminary results of the Bangladesh Maternal Mortality and Health Care Survey (BMMS) released on Wednesday in Dhaka showed that the maternal deaths were 196 per 100,000 live births in 2016 when the survey was carried out.
It was 194 in 2010 when Bangladesh witnessed a steady decline in maternal deaths from 322 in 2001.
But, in 2016, a total of 50 percent of births were attended by trained health professionals compared with only 27 percent in 2010.
An analysis of the survey points to the ‘low quality of care’ for this increasing rate of mortality despite women seeking medical care.
It comes as a shock to most health experts as Bangladesh was once globally acclaimed for cutting maternal deaths.
Dr Ishtiaq Mannan, Deputy Country Director, Save the Children in Bangladesh, who was one of the key analysts of the survey, called it an “alarming” trend while speaking to bdnews24.com.
“We have seen a substantial increase of some key indicators like increasing rate of facility deliveries, skill birth attendants, and healthcare utilisation rate, but the mortality rate has not dropped.”
“It means the quality of care is not good. It means women went to the hospital, but they received sub-standard treatment,” he told bdnews24.com.
The increase in the number of medically trained providers is driven by a rapid rise in 'facility births'. The percentage of births in health facilities increased to 47 percent in BMMS 2016 from the 23 percent in 2010.
Medically trained attendance for home deliveries has consistently been around three to four percent during 2001–2016. The private sector accounted for most of the increase in facility deliveries, the survey shows.
Between BMMS 2010 and 2016, the percentage of deliveries in private facilities jumped from 11 percent to 29 percent, while deliveries in public facilities increased from 10 percent to 14 percent.
In the public sector, 13 percent (out of 14 percent) of the births take place in Upazila and higher-level facilities. NGO facilities now account for 4 percent of births, up from 2 percent in BMMS 2010.
Delivery by C-section increased dramatically, from 12 percent in 2010 to 31 percent in 2016, an abnormal rise as WHO says 10 percent to 15 percent of the total deliveries may be C-section because of complications.
In private facilities, C-sections accounted for 83 percent of deliveries, compared with 35 percent in public facilities and 39 percent in facilities run by NGOs, according to the survey.
The percentage of women receiving the complete continuum of maternity care (antenatal care, delivery care, and postnatal care from medically trained providers) has increased significantly from five percent in 2001, to 19 percent in 2010, and to 43 percent in 2016.
Seeking facility-based care for reported maternal complications has increased from 29 percent to 46 percent between 2010 and 2016.
What went wrong?
Dr Mannan said Bangladesh is not the only country that has experienced increased utilisation of maternal services with no impact on maternal mortality rate.
“There is international precedence for a stall in MMR decline in low- and middle-income countries, even with increased care in facilities,” he said, “but we expected progress in Bangladesh.”
An analysis of 37 countries in sub-Saharan Africa (SSA) and South and Southeast Asia (SSEA) found a weak association between the MMR and the percentage of deliveries occurring in a health facility.
These data suggest that increasing facility delivery is important but not sufficient to lower maternal mortality rate or MMR.
“Quality of care is fundamental to improve maternal health outcomes,” he said. “Most facilities in Bangladesh are not fully ready to provide quality maternity care.”
Findings from other studies, including the Bangladesh Health Facilities Survey 2014, show substantial deficiencies in the readiness of both public and private health facilities to provide high-quality maternity care.
Only 39 percent of facilities that provide normal delivery care had a delivery care provider on call or on-site around the clock.
Only 3 percent of facilities had service readiness to provide quality normal delivery services.
“Maternal deaths will only be prevented when women go to facilities and those facilities are fully staffed and equipped with competent health workers and prepared to handle obstetric emergencies when they occur,” Dr Mannan said.
The new survey found only 46 percent of Upazila and higher level public facilities and 20 percent of private hospitals had at least one staff member who ever received training in emergency obstetric care (EmOC).
It says 30 percent of public facilities at the Upazila level and above perform Caesarean deliveries, but only 10 percent have comprehensive EmOC services.
The increase in facility delivery between BMMS 2010 and BMMS 2016 is mostly driven by an increase in births in private facilities when most of the women underwent C-section, according to the study.
Service readiness for maternal care is poorer at private facilities compared to Upazila level and higher level public facilities, it has found.
Hemorrhage and eclampsia account for 55 percent of maternal deaths, the study says.
The risk of dying from these causes remained unchanged between BMMS 2010 and BMMS 2016.
There has been little progress in interventions to address these causes, according to the study.
Over 50 percent of deliveries are occurring at home; community distribution of misoprostol for prevention of haemorrhage only covered about 17 percent of births, according to the survey.
Just 40 percent of all facilities (excluding community clinics) have supplies of injectable oxytocin to stop the haemorrhage. Only 28 percent have injectable magnesium sulphate to treat eclampsia.
Dr Mannan has three recommendations to change the situation.
“First, we have to improve overall implementation efficiency of any programme or initiatives.”
And for that, he suggests ensuring comprehensive standards or quality care, effective coverage of key components for preventing eclampsia and haemorrhage deaths, and good referral system.
“We have to have a functional referral in place. Nineteen percent women died on the way to the facility where they were referred. That rate was 13 percent in 2010.”
The other two recommendations include regulation and quality control of the private sector, and monitoring of quality of care along with the coverage quantity.
BMMS is one of the largest household sample surveys in Bangladesh which covered about 100,000 households in 2001, 175,000 households in 2010, and about 309,000 households in 2016.
Like previous surveys, BMMS 2016 was conducted by the National Institute of Population Research and Training (NIPORT).
MEASURE Evaluation, USA, the International Centre for Diarrheal Disease Research, Bangladesh (ICDDR, B), and the United States Agency for International Development (USAID) are providing technical assistance for the survey.
Apart from the government of Bangladesh, the USAID, and the DFID funded the survey.