State of the World's Midwifery 2014 - Bangladesh: Achieving MDG 5
Publication date: 2014
Bangladesh Achieving MDG 5 Maternal Mortality With a population of 155 million in 2013i, Bangladesh is the 8th most populous countries in the world. It is also among the top fifteen countries in the world when it comes to maternal mortality. With an estimated 5,200 women dying in pregnancy or childbirth each year, Bangladesh accounts for almost 2% of the global maternal death burdenii. Bangladesh has made significant progress in reducing the maternal mortality ratio and is currently on track to reach the 75% reduction in the MMR required by MDG5. According to UN data, in 2013 the MMR is 170 per 100,000 live births. If the current trend continues Bangladesh should be able to reach the MDG goal of a MMR of 143 by 2015. Fifty percent of all maternal deaths in Bangladesh are due to just two direct obstetric causes – hemorrhage (31%) and eclampsia (20%). 36.5% of maternal deaths are due to indirect causesiii. An estimated 650 of these deaths are among adolescentsiv. Family Planning and Maternal Health v,vi,vii,viii In addition to a 75% reduction in the MMR, MDG5 also calls for universal access to reproductive health care by 2015. While Bangladesh is doing well with access to FP, maternal care indicators need to be improved. The following shows current coverage with key reproductive services in Bangladesh. Family Planning 52.1% of women in Bangladesh use modern family planning methods, 13.5% have an expressed unmet need for family planning (DHS 2011). Antenatal Care Just 26% of pregnant women had at least 4 ANC visits. Skilled Delivery Care As measured by the 2011 DHS survey, only 32% of the annual 3.0 million births in Bangladesh were assisted by a skilled attendantviii. Estimated Impact of Universal Access to Reproductive Health Family Planning Providing women with access to family planning and making it possible for them to decide how many children they want and when to have them, reduces the overall number of deaths by reducing the number of women dying due to pregnancies they never intended to have. Meeting only 25% of the unmet demand for family planning in Bangladesh, i.e., supplying 1.2 million additional women with access to family planning would reduce the number of unintended pregnancies by 440,000 and deaths related to unintended births and abortions by about 770. Maternal Health Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. The following interventions and drugs tackle the four top causes of maternal deaths in Bangladesh: Prevention and management of hemorrhage/treatment of postabortion complications - Oxytocin/Misoprostol: Prevention and management of eclampsia with Magnesium sulfate Prevention and treatment of sepsis with Clean delivery kits and antibiotics Number of Maternal Deaths that Could be Prevented Providing all women with the required maternal health medicines and supplies would prevent an additional 1,750 deaths, reducing the annual number of deaths to 2,700 and the MMR to about 95, making it possible for Bangladesh to not only reach, but substantially exceed its MDG goal of 143. In addition, these interventions would have a significant impact on child, and in particular, newborn mortality. Currently Bangladesh has about 75,000 neonatal deaths a year. More than 13% of these, or almost 10,000, could be prevented by providing women with the above life-saving interventionsix. Essential Drug Requirements and Costs Maternal Health Drugs For Universal Coverage Drug and commodity requirements to provide the care detailed above would cost approximately $12 million, $4.2 million for additional FP supplies and $8 million for maternal health (detailed calculations are available in Annex 1). Required health system investments Additional investments will be necessary to strengthen countries’ logistics systems and to ensure that health providers (both at facility and community level) know how to administer these drugs. Annex 1. Methodology The following describes the methodology used to arrive at the impact and cost estimates in the factsheet. Maternal Mortality The number of current annual maternal deaths was calculated using the 2013 MMR from the 2014 publication: Trends in Maternal Mortality: 1990-2013. UNFPA, WHO, World Bank, UNICEF http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/ applied to the estimated number of births in 2013 (based on population data from the UN Population Division). Deaths Prevented through Family Planning The number of unintended pregnancies averted was calculated by comparing the number of pregnancies that would have happened if the 1.2 million (25% of the 4.8 million women with currently unmet need in Bangladesh) had not been able to access contraception to the number of pregnancies that would occur if these women used contraception (i.e. only experienced pregnancies due to failure of their chosen method). It was assumed that 40% of all women would have gotten pregnant if not using contraception. The average failure rate of contraceptives was estimated to be 3%. Based on regional data collected by the Guttmacher Institute for its 2014 update of “Adding It Up” it was estimated that only about 39% of unintended pregnancies would be carried to term, 49% would be aborted and 13% would end in a miscarriage. Family planning reduces the absolute number of maternal deaths in a country but since it reduces both numerator AND denominator of the Maternal Mortality Ratio (defined as deaths per 100,000 live births) the reduction in maternal deaths caused by family planning is not reflected in the MMR. The estimated reduction in number of deaths required to achieve the country’s MMR goal differs therefore slightly depending on the assumption made about the number of births. The estimate in the first paragraph uses the current number of births, while the estimate in the Estimated Impact paragraph is based on a lower number of births (originally projected number of births minus unintended births averted through the provision of contraception to women with unmet need). Deaths Prevented through Maternal Health Interventions It was assumed that half of the women currently covered by skilled birth attendance, i.e. about 16%, already had access to the three live-saving drugs. This coverage was then scaled up to 100%. The following effectiveness data were used in estimating the expected reduction in maternal deaths: Intervention Effectiveness Source 1. Hemorrhage Prevention - Oxytocin 62% Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. In: The Cochrane Library, Issue 1. 2. Hemorrhage Prevention - Misoprostol 43% Found to be about 30% less effective than oxytocin Gulmezoglu AM, Villar J, Ngoc NTN, et al. WHO multicentre randomized trial of misoprostol in the management of the third stage of labour. Lancet. 2001; 358:689-695 3. Hemorrhage Treatment - Oxytocin 80% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 4. Eclampsia Management - MgSulfate 43% Cochrane Database Syst Rev. 2010 Nov 10 5. Sepsis Prevention - Facility Births 60% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 6. Sepsis Prevention - Home Births 60% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 7. Sepsis treatment - Antibiotics 80% Pollard et al. Estimating the impact of interventions on cause- specific maternal mortality: a Delphi approach. BMC Public Health 2013, 13(Suppl 3):S12 8. PAC management - Misoprostol 50% The MMR after FP and MH scale-up was calculated by dividing the remaining number of maternal deaths by the number of births expected at the new contraceptive prevalence level (current 3.1 million births annually minus 170,000 averted through increased use of family planning. Cost Estimates Family Planning Unit costs for the different supply methods were taken from UNFPA’s RH Interchange database and multiplied by the amount required to provide one couple-year of protection (CYP). It was assumed that 15 cycles of the pill, 120 condoms or 4 injectables would provide one CYP. IUDs and Implant were assumed to provide 3.5 years of protection or CYPs. Their cost was thus divided by 3.5. The RH Interchange price for implants ($18.80) was replaced with a cost estimate per implant of $8.50 to reflect the recent price reduction seen, but not yet reflected in the database, due to the introduction of Sino- Implants. Drug and supply cost for male and female sterilization came from calculations carried out by the Guttmacher Institute for its Adding It Up 3 publication using UNFPA’s RHCT costing tool with updated 2013 prices. It was assumed that new users would adopt methods based on the current modern method mix. Cost Estimates Maternal Health Interventions Based on WHO treatment guidelines the following drugs and supplies were costed using drug prices from both the MH International Drug Price Indicator and the UNICEF Supply Catalogue. Hemorrhage Prevention and Treatment Sepsis Prevention and Treatment Pre-Eclampsia/Eclampsia Treatment i UN Population Division. World Population Prospects: The 2012 Revision, data for 2013 ii WHO 2014. Trends in maternal mortality:1990 to 2013;Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division iii Bangladesh Maternal Mortality and Healthcare Survey 2010. iv According to the BMMS 2010, the 15-19 yr age specific mortality rate is 49/100,000LB and Lancet Global Health it’s 93 (Lancet Glob Health 2014;2: e155– 164;Published Online;January 21, 2014http://dx.doi.org/10.1016/S2214-109X(13)70179-7). Check current number with regard to these estimates. v Bangladesh Demographic & Health Survey 2011 vi UN Population Division. World Population Prospects: The 2012 Revision, data for 2013 vii UN Population Division. World Marriage Data 2012. viii Bangladesh Demographic & Health Survey 2011 ix Futures Institute. Spectrum, LiST module.