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Risk factors in maternal mortality ratio

Munshi Jalal Uddin The risk of maternal death in Bangladesh has come down to less than one in 500 births. The maternal mortality ratio (MMR) is now 194 per hundred thousand live births which were 322 in 2001 (Bangladesh Maternal Mortality and Health Care Survey- BMMS 2010). What are the factors behind this? In the BMMS 2001, the two major causes of maternal deaths were hemorrhage (29%) and eclampsia (24%). Both of these normally require management at facility by a medically trained provider. In BMMS 2010, it is seen that very substantial decline has occurred in both these causes - a 35% reduction in hemorrhage and 50% reduction in eclampsia. This implies greater use of facilities for delivery and better management of obstetric complications. BMMS 2010 produces sufficient evidences that support MMR decline and related behavior pattern. These evidences are of two kinds: i) behavior change in seeking health care and ii) demographic factors that change the behavior pattern. The proportion of women delivering in a facility rises from 9% in 2001 to 23% in 2010. Much of this increase has come through the private sector (2.7% to 11.3%), although the public sector has seen some increase from a higher base (5.8% to 10.0%). Births with skilled birth attendants (SBAs) have been more than double - from 12.2 % to 26.5%. Use of facilities for maternal complications increased from 16% to 29% between BMMS 2001 and 2010. There has been a 5-fold increase in use of C-section (caesarian-section) (2.6% to 12.2%), with much of the increase occurring in the private sector, which has implications for access of the poor. This intervention should reduce mortality from prolonged labor cases, and eclampsia where use of Magnesium Sulphate does not reduce the problem. Not all women who experienced these complications were managed through C-section, though 15% of those with convulsions did and 26% of those with elevated blood pressure did. There is a concern that while some women who need a C-section may not get it, also some women who do not need it are getting it unnecessarily. What accounts for these behavioral changes? Major factors are: i) improved access to health programs, ii) higher education levels, iii) increased awareness, and iv) a better economic condition. During the nine years between 2001 and 2010, 129 new upazilla health centers began to offer EmOC (Emergency Obstetric Care) in addition to district hospitals and the then 63 MCWCs (Mother and Child Welfare Centers) located mainly at district headquarters. Wide spread availability of mobile phones has contributed to more rapid contact with service providers. Overall improvement in road communications seems to have increased the use of facilities. However, health behaviors are not determined by availability of facilities and services only. They are also influenced by socio-economic factors. Globally higher female education is associated with behaviors which reduce risk of maternal (and child) mortality. The investments by the Government (and some NGOs) over the past several decades in female primary and secondary education are starting to show positive impacts on risk behaviors. The levels of education of recent mothers have risen dramatically in the past decade as well educated young women enter the childbearing years. The proportion of mother with no education has halved since 2001, and the proportion with secondary schooling has nearly doubled. Awareness and behavior is changing positively not only among the educated women but also among the uneducated. For example, seeking care for complications at a facility has doubled (8.6% to 16.9%) among uneducated women, while remaining unchanged among women with secondary plus education (56.1% to 52.2%). Bangladesh has undergone an improvement in overall economic wellbeing since 2001 (GNI per capita up from $350 in 2000 to $550 in 2008), which is reflected in better housing, greater access to electricity, and presumably greater ability to mobilize funds for medical emergencies. Virtually all indicators of use of health services by the poorest quintile show considerable improvement and a reduction in the inequity between rich and poor. Between BMMS 2001 and BMMS 2010, the total fertility rate fell from 3.2 to 2.5. The fall in fertility has some implications on reductions of risks of maternal deaths. As fertility has fallen, the proportion of births to women of higher parities has fallen. The whole thing reduces the overall risk of maternal deaths. To say what to do for further declining of MMR is easy, but to implement it may be somewhat difficult. Usually, after substantial improvement further improvement in a health indicator becomes more difficult. Hence, more attention and stronger commitment is necessary. However, as we have identified the contributing factors which have already declined MMR substantially, first we have to strengthen and scale up all these things. With these, at least three things in particular should be given importance - i) expansion of demand side financing (DSF) maternal health voucher scheme for pregnant women, ii) fortification and supplementation of nutrition and micronutrients for the adolescent girls and women of reproductive ages, and iii) meeting the unmet need of family planning, particularly targeting the women of poor families.