Bangladesh is one of the few countries in South Asia which has significantly decreased the mortality of children under the age of 5, reaching Millennium Development Goal (MDG) 4 well before the deadline. However, neonatal deaths (death during the first 28 days after birth) still account for 61% of all deaths of children under-five and thus the reduction of neonatal mortality has not been able to keep pace with the realization of achievements like MDG 4.
In the era of Sustainable Development Goals (SDGs), the Government of Bangladesh is committed to avert neonatal mortality by 57%, from 28 deaths per 1000 live births to 12 deaths per 1,000 live births by 2030. The “Bangladesh Every Newborn Action Plan” has envisioned several newborn interventions to prevent newborn deaths which occur mainly due to prematurity, birth asphyxia and infections. But given the current trend in the reduction of newborn mortality, the Government’s proposed interventions and expected national coverage may not reach the target for averting an additional 16 newborn deaths per 1000 live births by 2030. Hospital-based delivery is one of the prerequisites for several newborn interventions but still, nearly 63% of the deliveries take place at home in Bangladesh.
To discuss the current progress, opportunities, challenges and strategies to further accelerate the reduction of newborn deaths in Bangladesh the Centre of Excellence on the Science of Implementation and Scale-Up (CoE-SISU) at BRAC James P Grant School of Public Health (JPGSPH), BRAC University with the support of UNICEF Bangladesh, organized a panel discussion on “Quality of Newborn Care in Bangladesh” on 18 October 2017 at Hotel Amari Dhaka. Leading maternal and neonatal health experts representing the government, UNICEF, NGO, research institutions and organizations participated in the event and shared their valuable experiences and views on how best to ensure the achievement of the target of reducing newborn deaths by 2030.
The newborn health programme in Bangladesh is considered in the region as a good example of evolution of a programme based on empirical evidence and scale up of the programme nationwide. The Government of Bangladesh has incorporated a special newborn health component in the current health sector programme. However, ‘implementation inertia’ continues to pose a major impediment in the achieving the maternal and child health targets in Bangladesh.
In the late 1990’s a separate neonatal programme was originally envisaged in the plan but there were some major implementation challenges. The current programme has placed due importance on the ‘provider’ side challenges but with little emphasis on the ‘demand’ side challenges from the client perspective as the effective coverage of essential newborn care in Bangladesh remains abysmally low at around 10%. Health programme should focus on the process of delivering the services, improvement of the quality and increasing the effective coverage of the interventions. Redesigning the current programme and combining the maternal and newborn service delivery measures including integration and coordination with other services like nutrition and WASH is necessary to ensure synergy and cost-effectiveness.
Along with the government, different NGOs are also implementing newborn health programmes in Bangladesh and in many cases NGO-driven programmes are standalone and there is a need for better collaboration with the public sector in order to make such programmes more acceptable by the community. Harmonization and coordination among different actors is crucial in newborn health programme planning and implementation. The existing ‘National Newborn Cell’ of the government can take the lead to coordinate between public and private organizations.
In Bangladesh, as a result of more than 60% of births taking place at home, if any maternal and neonatal complications arise, it becomes difficult to effectively manage it at home. The situation is further aggravated by a poor referral and transport services to a designated health facility that has the capacity to effectively manage a complicated delivery. The decision to seek care in a health facility from a medically trained service provider depends on the complex decision making process within the family. It has been observed that in a majority of instance it is the mother-in-law who is the prime decision-maker to influence the health-seeking behavior in a family setting. Raising awareness among decision-makers at the family and community-level (particularly mothers-in-law and husbands), is necessary to increase facility-based deliveries. The quality of care provided by the private sector that is accessed by a large segment of the population requires a critical review in terms of whether the quality of service being rendered at the facility meets the minimum standard as well as the cost implication and affordability.
It has been observed that in many countries, midwives play an important role in implementing maternal and neonatal health care and also provide effective maternal and neonatal care which contributes in the reduction of maternal neonatal mortality. In Bangladesh’s context, the important role of midwives in the maternal and newborn sector programme needs to be revisited. Midwives employed in different health facilities are often assigned with traditional nursing care which is not adding value to the intent and purpose of a midwife’s role and function in the broader context of maternal, newborn and child health (MNCH) services. Higher level advocacy is needed to sensitize people and health care providers about the important role of midwifery in MNCH services.
Furthermore, trained human resources and community-based services must ensure accountability and identification of key indicators to track progress. Donor funds must be allocated and utilized efficiently, which is essential for sustaining the newborn care services in Bangladesh. Moreover, the importance of research cannot be ignored. Evidence from many successful public health programmes in Bangladesh such as oral rehydration therapy, family planning and the Expanded Programme on Immunization to name a few, can be applied to design and implement neonatal health programmes in Bangladesh.
The important role of ‘implementation science’ in the specific context and challenges is critical. It was suggested that researchers, development partners, UN agencies working in health sector need to collaborate and develop a common framework for conducting implementation research in both maternal and newborn health. This will help the Government and other key stakeholders to better understand some of the key supply and demand side challenges in averting neonatal deaths in Bangladesh.
This blog was written by Dr. ASM Shahabuddin, Dr. Rajat Das Gupta and Dr. Yameen Mazumder at the Centre for Science of Implementation and Scale-Up (SISU), BRAC JPGSPH.