Bringing a Baby into the World at the Cost of the Mother’s Health

By Dr Nahitun Naher


There are so many special days we celebrate throughout the year that nowadays they do not create enough excitement. But among these plethora of special days, Mother’s Day is unique as it is a reminder to all to acknowledge and honour one’s mother. This should not only be a one day celebration, rather a mantra in our lives. Mother’s Day is the perfect time to talk about motherhood and maternal health and to express love and gratitude to the most unconditional bond between two human beings.

From my personal experience, the day when my son was born there was an overnight shift in all the equations and dimensions of my life. However, the journey towards motherhood is not an easy one to trail; motherhood is difficult and the amount of physical and emotional stress it places on a woman is not an easy one to endure despite that fulfilling experience of bringing a life into the world. 

According to the World Health Organization (WHO), more than 135 million women experience pregnancy and childbirth each year. One of the lesser discussed topic are the issues a woman will face during this experience.

Maternal health refers to a woman’s health during the period of pregnancy, childbirth and postpartum. For many women around the world, it is also associated with ill health and sometimes even life threating complications. Although the global maternal mortality ratio declined 44 per cent from 1990 to 2015 (as per UN inter-agency estimates), 830 women will die every day from pregnancy and child birth related complications. Unsurprisingly, 99 per cent of these deaths take place in developing countries, with a higher rate in rural areas and with an even higher rate among young adolescent mothers. 

The five main causes of maternal mortality are severe bleeding, infection, unsafe abortion, hypertensive, and medical complication in pregnancy. Out of the 135 million women who give birth per year, nearly 20 million of them suffer from various complications even after birth. 

Many of these mortalities and morbidities can be prevented through skilled care and delivery, however shortage of qualified health workers to provide these services remains a major obstacle in ensuring safe motherhood (WHO).

Bangladesh has made significant improvements in maternal health in terms of achieving Goal 5 of the Millennium Development Goals (MDG). As per the United Nations and WHO, the maternal mortality rate in Bangladesh is 176 per 100,000 live births (2015) with an annual rate of 5.9 per cent reduction from 2005 to 2015. Multiple factors contributed to this achievement, primarily the government’s strong commitment to highlight maternal health as a national priority.

Despite the achievement, the number of skilled birth attendants present during delivery is still below the national goal of 55 per cent (it is currently 42 per cent). On the other hand, the high rate of unnecessary Caesarean sections (23 per cent in 2014 despite the WHO recommendation of 10 to 15 per cent) reflects an imbalance in terms of utilisation of maternal health services. The government institutions, private organisations, and NGO’s including BRAC, are producing midwives towards so as to bolster the maternal and new born healthcare services available in Bangladesh. 

However, while the country is making strides in promoting better maternal healthcare services, it is also hampering progress due to the high rate of child marriage and adolescent pregnancy – a new law was recently passed which allowed a marriage to take place between parties under the age of 16 due to “special circumstances”.

Because every single mother matters and deserves care, safe delivery through the presence of skilled birth attendants and ensuring equitable provision of comprehensive reproductive healthcare services, while at the same time working on issues of child marriage and adolescent pregnancy are crucial to accelerate the progress of maternal health in Bangladesh in the coming years.

The author is a senior research associate at BRAC School of Public Health. 

 

How Can Civil Society Help Influence Health Policy?

By Anushka Zafar

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Bangladesh’s health sector has come a long way, reaching several millennium development goals and making foremost improvements in areas of maternal and child health, immunisation coverage and TB control. But the double burden of existing communicable and emerging non-communicable diseases (NCDs) is threatening to undermine the benefits of development and growth that have been achieved over the past four decades.

NCDs are not passed from human to human like many traditionally observed illnesses in tropical countries such as Bangladesh. Instead a person may be genetically predisposed to, or at risk of NCDs from behavioural or environmental factors. The four most common forms of NCDs are cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma) and diabetes.

In Bangladesh, there has been a slow decline in tobacco use – one of the main reasons for asthma, cancer and chronic obstructive pulmonary diseases. Cardiovascular diseases account for the greatest number (17 per cent) of all NCD-related deaths (WHO 2014), and more than eight per cent of the adult population suffers from diabetes (WHO 2013). Yet the country’s health system and policies still continue to prioritize the needs of children and reproductive-age women with little preparedness and skills to address the emerging epidemic of the NCDs.

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Having not been addressed in the previous MDGs, NCDs have now been recognized as a major global health challenge and included in the Sustainable Development Goals. As a result, currently two significant policies are being developed in Bangladesh that includes NCDs – the seventh five-year plan (2016-2020), and the fourth health sector plan (HPNSIP 2016-2021).

“While these documents are being formulated, it is high time to discuss, debate, and strategise approaches and interventions to mainstream preventive NCD interventions in the existing primary healthcare infrastructure in a sustainable manner,” said Dr Syed Masud Ahmed, professor and director of the BRAC School of Public Health’s Centre of Excellence for Universal Health Coverage. The School currently hosts the secretariat of Bangladesh Health Watch (BHW), a civil society initiative comprised of multiple stakeholders.

Since 2006, BHW has been monitoring the health sector agenda and programmes, while advocating for the improvement of the country’s health system. The group’s members have joined forces to carefully review health policies and recommend appropriate actions for change that will have a lasting impact on the lives of Bangladeshi people.

The collective is comprised of several key public and private sectors players including high-ranking representatives from BRAC, EngenderHealth, and WaterAid. Others include individuals who were previously holding prominent positions at the National Institute of Population Research and Training, WHO, and government ministries including Health and Family Welfare. BHW also includes members from research hospitals such as the Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), think tanks such as Centre for Policy Dialogue, academicians from BRAC University and Dhaka University, as well as members of the media and activist groups. Including a wide range of perspectives and expertise provides BHW with the legitimacy that allows for access to those who directly inform and formulate policy change.

Civil society has already been active in monitoring the country’s progress in various sectors, such as education, with the Education Watch having been established in the late 1990s. Reports released annually by Education Watch have been widely considered a credible source of information used to inform national policy and programming. Similarly, BHW has also been playing a part in influencing the national health agenda through its series of reports. The first report published focused on the theme of health equity (2006), followed by health workforce (2007), health governance (2009), universal health coverage (2011), and urban health challenges (2014).

As a result of its continuous efforts, BHW has become a credible source for instigating policy changes at the top level. For instance, based on findings from the health governance report, governance and stewardship were included as legislative priorities in the next Health, Nutrition and Population Strategic Investment Plan 2016-2021. Additionally, recommendations from the report on health workforce stated the need to restart recruitment and training of additional medical assistants and family welfare visitors as a matter of urgency. Subsequently this was reflected in the Health Workforce Strategy 2008, stating special attention would be placed on improving the production capacity of the institutes responsible for production of nurses, health technologists, medical assistants, family welfare visitors and skilled birth attendants.

This year, the collective has decided to focus on the theme of tackling emerging NCDs. With both the five-year plan and next health sector plan already on its way to being drafted, the BHW group believes it is imperative to release a report and give recommendations to be included in the final policies and operational plans. With already low spending in health resources, along with the rise of NCDs, findings have shown that NCDs can have a catastrophic impact on spending and impoverishment caused by large out-of-pocket expenditures for treatment. Thus one of the recommendations made by BHW is that the government must urgently focus on mainstreaming NCD care in primary healthcare facilities, emphasize prevention over treatment, screening and appropriate referral for early diagnosis and treatment. This will help provide population-based and cost effective services.

However, these recommendations are not a silver bullet, but rather a catalysing force comprised of civil society members capable of aiding greater action and influencing lasting solutions. Much work is still left to be addressed in order to continue the sustainable development of the national health system. NCDs include a large spectrum of illnesses, including mental health and road accidents, which will not be included in the most recent BHW report. However the collective agree that the significance of these problems in Bangladesh are deserving of their own reports as policies continue to evolve to include these immediate and emerging health sector issues.


A version of this article was originally published in the Dhaka Tribune. The author is Communications and Knowledge Manager, BRAC School of Public Health