ArticlesMaternal mortality in Bangladesh: a Countdown to 2015 country case study
Introduction
The Countdown to 2015 for maternal, newborn, and child survival in its 2012 cycle reports that only nine of the 75 Countdown countries are on track to achieve the Millennium Development Goal (MDG) 5 target to reduce the maternal mortality ratio (MMR, maternal deaths per 100 000 livebirths) by three-quarters between 1990 and 2015.1 We reviewed the experience of Bangladesh, one of the nine countries on track, in the improvement of maternal health as part of a series of in-depth country case studies commissioned by Countdown.
Bangladesh has one of the highest population densities in the world, with a population of more than 150 million and a land size of 144 000 km2. Situated at the top of the Bay of Bengal, it is largely surrounded by India. Administratively, the country is divided into divisions (seven), districts (64), Thanas and Upazilas (485) or Municipalities and City Corporations (324), and unions (4546).2
Recent economic growth in Bangladesh has been robust, averaging 6% annually between 2001 and 2012 despite periods of political turmoil and frequent natural disasters; income per head reached US$848 per year in 2012. Progress has also been rapid in the social sector with increasing educational levels, especially for women.3 However, Bangladesh remains one of the poorest countries in the world, with nearly a third (32%) of the population living below poverty and 29% underemployed.4, 5 Total health expenditure has remained low, representing only 3% of gross domestic product (GDP), with only a quarter of health spending coming from the public sector.6
Several factors influenced Countdown's decision to invite Bangladesh to undertake this in-depth analysis of the country's progress in improvement of maternal health. First, Bangladesh is one of the very few countries that are on track to achieve the MDG 5 target.7 Second, Bangladesh is unique among low-income and middle-income countries in having valid, nationally-representative household survey-based statistical evidence of progress towards MDG 5. Third, the reduction in maternal mortality has been accompanied by important changes in other indicators of maternal health and socioeconomic development. These factors render Bangladesh an ideal real-world setting for the study of the driving forces behind large changes in risk of maternal mortality at a population level.
We explored how Bangladesh achieved these reductions in maternal mortality. We focused on change between 1998–2001 and 2007–10, on the basis of the reference periods of the 2001 and 2010 Bangladesh Maternal Mortality Surveys (BMMS).
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Data sources
We used data from two high-quality and highly comparable household surveys, the 2001 and 2010 BMMSs, for the primary analyses in this study. The BMMSs were designed to assess the situation of the country with respect to maternal health, and particularly to provide national estimates of MMR. Both surveys were large, covering about 100 000 households in 2001 and 174 000 households in 2010, and nationally representative, using a three-stage sampling design.8, 9 Deaths of women of reproductive age
Results
MMR in Bangladesh substantially decreased from 322 (95% CI 253–391) deaths per 100 000 livebirths in 1998–2001, to 194 (149–238) deaths per 100 000 livebirths in 2007–10. The implied average annual rate of decrease is 5·6%, slightly faster than the average annual reduction rate required (5·5%, based on the formula: Pt = P0 × ert; for which Pt is the value at time t, P0 is the initial value, r is the growth rate, and t is the time in years) between 1990 and 2015 to meet the MDG 5 target. The
Discussion
At the current rate of MMR reduction, Bangladesh would reach the MDG 5 target of 143 per 100 000 livebirths by 2014, a year ahead of schedule. This rate of reduction is very similar to that noted in the ICDDR,B Matlab Government Service Area (5·3%; appendix). In their 2010 modelled estimates of maternal mortality in 181 countries,22 Hogan and colleagues had reported an annual rate of decrease of 6·4% for Bangladesh for the period 2000–08.22 The 2012 WHO/UNFPA/UNICEF/WB model estimates arrive at
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