How Bangladesh Increased Maternal Health Care Utilization and Reduced Inequities
Despite achieving a 70% reduction in its national maternal mortality ratio (MMR) between 1990 and 2015, Bangladesh has had difficulty finding solutions for geographic and socioeconomic differences in maternal death rates. Demographic and Health Survey (DHS) data from 2014 revealed that the MMR among women in the richest quintile was 37% lower than the national average, while that of women in the poorest quintile was 20% higher than the national average. Similar disparities persisted across several maternal health indicators including facility-based delivery, antenatal care (ANC) utilization and skilled birth attendance.
A paper recently published in PLOS One examined the impact of the Maternal and Neonatal Health Initiatives in Bangladesh (MNHIB) program—implemented by the Government of Bangladesh in partnership with the United Nations Population Fund, the United Nations Children’s Fund and the World Health Organization—on maternal health care utilization and equity in four districts of Bangladesh between 2008 and 2013.
The MNHIB program
The MNHIB program was launched in 2007 with the goal of addressing maternal and neonatal mortality and morbidity in four districts of Bangladesh: Maulvibazar, Jamalpur, Narail and Thakurgaon. As part of its strategy, MNHIB enlisted the help of local non-governmental organizations to strengthen the community health system and encourage birth planning, ANC and postnatal care (PNC) utilization and facility-based delivery. Another core component was ensuring a constant supply of drugs, equipment and human resources at all facility levels.
Impact on maternal health care utilization and socioeconomic disparities
The authors analyzed survey data from 2008 and 2013 to explore the impact of MNHIB on maternal and newborn health inequities in the four districts. They also compiled 2007 and 2011 DHS data from comparable districts that did not participate in the program to gain better insight into the potential effectiveness of MNHIB. The results of the analysis are summarized in the table below.
| MNHIB districts | Comparison districts | |||
| Maternal health indicator | 2008
(n=13,206) | 2013
(n=7,717) | 2007
(n=1,004) | 2011
(n=1,346) |
| At least 4 ANC visits | 21.3% | 32.5% | 19.4% | 28.5% |
| ANC with skilled provider | 53.2% | 61.2% | 54.4% | 48.1% |
| Facility-based delivery | 14.8% | 34.6% | 16.6% | 28.9% |
| Delivery with skilled provider | 19.4% | 39.0% | 19.1% | 24.9% |
| PNC with skilled provider within 48 hours of delivery | 18.3% | 31.5% | 18.5% | 26.4% |
| Facility-based care for obstetric emergency | 40.2% | 57.2% | N/A | N/A |
There was a significant increase in facility-based delivery with a skilled provider between the MNHIB and comparison districts, but not for the other maternal health indicators.
Both the MNHIB and comparison districts saw significant decreases in socioeconomic disparities for attending at least four ANC visits, PNC utilization with a skilled provider and facility-based delivery, but only the MNHIB districts were able to lessen these disparities in receiving antenatal and delivery care from a skilled provider.
Beyond utilization
The results of this study suggest that the MNHIB program was effective in reducing wealth-based inequity in some maternal health indicators. However, further efforts are needed to ensure that every woman in Bangladesh has access to skilled maternal health care, regardless of her socioeconomic status. Furthermore, increases in utilization are not sufficient to improve maternal health outcomes. It is critical that women receive high quality care once they arrive at a facility for ANC, delivery or PNC. In order to reach the maternal health-related Sustainable Development Goals, countries including Bangladesh will need to focus on quality, equity and dignity.
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Read open access papers from the MHTF-PLOS Collection, “Neglected Populations: Decreasing Inequalities & Improving Measurement in Maternal Health.”
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