Effective multi-sectoral approach for rapid reduction in maternal and neonatal mortality: the exceptional case of Bangladesh

Abstract

Background: Bangladesh experienced impressive reductions in maternal and neonatal mortality over the past several decades with annual rates of decline surpassing 4% since 2000. We comprehensively assessed health system and non-health factors that drove Bangladesh's success in mortality reduction.

Methods: We operationalised a comprehensive conceptual framework and analysed available household surveys for trends and inequalities in mortality, intervention coverage and quality of care. These include 12 household surveys totalling over 1.3 million births in the 15 years preceding the surveys. Literature and desk reviews permitted a reconstruction of policy and programme development and financing since 1990. These were supplemented with key informant interviews to understand implementation decisions and strategies.

Results: Bangladesh prioritised early population policies to manage its rapidly growing population through community-based family planning programmes initiated in mid-1970s. These were followed in the 1990s and 2000s by priority to increase access to health facilities leading to rapid increases in facility delivery, intervention coverage and access to emergency obstetric care, with large contribution from private facilities. A decentralised health system organisation, from communities to the central level, openness to private for-profit sector growth, and efficient financing allocation to maternal and newborn health enabled rapid progress. Other critical levers included poverty reduction, women empowerment, rural development, and culture of data generation and use. However, recent empirical data suggest a slowing down of mortality reductions.

Conclusion: Bangladesh demonstrated effective multi-sectoral approach and persistent programming, testing and implementation to achieve rapid gains in maternal and neonatal mortality reduction. The slowing down of recent mortality trends suggests that the country will need to revise its strategies to achieve the Sustainable Development Goals. As fertility reached replacement level, further gains in maternal and neonatal mortality will require prioritising universal access to quality facility delivery, and addressing inequalities, including reaching the rural poor.

Keywords: Child health; Health policy; Health systems evaluation; Maternal health; Obstetrics.

Figure 1. National trends and inequities in maternal and newborn mortality from Bangladesh Maternal Mortality Surveys (BMMS), 2000−2020. NMR, neonatal mortality rates; MMR, maternal mortality ratio; PRMR, Pregnancy related mortality ratio.

Figure 2. Trends in reproductive and maternal health intervention coverage indicators, 1993, 1999 and 2019. ANC1+, one or more visits of antenatal care with a skilled provider; ANC4+, four or more visits of antenatal care; c-section, cesarean sections; Early BF, baby was breastfed in the first hour after delivery; EBF, infants less than 1 month of age received only breastmilk in the previous 24 hours; ideliv, birth occurred at a health institution/health facility; mDFPs, demand for family planning satisfied with modern contraceptive methods; PNC-babies, baby received a postnatal check-up within 2 days postdelivery; PNC-mom, women received a postnatal check-up within 2 days postdelivery; TT, baby was born protected from tetanus toxoid infection.

Figure 3. Maternal lives saved by interventions (A), groups of interventions by continuum of care and by facility types (B). BEmOC, basic emergency obstetric care; CEmOC, comprehensive emergency obstetric care; PROM, premature rupture of membranes.

Figure 4. Neonatal lives saved by interventions (A), groups of interventions by continuum of care and by facility types (B). BEmOC, basic emergency obstetric care; CEmOC, comprehensive emergency obstetric care; PROM, premature rupture of membranes.

Figure 5. Maternal and newborn policy timeline. UNFPA, United Nations Population Fund; GoB, government of Bangladesh; BRAC, Building Resources Across Communities.