Maternal, Child and Maternal, Child and Reproductive Health Reproductive Health

Service Delivery Service Delivery Programme in Programme in

BangladeshBangladesh

Dr. Jafar Ahmad HakimDr. Jafar Ahmad HakimDirector (MCH-Services) in-charge andDirector (MCH-Services) in-charge and

Line Director (MC&RH Service Delivery)Line Director (MC&RH Service Delivery)DGFPDGFP

July 2005

Bangladesh Country Bangladesh Country ProfileProfile

Population: 135 millionPopulation: 135 million MMR: 320/100,000 LB MMR: 320/100,000 LB CPR: 58%CPR: 58% TFR: 3/ womanTFR: 3/ woman Total annual births: 3 Total annual births: 3

millionmillion IMR 65/1000 LBIMR 65/1000 LB NMR: 41/1000 LBNMR: 41/1000 LB U5MR: 88/1000 LBU5MR: 88/1000 LB

Bangladesh Scenario of Bangladesh Scenario of Maternal HealthMaternal Health

• About 90% deliveries occur at homeAbout 90% deliveries occur at home• Only 12% deliveries are conducted by Only 12% deliveries are conducted by

Medically trained personnel.Medically trained personnel.• Low ANC (56%) and PNC (18 %)Low ANC (56%) and PNC (18 %)• Poor knowledge of community on danger Poor knowledge of community on danger

signs of pregnancysigns of pregnancy• Socio-economic differentia:Socio-economic differentia:

– Do not have access to any ANCDo not have access to any ANC• 69% in lower wealth quintile69% in lower wealth quintile• 22% in richest quintile 22% in richest quintile

MMR in MMR in BangladeBanglade

sh sh by by Geographic Geographic

Division: Division: 1999- 20001999- 2000

Safe Motherhood-Safe Motherhood-DefinitionDefinition

Safe motherhood means Safe motherhood means ensuring that all women receive ensuring that all women receive the care they need to be safe the care they need to be safe and healthy throughout and healthy throughout pregnancy and child birth.pregnancy and child birth.

Safe Motherhood- ElementsSafe Motherhood- Elements

• Antenatal care (ANC)Antenatal care (ANC)

• Safe Delivery including Emergency Safe Delivery including Emergency Obstetric Care: C-section etc.Obstetric Care: C-section etc.

• Postnatal care (PNC)Postnatal care (PNC)

• Family PlanningFamily Planning

• Prevention of Unsafe Abortion and Prevention of Unsafe Abortion and management of complications of abortion.management of complications of abortion.

• Neonatal careNeonatal care

Causes of MMRCauses of MMR

Causes of maternal deathCauses of maternal death• Complication of unsafe abortionComplication of unsafe abortion• Severe BleedingSevere Bleeding• EclampsiaEclampsia• Obstructed labourObstructed labour• Infection/sepsisInfection/sepsis• ViolenceViolenceMaternal Morbidities due to Child BirthMaternal Morbidities due to Child Birth• Fistula (VVF & RVF)Fistula (VVF & RVF)• ProlapseProlapse• InfectionInfection• SterilitySterility

Barriers to Safe Barriers to Safe MotherhoodMotherhood

• Limited access to good and quality health Limited access to good and quality health services for antenatal, postnatal and services for antenatal, postnatal and delivery care.delivery care.

• Socio ecoinomic factorsSocio ecoinomic factorsInadequate community awarenessInadequate community awarenessFamily beliefs, norms, objectionFamily beliefs, norms, objectionDistanceDistanceLack of transportLack of transportCostCost

Barriers to Safe Barriers to Safe MotherhoodMotherhood

The Delays for Safe MotherhoodThe Delays for Safe MotherhoodFirst DelayFirst Delay- Decision making at home- Decision making at homeSecond DelaySecond Delay- Transportation to - Transportation to

service centre.service centre.Third DelayThird Delay-Delay in receiving -Delay in receiving

treatment in service centre.treatment in service centre.

National Maternal Health StrategyNational Maternal Health Strategy

By 2010:By 2010:• to increase skill attendance at birth from to increase skill attendance at birth from

12% to 50%;12% to 50%;• to increase met need of EOC from 27% to to increase met need of EOC from 27% to

70%;70%;• to achieve universal knowledge about to achieve universal knowledge about

danger signs of pregnancy/child birth and danger signs of pregnancy/child birth and referral to centres with EOC services andreferral to centres with EOC services and

• to increase CPR from 54% to 70%.to increase CPR from 54% to 70%.

Possible RemediesPossible Remedies

• Good quality maternal health care is the single Good quality maternal health care is the single most important intervention to prevent maternal most important intervention to prevent maternal and newborn mortality and morbidity.and newborn mortality and morbidity.

• Maternal health services, including essential Maternal health services, including essential obstetric care for complications, must be made obstetric care for complications, must be made accessible and available to all women during accessible and available to all women during pregnancy and childbirth.pregnancy and childbirth.

• Families and communities have to play critical Families and communities have to play critical role in ensuring that safe motherhood is role in ensuring that safe motherhood is achieved.achieved.

Possible Remedies Possible Remedies ContdContd……

• Education program should focus on improving Education program should focus on improving nutrition for girls and women; facilitating nutrition for girls and women; facilitating women’s access to maternal health care women’s access to maternal health care before, during and after pregnancy.before, during and after pregnancy.

• Men to be sensitized on their role in Safe Men to be sensitized on their role in Safe MotherhoodMotherhood

• Political commitmentPolitical commitment• Address three delays- delay in decision-Address three delays- delay in decision-

making by families, delay in transportationmaking by families, delay in transportation to to hospitals/clinics and delay in getting hospitals/clinics and delay in getting emergency obstetric care services.emergency obstetric care services.

Four pillars of Safe Four pillars of Safe MotherhoodMotherhood

Trends in total fertility Trends in total fertility rate, Bangladesh 1971-rate, Bangladesh 1971-

20042004

6.3

5.1 4.84.3

3.4 3.3 3.3 3

0

1

2

3

4

5

6

7

1971-75

1984-88

1986-88

1989-91

1991-94

1994-96

1997-99

2001-2003

Trends in contraceptive Trends in contraceptive UseUse

30.8

39.944.4

49.253.8

58.1

0

10

20

30

40

50

60

1989 1991 1993-94

1996-97

1999-2000

2004

Trends in Current use of Family Trends in Current use of Family Planning methods (Method Planning methods (Method

mix-%)mix-%)1999-1999-20002000

20042004

PillPill 23.023.0 26.226.2

IUDIUD 1.21.2 0.60.6

InjectablesInjectables 7.27.2 9.79.7

NorpltantNorpltant 0.50.5 0.80.8

Vaginal methodsVaginal methods UU UU

CondomCondom 4.34.3 4.24.2

Female sterilizationFemale sterilization 6.76.7 5.25.2

Male SterilizationMale Sterilization .5.5 0.60.6

Periodic abstinencePeriodic abstinence 5.05.0 5.45.4

WithdrawalWithdrawal 1.91.9 4.04.0

Other traditional methodOther traditional method 0.80.8 0.90.9

TotalTotal 54%54% 58%58%

Discontinuation rate of Discontinuation rate of Contraceptives (%) Contraceptives (%)

MethodMethod Reason for discontinuationReason for discontinuation

Method Method failurefailure

Desire Desire to to become become pregnanpregnantt

Side Side effects effects or or health health probleproblemm

Other Other reasonreasonss

TotalTotal

PillPill 3.93.9 8.58.5 20.820.8 13.313.3 46.546.5

InjectablesInjectables 0.40.4 5.25.2 33.633.6 9.59.5 48.748.7

CondomCondom 6.36.3 11.411.4 6.86.8 46.946.9 71.571.5

Periodic Periodic abstinenceabstinence

10.710.7 5.75.7 0.10.1 24.924.9 41.441.4

WithdrawalWithdrawal 8.28.2 13.513.5 0.80.8 37.037.0 59.659.6

All methodsAll methods 4.54.5 8.18.1 17.517.5 19.319.3 49.449.4

RH-EOC Services in RH-EOC Services in MCWCsMCWCs

• 67 MCWCs are providing EOC services in 67 MCWCs are providing EOC services in district, Upazila and union level.district, Upazila and union level.

• Services including ANC, PNC, Safe Services including ANC, PNC, Safe delivery, C-section, Treatment of delivery, C-section, Treatment of complication of abortion etc.complication of abortion etc.

• Family Planning services especially Family Planning services especially clinical contraception.clinical contraception.

• Counseling for adolescents, male services Counseling for adolescents, male services and VAWand VAW

• Syndromic approach for RTI/STI case Syndromic approach for RTI/STI case management and HIV/AIDS prevention management and HIV/AIDS prevention services.services.

Major MCH & RH Major MCH & RH activities/strategis under taken activities/strategis under taken

during HNPSP (2003-2006)during HNPSP (2003-2006)• To ensure domiciliary visits by FWAs for To ensure domiciliary visits by FWAs for

providing MCH-FP services.providing MCH-FP services.• Use of unit-wise FWA Registers for proper Use of unit-wise FWA Registers for proper

recording and ensuring of MCH-FP services.recording and ensuring of MCH-FP services.• Organization of satellite clinics:Organization of satellite clinics:

– 8 sat. Cl. per union per month8 sat. Cl. per union per month

• Increasing coverage for conducting safe Increasing coverage for conducting safe deliveries close to clients by skilled personneldeliveries close to clients by skilled personnel– SBA Training (6 months) for FWAs & FeHAsSBA Training (6 months) for FWAs & FeHAs– Six months Midwifery training for FWVsSix months Midwifery training for FWVs

----------------- Contd..----------------- Contd..• Improvement of MCH-FP services in 1,500 Improvement of MCH-FP services in 1,500

UH&FWCs (average three in each Upazila) UH&FWCs (average three in each Upazila) including safe delivery and VSC services.including safe delivery and VSC services.– Trained manpower (FWV, SBA)Trained manpower (FWV, SBA)– Equipment & furnitureEquipment & furniture– Physical expansion/renovationPhysical expansion/renovation– ““User-friendly” environmentUser-friendly” environment

• Expansion of coverage of EOC services in Expansion of coverage of EOC services in MCWCsMCWCs– Expansion of beds in MCWCs (from 10 to 20 beds Expansion of beds in MCWCs (from 10 to 20 beds

in 30 MCWCs) in 30 MCWCs) – Ten new EOC MCWCs is being constructed.Ten new EOC MCWCs is being constructed.

• Developing Adolescent Health Strategy in Developing Adolescent Health Strategy in collaboration with all stake holderscollaboration with all stake holders

• Establishing EOC services in ten newly constructed Establishing EOC services in ten newly constructed MCWCs.MCWCs.

------------- Contd…------------- Contd…

• Expansion of beds & services in MCHTI, Expansion of beds & services in MCHTI, Azimpur (from 100 to 173 beds)Azimpur (from 100 to 173 beds)

• Expansion/construction of MFSTC into 100 beds Expansion/construction of MFSTC into 100 beds MCH-FP hospital including EOC services.MCH-FP hospital including EOC services.

• Introduction of Emergency Contraceptive Pill Introduction of Emergency Contraceptive Pill (ECP)(ECP)

• Essential newborn care for reducing Neo-natal Essential newborn care for reducing Neo-natal mortality.mortality.

• Other Child Health activities such as EPI, IMCI, Other Child Health activities such as EPI, IMCI, ARI etc.ARI etc.

…………………….Contd….Contd…

• 862 UH&FWCs selected for upgrdation of 862 UH&FWCs selected for upgrdation of MCH-FP services.MCH-FP services.

• 16,000 B.P. machines and 16,000 16,000 B.P. machines and 16,000 stethoscopes procured and now being stethoscopes procured and now being distributed to all service centres of the distributed to all service centres of the country.country.

• 1,000 Labour Tables and 1,000 Baby 1,000 Labour Tables and 1,000 Baby Weight machines procured and being Weight machines procured and being distributed to the upgraded UH&FWCs. distributed to the upgraded UH&FWCs.

…………………….Contd….Contd…

• Adequate quantity of D.D.S kits procured Adequate quantity of D.D.S kits procured under Revenue and Development budget.under Revenue and Development budget.

• Drugs for RTI/STI case management Drugs for RTI/STI case management procured.procured.

• RH-EOC equipment procured with UNFPA RH-EOC equipment procured with UNFPA assistance for the MCWCs.assistance for the MCWCs.

• Revenue and Development allotment Revenue and Development allotment given to MCWCs for purchase of drugs given to MCWCs for purchase of drugs and MSR.and MSR.

Major Activities of the TA project Major Activities of the TA project “Strengthening Delivery of RH “Strengthening Delivery of RH Services” assisted by UNFPAServices” assisted by UNFPA

• Continuing support for providing RH-EOC Continuing support for providing RH-EOC services in 67 MCWCsservices in 67 MCWCs

• Ten MCWCs selected as Centre of Excellence Ten MCWCs selected as Centre of Excellence and providing Male services, Adolescent and and providing Male services, Adolescent and Youth Friendly service, VAW case management Youth Friendly service, VAW case management and referral.and referral.

• 67 MCWCs are developed to provide IP/PAC 67 MCWCs are developed to provide IP/PAC Syndromic Approach for RTI/STI case Syndromic Approach for RTI/STI case management, HIV/AIDS prevention servicesmanagement, HIV/AIDS prevention services

…… …… Contd.Contd.• Training of service providers from selected 16 MCWCs Training of service providers from selected 16 MCWCs

on early detection of Cervical Cancer through VIA on early detection of Cervical Cancer through VIA method.method.

• Skilled Birth Attendant (SBA) training for FWAs &FeHAs Skilled Birth Attendant (SBA) training for FWAs &FeHAs is going on in 28 districts.is going on in 28 districts.

• ECP training completed in almost all Upazilas (75%)ECP training completed in almost all Upazilas (75%)• RH-EOC training for Doctors and FWVs in Medical RH-EOC training for Doctors and FWVs in Medical

Colleges Hospitals, MCHTI and ICMH.Colleges Hospitals, MCHTI and ICMH.• Continuing Medical Education (CME) training for the Continuing Medical Education (CME) training for the

service providers of MCWCs on updated knowledge and service providers of MCWCs on updated knowledge and concept every year.concept every year.

• Client Data Recording System (CDRS) training of service Client Data Recording System (CDRS) training of service providers of 64 MCWCs for keeping clients information in providers of 64 MCWCs for keeping clients information in computerscomputers

--------------- Contd..--------------- Contd..

• Making all MCWCs and UH&FWCs women, Making all MCWCs and UH&FWCs women, baby and adolescent friendly in phases;baby and adolescent friendly in phases;

• To ensure high quality of RH: MCH-FP care in To ensure high quality of RH: MCH-FP care in all service centers.all service centers.

• Strengthen the provision of pro-poor Strengthen the provision of pro-poor reproductive health care services in reproductive health care services in disadvantaged geographic areas including urban disadvantaged geographic areas including urban slums.slums.

• Improve management skills, supportive Improve management skills, supportive supervision, performance monitoring and supervision, performance monitoring and program evaluation.program evaluation.

Maternal, Child and RH Service Delivery Maternal, Child and RH Service Delivery program under HNPSP 2003-2006program under HNPSP 2003-2006

626254 “54 “CPR %CPR %2.92.93.3 “3.3 “TFRTFR

323242 “42 “NMR per 1,000NMR per 1,000

484866 66 (BDHS-2000)(BDHS-2000)IMR per 1,000IMR per 1,000

2.752.753.2 3.2 (NMMS(NMMS--2001)2001)

MMR per 1,000MMR per 1,000

Projection Projection byby 20062006

Current Current statusstatus

20032003

IndicatorsIndicators

Discontinuation (%)Discontinuation (%)

rate of contraceptionrate of contraception48 “48 “ <30 <30

Maternal, Child and RH Maternal, Child and RH Service Delivery program Service Delivery program

2003-20062003-2006Indicators Current Status

(2003) Projection by 2006

ANC (%) 48 (NMMS-2001) 60

PNC (%) 16 “ 30

Delivery by skilled personnel %

12 “ 25

Met need of EOC services (%)

27% “ 40%

Performance of 64 Performance of 64 MCWCsMCWCsActivities Jul 00-Jun 01 Jul 01-Jun 02 Jul 02-Jun 03 Jul 03-June 04 Jul 04-Mar 05

Ante-natal care 203364 243820 257476 263590 213626Delivery 22894 29633 35131 37982 31794Post-natal care 40186 48765 52400 58187 50851C-section 2151 3489 4928 5578 4930Medical Treatment 3924 4758 5928 5882 4723RTIs/STDs 37276 35539 22490 36755 24029Tubectomy 3398 4647 4651 6658 7764Vasectomy 342 1711 3114 3495 5642Norplant 4350 7142 8257 10981 13156IUD 4397 5944 5544 6374 5371Injectables 104915 118252 127371 147520 118513Oral Pill (in cycle) 215744 230447 97854 102320 74718Condom (in dozen) 24477 29348 13802 16875 12032<5 Child care 282707 265490 303259 232698 211857General Patient 392965 363832 423610 351382 304458Immunization 223716 259571 272734 278796 218981

Lessons Learned and Lessons Learned and ConclusionConclusion

• MCWC programme has been considered as MCWC programme has been considered as one of the successful programmes of one of the successful programmes of MOH&FW;MOH&FW;

• Praised in home and abroad including UN;Praised in home and abroad including UN;• Commendable success with limited Commendable success with limited

manpower (only 02 MOs and 04 manpower (only 02 MOs and 04 FWV/MCWC);FWV/MCWC);

• Possible reasons of success:Possible reasons of success:– Commitment of doctors and other staff;Commitment of doctors and other staff;– Team spirit of the service providers;Team spirit of the service providers;– Support from programme managers of all level;Support from programme managers of all level;

……. Contd….. Contd….– Support of the community and field workers;Support of the community and field workers;– Linkages with upper and lower service Linkages with upper and lower service

centres;centres;– Support of other departments and agencies;Support of other departments and agencies;– Regular in-built supportive supervision by Regular in-built supportive supervision by

QAT, NPPP and MCRH unit, DGFP.QAT, NPPP and MCRH unit, DGFP.

• We hope that this success would be We hope that this success would be further strengthened and replicate in further strengthened and replicate in other fields of our national other fields of our national programme. programme.