Maternal Mortality Survey Bangladesh 2011

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The 2010 Bangladesh Maternal Mortality and Health Care Survey (BMMS 2010), a major new Government of Bangladesh sponsored survey aimed at studying maternal mortality and its determinants, has revealed that maternal mortality fell 40 percent from the levels found in a similar, 2001 survey. This drop is a major achievement for Bangladesh and places her ahead of pace to achieve the Millennium Development Goal 5 target of reducing the maternal mortality ratio to 143 deaths per 100,000 live births by 2015.

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Maternal Mortality Survey Bangladesh 2011

  1. 1.  Two day preliminary dissemination seminar:  13 February 2011 – Key findings  14 February 2011 – Extended technical  session
  2. 2. Millennium Development Goals and Maternal Mortality: Bangladesh Millennium Development Goal (MDG) 5 goal is  to reduce Maternal Mortality Ratio (MMR) by  three‐fourths between 1990‐2015 For Bangladesh it means a reduction in MMR  from 574 to 143 per 100,000 live births
  3. 3. Millennium Development Goal 5600 574500400 BMMS 2010 322 MMR300 ? BMMS 2001200 MMR 143100 0 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016
  4. 4. BMMS 2010 Objectives Assess progress toward MDG5, by providing  national estimates of maternal mortality  change in Bangladesh from 2001 Identify causes of maternal and non‐maternal  deaths to adult women Provide information on birth planning,  women’s experience with antenatal, delivery,  postnatal, and emergency obstetric care
  5. 5. BMMS 2010 Objectives Provide indicators of maternal health service  utilization in Bangladesh, including  Community Skilled Birth Attendants (CSBA) Provide qualitative information on  circumstances around maternal death and  identify factors that influenced use of  maternal health services in near miss cases
  6. 6. BMMS 2010 Field Implementation Data collection: 18 January to 6 August, 2010  in 6 phases Data collection teams: 47, each comprised of  6 members
  7. 7. Sample SizeObjective:To be able to detect a roughly 20 percent or larger decline in the Maternal Mortality Ratio with a high degree of statistical confidence2001 Sample Size: around 100,0002010 Target Sample Size: around 175,000
  8. 8. How We Ensure Comparability Between BMMS 2001 and 2010 Use comparable data collection tools Ensure quality Involve technical experts associated with BMMS  2001 Use same sampling technique
  9. 9. BMMS 2010 Data CollectionSample HOUSEHOLD Service Availability Roster All ever-married women age 13-49HOUSEHOLD WOMEN’Squestionnaire Identify deaths questionnaire since October 2007 Short questionnaire Female deaths (175,621) from age 13-49 Long questionnaire VERBAL (61,892) AUTOPSY questionnaire QUALITATIVE study
  10. 10. BMMS 2010 Field Implementation Quality controls  Three sets of independent quality control  teams  Phase wise discussions on field work and  refresher training  Feedback on field work through  computerized data quality checks 
  11. 11. Consistent Technical ExpertiseOut of nine core technical experts involved with BMMS 2010, seven were also involved in 2001
  12. 12. Organizations Involved
  13. 13. Funded by: GOB, USAID, AusAID and UNFPA
  14. 14. Overall coordination: NIPORT, MOHFW  K.C. Mondol  Subrata Kumar Bhadra  Mohammad Ahsanul Alam  Shahin Sultana
  15. 15. Technical Assistance:  ICDDR,B Peter Kim Streatfield Shams El Arifeen Quamrun Nahar Jannatul Ferdous Rasheda Khan Lauren Blum
  16. 16. Technical Assistance: MEASURE Evaluation  Peter M. Lance  Kenneth Hill (Stanton‐Hill Research)  Nitai Chakraborty  Ahmed Al‐Sabir  Han Raggers (ISDP)  Kalee McFadden  Wayne Hoover 
  17. 17. Technical Assistance: USAID/Bangladesh  Kanta Jamil
  18. 18. Data Collection Agencies Mitra and Associates: S N   Associates for Community and  Mitra and his team  Population Research (ACPR):  M. Sekandar Hayat Khan and  his team 
  19. 19. BEGINNING OF THE VOYAGE: JOURNEY BY BUS
  20. 20. WAITING FOR FERRY
  21. 21. CONTINUES WITH TEMPU
  22. 22. THEN . . . BOAT
  23. 23. THE WONDER CAR NASIMAN
  24. 24. WAITING FOR THE MECHANIC
  25. 25. BACK TO THE RICKSHAW VAN. . .
  26. 26. FOUR WHEELER BOAT
  27. 27. JUST FOOT POWER
  28. 28. LONG WAY TO GO
  29. 29. NO TRAIN ON RAIL LINE
  30. 30. NO BOAT, STILL THE JOURNEY CONTINUES
  31. 31. ACROSS EVERY BRIDGE
  32. 32. MIND THE GAP
  33. 33. INTERPRETING THE MAP FOR SELECTED HOUSEHOLDS
  34. 34. GETTING COMMUNITY HELP
  35. 35. GOING UP
  36. 36. EVEN WHEN THE RESPONDENTS ARE WORKING IN THE FIELD
  37. 37. OR . . . DOING LAUNDRY
  38. 38. OR . . . COOKING
  39. 39. “HARD TO REACH” HAS ITS OWN DEFINITION
  40. 40. BREAK TIME
  41. 41. HAVING FRUITS
  42. 42. REST WHEN YOU CAN
  43. 43. LOST ON THE WAY BACK HOME
  44. 44. STILL SMILING
  45. 45. QUALITY CONTROL IN ACTION
  46. 46. CANDLE LIGHT (DINNER) DATA SORTING
  47. 47. JOURNEY TOWARDS A NEW DESTINATION
  48. 48. THANKS TO OUR INTERVIEWERS FOR BRINGING BACK THE INFORMATION WE NEED
  49. 49. Sampling and BasicCharacteristics of the Sample
  50. 50. Sample SizeObjective:To be able to detect a roughly 20 percent or larger decline in the Maternal Mortality Ratio with a high degree of statistical confidence2001 Sample Size: around 100,0002010 Target Sample Size: around 175,000
  51. 51. Sample Sizes Selected Domains Clusters Households Urban 654 42510Other Urban 488 31720 Rural 1566 101790 Total 2708 176020
  52. 52. SylhetRajshahi Dhaka Khulna Chittagong Barisal
  53. 53. SylhetRajshahi Dhaka Khulna Chittagong Barisal
  54. 54. SylhetRajshahi Dhaka B Khulna Chittagong Barisal
  55. 55. SylhetRajshahi Dhaka Khulna Chittagong Barisal
  56. 56. Rural Areas Urban Areas Unions Wards Mouzas Mohallas Segment Segment Household HouseholdSpecial Households Special Households
  57. 57. Response Rates: Households 2001 2010 98.6 98.2 98.9 98.6 98.8 98.4100755025 0 Urban Rural Total
  58. 58. Response Rates: Ever-married Women 2001 2010 96.6 96.9 97.3 97.7 97.2 97.3100755025 0 Urban Rural Total
  59. 59. Percentage of Ever-married Women Age 13-49 25 BMMS 2001 BMMS 2010 20 15% 10 5 0 13-14 15-19 20-24 25-29 30-34 Age
  60. 60. Percentage of Ever-married Women Age 13-49, by Education60 BMMS 2001 46.5 BMMS 201040 34.3 26.6 17.9 18.320 15.7 14.3 10.4 9.0 6.9 0 No education Primary Primary Secondary Secondary incomplete complete incomplete complete or higher
  61. 61. Basic Household Amenities60 2001 Poorest Quintile 52.8 2010 Poorest Quintile 49.640 28.420 11.3 10.6 4.40 Have Electricity Have Toilet Wall Material: Non- Katcha
  62. 62. Conclusion Large sample size Sampling protocol identical to 2001 Response rates essentially the same Background characteristics changed  because Bangladesh has changed
  63. 63. Maternal Mortality in Bangladesh
  64. 64. Definitions (ICD 10) Maternal Death:    Death of a woman while pregnant or within 42  days of termination of pregnancy … from any  cause related to or aggravated by the  pregnancy …, but not from accidental or  incidental causes Pregnancy‐related Death:    Death of a woman while pregnant or within 42  days of termination of pregnancy, irrespective  of the cause of death 
  65. 65. Definitions (ICD 10) Direct obstetric death:  Deaths resulting from  obstetric complications  Haemorrhage  Eclampsia  Obstructed  Infection  Abortion related
  66. 66. Definitions (ICD 10) Indirect obstetric death: Deaths from  previous existing disease   Cardiovascular disease aggravated by  pregnancy/delivery  Respiratory disease aggravated by  pregnancy/delivery  Anaemia
  67. 67. Key Measures of Maternal Mortality Maternal Mortality Ratio (MMR):  Maternal  deaths per 100,000 live births Pregnancy‐Related Mortality Ratio:   Pregnancy‐related deaths per 100,000 live  births, a common proxy for the MMR
  68. 68. BMMS Data Sources Concerning Reproductive Mortality 1Household Deaths:   Death in the last three years? If yes, name, sex, age at death recorded   For deaths of women aged 13 to 49: whether pregnant,  delivering, or within two months of delivery  at the time  of deathVerbal Autopsy:   For all household deaths of women aged 13 to 49  Maternal deaths identified on basis of review by  physicians
  69. 69. BMMS Data Sources Concerning Reproductive Mortality 2Survival of Sisters:   Each married woman asked about brothers and sisters:  Age if still alive  Age at death and year of death if dead    For any sister who died between the ages of 10 and 49:  whether she was pregnant, delivering, or within two  months of delivery at the time of death
  70. 70. In summary, the survey provides three different estimates of reproductive mortality:Basis Estimate of Time FrameHousehold deaths‐ Pregnancy‐related 3 years time of death mortality before surveyHousehold deaths‐ Maternal  3 years  verbal autopsy mortality before surveySisterhood Pregnancy‐related ~ 15 years   mortality before survey
  71. 71. Verbal Autopsy:Identifying Causes of Death
  72. 72. Household QuestionnaireHousehold deaths in previous 3 yearsFemale death between ages 13-49 years Verbal Autopsy Interview
  73. 73. The Verbal Autopsy Questionnaire The 2010 BMMS verbal autopsy questionnaire  was based on the 2001 BMMS The questionnaire was reviewed and revised  based on:  2001 BMMS survey experience and data  WHO international standard VA instrument  for ages 15 years and above ICD 10 Codes used to assign causes of deaths
  74. 74. The Review Process
  75. 75. Independent Review by 2 901 deaths Physicians Agreement on Cause764 (85%) 137 (15%) Yes No deaths deaths Review by 3rd Physician101 (11%) 36 (4%) Yes No deaths deaths Expert Committee Review
  76. 76. Results
  77. 77. Progress Towards MDG-5: Where Are We?600 574500400 Millennium Development 322 Goal300200 143100 0 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016
  78. 78. Progress Towards MDG-5: Where Are We?600 574500400 Millennium Development 322 Goal300200 194 143100 2010 BMMS MMR Estimate 0 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016
  79. 79. How Much Confidence Should We Have in These Results?
  80. 80. Sampling Errors: 95% Confidence Intervals Do Not Overlap450400350 322300250200 194150100 50 0 1998-2001 2007-2010
  81. 81. Internal and External Consistency Initial evaluations support confidence in data  quality:  Consistency between estimates from  household and sibling mortality estimates  Plausible patterns by age and sex  Consistency with mortality estimates from  the Matlab Health and Demographic  Surveillance System (HDSS)
  82. 82. Age Specific Maternal Mortality Ratios per 100,000 Live Births: Bangladesh, 2001 and 20103000 2001 2010 24352500 19452000 1,7981500 2001: 80% of all deaths 2010: 75% of all deaths 9281000 516 500 358 237 170 561 130 402 492 49 194 0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age
  83. 83. Age Specific Maternal Mortality Ratios per 100,000 Live Births: Bangladesh, 2001 and 2010, 15-34 years only600 2001 516500 2010400 358 402300 237200 170 194100 130 49 0 15-19 20-24 25-29 30-34 Age
  84. 84. Conclusions The Maternal Mortality Ratio declined significantly  by around 40% from the late 1990’s to the late 2000’s Having two surveys using the same methodology and  multiple data sources for estimation increases  confidence in results   Similar biases would not affect trends  Consistency across data sources within surveys is  high Results broadly consistent with estimates from  ICDDR,B’s Matlab HDSS
  85. 85. Causes of Adult Female Deaths
  86. 86. Causes of Deaths among Women of Reproductive Age (15-49 Years): Bangladesh, 2010 Suicide 9%
  87. 87. Mortality Rates (per 100,000 women) among Women of Reproductive Age by Cause of Death: Bangladesh, 2001 and 2010 Maternal 54% Infections 54% CancersCirculatory diseases 25% Suicide 2001 2010 41% Injury Miscellaneous 0 10 20 30 40 Mortality Rate
  88. 88. Common Causes of Death AmongReproductive Age: Bangladesh, 2010 Maternal deaths are the most common cause of death  (about 1/4) among women 20‐34 years, and is also an  important cause of death for women aged 35‐39 years Suicide is the single most common cause of death  (22%) among women 15‐19 years, and remains a  common cause among  women aged 20‐29 years Cancers (28‐37%) and circulatory conditions (20‐29%)  are the most important causes of death among older  women (25‐49 years)
  89. 89. Causes of Maternal Deaths: Bangladesh, 2010 Obstructed or Prolonged Labor 7% Hemorrhage Abortion 31% 1% Other Direct 5% Indirect 35%Undetermined 1%
  90. 90. Maternal Mortality Ratio Decline in Bangladesh by Cause, 2001-2010350 322.0 BMMS-2001 BMMS-2010300250 224.8 194.0200150 122.7100 68.2 48.7 51.3 50 2.3 0 Total Direct Obstetric Indirect Obstetric Undetermined Maternal Death
  91. 91. Cause-Specific Maternal Mortality Ratios (per100,000 live births): Bangladesh, 2001 and 2010 Hemorrhage 35% Eclampsia 50% Obstructed 26% 2001 2010 Abortion 85% Other Direct 57% Indirect Undetermined 0 25 50 75 100 Maternal Mortality Ratio
  92. 92. Maternal Mortality Ratios (per 100,000 live births) by Timing of Death: Bangladesh, 2001 and 2010 250 2001 2010Maternal Mortality Ratio 34% 200 150 100 216 51% 142 50 50% 71 35 36 0 18 During Pregnancy During Delivery Post Partum
  93. 93. Proportional Distribution of Maternal Deaths by Age: Bangladesh, 2001 and 2010100.0 2001 2010 75.0 61.6 53.2 50.0 46.8 38.4 25.0 0.0 15-29 Age 30-49
  94. 94. Case Study (Qualitative Study) - Eclampsia - Woman attended ANC monthly in NGO clinic with EmOC Woman fainted Friday; husband went to clinic but no doctors Convulsions occurred 10 hours later; family sought care in the  NGO clinic  The clinic was unable to treat and referred woman to MCH Reached MCH around 1 am; woman was seen by an internee  doctor who consulted with a senior doctor on the phone Family unable to find prescribed medications; nurses angry at  family for not obtaining drugs Woman died in MCH around 5 am Saturday
  95. 95. Case Study (Qualitative Study) - Hemorrhage - TBA tried to deliver entire night; family took woman to the  hospital the following morning (Friday)  Woman seen by doctor later on Friday, but delivered with  Aya Saturday evening Started bleeding just after delivery; nurse asked to get blood As no blood was available, woman referred to MCH, reached  there around 1 am  Doctor angry for arriving so late, requested to get blood Family searched for blood for several hours during the night  Found blood bank at 4 am, told blood to be available at 4 pm Woman died around 3:30 pm
  96. 96. Case Studies: Key Lessons Delays in seeking care Care first sought from a facility that could not  provide the care needed Arrival at final facility of care late and at odd  hours/days Critical, life‐saving care at the final facility not  rapidly available
  97. 97. Causes of Maternal Deaths among Women in the Reproductive Ages - A Summary - A remarkable decline in direct obstetric  deaths  Most likely the consequence of better care‐seeking  practices and improved access to higher level referral  care Abortion‐related deaths declined from 5% of  MMR in 2001 to about 1% of MMR in 2010 No case of infection as an underlying cause of  maternal deaths
  98. 98. Causes of Maternal Deaths among Women in the Reproductive Ages - A Summary - Hemorrhage and eclampsia, despite impressive  declines, still cause more than half of maternal  deaths  Prevention and treatment interventions must target  these conditions, and achieve high coverage
  99. 99. Causes of Maternal Deaths among Women in the Reproductive Ages - A Summary - Post‐partum deaths now comprise a higher   proportion of maternal deaths (73%), up  from  67% in 2001  Improved referral systems and rapid access to  strengthened referral level care will be essential
  100. 100. The Maternal Mortality Ratiohas fallen by an impressive 40% in the past decade
  101. 101. Why? The reasons for the fall are several:  Medical  Socio‐economic  Demographic
  102. 102. What Does the Pattern of Causes of Maternal Deaths Tell Us? The decline in MMR since 2001 was due to the  following causes:  Eclampsia (30% of total decline)   Haemorrhage (25%)  Abortion related (10%)   Obstructed labour (3%), among others Can these conditions be managed at home – NO!  They require facility based treatment and medically  trained birth attendants and staff. Have there been improvements in use of such  facilities and medically trained staff?
  103. 103. Delivery by Medically Trained Provider, 2001 and 2010 30  Doubled 20 % 26.5 10 12.2 0 BMMS 2001 BMMS 2010
  104. 104. Home Deliveries by Medically Trained &Non-medically Trained Attendants, 2001 & 2010 Medically Trained Non-medically Trained In 2010, 100 CSBAs 90.8 delivered 0.3% 76.6 of these home 75 births nationwide. But in CSBA% 50 areas, they 87.3 delivered 2.5% <1 percentage  72.2 of home births. point increase 25 0 3.5 4.4 BMMS 2001 BMMS 2010
  105. 105. Facility Delivery, 2001 and 2010 30 25  Doubled 20% 15 23.3 10 5 9.1 0 BMMS 2001 BMMS 2010
  106. 106. Deliveries in Public, Privateand NGO Facilities, 2001 and 2010 25 1.4 percentage  2.0 points increase 20 8.6  11.3 percentage  15 points % increase 10 0.6 4.2  2.7 5 percentage  10.0 5.8 points  increase 0 BMMS 2001 BMMS 2010 Public Private NGO
  107. 107. Trends in Facility Deliveries by Type of Facilities30 26.4 22.6 19.6 NGO20 18.1 Private 15.7 Public100 2005 2006 2007 2008 2009
  108. 108. Deliveries by C-Sections1510 12.2 5 2.6 0 BMMS 2001 BMMS 2010  Deliveries by c-section increased by almost 5 times due to client choice, provider bias, or actual need
  109. 109. Proportion of Facility Deliveries Performed by C-Section, 2010 288,000 438,000 126,000% 22,000 23.4% 10.0% 11.3% 2.0%
  110. 110. There have been substantialimprovements in use of medically trained attendants, and use of facilities for delivery. Next, we examine Care Seeking Behaviours for Maternal Complications.
  111. 111. Care Seeking for Maternal Complications Sought Any Treatment Sought treatment from health facilities75 7550 50 6825 53 25 29 16 0 0 BMMS 2001 BMMS 2010 BMMS 2001 BMMS 2010
  112. 112. The Poor-Rich Inequity in Treatment Seeking from Facilities for Maternal Complications 50 40 30 47 20 34 10 15 7 0 BMMS 2001 BMMS 2010 Poorest Richest
  113. 113. What Accounts for the Increased Use of Maternal Health Services?Access to Health Services: Numbers and distribution of facilities offering  maternal health services has increased Improved road transport (roads, bridges, bus services)  have reduced travel times Mobile phones available nationally, and at low cost Income at national and household levels have  improved, including among poor households 
  114. 114. What Accounts for the Increased Use of Maternal Health Services?
  115. 115. Treatment Seeking from Facilities forMaternal Complications by Education  6.2 times  3.1 times 60 higher for higher for 50 women with women with secondary secondary 40 education education 30 56 52 20 10 17 9 0 BMMS 2001 BMMS 2010 No Education Secondary Complete or Higher
  116. 116. Demographic Factors - Fertility -Fertility has fallen:  22% ‐‐ from 3.2 (2001) to 2.5 (2010) births  per woman  more among older women (>50% for  women aged 40+ compared to 15% in  among women <30 years).  among high parity births (birth order 4+  down from 30% to 19%).
  117. 117. Now we will compare the roles of these factors in the reductions in numbers ofmaternal deaths in Bangladesh
  118. 118. BMMS 2001 Annual Maternal Deaths, 2001 MMR:     18000 322/100,000 LB Number of births:  3.7 million  12000 Maternal deaths:     12,000 annually 6000 12000 0 2001
  119. 119. Expected Maternal Deaths in 2010 Annual Maternal Deaths, 2001 and 2010 (expected) Number of women  18000 of reproductive age  (WRA) increased by 29%.  12000 If TFR and MMR  remained at the 2001  levels – there would be  15800 15,800 maternal deaths  6000 12000 in 2010 (due to increase  in WRA)  0 2001 2010
  120. 120. BMMS 2001-2010 Reduction in Maternal Deaths due to fertility decline, ageing and MMR decline, 201018000 3990 25% due to TFR decline 40%12000 650 4% fertility pattern change 3870 24% due to MMR decline6000 12000 7300 Current maternal deaths per year 0 2001 2010
  121. 121. Implications for Achieving MDG 5 In two decades Bangladesh has achieved much of the  target for MDG5.  What is needed to attain that goal? Education  of young women have been rising rapidly,  increasing use of maternal health services.   Will this trend continue?  Yes – two‐thirds of older  teenage girls now have secondary schooling. Further reductions in older maternal age and higher  parity births will bring MMR reductions. To achieve this, Family Planning services must be  supported and strengthened. 
  122. 122. Implications for Achieving MDG 5 Following public sector, private sector is responding to  the demand for maternal health services. However, the  private sector may be too expensive for the poor. Cost‐effective systems of health insurance  (like Demand Site Financing?) will be needed. Further expansion of public facilities is an option  (upgrading UHFWCs, more MCWCs, should more UHCs be  upgraded?), but staffing issues persist. CSBAs may not be the solution to achieving the MDG  Goal of 50% skilled birth attendants at delivery.  
  123. 123. Implications for Achieving MDG 5 Greater use of formal maternal health services is happening,  but quality is still a concern. Our qualitative data suggest that health system problems  persist, particularly with staffing, staff attendance, logistics  (medicines, blood), and skills. Health awareness of the population improving, but patients  are still spending time inefficiently on home treatments.   Then they are often going to inappropriate or ill‐equipped  facilities for emergency obstetric care.
  124. 124. In Conclusion Congratulations on this very impressive achievement, not  only to the health services, but to the families of  Bangladesh. The momentum for further progress is in place – families  are aware, and women are making the decision to seek  and use maternal health services. It must be ensured in future that these maternal health,  and family planning services, are as accessible as possible,  and fully functional.  Women have the right not only to survive childbirth, but  for it to be an enjoyable, rewarding and affordable  experience.

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