Presentation from the dissemination of the Bangladesh Maternal Mortality and health Care Survey 2016. Dhaka, Bangladesh, November 22, 2017. United States Agency for International Development; UKaid; MEASURE Evaluation, the International Centre for Diarrhoeal Disease Research, Bangladesh; Bangladesh Ministry of Health and Family Welfare, and the Bangladesh National Institute of Population Research and Training

1. Bangladesh Maternal Mortality
and Health Care Survey
2016

2. • BMMS 2016 is implemented by
• With technical assistance from
Organizations involved
BMMS: Bangladesh Maternal Mortality and Health Care Survey

3. • BMMS 2016 is funded by
Organizations involved

4. The BMMS provides an estimate of MMR
Measuring maternal mortality
Its importance
HPN: health, population and nutrition
SDG: sustainable development goal MMR: maternal mortality ratio
4th HPNSP:
121 deaths
per 100,000 LB
SDG:
70 deaths
per 100,000 LB
MMR targets for Bangladesh
2022 2030

5. Bangladesh maternal mortality and
health care surveys

6. BMMS 2016 objectives

7. BMMS 2016 objectives

8. BMMS 2016: field implementation
• Training
• Data collection
• Data collection agencies

9. BMMS 2016: quality control
• Quality control activities were done extensively by
20 independent teams from NIPORT and icddr,b
• Phase-specific discussions on fieldwork and detailed
debriefing sessions
• Feedback on fieldwork through computerized data
quality checks
• Fieldwork also monitored by MOHFW, USAID,
MEASURE Evaluation, NIPORT, icddr,b

10. BMMS sampling
104,323
175,600
306,961
BMMS 2001 BMMS 2010 BMMS 2016

11. Sample selection
Union/Ward- 2375
Moholla/Mouza-4750
Cluster-4750
Household-308,750

12. Sample size and response rate
335,896
321,214
Eligible women
Women interviewed
306,961
300,986
298,284
Households selected
Households occupied
Households interviewed 99%
Response
96%
Response

13. Making of BMMS 2016

14. So, how do we do survey?

15. There is no such thing as consensus science. If it's
consensus, it isn't science. If it's science, it isn't
consensus. Period.” ― Michael Crichton

16. Planning
requires
every
resource in
hand –
from phone
to pen, led
by
‘expressive
’ leadership

17. Putting on the
thinking cap

18. In goes the
interactive
training
sessions

19. Journey involves
four wheeler to no
wheeler!

20. The night
before data
collection
involves
meeting,
planning, and
assignment
distribution

21. The morning starts with
finding the clusters
following the maps

22. Climbing up

23. Walking
down

24. Holding
hands

25. Figuring
out on
your own!

26. Following
the
respondents

27. Yet there is
no shortage
of smiles!

28. The Big Data

29. Editing Data
Data Entry

30. Big Data requires
Dr. Peter and Prof. Nitai

31. It also requires more
than one pair of eyes!

32. Life cycle of a graph

33. People
behind
the
designs

34. Each slide gets
dissected

35. Each line gets argued

36. Each person practices as if there is no
tomorrow!

37. And . . .
this is how
BMMS
2016 is in
front of
you today!

38. Background Characteristics

39. Trend in respondents’ age group
15
53
32
11
54
36
10
53
37
15-19 20-34 35-49
Percentage
BMMS 2001 BMMS 2010 BMMS 2016

40. Trend in women’s education
47
28
25
34
30
36
21
32
47
No Education Some Primary Some Secondary
Percentage
BMMS 2001 BMMS 2010 BMMS 2016

41. Trends in socioeconomic indicators
31
24
41
55
60
67
79
83 85
Electricity (national
grid)
Toilet (improved) Wall (non-kacha)
Percentage
BMMS 2001 BMMS 2010 BMMS 2016

42. Trends in socioeconomic indicators
among the lowest two wealth quintiles
4
22
1111
40
50
53
70
76
Electricity (national
grid)
Toilet (improved) Wall (non-kacha)
Percentage
BMMS 2001 BMMS 2010 BMMS 2016

43. Access to communication channels
52
6360
94
Exposed to either TV or radio
once a week
Household owns at least one
mobile phone
Percentage
BMMS 2010 BMMS 2016

44. Summary
Between 2010 and 2016:

45. Maternal Mortality and
Causes of Death

46. 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

47. BMMS data sources
Household questionnaire
Household deaths in previous 3 years
Female deaths (13–49 years)
* At the time of death: whether pregnant, delivering or within
two months of delivery, or none of the above
Verbal autopsy interview (13–49 years)
* Causes of death identified by independent physician reviews

48. The verbal autopsy
Verbal autopsy questionnaire
• The BMMS 2010 VA questionnaire was
reviewed and revised based on:
Assignment of cause of deaths
• ICD-10 codes used to assign cause of
deaths
VA: verbal autopsy ICD: international classification of diseases

49. 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

50. Definitions (ICD-10)
Direct obstetric death

51. Definitions (ICD-10)
Indirect obstetric death
• Deaths from previously existing disease
aggravated by or complicating
pregnancy/delivery:

52. *where physicians agreed that there was a maternal cause of death but could not agree whether it was
direct or indirect obstetric
The physician review process
1,524
adult female deaths
1,402 (92%)
deaths
122 (8%) deaths
Yes
66 (4%) deaths 56 (4%) deaths
Independent review by 2 physicians
Agreement on cause
Review by third physician
Agreement on cause
Expert committee review (10 cases*)
No
No
Yes

53. Results

54. 322
194 196
1995 2000 2005 2010 2015 2020
Trends in maternal mortality ratio
BMMS
2010
BMMS
2001
BMMS
2016

55. UN
322
194 196
176178
1995 2000 2005 2010 2015 2020
BMMS
2001
BBS
Trends in maternal mortality ratio
BMMS
2010
BMMS
2016

56. 170 237
358
516
492
1945
2435
49 130 194
402
928
561
1798
134
137 177
384
751
321
2031
15–19 20–24 25–29 30–34 35–39 40–44 45–49
2001 2010 2016
Age-specific maternal mortality ratios
per 100,000 live births, Bangladesh

57. 170
237
358
516
49
130
194
402
134
137
177
384
15–19 20–24 25–29 30-34
2001 2010 2016
Age-specific maternal mortality ratios
per 100,000 live births, Bangladesh

58. Causes of Adult
Female Deaths

59. Causes of deaths among women of reproductive
age (15–49 Years), Bangladesh, 2016
Maternal
13%
Infections
4%
Cancers
24%
Circulatory
diseases
23%
Suicide
6%Injury
6%Miscellaneous
17%Undetermined
7%

60. Age
(years)
Deaths per 1,000 woman-years of exposure
Maternal Infections Cancers
Circulatory
disease Suicide
Other
violent
causes
Misc.
causes
Not
classified
15–19 0.145 0.037 0.063 0.061 0.124 0.058 0.132 0.067
20–24 0.201 0.026 0.055 0.109 0.070 0.059 0.100 0.018
25–29 0.192 0.048 0.129 0.082 0.069 0.079 0.154 0.095
30–34 0.230 0.026 0.278 0.177 0.025 0.032 0.176 0.082
35–39 0.162 0.069 0.362 0.404 0.074 0.062 0.220 0.040
40–44 0.026 0.082 0.617 0.504 0.045 0.082 0.288 0.075
45–49 0.017 0.053 1.223 1.190 0.035 0.135 0.629 0.256
Cause-specific mortality rates
among women (15–49 Years), by
age, Bangladesh, 2016

61. Causes of maternal deaths among women of
reproductive age (15–49 years) Bangladesh, 2016
Hemorrhage
31%
Eclampsia
24%
Obstructed or
Prolonged
Labor
3%
Abortion
7%
Other Direct
7%
Indirect
20%
Undetermined
8%
18% of maternal
deaths were due to
or associated with
NCDs

62. 123
68
2
141
38
16
Direct Indirect Undetermined
2010 2016
Maternal mortality ratio decline in
Bangladesh, by cause, 2010–2016

63. 60
39
13
2
9
68
2
61
46
5
15
15
38
16
Hemorrhage
Eclampsia
Obstructed or prolonged labor
Abortion
Other direct
Indirect
Undetermined
2010 2016
Cause-specific maternal mortality
ratios: Bangladesh, 2010 and 2016

64. Maternal mortality ratios by timing of
death: Bangladesh, 2010 and 2016
35
18
142
48
13
135
During Pregnancy During delivery Postpartum
2010 2016

65. Measurement of maternal morbidity
Obstetric fistula (OF) and pelvic organ prolapse (POP)
• Used a screening tool in BMMS 2016 to identify reported
cases of OF and POP (3rd and 4th degree)
• Same tool used in a study population of 50,000 households
• Reported cases in the study population followed up and
clinically confirmed by physicians
• Adjustment factor derived from the study to be used to
estimate national prevalence of OF and POP from BMMS
2016
• The findings will be disseminated in January 2018

66. Summary

67. Summary
The MMR in Bangladesh is 196
per 100,000 live births; The
MMR has stalled since 2010.

68. Utilization of Maternal
Health Services

69. Utilization of maternal health services
• Antenatal care
• Delivery attendance by medically trained
providers
• Continuum of care
• Care seeking for maternal complications
• Delivery by C-section
• Out of pocket expenditure for delivery

70. Trends in Antenatal Care (ANC)
ANC: antenatal care
40
55
74
BMMS 2001 BMMS 2010 BMMS 2016
ANC from
Medically Trained Provider
12
23
37
BMMS 2001 BMMS 2010 BMMS 2016
4 + ANC
Percentage
Percentage

71. Trends in delivery by medically trained
providers
9
23
47
3
4
3
BMMS 2001 BMMS 2010 BMMS 2016
Percentage
Facility Non-facility births by medically trained provider
50
27
12

72. 9
23
47
BMMS 2001 BMMS 2010 BMMS 2016
PercentageTrends in facility delivery
Increased 1.6
percentage
points/year
Increased 4
percentage
points/year
Doubled

73. Deliveries in public, private, and NGO
facilities
Increased by
4 percentage
points
Increased by
18 percentage
points
Increased by
2 percentage
points
NGO: nongovernmental organization
6
10
143
11
29
1
2
4
BMMS 2001 BMMS 2010 BMMS 2016
Percentage
Public Private NGO
10
23
47

74. Deliveries in public, private, and NGO
facilities
6
10
143
11
29
1
2
4
BMMS 2001 BMMS 2010 BMMS 2016
Percentage
Public Private NGO
47
10
13% Upazila & above,
1% Union & below
Little information
on types of
facilities
NGO: nongovernmental organization
23

75. The poor-rich inequity in use of
health facilities for delivery
3
8
23
30
53
76
BMMS 2001 BMMS 2010 BMMS 2016
Percentage
Poorest Richest
Rich-poor
ratio 10 6.6
3.5
27%
point
45%
point
53%
point

76. Complete continuum of care (ANC + DC + PNC from
medically trained provider)
DC: delivery care
PNC: postnatal care
NO
maternity
care
21%
43%

77. Complete continuum of care (ANC +
DC + PNC from medically trained provider)
5
19
43
BMMS 2001 BMMS 2010 BMMS 2016
Percentage

78. There have been substantial
improvements in use of
medically trained attendants
and facilities for delivery.
Now we will examine care-
seeking behaviours for maternal
complications.

79. 53
68 67
BMMS 2001 BMMS 2010 BMMS 2016
Percentage
Sought any treatment
Care seeking for maternal complications

80. 53
68 67
BMMS 2001 BMMS 2010 BMMS 2016
Sought any treatment
Care seeking for maternal complications

81. Care seeking for maternal complications
16
29
46
BMMS 2001 BMMS 2010 BMMS 2016
Sought treatment from health facilitiesSought any treatment
53
68 67
BMMS 2001 BMMS 2010 BMMS 2016
Percentage

82. Deliveries by C-section
3
12
31
0
5
10
15
20
25
30
35
40
45
50
55
60
BMMS 2001 BMMS 2010 BMMS 2016
Percentage
15%
WHO: World Health Organization
C-section: Cesarean section
* WHO recommends 10 -15 percent.

83. Proportion of facility deliveries
performed by C-section
65
35
39
83
All facilities Public sector NGO sector Private sector
Percentage
1 million
155,000
750,000
43,000
Number of
C-sections
per year

84. Median out-of-pocket expenditure for
deliveries
All amounts in Bangladeshi taka
1000
5000
6100
19000
Home Public sector NGO sector Private sector
Health Facility

85. Median out-of-pocket expenditure for
normal and C-section deliveries
1,000
3,000 2,600
6,800
12,400
15,500
20,000
Home Public NGO Private
Outofpocketexpenditure(BDT)
Normal delivery C-section

86. Source of funds for facility delivery, by
wealth status, 2016
68
33
28
6
85
15
20
2
Family fund Loan Gift from
relatives
Others
Percentage
Poor (bottom two quintiles) Non-poor (top three quintiles)

87. Summary findings

88. Summary findings

89. Have other countries
experienced stalling,
or a plateau, in
MMR decline?

90. 322
194 196
0
50
100
150
200
250
300
350
400
1995 2000 2005 2010 2015 2020
MaternalMortalityRatio/100,000LB
BMMS
2001
Trends in Bangladesh
Maternal Mortality Ratio
BMMS
2010
BMMS
2016
• 2001 sample size
was 100,000 but
300,000 in 2016.
• CI’s in 2010 and
2016 do not
overlap with CI in
2001, so MMR is
significantly lower
than 2001 in later
surveys.
• Estimate for 2010
not significantly
different from 2016.
391
253
238
149
234
159
95%
Confidence
Intervals
Significant difference

91. Bangladesh ‘Hockey Stick’ MMR, ANC 4+,
Facility Delivery, 1990-2016
0
10
20
30
40
50
60
70
80
90
100
0
100
200
300
400
500
600
1990 2001 2010 2016
ANC4+,FacDelPercent
MaternalDeaths/100,000LB
ANC4+ FacDel MMR
• Steep decline in MMR
until 2010.
• Although use of ANC 4+,
and Facility Delivery
continued to increase.
• Why is there a plateau in
MMR when ANC & Facility
Deliveries are rising?
• Other factors must play a
role in the MMR trend.

92. MMRs stalling or fluctuating at high levels
0
100
200
300
400
500
600
700
800
900
1000
1990 95 2000 05 2010 15
Lesotho
• In Africa, HIV/AIDS has a big impact on MMR. Increases risk of
direct (haemorrhage, eclampsia) & indirect (e.g. TB) conditions.
• Ghana: MMR stalled ~300, though Facility Delivery still rising.
Low HIV/AIDS level, but poor quality of care in health services.
• Lesotho had up to 50% maternal deaths due to AIDS (2005), but
free maternal health services after 2005 shows MMR declining.
0
20
40
60
80
100
0
100
200
300
400
500
600
700
800
900
1000
1990 95 2000 05 2010 15
Ghana
FacDel MMR

93. MMRs stalling or fluctuating at medium levels
0
20
40
60
80
100
120
140
160
180
200
1990 1995 2000 2005 2010 2015
South Africa
0
10
20
30
40
50
60
70
80
90
100
0
20
40
60
80
100
120
140
160
180
200
1990 1995 2000 2005 2010 2015
Philippines
ANC 4+ FacDel MMR
• Philippines stalled 20 years, poor quality of care, but MMR decline
resuming as UHC reaches 80% after 2012, with free maternity care.
• South Africa: 1999-2009 Health Minister promoted ineffective ‘natural’
HIV cure, so many AIDS maternal deaths (67% in 2005) but from 2009
new Minister pushed Antiretroviral drugs for pregnant women.
No AIDS drugs
available
ARVs

94. MMRs stalling at low levels
0
10
20
30
40
50
60
1990 1995 2000 2005 2010 2015
Thailand
0
10
20
30
40
50
60
1990 1995 2000 2005 2010 2015
Cuba
• Cuba has very strong health system, but cannot get MMR down
below 40, ~ poor nutrition among women, and domestic violence.
• Thailand had HIV/AIDS (25% of maternal deaths in 2000), but from
2001 $1 UHC provides ~ free maternity services. HIV still 18% of MMR.
So MMR also affected by poor health services, lack of political will,
socio-economic factors, maternal nutrition, and other non-maternal
diseases like HIV and malaria.

95. Maternal Mortality Ratio and Facility Deliveries in 35
Sub-Saharan Africa, and South and South East Asia
R² = 0.068
0
100
200
300
400
500
600
700
800
20 30 40 50 60 70 80 90 100
MMR
Facility Delivery %
• Countries have very different
levels of MMR and Facility
Delivery.
• Modest trend of MMR decline
with increasing Facility Delivery.
• Can have high Facility
Deliveries (75%+) but MMR 2x
or 3x higher than Bangladesh
• No countries have lower MMR
than Bangladesh unless Facility
Deliveries more than 60%.

96. To achieve lower MMR, do C-section Rates
need to be higher than 31% (52 countries)?
• 80% have C-section rates
below 31, the Bangladesh
level.
• Most of these (75%) have
MMR below 20. Lowest
MMR at 10-15% C-Section.
• Answer is NO. No need for
a higher rate of C-sections
to achieve lower MMR.
• How can we stop or slow
the increase in C-sections?
R² = 0.3793
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60
MMR
C-Section Rate (%)

97. • As C-sections rose(2000-2010), MMR stalled with increases in ICU admissions, blood
transfusions, hysterectomies, and maternal deaths.
• Since 2012, hospitals must show proof of need for C-sections (e.g., partogram) to
get reimbursed.
• Partnership between 150 hospitals and Govt has increased % vaginal births (fewer
C-sections), and reduced obstetric complications.
Brazil is an example of high C-section (CS) use,
but recently declining
38
56
0
10
20
30
40
50
60
0
20
40
60
80
100
120
1990 1995 2000 2005 2010 2015
C-sectionRate%
MMR
Brazil
C-sections MMR

98. Summary 1/2
• MMR can stall or at different levels, and for different reasons.
• Contributing factors: diseases like HIV/AIDS, malaria, weak health
systems, high costs, malnutrition, social factors like violence.
• Most not relevant to Bangladesh MMR plateau. What applies
most for Bangladesh is weak preparedness of health
facilities/providers to offer quality of care.
• May be other contributing factors, such as rising NCDs, and the
high rate of C-sections in ‘non-ready’ facilities may be having
unrecognized negative consequences.

99. Summary 2/2
In February 2011, we wrote in Implications from 2010 BMMS:
• “…quality of care is a concern”.
• “Health system problems persist, particularly with staffing, staff
attendance, logistics (medicines, blood), and skills.”
In 2014 BDHS Policy Briefs on Maternal Health:
• “Improving and Ensuring Quality of Care is Fundamental”.
In 2014 Bangladesh Health Facility Survey Policy Brief highlighted:
• “Bangladesh’s health facilities are not fully prepared to
provide quality health services”.

100. Let’s get the basics right

101. MMR: 576
MMR: 322
MMR: 194
Final hundred meters:
business as usual will not work
10 years
10 years
?? years
MDG5: 143
Malaysia: 31
Kerala: 81
2010 - 2016

102. Success is a lousy teacher, it
seduces smart people into
thinking they can’t lose.
It’s fine to celebrate success
but it is more important to
heed the lessons of failure.
- Bill Gates

103. Science Skill Implementation Survival
Utopia 1 1 1 = 1.00X X
Ideal .9 .9 .9 = 0.72X X
Attainable .8 .9 .5 = 0.36X X
Actual .8 .5 .5 = 0.20X X
Utstein Formula of Survival
X X =
Ref: Soroide E et al, The formula of survival in resuscitation, Resuscitation 2013 Nov, 84 (11): 1487-93.

104. 31% maternal
deaths are due
to hemorrhage
53% deliveries are
occurring at home,
17% Misoprostol coverage
24% maternal
deaths are due
to Eclampsia
28% facilities have
magnesium sulphate to
treat Eclampsia
Disjointed program focus
18% maternal
deaths are due
to or associated
with NCD
No screening,
management of NCD at
Primary Care level

105. Skilled providers are not available
46
20
Public (UHC+DH+MCWC) Private hospitals & clinics
Percentageoffacilitiesofferingnormal
deliveryserviceshaveatleastonestaff
trained
Ref: NIPORT, Bangladesh Health Facility Survey 2014

106. Science Skill Implementation
Survival
Utopia 1 1 1 = 1.00X X
Ideal .9 .9 .9 = 0.72X X
Attainable .8 .9 .5 = 0.36X X
Actual .8 .5 .5 = 0.20X X
Utstein Formula of Survival
X X =

107. Universal Health
Coverage
Essential
Service
Package
Coverage
Quality
Primary level: Preventive,
Promotive, Screening and
Primary care
Secondary+ level: Curative,
Advanced and Referral level
care
Service or clinical or procedural
Diagnostics
Communication
Physical and environmental
Equipment
Drugs and supplies
HR including skills, competencies
Infection prevention
Waste management
Record keeping and reporting
Management and administrative
Standard
Operating
Procedure
Regulatory
control
Quality of care: setting standards is key
Referral
Ref: Measure Evaluation,
Bangladesh Health Facility
Survey 2014 Policy Brief

108. Health care providers are not available
24 hours
39
89
7
62
55
All facilties
(excluding CC)
Public
(UHC+DH+MCWC)
Public (Union level) NGO Private hospitals &
clinics
Percentoffacilitiesprovidednormal
deliveryservices Ref: NIPORT, Bangladesh Health Facility Survey 2014

109. 3
8
0
10
0
All facilties
(excluding CC)
Public
(UHC+DH+MCWC)
Public (Union level) NGO Private hospitals &
clinics
Percentoffacilitiesprovidednormal
deliveryservices
We are simply not ready
Ref: NIPORT, Bangladesh Health Facility Survey 2014

110. Appropriate care is not available
30
96
10
16
Public (UHC+DH+MCWC) Private Hospitals
Provided CS service Had all 9 CmOC signal functions
Percentageof
facilities
Ref: NIPORT, Bangladesh Health Facility Survey 2014

111. Universal Health
Coverage
Essential
Service
Package
Coverage
Quality
Primary level: Preventive,
Promotive, Screening and
Primary care
Secondary+ level: Curative,
Advanced and Referral level
care
Service or clinical or procedural
Diagnostics
Communication
Physical and environmental
Equipment
Drugs and supplies
HR including skills, competencies
Infection prevention
Waste management
Record keeping and reporting
Management and administrative
Standard
Operating
Procedure
Regulatory
control
Quality of care: setting standards is key
Referral

112. 6
10
143
11
29
1
2
4
BMMS 2001 BMMS 2010 BMMS 2016
Percentage
Consequences of unregulated market
164%
40%
Private dominance leads to–
• Deprivation of care for the poor
• Suppression of public sector
growth
• Substandard quality at high
price
Public sector should gear up, to –
• Cater to the need of the poor
• Attract people with high quaiity
of care

113. Home: 53% Facility: 47%
CS: 65%
of facility deliveries
15%
Life saving
CS Unnecessary
CSNeed life-saving
CS, Can’t have it
Impact of lack of quality regulation

114. Delay in decision
making to seek care
Delay in reaching
appropriate care
Delay in receiving
appropriate care
Household
Health
Care
Facility
The three delays
19%
13%
• 29% facilities have
24/7 providers
• Low levels of
readiness
• 24/7 CEmOC not
available
• CEmOC signal
functions not
available
Maternal deaths in transit
3% SBA coverage at
home deliveries
2010
2016

115. Way forward
• Improve overall implementation efficiency:
• ‘Comprehensive’ standard based quality of care
• Effective coverage of ‘key components’ by cause of
death
• Revisit quality of ‘program design’ – get basic concepts
and elements right
• Regulate market for quality standards, and
ensure accountability
• Incorporate quality parameters in routine
measurement

116. ANC
83% + MTP
74% + MTP
34%
15%
ANY
ANC
4
+All Components
ANC
+ MTP4 ANC
We should look at the right indicator

117. Thank You

118. “Be brutally honest”

119. ANC
83% + MTP
74% + MTP
34%
15%
ANY
ANC
4
+All Components
ANC
+ MTP
4 ANC
We should look at the right indicator
4% 31%

120. Thank You