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.

2.  Two day preliminary dissemination seminar:
 13 February 2011 – Key findings
 14 February 2011 – Extended technical
session

3. 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

4. Millennium Development Goal 5
600
574
500
400 BMMS 2010
322 MMR
300
?
BMMS 2001
200
MMR
143
100
0
1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016

5. 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

6. 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

7. BMMS 2010 Field Implementation
 Data collection: 18 January to 6 August, 2010
in 6 phases
 Data collection teams: 47, each comprised of
6 members

8. Sample Size
Objective:
To be able to detect a roughly 20 percent or
larger decline in the Maternal Mortality Ratio
with a high degree of statistical confidence
2001 Sample Size: around 100,000
2010 Target Sample Size: around 175,000

9. 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

10. BMMS 2010 Data Collection
Sample HOUSEHOLD Service Availability Roster
All ever-married women age 13-49
HOUSEHOLD WOMEN’S
questionnaire 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

11. 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

12. Consistent Technical Expertise
Out of nine core technical experts involved
with BMMS 2010, seven were also involved in
2001

13. Organizations Involved

14. Funded by: GOB, USAID, AusAID
and UNFPA

15. Overall coordination: NIPORT, MOHFW
 K.C. Mondol
 Subrata Kumar Bhadra
 Mohammad Ahsanul Alam
 Shahin Sultana

16. Technical Assistance: ICDDR,B
 Peter Kim Streatfield
 Shams El Arifeen
 Quamrun Nahar
 Jannatul Ferdous
 Rasheda Khan
 Lauren Blum

17. Technical Assistance: MEASURE Evaluation
 Peter M. Lance
 Kenneth Hill (Stanton‐Hill Research)
 Nitai Chakraborty
 Ahmed Al‐Sabir
 Han Raggers (ISDP)
 Kalee McFadden
 Wayne Hoover

18. Technical Assistance: USAID/Bangladesh
 Kanta Jamil

19. 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

21. BEGINNING OF THE VOYAGE: JOURNEY BY BUS

22. WAITING FOR FERRY

23. CONTINUES WITH TEMPU

24. THEN . . . BOAT

25. THE WONDER CAR NASIMAN

26. WAITING FOR THE MECHANIC

27. BACK TO THE RICKSHAW VAN. . .

28. FOUR WHEELER BOAT

29. JUST FOOT POWER

30. LONG WAY TO GO

31. NO TRAIN ON RAIL LINE

32. NO BOAT, STILL THE JOURNEY CONTINUES

33. ACROSS EVERY BRIDGE

34. MIND THE GAP

35. INTERPRETING THE MAP FOR SELECTED HOUSEHOLDS

36. GETTING COMMUNITY HELP

37. GOING UP

38. EVEN WHEN THE RESPONDENTS ARE WORKING IN THE FIELD

39. OR . . . DOING LAUNDRY

40. OR . . . COOKING

41. “HARD TO REACH” HAS ITS OWN DEFINITION

42. BREAK TIME

43. HAVING FRUITS

44. REST WHEN YOU CAN

45. LOST ON THE WAY BACK HOME

46. STILL SMILING

47. QUALITY CONTROL IN ACTION

48. CANDLE LIGHT (DINNER) DATA SORTING

49. JOURNEY TOWARDS A NEW DESTINATION

50. THANKS TO OUR INTERVIEWERS FOR BRINGING
BACK THE INFORMATION WE NEED

51. Sampling and Basic
Characteristics of the Sample

52. Sample Size
Objective:
To be able to detect a roughly 20 percent or
larger decline in the Maternal Mortality Ratio
with a high degree of statistical confidence
2001 Sample Size: around 100,000
2010 Target Sample Size: around 175,000

53. Sample Sizes Selected
Domains Clusters Households
Urban 654 42510
Other Urban 488 31720
Rural 1566 101790
Total 2708 176020

54. Sylhet
Rajshahi
Dhaka
Khulna Chittagong
Barisal

55. Sylhet
Rajshahi
Dhaka
Khulna Chittagong
Barisal

56. Sylhet
Rajshahi
Dhaka
B
Khulna Chittagong
Barisal

57. Sylhet
Rajshahi
Dhaka
Khulna Chittagong
Barisal

64. Rural Areas Urban Areas
Unions Wards
Mouzas Mohallas
Segment Segment
Household Household
Special Households Special Households

65. Response Rates: Households
2001 2010
98.6 98.2 98.9 98.6 98.8 98.4
100
75
50
25
0
Urban Rural Total

66. Response Rates: Ever-married Women
2001 2010
96.6 96.9 97.3 97.7 97.2 97.3
100
75
50
25
0
Urban Rural Total

67. 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

68. Percentage of Ever-married Women
Age 13-49, by Education
60
BMMS 2001
46.5 BMMS 2010
40 34.3
26.6
17.9 18.3
20 15.7 14.3
10.4 9.0
6.9
0
No education Primary Primary Secondary Secondary
incomplete complete incomplete complete or
higher

69. Basic Household Amenities
60
2001 Poorest Quintile 52.8
2010 Poorest Quintile 49.6
40
28.4
20
11.3 10.6
4.4
0
Have Electricity Have Toilet Wall Material: Non-
Katcha

70. Conclusion
 Large sample size
 Sampling protocol identical to 2001
 Response rates essentially the same
 Background characteristics changed
because Bangladesh has changed

71. Maternal Mortality in
Bangladesh

72. 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

73. Definitions (ICD 10)
 Direct obstetric death: Deaths resulting from
obstetric complications
 Haemorrhage
 Eclampsia
 Obstructed
 Infection
 Abortion related

74. Definitions (ICD 10)
 Indirect obstetric death: Deaths from
previous existing disease
 Cardiovascular disease aggravated by
pregnancy/delivery
 Respiratory disease aggravated by
pregnancy/delivery
 Anaemia

75. 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

76. BMMS Data Sources Concerning
Reproductive Mortality 1
Household 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 death
Verbal Autopsy:
 For all household deaths of women aged 13 to 49
 Maternal deaths identified on basis of review by
physicians

77. BMMS Data Sources Concerning
Reproductive Mortality 2
Survival 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

78. In summary, the survey provides three
different estimates of reproductive mortality:
Basis Estimate of Time Frame
Household deaths‐ Pregnancy‐related 3 years
time of death mortality before survey
Household deaths‐ Maternal 3 years
verbal autopsy mortality before survey
Sisterhood Pregnancy‐related ~ 15 years
mortality before survey

79. Verbal Autopsy:
Identifying Causes of Death

80. Household Questionnaire
Household deaths in previous 3 years
Female death between ages 13-49 years
Verbal Autopsy Interview

81. 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

82. The Review Process

83. Independent Review by 2
901 deaths
Physicians
Agreement on Cause
764 (85%) 137 (15%)
Yes No
deaths deaths
Review by
3rd
Physician
101 (11%) 36 (4%)
Yes No
deaths deaths
Expert Committee Review

84. Results

85. Progress Towards MDG-5:
Where Are We?
600
574
500
400 Millennium
Development
322 Goal
300
200
143
100
0
1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016

86. Progress Towards MDG-5:
Where Are We?
600
574
500
400 Millennium
Development
322 Goal
300
200
194 143
100 2010 BMMS
MMR Estimate
0
1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016

87. How Much Confidence Should
We Have in These Results?

88. Sampling Errors: 95% Confidence
Intervals Do Not Overlap
450
400
350
322
300
250
200 194
150
100
50
0
1998-2001 2007-2010

89. 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)

91. Age Specific Maternal Mortality Ratios
per 100,000 Live Births: Bangladesh,
2001 and 2010
3000
2001 2010 2435
2500
1945
2000 1,798
1500
2001: 80% of all deaths
2010: 75% of all deaths
928
1000
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

92. Age Specific Maternal Mortality Ratios
per 100,000 Live Births: Bangladesh,
2001 and 2010, 15-34 years only
600
2001
516
500 2010
400 358 402
300
237
200 170
194
100
130
49
0
15-19 20-24 25-29 30-34
Age

93. 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

94. Causes of Adult Female Deaths

95. Causes of Deaths among Women of Reproductive
Age (15-49 Years): Bangladesh, 2010
Suicide
9%

96. Mortality Rates (per 100,000 women) among
Women of Reproductive Age by Cause of Death:
Bangladesh, 2001 and 2010
Maternal
54%
Infections
54%
Cancers
Circulatory diseases
25%
Suicide 2001 2010
41%
Injury
Miscellaneous
0 10 20 30 40
Mortality Rate

97. Common Causes of Death Among
Reproductive 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)

98. Causes of Maternal Deaths:
Bangladesh, 2010
Obstructed or
Prolonged Labor
7%
Hemorrhage Abortion
31% 1%
Other Direct 5%
Indirect
35%
Undetermined
1%

99. Maternal Mortality Ratio Decline in
Bangladesh by Cause, 2001-2010
350 322.0 BMMS-2001
BMMS-2010
300
250 224.8
194.0
200
150 122.7
100 68.2
48.7 51.3
50
2.3
0
Total Direct Obstetric Indirect Obstetric Undetermined
Maternal Death

100. Cause-Specific Maternal Mortality Ratios (per
100,000 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

101. Maternal Mortality Ratios
(per 100,000 live births) by Timing of Death:
Bangladesh, 2001 and 2010
250
2001 2010
Maternal Mortality Ratio
34%
200
150
100 216
51%
142
50 50%
71
35 36
0 18
During Pregnancy During Delivery Post Partum

102. Proportional Distribution of Maternal Deaths
by Age: Bangladesh, 2001 and 2010
100.0
2001 2010
75.0
61.6
53.2
50.0
46.8
38.4
25.0
0.0
15-29 Age 30-49

103. 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

104. 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

105. 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

106. 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

107. 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

108. 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

109. The Maternal Mortality Ratio
has fallen by an impressive 40%
in the past decade

110. Why?
 The reasons for the fall are several:
 Medical
 Socio‐economic
 Demographic

111. 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?

112. Delivery by Medically Trained Provider,
2001 and 2010
30
 Doubled
20
%
26.5
10
12.2
0
BMMS 2001 BMMS 2010

113. 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

114. Facility Delivery, 2001 and 2010
30
25
 Doubled
20
% 15
23.3
10
5 9.1
0
BMMS 2001 BMMS 2010

115. Deliveries in Public, Private
and 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

116. Trends in Facility Deliveries by
Type of Facilities
30
26.4
22.6
19.6 NGO
20 18.1
Private
15.7 Public
10
0
2005 2006 2007 2008 2009

117. Deliveries by C-Sections
15
10
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

118. 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%

119. There have been substantial
improvements in use of medically
trained attendants, and use of
facilities for delivery.
Next, we examine
Care Seeking Behaviours
for Maternal Complications.

120. Care Seeking for Maternal
Complications
Sought Any Treatment Sought treatment from health
facilities
75 75
50 50
68
25 53 25
29
16
0 0
BMMS 2001 BMMS 2010 BMMS 2001 BMMS 2010

121. 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

122. 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

123. What Accounts for the Increased Use
of Maternal Health Services?

124. Treatment Seeking from Facilities for
Maternal 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

125. 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%).

126. Now we will compare the
roles of these factors in the
reductions in numbers of
maternal deaths in Bangladesh

127. 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

128. 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

129. BMMS 2001-2010
Reduction in Maternal Deaths due to fertility decline,
ageing and MMR decline, 2010
18000
3990 25% due to TFR decline
40%
12000 650 4% fertility pattern change
3870 24% due to MMR decline
6000 12000
7300 Current maternal deaths
per year
0
2001 2010

130. 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.

131. 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.

132. 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.

133. 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.