Despite slow progress in increasing the number of skilled birth attendants, Bangladesh has made enormous reductions in maternal mortality by improving girls' education.
The maternal mortality rate (MMR) more than halved in less than a decade, from 724 deaths per 100,000 live births in 1990, to 338 per 100,000 in 2008, according to a recent study published in British medical journal The Lancet. By comparison, the 2008 MMR in India was 254 deaths per 100,000 live births, 47 in Thailand and 7 in Japan.
"There is still work to do, and we may not meet our MDG [UN Development Programme Millennium Development Goal] of 144 by 2015, but it's the significant decline and sustained progress that must be noted and must be continued," said Shams El Arifeen, a senior scientist at the Dhaka-based International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B).
Educated girls and women
Improving the education of women has been a key factor in bringing down the MMR. In 2001, the Bangladesh government began offering free education for girls up to 12th grade, with additional incentives like food for education. Girls' enrolment in secondary schools jumped from 1.1 million in 1991 to 3.9 million in 2005, according to the UN Children's Fund (UNICEF).
The Bangladesh Demographic Health Survey (BDHS) showed that the percentage of uneducated girls and women from the age of six in rural areas dropped from 50 percent in 1993 to 32 percent in 2007; in urban areas the figure fell from 34 percent in 1993, and to 23 percent in 2007.
Photo: David Swanson/IRIN
|Maternal mortality remains a key challenge for the country|
Increased access to education has had huge ramifications in socioeconomic development and maternal mortality. "Girls are going to school, getting a better education, getting jobs and, as a result, delaying marriages - it's as simple as that," said Ishtiaq Mannan, of Save the Children.
Women who are better informed are also more active in making family planning choices. The government health survey indicated that married women using contraception - modern methods like the pill or condoms, or traditional methods like periodic abstinence - rose dramatically, from 8 percent in the 1970s to 45 percent in 1993, and reached 56 percent in 2007.
Married women are also having fewer children: a woman had an average of 6.3 children in the 1970s, 3.4 in the early 1990s, and 2.4 in the survey period between 2004 and 2006.
Although women traditionally give birth at home because they are not comfortable with male health workers, more women are aware of the risks of home delivery and are having their babies in health facilities According to the UN Children's Fund, the primary challenge for the Bangladesh health care system is the shortage of women doctors.
In 2007, 15 percent of births took place in a health facility, up from 4 percent in the early 1990s. Still, the government survey noted that 85 percent of babies were delivered at home.
"You cannot change something that is culturally ingrained like this, overnight, but only through education can you address this," said Mohammad Abdul Quaiyum, an associate scientist at ICDDR,B.
Experts have warned that school dropout rates could curtail progress in MMR A baseline survey on primary education by the Directorate of Primary Education (DPE) showed that the dropout rate for boys and girls rose from 33 percent in 2002, to 47 percent in 2006, because of poor school facilities and lack of teachers.
Koasar Afasana, associate health director of BRAC, a Dhaka-based NGO, commented: "If we want a long-term and sustained decline in MMR, we have to invest in the education and employment of women. This goes hand in hand with other interventions, like access to family planning and [emergency obstetric care]."