Benchmarking progress in Bangladesh

In assessing neonatal and maternal mortality progress in Bangladesh, it is valuable to contextualize this progress in comparison with peer countries and international targets. Although lessons from Exemplar countries like Bangladesh are designed to provide insights for peer countries, Exemplar countries themselves can still benefit from cross-country comparisons. Positioning progress on an international scale is important to understand trajectories of mortality reduction, potential future challenges, and progress toward global targets.

The maternal and peri-neonatal morality transition framework

Multi-country comparison

Bangladesh has made remarkable progress and has emerged as a clear Exemplar for reductions in neonatal and maternal mortality. However, additional progress is needed to reach the country’s Sustainable Development Goal (SDG) targets of 86 maternal deaths per 100,000 live births and 12 neonatal deaths per 1,000 live births by 2030.

Bangladesh’s maternal mortality ratio (MMR) in 2017 was 173 maternal deaths per 100,000 live births, while its neonatal mortality rate (NMR) was 20.9 neonatal deaths per 1,000 live births.^1,2 Although Bangladesh serves as an Exemplar in our study, findings from other Exemplar countries could still prove valuable in helping the country accelerate progress toward the SDG target.

Learnings from a multicountry analysis, using an integrated maternal, neonatal, and stillbirth mortality transition framework could prove useful as Bangladesh looks to further reduce NMR and MMR. In this framework, mortality levels are categorized into five stages, with stage I indicating higher mortality levels and stage V indicating lower mortality levels. The transition framework is a tool that can be used to benchmark country progress and chart a path to progress—with distinct drivers mapped to successive steps.

Stepwise trajectory to progress

From 2000 to 2017, Bangladesh progressed from stage II to stage III for maternal mortality and advanced from stage I to stage III for neonatal and stillbirth mortality. Now in stage III, Bangladesh looks to continue its trajectory into stage IV as it closes in on SDG targets.

Through our multicountry analysis, we identified key factors associated with advances along this transition. Advancements beyond stage I were often linked to contraceptive use and fertility declines. Further progress through stages II and III often occurred as coverage of antenatal care, in-facility delivery, skilled birth attendance, and postnatal care improved, in part due to an expansion of physical infrastructure and human resources for health. This often led to a transition in causes of death in stage III, as preventable deaths, often by way of infectious disease, shrink and indirect causes contribute to a growing share of deaths. Finally, transitions to stage IV and V frequently reflect a prioritization of health equity, as vulnerable communities gain access to interventions previously more accessible to wealthier, more urban, or highly educated communities.

Bangladesh is currently situated in stage III for both indicators, having undergone a rapid fertility decline, a dramatic expansion of health care services largely driven by the private sector, a substantial rise in the number of health care providers, and a cause-of-death transition in which infectious disease constitutes fewer deaths. According to this framework, to advance beyond stage III and into stages IV and V, the next challenge for Bangladesh is to address existing equity gaps. As such, the following sections of this report will highlight trends in health care equity.

Progressing toward the Sustainable Development Goals

As highlighted in this report, Bangladesh has made exemplary progress in reducing neonatal and maternal mortality in the past two decades. This progress has positioned Bangladesh within reach of the SDG targets, although continued advancements will be necessary to reach these goals. To attain the SDG for maternal mortality, the average annual reduction rate (AARR) for MMR will need to be sustained at 5.23%, which is just below the 5.27% observed from 2000 to 2017, and the 5.55% observed from 2010-2017.¹ Bangladesh is also on track to meet the SDG target of 12 neonatal deaths per 1,000 live births by 2030 as the AARR observed from 2000 to 2017 and the AARR observed from 2010 to 2017 exceed the AARR required to reach the goal.² Existing trajectories of progress must be sustained to make this target a reality.

Equity trends for key reproductive, maternal, newborn and child health indicators in Bangladesh

Narrowing equity gaps in Bangladesh that have expanded since 2000—including antenatal care coverage, institutional delivery, the presence of a skilled birth attendant, and rates of cesarean section (C-section) operations—will be instrumental in progressing through the transition framework and achieving the SDG targets.

Coverage of reproductive, maternal, newborn and child health indicators across equity gradients reflects physical, logistical, and financial access to care. Much of the inequality in Bangladesh’s neonatal and maternal mortality outcomes could be linked to facility type, as wealthier women are able to access more expensive private facilities than poorer women. As one interviewee said:

The proliferation of private facilities is a driver of improved access to maternal health care, but low-income families who cannot easily pay the out-of-pocket expenses may not benefit from this expansion.

Family planning

With a deep-rooted history in Bangladesh, family planning is one key area in which the country has ensured equitable access for several decades. In 1993 there was a modest 6.9% difference between wealth quintiles in terms of demand for family planning among married women satisfied by modern methods, and gaps have remained consistently small in the past three decades.³ Coverage rates have also remained nearly identical across urban and rural residence. A 7.3% absolute gap in family planning met need between urban and rural communities in 1993 declined further to a 4.6% gap by 2018.³

There are no substantial differences between income quintiles or urban versus rural residence in terms of family planning decision-making, with wives and husbands predominantly making decisions jointly. However, there are differences in the underlying methods used by women of different income quintiles and women living in urban versus rural areas. In 2018, 16.4% of the poorest women used injections compared with 5.8% of the wealthiest women, 4.0% of the poorest women used implants compared with 0.5% of the wealthiest women, and 2.4% of the poorest women used condoms compared with 16.2% of the wealthiest women.³ Condoms were also substantially more common among women living in urban areas, as 12.4% of women in urban areas used condoms compared with 5.1% in rural areas.³

Slight regional variation in use of family planning also exists, as the divisions of Chittagong and Sylhet have lower coverage rates than other divisions.³ Demand satisfied by modern methods is the highest in Northwestern divisions of Mymensingh and Rangpur.³

Antenatal care

In contrast to family planning, progress in pregnant women attending at least four antenatal care visits (ANC4+) was not as equitably distributed across income quintiles. In 1996, the absolute gap in ANC4+ coverage between the wealthiest and poorest quintiles was 25.2%, but by 2018 this gap had grown to 45.8%.³ ANC4+ coverage continued to be more common among women in urban areas than rural areas, with a 28.7% gap in coverage in 1996 and decreasing to 17.6% by 2018.³

ANC4+ coverage among the wealthiest quintile stands in stark contrast to other income quintiles, and large disparities do not exist among the poorest three quintiles. This suggests that much of the progress in ANC4+ coverage is driven specifically by improvements in the wealthiest quintile in particular—often a population that uses health care in the private sector.

There is also disparity in terms of the type of provider administering antenatal care. Of women who received antenatal care, 94.8% of the wealthiest were seen by doctors at their visits, compared with 53.2% of the poorest women.³ Regional variation in antenatal care coverage shows more variation than family planning.

Rangpur, the division with the highest ANC4+ coverage at 59.2% has coverage rates 1.7 times higher than Sylhet, with 34.6% ANC4+ coverage.³ Other eastern divisions such as Chittagong and Barisal also have lower ANC4+ coverage rates, suggesting that these could be high-priority regions moving forward.

In-facility delivery

Similar to antenatal care, disparities in facility-based delivery coverage have also widened over time. The absolute gap in facility-based delivery between the wealthiest and poorest quintiles grew from 16.5% in 1996 to 51.6% in 2018.³ The wealthiest quintile specifically distanced itself from even the second wealthiest quintile, suggesting that progress is largely driven by the wealthiest communities. The type of facilities that wealthier women deliver in also differs, as in 2018, 70.5% of facility-based deliveries among the wealthiest women occurred in private facilities, compared with 21.6% in public facilities.³ For the poorest women, these values were more even, with 40.7% of facility-based deliveries occurring in public facilities as opposed to 53.6% in private facilities.³ The gap in facility-based delivery coverage between urban and rural areas decreased slightly from 21.0% in 1996 to 17.9% in 2018 further indicating that access to private facilities is driving the increase in facility-based delivery.³

Regional variation exists for in-facility delivery coverage, with the divisions of Sylhet, Barisal, and Mymensingh having particularly low coverage. Khulna and Dhaka emerge as divisions with the highest percentage of facility-based deliveries.

C-section

Rates of C-section coverage have increased dramatically among the wealthiest women in Bangladesh over recent years, reaching 61.5% among the wealthiest quintile in 2018.³ This resulted in a 48.5% absolute gap between the wealthiest and poorest income quintiles.³ The disparity in C-section rates between urban and rural communities has similarly widened in recent decades. In 2018, women in urban areas gave birth via C-section 43.8% of the time compared with 28.7% of the time for women in rural areas.³

Regional variation in C-section rate is stark, with divisions like Khulna and Dhaka having nearly double the C-section rates of divisions such as Sylhet and Barisal.³ Bangladesh has instituted approaches to promote access to C-sections for poor women in key districts, especially in medically necessary cases via programs like the Maternal Health Voucher Scheme. Moving forward, however, regulating C-sections in medically unnecessary scenarios could be a high priority considering the relative expenditure of this procedure, compared with vaginal delivery.

Postnatal care

Large gaps also exist between income quintiles for postnatal care, with an absolute gap of 49.8% in coverage for maternal postnatal care within four hours of birth between the richest and poorest women in 2018.³ Similarly, children born to the richest women received care within one hour of birth more often than children born to the poorest women—reflected by a 39.2% absolute gap in 2018.³ These trends are mirrored in disparities that exist between urban and rural communities. Of births occurring in health facilities in 2018, 91.4% of women received their first postnatal care visit within four hours and 70.8% of newborns received care within one hour.³ This suggests that lagging postnatal care coverage for poorer income quintiles is largely linked to lower in-facility delivery rates, not suboptimal care provided within facilities.

Regional variation in postnatal care follows similar trends to other care indicators such as in-facility delivery, with the highest rates occurring in Khulna and the lowest rates occurring in Sylhet and Mymensingh.