Why is Bangladesh an Exemplar?

Exemplar countries for neonatal and maternal mortality are defined as those that have demonstrated exceptional progress at reducing neonatal and maternal mortality —beyond what could be attributable to their socioeconomic progress alone. Figure 2 shows the association between gross national income (GNI) per capita increases and NMR/MMR declines across low- and middle-income countries with populations of at least 2 million that have not yet reached the Sustainable Development Goals Target. A fitted linear regression line is overlaid, indicating the expected relationship between GNI per capita change and mortality change. Countries falling below the fitted line are those that have experienced faster declines in mortality than what would be expected based on their GNI per capita increases alone.

Bangladesh stands out clearly as an Exemplar for both its neonatal and maternal mortality reductions. Estimates of maternal mortality in Bangladesh show a reduction of 5.4% per year, from 434 deaths per 100,000 live births in 2000 to 173 in 2017.¹ In addition, the country’s neonatal mortality rate declined by 5% per year, from 42 deaths per 1,000 live births in 2000 to 17 in 2018—the fastest of its region.²

Maternal mortality

Bangladesh achieved impressive reductions in maternal mortality over recent decades, although specific trendlines vary slightly by source. Figure 3 includes estimates from both the Institute for Health Metrics and Evaluation (IHME) and United Nations Maternal Mortality Estimation Inter-Agency Group (UN MMEIG), with the UN MMEIG estimates predominantly used in analyses throughout this narrative.^1,3 According to UN MMEIG estimates, from 2000 to 2017, MMR decreased from 434 to 173 maternal deaths per 100,000 live births, which represents a 60% decrease.¹ MMR in Bangladesh declined at an average annual reduction rate (AARR) of 5.3% over this period, which is slightly faster than regional progress in South Asia, which saw an AARR of 5.2%.¹ Trends similar to regional values are suggestive of success considering the strong performance of the entire region and especially of another Exemplar country, India, which strongly influences regional values due to its large population. If Bangladesh continues at a pace of 5.3% AARR until 2030, it will meet the country’s Sustainable Development Goal target of 86 maternal deaths per 100,000 live births.

According to IHME estimates, hemorrhage, indirect maternal deaths, and late maternal deaths were the most common causes of maternal death in Bangladesh in 2019, respectively accounting for 79, 76, and 33 maternal deaths per 100,000 live births as shown in Figure 4.³ From 1990 to 2019, deaths due to hypertensive disorders and abortion/miscarriages saw the most notable declines, respectively accounting for 20.9% and 21.2% of maternal deaths in 1990 but only 2.3% and 10.0% of maternal deaths in 2019.³ Other leading causes of death such as hemorrhage, indirect maternal deaths, and late maternal deaths have not seen large reductions occur similarly.

The Bangladesh Maternal Mortality and Health Care Survey (BMMS) series has also identified hemorrhage, eclampsia, and indirect causes as the largest contributors to maternal mortality, respectively accounting for 46, 35, and 29 maternal deaths per 100,000 live births according to BMMS 2016.⁴ The leading causes of hemorrhage and eclampsia have made up a relatively constant portion of maternal deaths over time in BMMS, respectively constituting 29% and 23% of maternal deaths in BMMS 2001, compared with 31% and 23% of maternal deaths in 2016.^4,5 Over time, a slightly larger portion of maternal deaths have been linked to indirect causes, while a declining proportion of maternal deaths has been attributed to direct causes such as sepsis, puerperal fever, abortion complications, and obstructed labor.

Findings from BMMS also indicate that maternal mortality reductions have occurred before, during, and after delivery as shown in Figure 5. Consistently, the majority of maternal deaths have occurred in the postpartum period. The MMR specifically during delivery has seen the sharpest relative declines according to BMMS.

Inequality gaps in MMR have closed across divisions and wealth quintiles, due in no small part to policies that have targeted the poorest geographical divisions and income categories. MMR generally declined in all divisions, although certain divisions have made faster progress than others. Sylhet, a division in the northeastern region of Bangladesh with constant borders during the study period, had the highest MMR in 2001 at 471 maternal deaths per 100,000 live births.⁵

However, Sylhet experienced the fastest reduction during the study period, more than halving its MMR to 214 maternal deaths per 100,000 live births by 2016 as highlighted in Figure 6.⁴ BMMS 2016 found that MMR is about twice as high among the poorest quintile as it is among the wealthiest quintile—265 compared with 131 maternal deaths per 100,000 live births—and that the gap is comparable to disparities that existed years before.⁴ Additional progress can be made to reduce equity gaps in MMR, of which the urban–rural gap is particularly notable as it has expanded in recent years.

Neonatal mortality

Bangladesh has also seen rapid declines in NMR over recent decades.² According to UN IGME estimates (Figure 7), NMR decreased from 66 to 18 neonatal deaths per 1,000 live births from 1990 to 2020, which represents a 73% reduction.² In Bangladesh over this time period, NMR experienced an AARR of 4.7% compared with 3.0% regionally for South Asia.² After a period of stagnation in the 1960s and 1970s where NMR remained above 90 neonatal deaths per 1,000 live births, rapid improvements began in the 1980s leading up to our study period. If Bangladesh continues at an AARR of 4.7% until 2030, the country will successfully reach the Sustainable Development Goals target of 12 neonatal deaths per 1,000 live births. That pace would result in an NMR of 9.6 neonatal deaths per 1,000 live births, substantially below the target—a remarkable achievement considering the high NMR in Bangladesh decades prior.

According to the World Health Organization Maternal and Child Epidemiology Estimation Group, in 2017 the leading causes of neonatal death were prematurity, birth asphyxia or trauma, and sepsis or infections, respectively contributing 5.5, 4.2, and 3.6 neonatal deaths per 1,000 live births.⁶ Despite remaining the most common causes of neonatal death, the rate of each of these was more than halved from 2000 to 2017 as shown in Figure 8.⁶ There were also substantial reductions in the rates of other communicable diseases including acute respiratory infections, tetanus, and diarrheal diseases. Congenital anomalies do not follow the trends of other neonatal causes and became slightly more common over the study period. Due to reductions in other neonatal causes of death, congenital anomalies climbed from the sixth most common cause of neonatal death to the fourth most common cause of neonatal death in Bangladesh.

Disparities in NMR narrowed across divisions, wealth quintiles, and place of residence as shown in Figure 9.^4,5 Sylhet, which was previously highlighted for remarkable MMR progress, made remarkable progress in reducing gaps for NMR. Although additional progress is needed, most divisions in Bangladesh now have similar NMRs. NMR in urban and rural areas saw almost identical progress, with no evidence of substantial disparities. These findings are further seen in shrinking disparities by wealth quintile—despite the wealthiest quintile having an NMR substantially lower than other income quintiles.

Stillbirths

The stillbirth rate in Bangladesh decreased from 41.4 to 24.3 stillbirths per 1,000 total births from 2000 to 2019, which represents a 41.3% decrease.⁷ This rate is slightly higher than the regional value for South Asia, which was 18.2 stillbirths per 1,000 total births in 2019.⁷ Stillbirth progress in Bangladesh has seen an AARR of 2.77% compared with 2.99% regionally for South Asia. Although the stillbirth rate in Bangladesh has decreased in recent years, as shown in Figure 10, the country is not currently on track to reach the Every Newborn Action Plan target of 12 stillbirths per 1,000 total births.

Stillbirth rates improved across divisions, residence, and wealth quintile, as shown below in Figure 11. The gap between divisions narrowed, as most divisions saw notable reductions in their stillbirth rates between 2004 and 2017, while progress in Chattogram was slower. Progress in urban areas and among the wealthiest quintiles were quicker than progress among rural communities and among the poor.