Written evidence submitted by Women and
Children First (WCF), The Diabetic Association of Bangladesh (BADAS)
and the Centre for International Health and Development (CIHD)
at UCL's Institute of Child Health
ACRONYMS
|
| ADB | Asian Development Bank
|
| BDHS | Bangladesh Demographic and Health Survey
|
| EOC | Emergency Obstetric Care
|
| GOB | Government of Bangladesh
|
| KfW | Reconstruction Credit Institute (Kreditanstalt fuer Wiederaufbau)
|
| MMR | Maternal Mortality Rate
|
| MNCH | Maternal, Newborn and Child Health
|
| NMR | Neonatal Mortality Rate
|
| PHC | Primary Health Care |
| SBA | Skilled Birth Attendant
|
| UNDP | United Nations Development Programme
|
| WHO | World Health Organisation
|
|
1. Summary
This submission is co-submitted by Women and Children First
(WCF), The Diabetic Association of Bangladesh (BADAS) and the
Centre for International Health and Development (CIHD) at UCL's
Institute of Child Health. The following key issues for the inquiry
are addressed: the appropriate size and scope of DFID's programme
in Bangladesh; DFID's strategy for reducing poverty and inequality,
including gender inequality; and the role of community-led initiatives
in reducing poverty and increasing access to basic services. Specific
recommendations for DFID are included.
This submission focuses on the urgent need to stimulate further
commitment and action to achieving Millennium Development Goals
(MDG) 4 and 5 in Bangladesh and the role that DFID needs to play
in doing this. Although there has been progress towards achieving
MDG 4, more than 9.2 million children worldwide die before their
5th birthday and it is widely acknowledged that MDG 5 is the goal
least likely to be achieved globally. Further progress in reducing
neonatal mortality in particular and addressing the linkages with
maternal health are essential to achieve MDGs 4 and 5 by 2015.
South Asia experiences the highest number of neonatal deaths in
the world and the second highest number of maternal deaths. Maternal
mortality rates remain appalling and Bangladesh needs to accelerate
present rates of progress. Support from DFID and other donors
is essential.
The women and children of Bangladesh must not pay for the
current financial crisis and DFID's maternal, newborn and child
health (MNCH) spending and efficiency must increase. MNCH should
be afforded greater priority in DFID's Bangladesh Country Plan
and DFID should also use its role as an international champion
for MNCH issues and as Bangladesh's largest bilateral donor to
persuade other donors to provide greater support to MNCH initiatives
in Bangladesh.
Healthy health systems translate into healthy mothers, newborns
and children. Continued support for health system strengthening,
including the improvement of facilities, is essential. Supporting
the integration of MNCH across Bangladesh's national health plans
and placing progress made against MDGs 4 and 5 at the core of
DFID's Bangladesh Country Plan would help ensure that the specific
needs of mothers, newborns and children are not overlooked. Ensuring
that progress made towards MDG 5 is used as a litmus test for
the health of Bangladesh's health and overall level of development
would also improve accountability.
Community-based interventions can play a significant role
in improving both the demand and supply sides of MNCH care and
should be supported by DFID. Women's groups are a cost effective
and evidence based intervention and if scaled to adequate coverage,
have the potential to reach the poorest and bring about substantial
health and non-health benefits.
Efforts to reach all Bangladeshi people equitably need to
be intensified. The social determinants of these inequities need
to be addressed, particular concerning nutrition, without which
improvements in MNCH will not be achieved. Gender inequity, an
integral part of achieving the MDG 4 and 5 targets, is also an
area of particular concern. As a global advocate for family planning,
safe abortion and gender equity DFID has a key role to play and
must increase and expand investments in MNCH if achievements are
to be sustained and further progress made.
2. Recommendations for DFID's Programme in Bangladesh
1. DFID must ensure that the women and children of Bangladesh
do not pay for the current financial crisis, and that it is not
used as a reason not to invest in the services that could save
their lives. In line with the UK government international commitments
to improve MNCH DFID must specifically prioritise MNCH in its
Bangladesh Country Plan. DFID must ensure that aid flows for MNCH
in Bangladesh increase and improve through predictable and long
term support. DFID must also use its international leadership
role in the health sector to encourage other donors operating
in Bangladesh to prioritise and fund MNCH programmes.
2. DFID should continue support for health system strengthening
in general and universal access to reproductive health services
and the Skilled Birth Attendant programme to improve access to
Emergency Obstetric Care in particular. DFID should support the
integration of MNCH across Bangladesh's national health plans
and ensure that progress made towards MDGs 4 and 5 is at the core
of DFID's Bangladesh Country Plan. DFID should ensure that progress
made towards MDG 5 is used as a litmus test for the health of
Bangladesh's health system and overall level of development.
3. DFID should support Bangladesh civil society to improve
health outcomes where the government of Bangladesh cannot. DFID
should embrace the principles of community participation in health
systems and support resilient and sustainable community responses
to heath challenges such as community mobilisation through women's
groups. Where evidence for successful community mobilisation and
women's groups exists DFID should financially assist scale up
and research into other existing and innovative community based
approaches to improve MNCH. This investment should include better
MNCH data collection and the implementation of research findings.
4. DFID should address inequalities in MNCH outcomes
and determinants, including equitable access to MNCH services
eg by continuing support for the Maternal Voucher Scheme. DFID
should address the social determinants of these inequities, including
nutrition. Socio-economic inequalities in MNCH outcomes and determinants,
and the impact of DFID policy on these inequalities should be
systematically monitored and reported.
5. DFID should recognize the fundamental links between
improving MNCH and gender equity in Bangladesh and ensure that
gender is integrated across its Bangladesh Country Plan. DFID
should provide support to the GOB for gender analyses of health
planning and financing and support stronger collection, analysis
and dissemination of gender-disaggregated data in the health sector,
to enable the effective and regular measurement and assessment
of gender equity and equality.
3. The WCF, BADAS and CIHD Consortium
Women and Children First (WCF), The Diabetic Association
of Bangladesh (BADAS) and Centre for International Health and
Development (CIHD) at UCL's Institute of Child Health are currently
working together in a five year consortium, undertaking a strategic
programme to scale up responses to improve MNCH in India and Bangladesh.
WCF is a UK based international NGO at the forefront of working
to achieve MDGs 4 and 5. Through promoting safe motherhood and
newborn care, WCF develops effective and sustainable solutions
to MNCH problems and strengthens accessible and appropriate health
services. As well as helping to improve MNCH services WCF works
with local communities, raising women's knowledge of how best
to take care of themselves during pregnancy and improving skills
in newborn care. This is done through both strengthening health
services and mobilising communities through establishing women's
groups where the women are supported to identify the problems
they face, then develop and implement strategies to solve them.
Building on experience in the field, WCF is also engaged in an
evidence-based advocacy programme, striving to bring about changes
related to the continuum of care in MNCH that make a real difference
to people's health and welfare.
BADAS is a Bangladeshi non-profit voluntary socio-medical
organisation registered with the Ministry of Social Welfare and
working closely with the Government of Bangladesh (GOB). It is
the second largest provider of health care after the government.
The Perinatal Care Project (PCP) is a joint collaborative programme
between BADAS, WCF and UCL's Centre for International Health and
Development (CIHD) working towards improving MNCH. PCP is implementing
community mobilisation and health system strengthening activities
in safe motherhood and essential newborn care in three districts:
Bogra, Faridpur and Moulavibazar, covering a population of 500,000.
Lessons learned are being promoted to work towards national level
scale up, by building the capacity of other local organisations
to utilise existing community groups where possible eg micro-credit
groups. Local MNCH services are being strengthened at the district
and regional levels to improve team building using participatory
approaches, and linking with other programmes to strengthen health
systems. BADAS is also facilitating community health committees
involving members of the local community and other key stakeholders,
promoting a rights based approach to strengthen the link between
the community and the healthcare providers, and ensure that the
needs of local women and children are met.
CIHD works to promote the health, nutrition and welfare of
children and their families in less developed countries. Research
undertaken aims to develop the scientific basis for improvement
in clinical practice and public health using robust epidemiological,
laboratory and social science methodologies. CIHD is committed
to capacity-building with partner organisations in developing
countries to disseminate work as widely as possible.
4. Prioritise Health and MDGs 4 and 5
Ill health and poverty are interlinked and mutually reinforcing—poor
people are more likely to become ill, suffer from higher incidence
of disease, have limited access to health care and be forced to
sell assets or to borrow at high rates to deal with health crises
(UNDP, 1998). The burden of poverty and ill health falls disproportionately
on women and girls. It has been estimated that the poor health
of women and children leads to US$15 billion in lost potential
productivity globally (WHO, 2009). As The World Health Organisation
(WHO) has recently demonstrated investing in MNCH makes absolute
economic sense and can also generate huge economic returns, benefitting
women and children themselves, their families, communities and
society as a whole (WHO, 2009). Healthy mothers can work more
productively (informally or formally) and ultimately households
with healthier and better nourished mothers and children spend
less on healthcare. Reducing unexpectedly large and catastrophic
out-of-pocket expenses for women and children is particularly
important for the poor, ensuring that they can hold on to their
savings, helping them improve their own lives and contribute more
positively to the wider economy.
The Millennium Development Goals have galvanized unprecedented
efforts to meet the needs of the world's poorest but there is
still an urgent need to stimulate further commitment and action
to achieving MDGs 4 and 5 in particular. Despite growing international
attention to MNCH issues, for example at the 2009 G8 and in the
recently published UK government White Paper on International
Development, 99% of maternal and newborn deaths occur in the developing
world (UNICEF, 2009), most of which are preventable. Although
there has been progress towards achieving MDG 4, more than 9.2
million children in the world die before their 5th birthday (UNICEF,
2009). There has been little improvement in the health of newborns
with an estimated 4 million newborn deaths occurring globally
every year, constituting an estimated 37 percent of global deaths
among children under five (WHO, 2009). Recently the World Bank
estimated that over two million children could die as a result
of the downturn (Economist, 2009). It is widely acknowledged that
MDG 5 is the goal least likely to be achieved globally. More than
529,000 women continue to die in pregnancy or childbirth every
year and it leaves 10-20 million women and girls every year with
long terms physical, psychological, social and economic problems
(APPG PD&RH, 2009). The health of a mother and her children
is inextricably linked—saving a mother's life helps her
other children too, because without her they would be between
three and 10 times more likely to die (WHO, 2009). Further progress
in reducing neonatal mortality in particular and addressing the
linkages with maternal health are essential to achieve MDGs 4
and 5 by 2015.
The situation is particularly dire in South Asia where MDGs
4 and 5 are dangerously off track (Greco et al, 2008). South Asia
experiences the highest number of neonatal deaths in the world,
and the second highest number of maternal deaths following sub-Saharan
Africa. The main causes of under five deaths in Bangladesh are
neonatal sepsis, acute respiratory infection, birth asphyxia,
low birth weight/prematurity and diarrhoea. Despite Bangladesh's
progress in meeting all three MDG 4 indicators (GOB, 2007, see
table one below) distinct regional variations exist that need
to be addressed. Urban slums, the Chittagong Hill Tracts, coastal
belt regions and other ecologically vulnerable areas are falling
behind (GOB, 2007).
Table 1
MDG 4 STATUS IN BANGLADESH
|
| Goal 4 | Targets
| Indicators | Base year (1991)
| Current Status (2006)
| Target |
|
| Reduce Child Mortality | Reduce by two thirds, between 1990 and 2015, the under five child mortality rate
| 1. Under five mortality rate (per 1,000 live births)
| 151 | 62
| 50 |
| | 2. Infant mortality rate (0-1 year per 10,000 live births)
| 94 | 45
| 31 |
| | 3. Proportion of one year-old children immunised against measles
| 54% | 87%
| 100% |
|
| Source: Base year indicator 1, 2: Bangladesh Bureau of Statistics (SVRS), 3: Bangladesh Bureau of Statistics (MICS); Current status indicator 1, 2: Bangladesh Bureau of Statistics (SVRS), 3: Bangladesh Bureau of Statistics (MICS).
|
Maternal mortality rates remain appalling with the main causes
of maternal death being haemorrhage, infections, unsafe abortion,
obstructed labour and eclampsia, all of which are preventable
and with a functioning health system easily treated. There has
been some progress in reducing Maternal Mortality Rates (MMR)
(see table 2) and deliveries attended by skilled health personnel
have increased four-fold between 1990 and 2006 (GOB, 2007). However,
Bangladesh needs to accelerate the present rate of progress to
meet the proportion of births attended by skilled health personnel
(GOB, 2007). The population is relatively young with 32% of people
aged between 10 and 24 years. It is estimated that if the population
of Bangladesh stabilises by 2035, there will be over 40 million
women of reproductive age in 2015 who will be the focus of preventive
and awareness raising programmes on safe motherhood as well as
clients of family planning services (KfW, 2006). This will make
the challenge of maintaining maternal mortality reduction harder,
particularly given the widespread practice of early marriage (GOB,
2007). Bangladesh must improve effective service delivery, health
sector governance (especially in primary and maternal health services),
and needs an extensive training programme to increase the number
of skilled birth attendants with support from DFID and other donors
to do this.
Table 2
MDG 5 STATUS IN BANGLADESH
|
| Goal 5 | Targets
| Indicators | Base year (1991)
| Current Status (2006)
| Target |
|
| Improve maternal health | Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
| 4. Maternal mortality ratio (per 100,000 live births)
| 574 | 290
| 147 |
| | 5. Proportion of births attended by skilled health personnel
| 5% | 20%
| 50% |
|
| Source: Base year indicator 4: Bangladesh Bureau of Statistics (SRVS), 5: Bangladesh Bureau of Statistics (MICS); Current status indicator 4: Bangladesh Bureau of Statistics (SVRS), 5: Bangladesh Bureau of Statistics (MICS); 16: United Nations Population Fund (UNFPA)
|
5. Increase Maternal, Newborn and Child Health Spending
and Efficiency
Overall, aid for MNCH has been highly volatile and variable,
and development assistance to MNCH has not been well targeted
towards countries, such as Bangladesh, with the greatest health
needs (WHO, 2009). At least US$15 billion in additional resources
is needed by 2015 in order to achieve MDGs 4 and 5 in the Asia
Pacific region and long term health and economic outcomes can
be achieved in some areas by investing as little as US$3 to US$12
additionally per mother or child in a year (WHO, 2009).
Bangladesh's Country Assistance Strategy (2006-09), jointly
developed by the World Bank, ADB, DFID and Japan focuses on improving
the investment climate and empowering the poor, but largely overlooks
specific issues related to child, and in particular newborn, and
maternal health. DFID's financial assistance to Bangladesh is
decreasing from a total spend in 2008-09 of £132.9 million
to the proposed £125 million in bilateral assistance in 2009-10
and in 2008-09 only 7% of DFID bilateral assistance was actually
spent on health (DFID, 2009). Spending on MNCH in Bangladesh needs
to increase and efficiency must be prioritised to ensure that
the government of Bangladesh can address these funding challenges
and ensure that progress towards MDGs 4 and 5 is sustained (GOB,
2007). DFID should also use its role as an international champion
for MNCH issues, supporter of health system strengthening and
as Bangladesh's largest bilateral donor to persuade other donors,
especially ADB, the government of Japan and the World Bank to
provide greater support to MNCH initiatives in Bangladesh.
Recommendation 1:
DFID must ensure that the women and children of Bangladesh
do not pay for the current financial crisis, and that it is not
used as a reason not to invest in the services that could save
their lives. In line with the UK government international commitments
to improve MNCH DFID must specifically prioritise MNCH in its
Bangladesh Country Plan. DFID must ensure that aid flows for MNCH
in Bangladesh increase and improve through predictable and long
term support. DFID must also use its international leadership
role in the health sector to encourage other donors operating
in Bangladesh to prioritise and fund MNCH programmes.
6. Strengthen Health Systems and Integrate MNCH into
National Plans
The poor face huge barriers to accessing healthcare in Bangladesh
including high user fees for healthcare; long distances to travel
to health facilities with limited transport; too few, under qualified,
untrained and/or demotivated healthcare staff, and a lack of medicines.
Increased supply side investment in Bangladesh's health system
to ensure health information and services are accessible will
be key to delivering MNCH services in Bangladesh. Maternal health
cannot be achieved without access to affordable high quality sexual
and reproductive health services which encompass three main areas:
contraceptive services, maternal health services (including safe
abortion/menstrual regulation, treatment for incomplete and botched
abortion and Emergency Obstetric Care (EOC)) and services related
to the diagnosis and treatment of sexually transmitted infections
(including HIV). Preventive interventions which will improve MNCH
are relatively simple and extremely cost-effective but require
a functioning health system, for example the provision of basic
family planning, antenatal care, skilled birth attendance, and
the prevention and management of common illnesses among newborns
and children.
The government of Bangladesh has been pursuing a policy of
health development that ensures the provision of basic services
to the entire population, particularly the under-served in rural
areas, through Primary Health Care (PHC). This includes the DFID
supported Skilled Birth Attendant (SBA) Training Programme which
aims to provide skilled attendants at birth in rural Bangladesh.
So far almost 4000 SBAs have been trained but 12,000 SBAs are
required in total, particularly as a recent survey revealed that
85 percent of births still occur at home and only 18 percent delivered
with assistance from medically trained providers (BDHS, 2007).
DFID should continue supporting this SBA programme to ensure that
a minimum of 4 million pregnant women will have been looked after
by SBAs by 2015 (DFID, 2009).
Ultimately, healthy health systems translate into healthy
mothers, newborns and children. Continued support for health system
strengthening, including the improvement of health facilities,
is essential. Supporting the integration of MNCH across Bangladesh's
national health plans and placing progress made against MDGs 4
and 5 at the core of DFID's Bangladesh Country Plan would help
ensure that the specific needs of mothers, newborns and children
are not overlooked. It is also recognized that progress towards
achieving the MDG 5 targets in particular is a good litmus test
for the functioning of a country's overall health system and the
level of development more generally; progress against which national
and donor governments can be held to account.
Recommendation 2:
DFID should continue support for health system strengthening
in general and universal access to reproductive health services
and the Skilled Birth Attendant programme to improve access to
Emergency Obstetric Care in particular. DFID should support the
integration of MNCH across Bangladesh's national health plans
and ensure that progress made towards MDGs 4 and 5 is at the core
of DFID's Bangladesh Country Plan. DFID should ensure that progress
made towards MDG 5 is used as a litmus test for the health of
Bangladesh's health system and overall level of development.
7. Support Community Mobilisation and Women's Groups
Few Government of Bangladesh (GOB) programmes have managed
to provide multiple pre- or postnatal home visits to mothers and
infants when scaled up18. Community-based interventions can play
a significant role in improving both the demand and supply sides
of MNCH care. Effective demand side strategies, particularly through
community mobilisation approaches, empower women to recognise
and press for their right to quality health services and increase
resilience to community health challenges, and are as important
as the requirement to improve and make health services more accessible
on the supply side. Community mobilisation enables communities
to come together to plan, carry out, and evaluate activities to
make sustained improvements to their health. Community mobilisation
can make deep and lasting improvements to the health and well-being
of community members by increasing their health knowledge and
enabling them to identify and address important healthcare needs.
In Bangladesh women do not have regular contact with other
community members, nor do they have an opportunity to voice their
opinions. Women's groups therefore provide opportunities not otherwise
available to bring women together to discuss key issues affecting
them during pregnancy and childbirth. The women's group meetings
enable women to develop their own knowledge about MNCH which they
can then use to educate others and challenge existing power structures.
The women's groups bring women with similar needs together to
discuss topics that are of concern to them, for example a lack
of access to high quality healthcare facilities. To date women's
groups have developed various low cost strategies to meet their
healthcare needs, for example: emergency funds, improved healthcare
facilities, stretcher schemes and clean home delivery kits. Women's
groups enable women to identify and prioritise MNCH issues, have
the support to find local and low cost solutions and build links
with local health services. Women's groups are a cost effective
and evidence based intervention, which have the potential to be
scaled up to reach out to all women and make a significant impact
on their lives, their children's lives and the lives of wider
community members.
There is growing evidence to suggest that women's groups
can significantly improve MNCH and reduce unnecessary deaths.
In Nepal, rigorous research showed that women's groups secured
a 30% reduction in deaths of newborn infants and a significant
reduction in maternal mortality (Manandhar et al, 2004). Soon
to be published research from India also demonstrates that there
is strong evidence that even where services are poor and under-utilized,
women coming together in groups to talk about ante-natal care
and childbirth can reduce the numbers of newborn deaths by at
least 30-40% (Professor Anthony Costello, 2009). Research undertaken
by BADAS, CIHD and Women and Children First in Bangladesh has
also shown that community mobilisation led to improvements in
thermal care and exclusive breastfeeding for newborns and no woman
attending a women's group has died since activities started in
2006. There was also evidence in this study of Iimproved links
between community health providers (eg Traditional Birth Attendants)
and health facility staff. Women's groups, if scaled to an adequate
coverage, have the potential to reach the poorest and bring about
substantial health and non-health benefits.
Recommendation 3:
DFID should support Bangladesh civil society to improve health
outcomes where the government of Bangladesh cannot. DFID should
embrace the principles of community participation in health systems
and support resilient and sustainable community responses to heath
challenges such as community mobilisation through women's groups.
Where evidence for successful community mobilisation and women's
groups exists DFID should financially assist scale up and research
into other existing and innovative community based approaches
to improve MNCH. This investment should include better MNCH data
collection and the implementation of research findings.
8. Increase Equity
The lack of progress towards MDG 5 in particular has been
a struggle because it is inextricably linked with complex social
and economic factors related to health beliefs and practices,
education and poverty (GOB, 2007). Efforts to reach all Bangladeshi
people equitably, including those who are regionally excluded,
need to be intensified (GOB, 2007). Socio-economic inequalities
in MNCH outcomes and determinants are an important concern. Under
five mortality is twice as high among the poor compared to the
rich (86 per 1,000 live births among the poorest population quintile,
compared to 43/1,000 among the richest quintile) (BDHS, 2007)
and neonatal mortality among the poor is nearly twice as high
compared to the rich (48/1000 compared to 27/1000). Inequalities
in MNCH outcomes are caused by inequalities in the health care
system as well as by social determinants of health. Health system
inequalities are stark: 31% of women in the poorest population
quintile use antenatal care, compared to 86% of the richest women
(BDHS, 2007). Professional care at birth is 5% among the poorest
population quintile, compared to 50% among the richest quintile
(BDHS, 2007). The DFID supported Maternal Health Voucher Scheme
goes some way in addressing such health inequities. It aims to
increase utilisation of quality maternal health services through
creating equity of access irrespective of the patient's ability
to pay and covers antenatal and postnatal care, safe delivery
and treatment of pregnancy complications (WHO, 2007). DFID support
for this scheme should be continued.
Child malnutrition, although registering improvements over
the last decade, is a major public health issue with 36% of children
under five years stunted and 46% underweight (BDHS, 2007). 23.2%
of children in the poorest population quintile are severely chronically
undernourished (stunted) compared to 7.6% in the richest quintile
(BDHS, 2007). Malnutrition also poses a variety of threats to
women (data in section 9). It weakens women's ability to survive
childbirth, makes them more susceptible to infections, and leaves
them with fewer reserves to recover from illness. HIV-infected
mothers who are malnourished may be more likely to transmit the
virus to their infants and to experience a more rapid transition
from HIV to AIDS. Malnutrition undermines women's productivity,
capacity to generate income, and ability to care for their families.
A pregnant woman's nutrition directly influences the course of
her pregnancy and normal foetal development. Children of malnourished
women are more likely to face cognitive impairments, short stature,
lower resistance to infections and a higher risk of disease and
death throughout their lives. Unless inequities around malnutrition
are seriously addressed in national plans improvements in MNCH
will not be achieved.
Recommendation 4:
DFID should address inequalities in MNCH outcomes and determinants,
including equitable access to MNCH services eg by continuing support
for the Maternal Voucher Scheme. DFID should address the social
determinants of these inequities, including nutrition. Socio-economic
inequalities in MNCH outcomes and determinants, and the impact
of DFID policy on these inequalities should be systematically
monitored and reported.
9. Integrate Gender
Gender inequity, an integral part of reaching the MDG 4 and
5 targets, is an area of particular concern. Bangladesh ranks
very low at 140 out of 177 countries on the Gender Empowerment
Index (UNDP, 2008) and the continuing high rates of maternal mortality
and morbidity indicate serious gender inequity issues and the
low priority afforded to the status of women and women's reproductive
rights in Bangladesh. In the above mentioned study conducted by
BADAS, CIHD and WCF in Bangladesh there are indications that gender-based
barriers were strong in some districts and may have prevented
some women from seeking health care. Evidence also suggests that
the benefits of specifically targeting women of reproductive age
(15-45 years) and newly pregnant women may also be greater. However,
men, acknowledging their key role in improving MNCH, must also
be targeted. Gender specific issues that require particular support
include early pregnancy, early marriage, access to family planning
and malnutrition.
Childbearing begins early in Bangladesh; half of women age
25-49 had their first birth by age 18 and 12% had their first
birth by age 15 (BDHS, 2007). Early pregnancy poses a particular
threat to the psychological and physical well being of adolescents
who have not yet reached maturity and it affects the nutritional
status of the mother as well as the fetus. The increased risks
of early pregnancy include pre-term birth, stillbirth, birth asphyxia,
low birth weight, infections, haemorrhage, anaemia and mortality.
Early pregnancy can also have negative impacts upon the education
of adolescent girls, limiting career choices and earning potential.
Half of women age 25-49 were married by age 15 (BDHS, 2007) (giving
Bangladesh one the highest rates of early marriage in Asia) (KfW,
2006). Childbearing among young women aged 15-19 is also quite
common in Bangladesh: 27% are already mothers and an additional
6% are pregnant with their first child (BDHS, 2007). Increasing
the median age of marriage in Bangladesh, which has barely changed
since 1993-94 (BDSH, 2007), and first birth is central to achieving
gender equality of capability and opportunity and to meeting the
MDG 4 and 5 targets and will require specific interventions focused
on the under 15 male/female age group (KfW, 2006).
Bangladesh has made significant progress over the last two
decades in halving fertility levels from an average of 6.3 in
1975 to 2.7 in 2007 (BDHS, 2007) and family planning programmes
are now well established in both rural and urban areas. However,
issues relating to both quality and equality of access persist,
particularly regarding inequities in access to health services
between wealthy and poor households and require targeted interventions
at both the household and district levels (KfW, 2006). Directing
contraception largely at women only (particularly in the form
of the contraceptive pill (BDHS, 2007)) and persistently high
contraceptive discontinuation rates (around 50%) are worrying
and will need to be addressed if Bangladesh is to sustain lower
fertility levels (KfW, 2006). As a global advocate for family
planning and safe abortion DFID has a key role to play and must
increase and expand investments in the sector if achievements
in fertility decline are to be sustained.
The major poor nutrition problem in Bangladesh also has clear
gender dimensions with nearly a third of children from the richest
quintile also suffering from malnutrition (GOB, 2005), indicating
that other inequity issues such as gender may play a significant
role in child health outcomes. In particular, the prevalence of
anaemia amongst women of childbearing age is extremely high with
consequent impacts upon both MNCH as well as productivity. A national
anaemia surveillance survey completed in 2001 indicated that 9
million women of reproductive age in Bangladesh were anaemic (KfW,
2006). The same survey also found that almost half of all pre-school
children in rural Bangladesh, or almost 23 million children, were
anaemic—suggesting a serious future health problem in the
absence of effective nutritional interventions over the next decade.
The persistent and growing gender gaps in nutritional indicators
with the female-male gap for severely stunted children increasing
from 10 percent in 1996-97 to 16% in 1999-2000 is alarming (GOB,
2005). The significant gender gaps in child mortality rates with
female rates in the 1-4 age group approximately one third higher
than male rates also raises serious questions—not least
concerning possibly gendered patterns of nutrition and health
care at the household level (KfW, 2006). Gender analyses of nutritional
levels/health care access/provision within the household are needed
and the GOB needs support from DFID, as a global gender equity
champion, to develop effective strategies to address these gaps
(KfW, 2006).
Recommendation 5:
DFID should recognize the fundamental links between improving
MNCH and gender equity in Bangladesh and ensure that gender is
integrated across its Bangladesh Country Plan. DFID should provide
support to the GOB for gender analyses of health planning and
financing and support stronger collection, analysis and dissemination
of gender-disaggregated data in the health sector, to enable the
effective and regular measurement and assessment of gender equity
and equality.
|
