Activity 8: Reproductive Health, including family planning, & Maternal Health

PI: Dr. Marge Kobilinsky (April’05 – July’07) and Dr. Mahbub Elahi Chowdhury (August 2007 onwards)

The IHP: HNPRP has provided support to the following completed or ongoing projects:

Scale-up of a new indicator of maternal health in all the Government EOC facilities in 12 districts in Bangladesh

This study was undertaken to scale-up a new indicator of maternal health: ‘Major Obstetric Interventions for Absolute Maternal Indications’ (MOI-for AMI) in the Government facilities in 12 districts in Bangladesh funded by the USAID. This is a simple and useful indicator for health managers and providers to assess the performance of EOC services at district level; and to monitor levels of caesarean sections in private and public facilities with the goal of improving coverage and quality of maternal health services. This indicator allows obstetricians and health managers to prioritize healthcare activities, and improve record keeping in healthcare facilities.

In 2005-06 ICDDR, B in collaboration with Director MIS unit of DGHS operationalized this new indicator (MOI- for-AMI) in 12 districts (Kurigram, Borgra, Tangail, Mymansingh, Moulivabazar, Hobigonj, Rangamati, Jessore, Bagerhat, Potuakhali, Barisal, Noakhali) of Bangladesh. In each of the 12 districts workshops were arranged to orient the health managers with this new indicator and to train the health providers to estimate MOI-for-AMI with the use of facility data. These workshops were participated by representatives from district level stakeholders of maternal health including public (civil surgeon, deputy-civil surgeon, TH&FPO, Medical officer), professional bodies (OGSB, MBA) and private. For collaborative activities with the Govt. IHP fund (US$19000) was used.

Collaborating Institutions:
Director MIS unit of DGHS

Results:
The study found that MOI-for-AMI was the highest in Jessore district (76%) and the lowest in Hobiganj district (27%) which suggest that maternal health status in Jessore is much better that that in Hobiganj.

Case Study for Safe motherhood: Learning from South Asian Programs

This study assessed trends and determinants of maternal mortality decline in Bangladesh with the DFID fund. In this study we have also documented the distribution of EOC facilities and human resources including quality of care in high and low performing districts (district component) in Bangladesh. Ultimate goal of this investigation was to strengthen the RH program of the government in order to achieve Millennium Development Goal (MDG) 5. In this study IHP fund was used to organize stakeholder meetings, to facilitate local travel and to provide partial salary support to the investigators. IHP fund is also allocated for publishing study findings in a special issue of a scientific journal. Total contribution from IHP fund was US$90,000.

Collaborating Institutions:
Reproductive Health (RH) program of the government is the major stakeholder in this study. Several national workshops have been arranged by involving program managers and policy makers from the Government and professional bodies.

Results:
This study shows a dramatic decline in maternal mortality in Matlab. In the ICDDR,B service area maternal mortality declined from  412 per 100,000 pregnancies in 1976-80 to 131 per 100,000 in 2001-05. In the Government service area maternal mortality declined from 451 per 100,000 in 1976-80 to 206 per 100,000 in 2001-05. Part of this decline is attributable to a fall in deaths from abortion, though the reduction in other causes was equally impressive. Quite remarkably, this decline occurred in the context of poor uptake of skilled care at birth, although uptake of emergency obstetric care increased substantially over the last decade.

Results from the analysis of ‘district component’ clearly depicts that the maternal health care programme could not ensure quality in public sector EOC facilities particularly in low performing districts (Sylhet and Moulvibazar districts) as compared to high performing districts (Khulna and Jessore) of the country. The major problems are unavailability of trained human resources and absence of blood bank. These supply side barriers were accentuated by some contextual factors (demand factors) in low performing districts like, conservativeness, poor mobility, and low literacy in women. Conversely both care and context is different in high-performing areas of the country. For example organization of EOC services including distribution and functionality of facilities and trained providers are better in Khulna region. Mothers are more literate, less conservative and are to cover less distance to access EmOC facilities than in low performing areas of the country. The study recommend to design interventions keeping contextual and sociocultural factors in mind. The other demand intervention – including geographical targeting should be considered seriously for maternal and neonatal health of the country.

 
Role of Nurses in Maternal and Neonatal Health Care Programs in Bangladesh

This DFID funded ongoing study is designed 1) to explore the role of nurses in maternal and neonatal health care program in Bangladesh and 2) to provide recommendations to stakeholders about training, retention, deployment, regulations covering practices, and pro-poor strategies and work with policymakers to operationalize the recommendations. Findings will be shared with the relevant stakeholders and policy makers of the country through meetings and workshops to increase the potential of the nurses. Specific focus will be given to increase coverage, improve quality and ensure equitable access of MNH services to impact on decreased neonatal and maternal mortality - thus help address MDG 4 & 5 targets. In this study we have plan to use IHP fund (US$4,000) for organizing stakeholder meetings.

Collaborating Institutions:
Directorate General of Health Services and Directorate of Nursing Services are major collaborators. Investigators from these institutions contributed in developing the proposal and currently collaborating for study implementation.

 Results:
This is an ongoing study – results will available by the end of 2008.

Evaluation of Partner Notification for sexually transmitted infection in Bangladesh.

Partner notification and treatment has been recommended as an essential component in STI management and control programs. This AusAID funded study is being implemented to understand perspectives of partner notification (PN) among STI patients and service providers and to identify a simple intervention and test effectiveness of that intervention to promote PN in Bangladeshi context. As part of the study, we mapped the hospitals and clinics involved in providing STI services in Dhaka and Chittagong city corporation area, conducted surveys among the service providers and STI patients. A randomized trial has been implemented to understand effectiveness of counseling on improving partner referral for STI patients. We have plan to organize workshop in selected public hospitals to share study findings with stakeholders and policy makers. This study will help understand different issues concerning PN in Bangladesh and guide us develop policy recommendations to improve partner referral and treatment for STIs. This has implication to control and prevent STI/HIV in Bangladesh and thus achieving MDG-6. In this study we have plan to use IHP fund (US$4000) to organize workshop in the selected hospitals to disseminate study findings.

Collaborating Institutions:
This study is being implemented in collaboration with Government hospitals and NGO clinics.
Among the government institutions we are collaborating with Skin & Venereal Disease Department of DMCH, Department of Skin & Venereal Disease, BSMMU; Skin and Social Hygiene Centre (American Hospital) in Chittagong

Results:
The preliminary results showed that in the government hospitals; partner referral rates were 37% among counseling group as compared to 25% among non-counseling group. Among NGO clinics, the corresponding figures were 49% and 40% respectively. The final analysis is ongoing and results will be available by March 2008.

Extent and consequence of catastrophic cost for caesarean section

This JHU/PPC funded study attempts to find out the extent and consequences of catastrophic household expenditure for caesarean delivery. This project was implemented in the government, NGO and private hospitals of Bogra, Jessore and Mymensingh. The project will be helpful for the GoB for decision making in terms of “Demand Side Financing”.

During the implementation of the project, the investigators collaborated with Reproductive Health Program, DGHS, Office of the Civil Surgeon ( Bogra, Jessore, Mymensingh ), Office of the DDFP (Bogra, Jessore, Mymensingh), Shaheed Ziaur Rahman Medical College, Bogra, Medical College, Mymensingh and other government hospitals performing caesarean section deliveries. The collaborative arrangements facilitated collection of data not only from the government facilities but also from the non-government settings. Advocacy meetings were arranged with the government and non-government officials in the districts to inform them of the objectives of the study and facilitate implementation of the study. The project aims at sharing findings from the project in the districts where the project was implemented. IHP fund (US$4000) will be used in organizing these workshops.

 

Collaborating Institutions:
This study was implemented in collaboration with Deputy Program Manager (Reproductive Health), DGHS; Civil Surgeons (Bogra,Jessore, Mymensingh), DDFP (Bogra, Jessore, Mymensingh), Director  SZRMC Bogra, Director of MMCollege, Mymensingh, Superintendent ofJessore District Hospital.

Results:
The study found that on average out-of-pocket expenditure (OOPE) for caesarean section delivery is US$ 168 in Bangladesh (US$ 158 in public facilities, US$ 139 in NGO facilities, and US$ 211 in private facilities). Fifty five percent of OOPE is from husband’s income followed by loan (17%), contribution from people other than household members (15%), and income of other household members (9%). Fifty one percent of loan was taken from local money lender, 24% from relatives, 10% from neighbours, and 4% from NGOs. Thirty three percent of households made catastrophic expenditure (spend >10% of their annual income) for C/S delivery.

The study recommendation is current policy of government to reimburse US$ 70 for caesarean section delivery is inadequate. Government need to either reduce cost of caesarean section at facility level or increase the amount of money for reimbursement.  GOs need to provide loan during the obstetric complications of women.

Maternal and neonatal care configurations in Bangladesh: Availability and Quality

This DFID funded ongoing study will report the location, availability and quality of maternal and neonatal health services in public, for-profit-private and not-profit-private facilities in Bangladesh. The project thus will also be able to recommend appropriate care and human resource configurations for each broad category of public for-profit-private and not-for-profit private facilities in Bangladesh. The potentials of these facilities to scale up of particular care configurations can also be reported. These findings will be critical in the development and modification of strategies to attain goals outlined in the HNPSP and PRSP as well as MDGs 4 and 5 and allocation of resources accordingly.

This study is currently being implemented in collaboration with the government. IHP fund (US$4000) has been allocated in organizing meetings and workshops with the collaborators.

Collaborating Institutions:
In this study we are collaborating with Reproductive Health Program, DGHS and Human Resource Development Unit, MoHFW.

Results:
The study is currently ongoing.