Md. Mosfequr Rahman¹, Md. Aminul Hoque², Md. Rajwanul Haque³

1. Department of Population Science and Human Resources Development, Rajshahi University, Rajshahi-6205, Bangladesh.

2. Department of Statistics, Rajshahi University, Rajshahi-6205, Bangladesh.
E-mail: mdaminulh@gmail.com

3. Assistant Research Officer, PDMER, Islamic Relief Bangladesh.
E-mail: rajwan@islamicrelief-bd.org

Correspondence to:
Md. Mosfequr Rahman,
Lecturer Department of Population Science and
Human Resources Development,
Rajshahi University,
Rajshahi-6205, Bangladesh
Fax: +88-721-750064 (Off),
Mobile: +88-1712196574,
E-mail: mosfeque@gmail.com

 

ABSTRACT Like other developing countries of the world IMR and MMR are reducing in Bangladesh. But these are still alarming in Bangladesh, especially in rural areas and in the poorest section of the country. This study investigated the impact of the maternal and child healthcare MCH) project on infant and maternal mortality using the data collected by MCH. Our analyses and findings indicated that both IMR and MMR are reduced significantly due to the project intervention. We also found the clear difference between project intervened and non-intervened beneficiaries due to pregnancy awareness training from MCH. The factors that cause maternal morbidity and death also affect the survival chances of the foetus and infant. In the present study we also indicated the dominating causes of high IMR and MMR in Bangladesh. High rates of maternal deaths occur in the same countries that have high rates of infant mortality reflecting generally lack of knowledge and medical care. Key Words: Project intervention, Infant mortality, Maternal mortality, Significance, Pregnancy awareness, Survival chance.

Despite significant improvements in child survival in recent decades, levels of infant and child mortality and morbidity remain unacceptably high in many developing countries (UNDP, 2004; World Bank, 2000). These problems are particularly serious among high-risk pregnancies and births and in many developing countries where the health-care system is still struggling to provide basic public health and maternal and child health to their population (Bryce et.al. 2005; Atiyeh and El-Mohandes, 2005). In such countries, adequate health-care services for managing high-risk pregnancy and delivery are usually available at the referral levels such as regional and national hospitals (Yucesoy et al. 2005; Ravikumara and Bhat 1996). However, access to these facilities remains limited owing to factors such as distance, transportation cost and medical fees; specifically for the poor women and women who live in the rural and remote areas.

Although a remarkable decline in mortality has been observed over the last half of the past century, but within country, mortality both in developed and developing countries varied often by different sub-group (Feachem, 2000; Gwatkin, 2000). Almost everywhere the poor suffer poor health and the gap in health condition by economic group, ethnicity, caste or place of residence remains very wide. In Bangladesh, many positive changes have taken place in various fields (for example, in food production, communication, education, life expectancy, fertility decline) over the past few decades (UNICEF, 2001), but the country still remains one of the world's poorest nations according to World Bank criteria. To improve health of the people, the government has intensified health services over the country since the Alma-Ata conference in 1978. This includes establishment of Health Complexes and provision of free health and family planning services in both the urban and rural areas. But these facilities are yet to create awareness of health to the majority of people in Bangladesh.

In Bangladesh maternal and child health problems pose a serious threat to the improvement of overall health status of the country and thereby negatively affect the socio-economic development. Mortality under age 5 in Bangladesh is 71 per 1000 live births and infant mortality rate is 53 per 1000 live birth (ESCAP Population Data Sheet, 2007). It is still unacceptably high. The reduction in maternal mortality in the past 15 years is 22%, right on target towards the Millennium Development Goal (MDG) of a 75% reduction between 1990 and 2015 (Ali et.al. 2004). The Maternal Mortality Survey 2001 indicates maternal mortality is 3.20 per 1000 live births. The high mortality rates indicate lack of health facilities and lack of knowledge as the major causes. Though a lot of the NGOs are working to reduce IMR and MMR through providing social and material support as well as government which is also creating awareness through different means like radio and TV programs, leaflets, posters, billboards etc.

In many low-income countries, non-governmental organizations (NGOs) deliver basic health services in particular areas or among certain populations. Their effectiveness in establishing sustainable primary health care (PHC) systems has been linked with promotion of community participation, having close links with the poor, being flexible and having committed staff (Gellert 1996). The comparative advantage of NGOs might be assessed in terms of efficiency, innovation, quality of services, ability to mobilize resources, contribution to the sustainability of the local health system and coverage of grass-roots communities (Gilson et al. 1994; Matthias and Green 1994; Stefanini 1995). However, the need for reliable evidence on the impact and effectiveness of NGO PHC provision has long been recognized (Edwards and Hulme 1995). This paper examines the effectiveness of a MCH project conducted by an NGO to reduce the infant and maternal mortality rate in Bangladesh.

In Bangladesh many NGOs are implementing mother and child healthcare projects to reduce infant and maternal mortality. Islamic Relief Bangladesh is one of them and conducting a project, which provides antenatal care, post natal care, pregnancy test, diagnosis risk pregnancy, child growth monitoring, provides safe delivery kits etc. from 1996 at the Mithapukur upazila of Rangpur district, Bangladesh. Reducing maternal and infant mortality, improving overall health situation, promoting health awareness, ensuring preventive measures, encouraging physical and psychological development of the poor in the area are the key concerns of the project.

For this study, information has been collected from selected respondents who have benefited from the project intervention directly or indirectly. Information has also been collected from non-intervened respondents. To collect information, a structured questionnaire, focus group discussion, and case study were used. A three stage stratified random sampling technique has been adopted for this survey with beneficiary as a sampling unit. The size of the total sample was selected at 300. A total of 100 non-intervened respondents were selected from two villages.

Health Services Obtained
It is observed from the survey that 84% of respondents including their children have been getting necessary immunization from the MCH project. Other services obtained by the respondents from the MCH project are: 79% received check up facilities during pregnancy, 77% of respondents including their children received facilities to measure weight during pregnancy for women and growth monitoring for below 5 years children. The respondents also received several types of facilities from the MCH project such as urine/pregnancy test, awareness on health education, child care, nutritious food during pregnancy, and awareness of breastfeeding.

Sources, Knowledge and Types of Services Received
From Figure 1 it is observed that 97% respondents said that they are getting effective messages on mother (ANC & PNC) and child health care through MCH health workers/nurses. Besides this 18% if respondents were aware by listening and watching Radio/TV. The most significant findings is that only 10.67% respondents received several lots of information regarding maternal and child health through government health workers, other NGO's health workers, CAP project's staff and poster/leaflet.

Fig. 1 Sources of Maternal and Child Health Care Services

Figure 2 represents that the antenatal care is the most imperative assistance for the pregnant woman. The essential services are regular check ups, taking iron tablets, heavy work, careful movement, taking TT vaccines, taking nutritious food, regular rest etc. After getting awareness training regarding antenatal care most of the respective pregnant women have been followed and taken same services (Fig. 3). The mentioned services are provided by MCH project 92%, other NGO's 5.3% and the rest from government hospitals/clinics (Table 3).

Fig. 2 Perception of Respondents about Services Needed by Pregnant Mother

Fig. 3 Types of Services

Medical Check-up and Realization of Pregnancy
Survey findings indicated that almost all respondents know medical check up is essential for caring for mother and her baby during the antenatal period. Table 4 shows that around 90% of women have had a medical check up before last birth and the remaining 10% could be a first time child bearer so it was not necessary to do that. Since all respondents are conscious about their own health during pregnancy and want to give birth to a healthy baby, 72% of respondents took a medical check up three times and 27% two times before the last child birth.

Table 5 indicates that 90% of women can recognize through vomiting tendency whether she is pregnant. Almost the same results observed both in the intervened and non-intervened group of women. Other pregnancy symptoms felt are dizziness, menstruation cessation, distaste, ill smelling etc. In comparison of both groups, 38% intervened respondents said they have confirmed pregnancy by urine test on the other hand only 2% of non-intervened women ensured by urine test as well.

Complications During Pregnancy
Table 6 shows that about four-fifths of pondents have given birth to their children without any complexity and 19% faced some complexity during delivery. The highest number of respondents (62%) faced excess bleeding following placenta delivery(26%). In contrast the non-project intervened respondents have suffered more excess bleeding and eclampsia than the intervened group of people. On the other hand about 4 times less response was found on placenta from non-intervened women. This may have happened because of lack of awareness. Among the sufferers they firstly go to project staff and the local TBA to take suggestions and ro solve the problem. A non-intervened woman goes to TBA, UHC and private clinic.

Fig. 4 Types of Complexity Faced by the Mother During Delivery

Breastfeeding and Complementary Feeding of Children
It is observed from Table 7 that in experimental groups 100% respondents are aware of breastfeeding the child whereas only 22% are in the non-experimental groups. Among the experimental group the respondents said that on average breastfeeding should be carried out for 25 months whereas 30 months is in the non-experimental groups. It also shows that supplementary foods should be provided to the child after 6 months whereas the non-experimental group responded that supplementary food should be given after 13 months with breastfeeding.

Place of Delivery
Proper medical support and hygienic conditions during delivery can reduce the risk of infection which could lead to serious illness or death to the mother or new born. Table 8 indicates that delivery at home nevertheless remains high (89%) which is close to Bangladesh Maternal Health Services and Maternal Morbidity Survey findings (91%) (NIPORT, 2003). Seven percent of deliveries occur in the private clinic or Govt. hospitals for the intervened groups. All non-intervened respondent's delivery occurs at the home though few number of child births have occurred.

Assistance During Delivery
From Table 9 we found that among the experimental group 43% of respondents delivered their children through the MCH trained TBA and 20% by MCH nurses. It also shows that 25% of respondents among the experimental group completed delivery through relatives, compared to 69% of respondents in the non-experimental group. Only 6% of respondents completed delivery using normal TBA among the experimental group whereas 19% in the non-experimental group did.

Types of Delivery
It is observed from the data given in Table 10, that about 94% of births occur by normal delivery and 3% occur by caesarean and use of forceps. The findings show all deliveries have been done normally for the non-intervened group without using any modern facilities. It depicts that the population of non-experimental group are still unaware regarding modern facilities of delivery than the project intervened areas.

Infant, Child and Maternal Mortality Rate

Fig 5. Comparison IMR, MMR and under 5 year Mortality Rate between Experimental and non experimental population

From Table 11 and Figure 5 we found that the infant mortality rate for the experimental group is 27 per 1000 live births which is less than half of non-experimental group 60. Under five year child mortality for the experimental group is only 18 per 1000 live births whereas for the non experimental group it is 71 per 1000 live births, which implies that the result for ther experimental group is about one-fourth of the non-experimental group. We also found that the maternal mortality rate is also lower for the experimental group than that of the non-experimental group. Significant changes have been found for IMR and under five child mortality due to MCH project intervention.

A nation's maternal mortality ratio is now widely considered to be an important indicator of the overall health status of women. High MMR represents failure of a health system to effectively provide services and care for women, and the failure of society to keep women in good health. The services most often linked to reduction of maternal mortality include antenatal care during pregnancy, tetanus toxoid vaccination, professional child delivery (including emergency services access), postnatal care and family planning services (UNICEF, 1999).

The main aim of the aforesaid project is to reduce maternal and infant mortality rate, improve the overall health situations, promotion of health awareness, ensure preventive measures, encouragement of physical and psychological development of the poor. We observed that most of the deliveries occurred by the project trained TBAs, relatives, project staff and general TBAs in the home. Risk delivery cases are brought to the government hospitals or private clinics for giving birth as suggested by the health worker and nurse. People said and also study findings say that maternal and infant mortality is reducing gradually after project intervention. Planners and policy makers should take all necessary actions to keep reducing the IMR and MMR throughout the country as did the MCH project.

Ali A, Islam M, Islam MT, Rahman J, Begum RA, Fateh WA, Rahman M, Mathai ST (2004). Thematic Review of Safe Motherhood in Bangladesh. MOHFW and UNFPA.

Atiyeh GN, El-Mohandes A (2005). Preventive healthcare of infants in a region of Lebanon: parental belief, attitudes and behaviours. Matern. Child Health J. 9:83-90.

Bryce J, Black RE, Walker N, Bhutta ZA, Lawn JE, Steketee RW (2005). Can the world afford to save the lives of 6 billion children each year? Lanceti. 365:2193-200.

Edwards M, Hulme D (1995). Non-govermental organizations- performance and accountability. London: Earthscan.

Feachem RGA (2000). Poverty and inequity: a proper focus for the new century. Bulletin of the World Health Organization. 78:1-2.

Gellert GA (1996). Non-governmental organizations in international health: past successes, future challenges. International Journal of Health Planning and Management. 11:19-31.

Gilson L, Sen PD, Mohammed S, Mujinja P (1994). The potential of health sector non-governmental organizations: policy options. Health Policy and Planning. 9:14-24.

Gwatkin DR (2000). Health inequalities and the health of the poor: what do we know? What can we do? Bulletin of the World Health Organization. 78:1-18.

Matthias AR, Green AT (1994). The comparative advantage of NGO (non-governmental mental organizations) in the health sector- a look at the evidence. World Hospital Health Services. 30:10-5.

NIPORT (2003). Maternal Health Services and Maternal Mortality Survey 2001: Preliminary report. Dhaka: National Institute of Population Research and Training and ORC Macro.

Ravikumara M, Bhat BV (1996). Early neonatal mortality in an intramular birth cohort at a tertiary care hospital. Indian J. Pediatr. 63:785-9.

UNICEF (1999). Situation Assessment of the Women and Children in Bangladesh. Bangladesh: Government of Bangladesh and UNICEF.

United Nation Development Program (2004). Human Development Report. New York: UNDP.

World Bank (2000). World Development Report. Washington, DC: World Bank.

Yucesoy G, Ozkan S, Bodur H et al. (2005). Maternal and perinatal outcome in pregnancies complicated with hypertensive disorder of pregnancy: a seven year experiences of a tertiary care center. Arch. Gynecol. Obste. 273:43-9.