Can we save dying mothers in Bangladesh?

“My mother-in-law insisted that the delivery be at home, as that is how most women deliver babies in our community. I went into labour late at night, and the traditional birth attendant gave up at around 3am. The pain was so immense, I thought I will not make it to dawn. Somebody from the neighborhood called a BRAC shashtya kormi (community health worker) and informed about the emergency. The next thing I remember was being assisted onto a van by a lady in a white apron with a BRAC logo on it. I think I passed out in the middle from pain. Then I woke up on a bed in a BRAC delivery centre. I looked around, the lady in the white apron was holding onto my hand and telling me ‘it is going to be fine, we have trained birth attendants here, they know how to deliver your baby. There is nothing to fear.’ Not long after that I gave birth to my beautiful baby boy. Holding him in my arms was the most beautiful moment of my life, and it would not have been possible without the lady in the white apron.”

Rupali Begum (25), resident of a slum in Dhamalkot, Dhaka, was saved by Shipra Rani Mridha, a BRAC community health worker.

Giving birth to new life is meant to be one of the most beautiful life experiences. However, unfortunately for many mothers across Bangladesh, that is far from reality.

Each year approximately 7,700 mothers die in Bangladesh while giving birth. That is 7,700 families and approximately 30,800 people directly affected every year.

830 women die every single day across the globe due to pregnancy and childbirth-related complications. This is higher than the number of people killed annually by natural disasters or terrorism.

The crucial question remaining in 2019 is why are we still failing to save our mothers?

BRAC health, nutrition and population programme has been working to safeguard maternal and child health in Bangladesh since the 1980s. Here are the three major challenges to ensuring safe motherhood, based on our decades of on-ground experience and knowledge generated in collaboration with partners:

The 3 killer ‘D’s: Three delays that push pregnant women towards risky delivery:

1. Delay in decision making: Many families, like Rupali Begum (above), choose traditional birth attendants and home deliveries over skilled help and specialised facilities. In many cases, the mother is taken to the facility when it is too late. Many people do not know about the life-threatening risks of giving birth at home without skilled help, superstition can complicate matters further and people are not able to identify the danger signs that may lead to a complicated delivery. People are yet not used to the idea of seeking specialised support and consultation throughout pregnancy, they miss danger signs and seek specialised help too late in the pregnancy.
2. Delay in transfer from home to facility: After the decision has been made about taking the mother to the clinic, the next challenge is arranging safe, appropriate transportation. Transportation is hard in many remote areas in Bangladesh at any time, but the fact that a woman may go into labour during odd hours of the night makes it even more difficult. The delay in transportation increases the risk to the mother and they are often beyond the scope of help by the time they reach the clinic.
3. Delay in service: Patients often do not get attended to immediately after reaching clinics. At the stage when every minute is expensive for the mother, they have to go through paperwork and wait until staff get the facility ready (arranging for blood, etc).

What are we doing to change the status quo?

BRAC health, nutrition and population programme takes a holistic approach to tackling the 3 killer ‘D’s. We ensure regular check-ups of pregnant women in the community and provide primary health care with a special focus on the following maternal and child health areas:

Community preparedness: Our community health workers ensure antenatal and postnatal care for mothers, provide health and nutrition counselling and educate mothers about the five crucial pregnancy danger signs. They identify initial complications and ensure proper care, and either give it directly or ensure it is provided through health facilities. During home visits, family members of pregnant women are oriented about the risks of giving birth without skilled help at home and about the importance of specialists and facility-based delivery. This helps in reducing the resistance towards skilled help and facility-based delivery, reducing the Delay in decision making.

Linkage:

During routine household visits, community health workers provide information about nearby hospitals, clinics, delivery centres and phone numbers of nearby drivers who can take people to facilities at time of need.

When a mother in her area goes into labour, family members immediately contact the community health worker. She accompanies the mother from home to the appropriate facility, ensuring the Delay in transfer from home to facility is reduced.

Facility preparedness:

Even though we ensure community preparedness and linkage through our vast network of 47,300 community health workers and volunteers across the country, reducing two out of three of the key delays will not solve the problem. To tackle the third D (in service), BRAC establishes maternity centres and deploys referral staff in health facilities. Our 47 maternity centres across the country offer respectful maternity care around the clock to people from under-served communities. These centres, completely run by midwives, exemplify safe delivery practices, and rates of c-section rates (10.9%) are much lower than the national average (24%). Referral staff work as a crucial linking point between the community and the facilities in emergencies, ensuring that the service is initiated as soon after the patient reaches the clinic as possible, including notifying clinic authorities to prepare beforehand while the patient is on her way.

We care about safe motherhood, for every mother. From identification of pregnancy to the birth of children and then postnatal care; we literally stand by mothers throughout every stage of this crucial phase of their lives.

BRAC health, nutrition and population programme is constantly testing new approaches and engaging key partners to decrease the 3 killer Ds further.

Tanjila Mazumder Drishti is Senior Manager at BRAC’s health, nutrition and population Programme.
Dr Morseda Chowdhury is Associate Director at BRAC’s health, nutrition and population Programme.