Iqbal Anwar

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Quality of Safe Motherhood Programme Evidence
from High and Low Performing Districts of
Bangladesh

• Iqbal Anwar
• Nahid Kalim
• Marge Koblinsky

WOMENDELIVER Conference ExCeL London 18-20
October 2007
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Background
Area 144 thou sq km Population
140 million. Population below poverty line
(1/day) 36 Position by HDI 139th
out of 177 MMR
320/100,000 LB Source. HDR 2005 BMMS 2001
But the country has made remarkable progress in
reducing MMR. A 38 reduction between 1990 and
2000.
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Projection of MMR in Bangladesh 1976-2015
Projection of MMR 191
Delivery by a SBA 13
But there is wide variation in both process and
outcome indicators by divisions
Courtesy Mahbub Elahi Chowdhury
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(No Transcript)
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Research Questions

• What is the quality of care in public sector EOC
  facilities in high and low performing areas of
  Bangladesh?
• What are the constraints in programming EmOC in
  rural areas of high and low performing areas of
  the country?

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Methods and Materials

• Study areas
• High and low performing areas selected on the
  basis of MMR (more or less than 400) and skilled
  attendance at birth (more and less than 15)
  through national level stakeholders meetings.
• Methods
• Facility survey with a quality monitoring
  checklist (N41)
• Review of MIS
• In-depth interviews (N19)

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Three Dimensions of Quality
Structure
Process

• Facilities
• Human resource
• Logistics
• Organization

• Diagnostic procedure
• Therapeutic procedure
• IPC
• Skill attitude
• Supervision monitoring

Outcome

• Coverage/utilization
• Cure
• Satisfaction
• Confidence/compliance

Source Donabedian A 1990
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Result
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StructureConcentration of functional EOC
facilities
No comprehensive EOC in rural areas of low
performing districts since 2006
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Structure Distribution of public sector doctors

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Structure Distribution of nurses
Rural Area
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Structure Operation Theatre
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Process Vital EOC functions
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Outcome Normal deliveries and referrals from
UHCs during last month
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Constraints in Programming EmOC

• 1. Human Resource
• Deployment and retention of specialist
• Non-residential status / absenteeism at rural
  EmOC
• Shortage of Anesthetists
• Nurses in low performing districts are mostly non
  local
• 2. Blood
• No blood bank at below district level
• 3. Logistics
• No additional budget for EmOC
• Maintenance of ambulance
• 4. Contextual barriers in Sylhet (low performing
  areas)

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Recommendations

• Some innovative solutions needed to overcome HR
  constraints. Good Management Practices are
  urgently warranted
• QOC improvement initiatives are to be undertaken
  incorporated in the routine monitoring
• Training on evidence based techniques like AMTSL
  are strongly recommended
• Programme should cater both care and context to
  impact MMR
• More in-depth studies recommended to overcome
  hurdles with the nurses

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Thank You