EDITOR’S NOTE: This article is part of a GlobalPost Special Report titled “Step by Step,” about the many challenges faced worldwide in an effort to reduce child mortality. In the coming months, GlobalPost will examine this issue around the world. The project is supported through a partnership with the Henry J. Kaiser Family Foundation as part of its U.S. Global Health Policy program.
DHAKA, Bangladesh — When Hashi Akhter delivered her baby on a January morning in her thatched home in Dergram Village, she knew something was wrong right away. The baby was not crying.
She couldn’t breathe. Hashi had already been in labor much of the night. As morning broke, a relative went on foot to find a health worker near this remote village more than two hours north of Dhaka, Bangladesh’s capital.
That decision saved the baby’s life. Shefali Akhter, a 24-year-old government health assistant, is also a skilled birth attendant with special training on neonatal asphyxia, one of the largest killers of newborns in Bangladesh. (Shefali has no relation to Hashi.)
Shefali quickly cleared mucus and fluids from the baby’s mouth so that she could take her first breath in the “golden minute,” the small window of time in which decisions can mean the difference between life and death.
Shefali learned last year to treat asphyxia by clearing airways with a tiny plastic face mask, air bag, and suction device. She was part of a program called Helping Babies Breathe, an international collaboration with the American Academy of Pediatrics, the American aid agency USAID, Save the Children, the Laerdal Foundation of Norway, and others. The program has trained 20,000 skilled birth attendants in Bangladesh alone.
Counter to the common perception of Bangladesh as hopelessly impoverished, the country has made dramatic strides in reducing overall child mortality in recent decades. Bangladesh is on track to achieve Millennium Development Goals (MDGs) 4 and 5, which aim to reduce under-5 child and maternal mortality, respectively. In fact, Bangladesh is one of only eight countries to have reduced its under-5 mortality rate by at least two-thirds since 1990.
In Bangladesh, deaths of children under age 5 decreased from 139 per 1,000 live births in 1990 to 46 in 2011. Compare that to 1970, when Bangladesh’s under-5 mortality rate was 239. Maternal deaths have also plummeted, from 800 per 100,000 live births in 1990 to 240 in 2010.
Bangladesh’s child and maternal health statistics are better than those in India, where the economy and resources far exceed those of its poorer neighbor to the East. How has Bangladesh come so far, and what are the challenges that remain?
In this upcoming GlobalPost Special Report, titled “The Seven Million,” correspondents in Africa and Asia will examine the progress and challenges that developing countries face as they fight to reduce deaths of the nearly seven million children under age 5 who die every year, largely due to preventable causes.
Laying the Groundwork
On a hot spring afternoon three months after the dramatic birth in Dergram, the 30-year-old mother, Hashi Akhter, lifts her healthy baby, Babli, from a bed occupying most of the one-room home. The girl yawns, eyes still shut mid-nap. Hashi eagerly welcomes the health assistant inside, and soon neighbors and children crowd under the corrugated metal roof to ogle the visitors.
Shefali, the health assistant, recalls: “If I was not present, perhaps the child wouldn’t survive. The mother told me, ‘You saved my child.’ Now she loves me very much.”
To keep more children like Babli alive and well, Bangladesh is focusing on programs like Helping Babies Breathe, launched in 2011. These programs aim to train more skilled birth attendants, spread prenatal and postnatal advice, and persuade women to give birth in clinics or hospitals rather than at home, where more than 70 percent of deliveries take place.
Newborns are particularly at risk in Bangladesh. For children under 5, 60 percent of deaths occur in the first 28 days of life. Most of those deaths are caused by infections, asphyxia, and low-birth weight.
But progress on child health has accelerated here in recent years. Kazal Begum, Hashi’s 50-something-year-old aunt, grimaces when remembering that in her day, women either had a normal birth without complications or died. A mother of four, Begum says her children were not vaccinated as infants. But things have changed dramatically within a generation. Child immunization coverage for diphtheria, whooping cough, and tetanus has reached 96 percent. In 2012 Bangladesh won an award for its outstanding work from Geneva-based Global Alliance for Vaccines and Immunization. There have been other changes too, including better awareness of hygiene and nutrition.
There is no single, simple answer to how Bangladesh has managed to come so far. Rather, a multifaceted set of factors has improved child health, and the country is trying to close in on the remaining weaknesses.
The Bigger Picture
Bangladesh is infamous for stories of bleak factories and industrial disasters, including the collapse of a garment factory near Dhaka that killed more than 1,100 people in April.
Less in the spotlight are workplaces that provide decent jobs with steady salaries to lift people out of extreme poverty. The $19 billion garment industry accounts for 80 percent of Bangladesh’s exports and has fueled economic growth of more than 6 percent in recent years.
The country’s garment industry is the world’s second largest, behind China, and employs three million people, 80 percent of whom are women. Remittances from Bangladeshis working overseas also boost the economy.
Although grim poverty and appalling working conditions still exist in Bangladesh, overall macroeconomic conditions have improved. In turn, rising incomes have contributed to more education and better health. Poverty fell 19 percentage points in the last decade and a half, though overall poverty is still significant, with 53 million people below the poverty line.
“It’s hard to disentangle health and development,” said Laura Reichenbach, director of the center for reproductive health at the International Center for Diarrheal Diseases Research (icddr,b), in Dhaka. “There has been broader social and development improvement. All these pieces together facilitate improvements.”
The adult literacy rate is still only at 56 percent, but that is a big improvement over the 21 percent it was in 1970. UNICEF statistics show that school enrollment has increased, and now there are more girls than boys in primary and secondary school. Those girls grow up to be women who can give better care to children, said Lianne Kuppens, UNICEF’s chief of health in Dhaka.
“Educated mothers have an impact on practices and behavior,” Kuppens said.
One benefit of being one of the world’s most densely populated countries — 152 million Bangladeshis live in a space about the size of Iowa — is that clinics and hospitals are within six miles of most homes, according to a report from icddr,b. Roads are in surprisingly good condition, and the terrain is mostly flat, allowing people to reach health facilities.
Programs with Big Impact
In addition to better macroeconomic conditions, important health programs seeded decades ago are now bearing fruit.
Family planning, spearheaded by the government with additional support from nongovernmental organizations (NGOs) has slashed birth rates. In 1975, women in Bangladesh had an average of 6.3 children. Now the fertility rate is 2.3, compared with 2.6 in India, according to the 2011 Bangladesh Demographic and Health Survey.
Wide availability of contraceptives through government workers and NGOs, combined with economic empowerment of women and greater health awareness, contributes to controlling population. Outside a village clinic run by the Naifa Maruf Foundation an hour from the southern city of Khulna, 22-year-old Mukta Begum spoke about her 3-year-old son, who was being treated for intestinal worms. Even with a group of men listening, Mukta said she used an IUD for birth control. Across the country, women mentioned contraceptives — from pills to injectables — without batting an eyelash.
Another program with far-reaching impact is the government’s child immunization program, which started in the late 1970s and intensified in 1985. Vaccination coverage has steadily risen since then.
Only trained medical personnel can administer vaccines, but both educated and uneducated workers spread the word among the poor about the importance of the vaccinations. Lower-rung government and NGO community health workers and volunteers reach the poor through home visits in villages and slums, encouraging mothers to visit vaccination camps and clinics.
Dr. S.A.J. Musa, director of primary care in Bangladesh’s ministry of health, said accessibility, strong local monitoring, and community involvement have all contributed to the program’s success.
“Now in the community, mothers ask, ‘When will you conduct vaccinations?’” he said.
The Role of NGOs
While international media tends to spotlight the role of NGOs in Bangladesh, government accounts for the bulk of primary health care. In addition, private clinics and hospitals are booming, as lower income people join the middle and upper classes in paying for health care as their incomes rise.
But without a doubt, strong NGOs have made a lasting impact in Bangladesh, and the people who run them are generally positive about collaborating with the government.
“NGOs are given a lot of space to operate,” said Dr. Shams El Arifeen, director of the center for child and adolescent health at icddr,b. The government has limited resources, he said, but the NGO workers are aware of that.
“There’s quite a bit of trust,” Arifeen said. “They have a willingness to ask for help.”
Arifeen’s organization, icddr,b, made one of the biggest contributions to child health care in the 1960s, during cholera outbreaks in Bangladesh. Cholera, a bacterial infection whose main symptoms of diarrhea and vomiting can lead to rapid dehydration, was at the time fatal to every third person who contracted it. Researchers at a lab that would later become icddr,b formulated an oral rehydration solution from a simple blend of clean water, salt, and sugar. It is the standard treatment for diarrhea today and has saved the lives of more than 50 million people around the world in the past three decades.
A Safer Delivery
In Korail, a slum of about 40,000 in Dhaka, cramped homes line narrow lanes with fetid open gutters. Goats wander the streets, and tinny music blasts from mobile phones, adding to the chatter and buzz in this teeming enclave.
In a two-room concrete birthing house run by BRAC, the world’s largest NGO, 10 women, all eight or nine months pregnant, sit in a circle on the cement floor. They listen intently as a midwife talks about danger signs during delivery that would require a hospital visit. She uses a flipchart with illustrations an illiterate person can understand. One picture shows a woman in bed, legs propped up. A small hand reaches out from between her legs - no translation necessary.
The BRAC birthing center is one of almost 400 in slums throughout Bangladesh that offer pregnant women a safe, clean place to give birth. In a country where some 70 percent of people live in rural areas and have little education, raising awareness about child health among the poor is a challenge.
To warn of childbirth complications and preventable child deaths, female health workers trained by NGOs and the government have focused on antenatal and postnatal care.
Vital information about hygienic deliveries and newborn care — washing hands with soap, cutting the umbilical cord with a clean blade, drying babies and keeping them warm, exclusive breastfeeding — all help reduce newborn deaths.
Traditional practices such as putting soil, cow dung, coal or brick dust, or even hot oil on an infant after cutting the umbilical cord are gradually being phased out. Now community health workers distribute clean delivery kits — a hand-size packet with soap, a sterile razor blade, and thread — to cut the umbilical cord and tie it off, and a plastic sheet to deliver on.
The birthing center handles only natural births without complications in a room with two mattresses on the floor and a bamboo rod suspended from the ceiling, for women who deliver standing up. If there is any sign of complications, the woman is referred to a nearby hospital by a BRAC doctor on call. A midwife visits several birthing centers each day.
Otherwise, this birthing center is staffed by Asiyah Begum, a petite woman in her 40s with a sixth-grade education. A traditional birth attendant for 20 years before joining the BRAC center five years ago, she estimates she has delivered 300 babies over the years.
Tariqul Alam Khan, the doctor who oversees the center, says traditional birth attendants are trained in what not to do. Superstition and misinformation is common among traditional birth attendants, and practices used to include inducing retained placentas by gagging a woman with hair or pushing her belly with a rope. With support from UNICEF, almost 200 health facilities in Bangladesh have received better training in emergency obstetric care since 2000.
However, that is still not enough. There is still a dearth of hospitals and trained doctors, nurses, paramedics, and midwives. It is especially hard to retain medical personnel in rural areas.
More poor women in Bangladesh are giving birth at health facilities, but more than 70 percent still deliver at home. Of those, only 3 percent have trained assistance during childbirth. Smiling Sun, a chain of 23 affordable clinics in Bangladesh focusing on maternal and child health, is trying to change that statistic. Even in cities, it is an uphill battle to get poor women to give birth in professional facilities.
But more women are coming to Smiling Sun, especially for childbirth complications. At one Smiling Sun clinic in a bright, modern three-story building in Dhaka, deliveries have doubled in the last five years, says I.F.M. Mostaque, Smiling Sun’s project director. Last year, Mostaque said, 300 babies were delivered here by Caesarean section, and nearly 200 were delivered by natural birth.
The Last Mile
Challenges to reduce child deaths increase in hard-to-reach parts of Bangladesh, especially in the east, which lags behind in a range of health indicators, from birth control to immunization, said Arifeen, the doctor at icddr,b.
In northeast Bangladesh, in the wetland villages of Sylhet District, farmers are busy harvesting rice from lush green paddies. Although the monsoon season is still months away, canals are expanding. In a couple of months these fields will be covered with water, and thatched huts built on elevated mounds of land will be accessible only by boat.
Inaccessibility means contraception is also less frequently used in this area. In remote villages across the wetlands, women have as many as 10 children, notes Abdul Mannan, a manager with Save the Children. Maternal and child mortality rates are also higher here. The fertility rate in Sylhet District is 3.1, compared with the national average of 2.3.
But water ambulances deployed by Save the Children and funded by USAID are helping health workers and paramedics work around geographic barriers.
Rayhen Uddin drives a boat that serves as a water ambulance, commanding a blue wooden vessel whose simple cabin holds two examination tables for babies and expectant mothers. Uddin, 29, can drive the boat as far as 15 kilometers during the rainy season to take a mother to health facilities on the mainland.
One morning last year, Uddin got a call on his mobile phone about a woman in Shirpur Village who was hemorrhaging. Mobile phone usage has exploded across Bangladesh. Nearly half of the population now has access to fixed and mobile phones, improving access to medical care across the country.
By the time Uddin arrived in Shirpur Village, the woman had lost so much blood she looked blue, he recalled. But he managed to get her to the hospital, and both mother and baby survived.
In spite of weak spots, change continues across Bangladesh. This change is evident in expectant mothers like Maskora Khaton, who lives in Siriganj Village, in Sylhet. The 20 year-old is eight months pregnant, and her mother-in-law and a young female friend are sitting together on a large bed, getting antenatal care advice from Tripti Deb, a community health worker. Deb sits cross-legged and holds a clean delivery kit as she explains how to use its contents.
Khaton, who has a fifth-grade education, welcomes the advice and says the clean delivery kit will be useful. She plans to use a skilled birth attendant, not a traditional one. When asked why, she simply replies, “Everybody has a choice.”
Jahara Khaton, her 55-year-old mother-in-law, remembers that when she was young, expectant mothers had no such counseling.
“It is all new,” the mother of five says. “When we were young, it was difficult to discuss such things.”
Back in Dhaka at the icddr,b’s offices, Dr. Mohammed Quaiyum finishes a three-hour overview of Bangladesh’s progress on child health. The pieces of the puzzle are coming together.
Quaiyum, a medical doctor and research scientist, has devised a simple birth mat of cotton and tissue paper to help women identify postpartum hemorrhage in home deliveries. The 20- by 20-inch square costs about 50 cents and could save even more babies by getting mothers to trained medical care sooner, before they bleed to death after childbirth.
Bangladesh has come a long way in the last three decades, and a host of new measures, from birth mats to infant-size breathing masks, could help close the remaining gaps, child by child.
Quaiyum succinctly sums up the challenge facing Bangladesh: “The last mile is the toughest.”