Christy and Kaosar Afsana of BRAC Write an Op-Ed for the Daily Star News Bangladesh
It is very late at night in early 2001. Fifteen year old Mitali [Note:*] lies writhing in pain in the corner of a dingy room deep within one of Dhaka's overcrowded slums. She is several hours into labour. Her adolescent body, emaciated from chronic malnourishment, is not the optimal environment to sufficiently host or deliver a baby.
Alone in the tiny room she shares with her husband, unattended by family let alone a skilled attendant, Mitali finally gives birth -- to a stillborn infant/fetus? She herself narrowly escapes death, only to be subjected to three more pregnancies over the next ten years and the loss of yet another child to pneumonia.
In the ten years since Mitali's first pregnancy, Bangladesh has come a long way towards protecting its mothers. It has been successful in reducing the maternal mortality ratio (MMR) from 322 per 100,000 live births in 2001 to 194 by 2010. And yet, women like Mitali continue to endure the terrifying "near miss" experience unnecessarily to this day.
Married off too early, girls and women have very little say in decisions related to family planning, pregnancy and reproductive health care, even though they are the ones who experience complicated, painful and often fatal pregnancies and deliveries. And even so, as there is room to celebrate a 40% reduction, there is still critical work to be done through a nationwide scale up of services.
A large part of the problem is a serious shortage in skilled human resources, as are issues such as inflexible operating hours for public medical facilities, inadequate supplies of medicines, diagnostic facilities, hospital beds and donor blood. All this, coupled with the lack of privacy and basic hygiene at these facilities and the neglect or disdain of its administrators, have prompted over 80% of the population to seek healthcare from informal providers. For a majority of Bangladeshi women, this means little or no prenatal check ups to identify possible complications and ultimately, home deliveries in unhygienic settings, alone or with the aid of female relatives or neighbors accustomed to unsafe birth practices that risk the lives of both mother and child.
Over 7,000 women in Bangladesh die every year as a result. What makes this statistic so tragic, and unjust, is the fact that most of these deaths are preventable -- the 40% decline over the last decade in Bangladesh's MMR is irrefutable proof. This decline has been largely due to reduction in fertility rate (from 3.2 to 2.5), improvement in access to emergency obstetric care in hospital settings (from 9% to 23%), increase in female education (literacy rate among women 18-24 years of age is 80%) and, most importantly, an overall increase in women's empowerment.
The empowerment of women has manifold repercussions on maternal and child health. Given the right kind of information and access to care, women are able to make better choices about when their bodies are at a safe age for conception, family planning, birth spacing, prenatal care, delivery and postnatal care. She is also then in a position to make better informed decisions about her child's health care, her child's educational opportunities and even her own daughter's age for marriage.
The entire family's future is dependent on the mother's health and wellbeing, which begins not when she gets married, but in fact from the time she herself is born. As a child and adolescent, a girl needs to receive proper nutrition for the adequate development of her body. She has to understand the changes her body goes through during adolescence, including learning healthy hygienic practices during menstruation.
Economic emancipation, education and awareness of her rights coupled with the support of her family and community might empower her with the space and confidence to marry at an age when she has the emotional capacity to fully participate in family decisions. A woman must be able to raise her voice regarding reproductive decisions like choosing when to conceive and where to deliver. On a larger scale, a collective raising of women's voices leads to increasing demands on adequate healthcare facilities and services, prompting greater action from both the public and the private sectors to cater to their specific needs.
Mitali is pregnant again. While we can do little to change her past experiences, there is much to be done to ensure she and her children will enjoy a better future. The government of Bangladesh has already begun initiating women-friendly hospitals, providing emergency obstetric care in existing facilities and introducing voucher schemes to increase institutional delivery. Development organisations such as BRAC; CARE; ICDDR,B; and UNICEF are working in partnership with the government to improve access to and quality of care in both rural and urban areas.
Working directly with mothers and their communities, these organisations have developed innovative solutions revolving around skill-mixing and task-sharing among community health resources, increasing awareness, demand and support for institutional deliveries, provision of skilled attendants and trained supervision during home deliveries, inventive referral systems for emergencies, usage of new technology such as mobile phones, and the development and leveraging of community support networks to enhance community ownership.
It is now a question of translating knowledge into action -- replicating successful innovations nationwide, especially to hard-to-reach populations, and ensuring that marginalised women have the resources and the freedom they need to take advantage of this access. Public-private partnerships which leverage the comparative strengths of the different players are absolutely essential in effectively reaching scale.
As we edge closer to the year 2015, with Bangladesh within reach of the 4th and 5th Millennium Development Goals regarding health, it is important not to become complacent. Perhaps the ultimate tragedy lies in the fact that Mitali considers her ability to give birth an obligation, and producing living children a luxury. This is our greatest challenge. Only when our mothers realise their worth and own their power to give birth will we as a society realise the full benefits of safe motherhood.
( *Real names have been changed to protect privacy.)
Christy Turlington Burns is the of Founder Every Mother Counts and Director/Producer, "No Woman, No Cry."
Kaosar Afsana PhD is Associate Director, BRAC Health and Project Director, Manoshi, BRAC's community based maternal, newborn and child health project.
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