Reproductive Healthcare Services

 বাংলা
Reproductive Healthcare Services services that contribute to reproductive health and well-being
through preventing and solving reproductive health problems. Reproductive health approach implies
to those people who have the ability to reproduce and regulate their fertility; women who are able to
go through pregnancy and child birth safely; the outcome of the pregnancy is successful in terms of
maternal and infant survival; and couples who are able to have sexual relations free of fear of
pregnancy and contracting disease.
An important implication for implementing reproductive health programmes is to ensure that the
quality of services is improved, particularly from the user perspectives. The focus of the programme
is based on women since they are the primary users of these programmes and also have the
greatest problem of access to health services. Equal importance should be given to promote male
responsibility and enhance their involvement.
Target groups for the reproductive healthcare services are women and men of different stages of
life; adolescent. Reproductive events in women's life can be divided in many parts such as:
preconception, conception, childbirth, post-natal, interconnection, perimenopausal and infertility. In
the ICPD (International on Population and Development) Conference in 1994 (held in Cairo) it was
decided that for ensuring the reproductive health services, the service should include reproductive
healthcare through Primary Healthcare System, family planning services, information education and
counselling; management of side-effects of family planning methods; information services for pre
and post-natal, safe delivery, breast feeding and women's healthcare; treatment of infertility and
reproductive tract infections and prevention and management of unsafe abortion; diagnosis and
treatment of sexually transmitted diseases and information, education and counselling, as
appropriate on human sexuality, reproductive health and responsible parenthood; diagnosis and
treatment of breast cancer and cancer of the reproductive tract; prevention and reduction of spread
of HIV infection, increasing awareness about consequences of HIV infection and ensuring adequate
medical care for HIV infected persons.
The above mentioned services should be provided with adequate care and quality but Bangladesh is
largely lacking these services due to the absence of proper infrastructure and therefore the services
are provided in a limited scale. Because the reproductive health agenda can only be achieved in a
situation where the client's needs are foremost and the desire to meet those needs motivates the
programme personnel to provide comprehensive reproductive health services, albeit the current
infrastructure which exists in Bangladesh does not fit to provide such services.
In terms of physical facilities to provide reproductive healthcare services, an impressive number of
facilities and staff are existing. The reproductive healthcare or the primary healthcare is provided in a
three-tired system: at district level, at upazila level and at the Union level. At the district level 93
(Maternal and Child Welfare Centres (MCWCs), at the upazila level at present 349 Maternal and
Child Health (MCH) units and at the Union level almost 3000 Union Health and Family Welfare
Centres (UHFWC) are providing reproductive healthcare services. Moreover countrywide at the
Union level, about 30,000 Satellite Clinics are organised every month to provide doorstep services.
The existing service provides women's health services, family planning, safe delivery care, Essential
Obstetric Care (EOC), referral services, and post-natal care. Prevention of unsafe abortion include
menstrual regulation (MR), prevention of unwanted pregnancy, treatment of complications of
abortion, post-abortion counselling, information and counselling for clients requiring MR.
The services available or activities performed in MCWCs at different level are not same due to
existing situation of resources like trained manpower, physical facilities, logistics support, etc.
Technical personnel like two medical officers and two family welfare visitors are posted to provide
reproductive health services.
The domiciliary services at the household level include health education, family planning, and
maternal and child health services, immunization, control of communicable and other endemic
diseases, which constitute the kernel of primary healthcare services and are provided by health
assistants (HAs) and family welfare assistants (FWA). Each is to serve a population of about 3500.
There are 13,500 sanctioned posts of FWAs. This has been increased to 22,500. There are also
satellite clinics at the community level operated by the staff of health and family welfare centres. The
H&FWC centre is at the union level and should provide services for a population of approximately
20,000. In the country there are about 4500 unions and approximately 3200 operating health and
family welfare centres. From these centres antenatal care, safe deliveries, health education,
childcare and family planning are provided.
At the upazila level there is a Upazila Health Complex (UHC) which provides indoor and outdoor
services. These are antenatal, and post-natal care, family planning, child healthcare and curative
care. All the upazila hospitals are 31 bedded of which 6 are earmarked for MCH services. The UHC
is staffed by 9-10 physicians and serve a population of about 200,000. There are about 489 upazilas
and 358 of those have operational THCs.
Secondary Healthcare System District hospitals in the 64 districts provide curative services. They
are being upgraded to 200-250 bedded hospitals.
Tertiary Healthcare System Provide specialized care in 19 GOB (Government of Bangladesh) and
private medical college hospitals, post-graduate institutional hospitals (one in a public medical
university), and in specialized hospitals both government and private. The NGO and private sectors
are also involved in activities like community-based distribution, clinical services, family planning,
research and evaluation and social marketing of contraceptives. Most of the grass-root level health
and family planning workers are given training, at 20 regional training centres, 12 family welfare
visitors training institutes, Institute of Population Research and Training (NIPORT), training on MR is
given by Menstrual Regulation Training and Services Programme (MRTSP), Mohammadpur Fertility
Services and Training Centre (MFSTC), and Bangladesh Women's Health Coalition (BWHC). The
MR training is being coordinated by Bangladesh Association for Prevention of Septic Abortion
(BAPSA) since 1985. So far a total of 7,338 doctors and 5,933 FWVs have been provided training on
MR.
The government has introduced Health and Population Sector Programmes (HPSP) from July 1998
in order to improve the reproductive health of the population. The main purpose of the programme is
the reduction of maternal and child mortality, contaminated diseases, unwanted fertility and total
fertility rate, enhancing of life expectancy, age of women at birth of first child and nutritional status
and healthy life style and ensuring of health and family planning services to the underserved rural
population of Bangladesh. The main strategy of the programmes is to introduce sector-wide
management approach, essential service package, building of union health and family welfare
centre, establishing of community clinics, and support services. Under HPSP there will be 13,500
set-up and 775 UHFWCs will be constructed inspite of existing 3,175 UHFWCs in the country. There
will be one clinic for 6000 population. To foster better understanding and bring attitudinal changes,
Behaviour Change Communication activities will also be strengthened.
Thus successful implementation of HPSP will be an important element of Bangladesh's poverty
reduction in three ways: firstly improvements in the health/family welfare status of the population are
important indicators of poverty alleviation. They will increase the labour productivity and, thus,
support the economic growth component of the poverty reduction strategy; secondly positive impact
of HPSP will be through targeting the underserved population; and thirdly improvements in health/
family welfare status will be achieved more easily and in a more sustainable way if government
promotes complementary actions in other sector such as education, water supply and sanitation,
environment, infrastructure, communication and with respect to the legal status of women.
Maternity health services Public service providing maternal care including ante-natal care, intra-
natal care, post-natal care and family planning. Safe Motherhood is unsafe in Bangladesh and
maternal mortality is a serious public health concern. There are about 3.5 million births in
Bangladesh every year, and for every thousand of which almost five women die as a result of
complications of pregnancy and childbirth. It is estimated that complications develop in about
600,000 of the 4 million women who become pregnant- annually. In Bangladesh, the utilization of
institutional delivery facilities is far below the recommended 'minimum acceptable level'. Only 5
percent of the expected 0.5 million obstetric complications attended medical facilities, 27.5 percent
of the pregnant women receive some ante-natal care, institutional delivery is only 3.5 percent, less
than 10 percent births are assisted by trained medical personnel.
In Rural Bangladesh 96 percent of deliveries take place at home, and for conducting deliveries only
26 percent of the Trained Traditional Birth Attendants (TBA) are utilized by the community, and only
6 percent of recent births are attended by Trained Birth Attendants. In this backdrop the increase
accessibility of healthcare facilities can improve the situation of maternal health in the country.
The recommended reproductive healthcare package especially the women's health and safe
motherhood includes: reduction of maternal morbidity and mortality, expansion of maternal health
services, increase age at marriage for girls, birth interval; increase nutritional status of pregnant and
nursing mothers, reduce number of life time pregnancies, prevention, detection and management of
high risk pregnancies, and create men's support for maternal health and safe motherhood.
To prevent maternal mortality and improve the maternal health in the country, it is prerequisite for
fundamental improvement of all maternal healthcare services and a change in attitudes of
individuals, families and communities about pregnancy and childbirth care. At the Union Health and
Family Welfare Centres the Family Welfare Visitors provide safe delivery care.
Antenatal care begins when the mother becomes pregnant and continues till the onset of labour. It
comprises medical check-up, advice, and treatment for any complaint and vaccination. Normal
puerperium is a period of 6 weeks following delivery when maternal system returns to pre-gravid
state. Care of the mother during this period is called post-natal care. Post-natal care is very
important because there may arise some complications during this period such as: post-partum
haemorrhage, puerperal sepsis, which needs attention to save the mothers' life. In this period mother
should be advised to take additional food to balance her physical wear and tear and for her suckling
baby. Mother should be advised for regular breast feeding which will help quick involution of uterus,
lactation and also protect her baby by providing immunity from the attacks of infection and
communicable diseases.
Generally from upazila and district level Maternal and Child Welfare Centres (MCWCs) offer ante-
natal care, referral of high-risk antenal cases to district hospital/medical college hospital, post-natal
care, referral of complicated post-natal cases to district hospital, medical college hospitals, normal
deliveries at MCWC and sometime conducted by Family Welfare Visitors at home.
Another way of providing maternity care is maternity service at the community level. This care is
provided by FWAs and trained TBAs through screening and referring high-risk cases. TBAs are
delivering around 25 percent of deliveries, the total coverage being less than 5 percent. Significant
effort has been made in Bangladesh to train TBAs starting in 1979. A total of 42,285 TBAs have
received training upto March, 1994. Now the total number trained personnel is more than 55,000.
Recently for further strengthening of maternity care in the country, the Government with the financial
assistance from UNICEF and UNFPA started to provide Emergency Obstetric Care (EOC). The
evaluation and reevaluation of solutions to the problem of maternal mortality indicates that there are
two important lessons: all pregnant women are at risk of serious obstetric complications, maternal
mortality cannot be substantially reduced unless women have access to emergency obstetric care.
These services are divided into three sub-groups: Obstetric First Aid, Basic EOC, and
Comprehensive EOC. Currently EOC services are rendered by 39 percent of district hospitals -
providing comprehensive EOC, 69 percent of MCWCs render basic EOC services and 56 percent of
Upazila Health Complexes render basic EOC services. Fifty-five percent district hospitals and only 8
percent Upazila Health Complexes provide general anesthesia.
For greater coverage of area under EOC, another project activities entitled 'Strengthening of
Emergency Obstetric Care (EOC) in 11 districts have been started. The project is being financed by
the UNICEF and implemented by the government for establishing of comprehensive EOC at 11
district hospitals, Basic EOC at 68 Upazila Health Complexes and First Aid EOC at the Union Health
and Family Welfare Centres (UHFWCs) in the project areas. The project has trained necessary
manpower - doctors, nurses, Family Welfare Visitors and also supplied equipment in the project
areas. Gradually, for 'Improvement of Women and Maternal Health' this project will extend its
activities throughout the country. Under Comprehensive Emergency Obstetric Care Project 40
Upazilas will be covered across the country.
Maternal services are also offered by NGOs and Private Sectors. Among the NGOs that provide
maternity services are OB/GYN Society of Bangladesh, ICDDR,B, BRAC, and Grameen Bank
Health Project. Several others have special programmes and facilities for providing antenatal care
and safe delivery care.
Maternal mortality This indicates the number of death of women during childbearing in a given year
per 100,000 births. The death of a woman while pregnant, or within 42 days of termination of
pregnancy, irrespective of the duration of the pregnancy, from any cause related to or aggravated by
the pregnancy or its management, but not from accidental or incidental causes, is a maternal death.
The World Health Organisation estimates that half a million women die in pregnancy and childbirth
every year, and about 90 percent of these deaths take place in the developing countries. These are
due to women's low social status and poverty which in turn lead to their poor health, high fertility and
lack of access to essential healthcare. According to recent estimation the total female population of
Bangladesh is about 60.4 million, and about 82 percent of them live in the rural areas, and among
them the number of married women of reproductive age was about 24.5 million in 1992 and by the
year 2001, this number is projected to rise to 31 million.
In Bangladesh about 50 percent of the girls aged 19 and younger are married, and the median age
of birth is around 18. It is also estimated that about 50 percent conceptions are unplanned and
almost 25 percent of the pregnancies are unwanted. Many mothers in Bangladesh do not receive
antenatal care, nearly three quarters of mothers received no antenatal care during pregnancy. Those
who received care only 20 percent of them received it from doctors, 7 percent from nurses, midwives
and family welfare visitors and one percent women received antenatal care from traditional birth
attendants. The urban-rural differential in receiving antenatal care is quite large. Fifty-eight percent
of urban births had received antenatal care from medically trained person, compared with only 23
percent in the rural areas. In Bangladesh institutional delivery is only 5 percent and rests are
conducted at home in presence of traditional birth attendance or other elderly women of the family.
During childbirth about 67 percent mothers were attended by untrained persons, 32 percent by
trained personnel and 1.6 percent delivery was unattended.
Maternal mortality is a serious public health concern and a great contemporary challenge. Studies
carried out by ICDDR,B and other research organisations in Matlab in Chandpur district, and in
Tangail, and Jamalpur districts demonstrate the magnitude of the maternal mortality in Bangladesh.
According to the official estimates the current level is 4.7 maternal deaths per 1000 live births- or
about 28,000 maternal deaths nationally each year- which is about 100 times higher than the level in
the Northern Europe, and one of the highest in Asia. The main causes of maternal mortality are:
postpartum haemorrhage, abortion, obstructed labour, puerperal sepsis, eclampsia and other
obstetric causes.
Besides mortality, there are numerous other factors responsible for maternal morbidities. These
include malnutrition and anaemia, infections, vesico-vaginal fistula, rectovaginal fistula, uterine
prolapse, diabetes, and morbidity resulting from unsafe delivery and abortions done by the traditional
practitioners. Mortality records probably exhibit only the half of the picture, because the incidences of
short-term and long-term mortality are not known. Attempts are being made to reduce maternal
mortality and morbidity by expanding and ensuring of safe motherhood services, combating of
unwanted pregnancies through promotion of family planning, and providing safe back-up services
who need it due to method failure. The government is committed for improving the accessibility of
Emergency Obstetric Care (EOC) services and improving the utilization of healthcare facilities
located at the periphery and at the community level.
Perinatal mortality Death immediately before or after birth. About 20 percent of the total population
under the age of five, but almost 50 percent of deaths occur in this age group. The neonatal, infant
and under-five mortality rates are 80, 66, and 112/1000 live births, respectively. Childhood mortality
in Bangladesh is primarily due to malnutrition, diarrhoeal diseases, acute respiratory infections,
neonatal tetanus, and measles. About 94% of children aged 6 months to 6 years suffer from various
degrees of malnutrition. About 30-50% of the newborn babies have low-birth weight less than 2.5 kg.
Acute respiratory infection (ARI), mainly pneumonia, causes 20% of under-five deaths, with another
17% due to vaccine preventable diseases.

Relative percentage of maternal deaths due to various factors

Data on peri-natal mortality in Bangladesh are not readily available and it seems that less research
had been done on this issue. Perinatal mortality includes death of foetus after 28 weeks of
pregnancy and death of newborn within 7 days after birth. Causes of peri-natal deaths can be
divided into three categories: (a) Ante-natal causes, (b) Intra-natal causes, and (c) Post-natal
causes. Ante-natal causes include: Maternal diseases hypertension diseases of cardio vascular
system, diabetes, tuberculosis, anaemia; Pelvic diseases uterine anomalies, endometriosis, ovarian
tumour; a natomical defects- uterine anomalies, incompetent cervix; Endocrine imbalance and
inadequate uterine preparation; Blood incompatibilities; Malnutrition; Toxemia of pregnancy; Anti-
partum haemorrhage; Congenital defects; and Advanced maternal age. Intra-natal causes are: birth
trauma, asphyxia, prolonged effort time, and obstetric complications. Post-natal causes includes:
pre-maturity, respiratory distress syndrome, infections respiratory and alimentary, and congenital
anomalies. The above listed causes greatly affect the perinatal mortality but in a summarized form
main causes of perinatal mortality can be listed as: intrauterine asphyxia, birth asphyxia, low-birth
weight, birth trauma, and intrauterine and neonatal infections.
Research findings reveal that of every 1000 babies born alive, 12 die within hours of birth, eight of
them due to injury during deliveries. In a recent study it was found that of the 695 admitted neonates
231 or 33 percent were due to birth asphyxia. One hundred and sixty-five (23.75%) neonates died in
the hospital, and 93 or 56 percent of them due to birth asphyxia and its complications. More than
one-third of the asphyxiated cases reach hospital more than 24 hours after the difficult delivery;
about 40% of them usually die. This death including neonatal can be prevented if more centres for
safe delivery and proper neo-natal treatment are made available in the country.