Multilevel time series modelling of antenatal care coverage in Bangladesh at disaggregated administrative levels
Section 2. Need for reliable regional statistics on maternal and neonatal mortality in Bangladesh
Bangladesh has made remarkable progress in reducing the maternal mortality ratio (MMR) and neonatal mortality rate (NMR) following the target of Millennium Development Goals 4 and 5. However, both the indicators MMR (170 per 100,000 live births (WHO, UNICEF and Others, 2014)) and NMR (28 per 1,000 live births (NIPORT, 2015a)) are still reasonably high compared to the Sustainable Development Goals (SDGs) of reducing MMR to 70 per 100,000 live births and NMR to 12 deaths per 1,000 live births in Bangladesh (BBS, 2020). Poor utilization of maternal health services such as antenatal care (ANC), skilled birth attendance (SBA) at delivery, and postnatal care (PNC) (NIPORT, 2016), is considered as one of the major reasons for these high mortality rates. Receiving sufficient ANC during pregnancy is important since it also increases usage of SBA and PNC (Mrisho, Obrist, Schellenberg, Haws, Mushi, Mshinda, Tanner and Schellenberg, 2009).
The most recent household survey indicates that the majority of pregnant women (75%) in Bangladesh receive ANC from medically trained providers. However, the proportion of women that receive WHO-recommended ANC is much less at 37% (BBS and UNICEF, 2019). These data suggest that Bangladesh lags behind in reaching the national target of 50% ANC utilization by the year 2016. To address this gap and to meet the target of the third SDG 3 of increasing 4+ ANC coverage to 98% by 2030 (NIPORT, 2015b), the country needs a comprehensive strategy and specific milestones. National level trends of ANC coverage indicate that the proportion of women having no ANC care (ANC0) improved to only 17.2% in 2019 from 85% in 1994, while the proportion of women who obtained at least four ANC (ANC4) increased to 37% in 2019 from 6% in 1994. The improvement of the indicators over this period varies by division. The most marked improvement is observed for the Khulna division where ANC0 and ANC4 shifted from about 70% and 5% to about 12% and 40%, respectively. The poorest development has been observed in Sylhet division.
The facilities for ANC services vary considerably within Bangladesh. There are community clinics and family welfare centers at the union level (also non-government organisation clinics), upazila health complexes at sub-district level and district and tertiary hospitals at district level. Moreover, the access to private doctors varies according to the level of urbanization as well as the distance between the district/sub-district and the corresponding Metropolitan cities, particularly the capital city Dhaka. This inequality in the access to ANC is also explicitly visible at the division level. At disaggregated administrative levels such as district and sub-district, it can be expected that inequalities are even larger. There are, however, no studies that confirm this hypothesis, mainly because sufficient detailed survey data at those levels are not available. Recent evidence from disaggregated level studies on poverty, child nutrition and morbidity indicate high levels of inequality at both district and sub-district levels (Haslett and Jones, 2004; Haslett, Jones and Isidro, 2014; Das, Kumar and Kawsar, 2020; Hossain, Das and Chandra, 2020).
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