Consequences of Maternal Mortality in Bangladesh Rural Families an Experience of Gonoshasthaya

An estimated 529,000 women, from developing countries including Bangladesh, continue to die each year from maternal causes (www.thelancet.com, 2006). In contrast, progress in reducing levels of maternal mortality, making pregnancy and childbearing safer for women, despite being a central element of the Millennium Development Goals (MDGs), has been much slower. To achieve this goal the GK has been working since 1972, to reduce the maternal mortality and to provide better health services. The objective of this paper is to examine the success rate and to provide the facts that helping to reduce maternal mortality in GK areas. GK has increased its coverage to more than 1.2 million rural population with 43 PHC centers in 631 villages across the country with 5 referral hospitals. This paper discusses maternal mortality in rural Bangladesh, using maternal mortality registration data from 19 Gonoshasthaya health programme areas along with 10 health sub-centers for the period from 2008-2018. After registration of pregnant women paramedics follow up by offering antenatal and post natal care services. The study was conducted by analyzing the panel data in the period of 14 April, 2008 to 13 April, 2018. The findings showed out of 3125236 female population, aged 15-49,16711 died during the study period yielding an adult death rate 0.64 per 1000 female population. This finding suggests that maternal mortality would reduce further if women had access to adequate health care during pregnancy and child birth.

developed countries only 1 in 2976 (UNFPA, 2002). Although, the number of births attended by trained health workers have slightly increased from 48% in 1985 to 55% in 1996, the maternal mortality ratios at the global level remained moderately constant (World Bank, 2003). According to Bangladesh Maternal Mortality and Health care survey 2010 the maternal mortality ratio is 193 per 100000 live births (NIPORT, 2010).
From the news published on 23.11.2017, in The Prothom Alo, it is observed from the survey that the rate of maternal mortality has been increased in the country. In the last survey on "The maternal mortality and the Public Health Services, conducted in 2016," the Govt. said the 196 mothers died in producing 1 (one) lac babies. The first survey on the maternal mortality was held in 2001 in the country while the mortality rate was 322 but that in 2010 decreased to 194. Researcher said that the lack of the proper steps with devotion and monitoring of the death rate is increasing. The results of the survey were published formally at the joint venture of the national population control forum and the training organizations under the Health Ministry. Here the technical supports were offered by the International Centre for Diarrhoeal Diseases Research, Bangladesh (ICDDR, B) and the major Evaluation an Organization based on the population Research of the USA, financed by the donors of the USA (US AID) and the U.K. (U.K AID). While doing cluster survey in 1(one) thousand and 922 urban areas of the country where 2,98,284 Households and 3,21,214 women of the age from 13 to 49 were interviewed. The surveys were conducted by the trained surveyors since 22 nd August, 2016 up to the 10 th February, 2017. Where the causes of the death were ascertained by the physicians. The causes of the maternal deaths are mainly Post-Partum Hemorrhage (PPH). Besides, among the other causes there are eclampsia, obstetric and prolonged labor, complication due to abortion and others. The survey in the country conducted on maternal mortality and public health, shows the 31% babies are caesarians. According to World Health Organization 10% to 15% may be common risky cases where caesarian section should be used for the safety of life. But in Bangladesh more than double numbers of babies are caesarians than the number given by the WHO. Now the researchers are afraid observing commercialized 31% caesarians now which was 12% in 2010 and 3% in 2001.
According to survey 10 lac babies are caesarians in the country where 31 lac babies are born in a year. 7 lac 50 thousand babies are caesarians in the private hospitals and clinics, 43 thousand in NGO and the rest are in the Govt. hospitals. In the Health Centers situated among 615 villages of 15 upazillas in the 13 districts of the country, under the study areas of Gonoshasthaya Kendra, the primary health care services are offered where the patients of the fatal cases are usually sent to 5 (five) referral hospitals. In the health programme of the Gonoshasthaya Kendra's study areas in 2018, among the total number of 12,54559 people 8181 are identified as Ultra poor, 634203 as poor 3,62,603 as lower middle class, 1,50037 as middle class, 67784 as upper middle class and 31,751 as the rich. The Demographic and Health services, information have been collected from among those people are mentioned below.

METHODOLOGY:
Gonoshasthaya Kendra (GK) is operating since war of liberation 1971. During that time it was a hospital only called Bangladesh Field Hospital which used to treat injured and sick freedom fighters and refugees in the eastern border of India. Following independence on 16 December, 1971 Bangladesh Field Hospital was renamed as GK or People's Health Center with head office in a Savar Village, 40 km. North of Dhaka the capital of Bangladesh and was registered as public Charitable Trust.
During the last four decades, GK has increased its health care services including reproductive and child health care from about 50,000 people in 50 villages in 1972 to more than one million rural people in 592 villages (Chowdhury and Chowdhury, 2007). Now the area further expanded and covers with 29 health Centers, 13 districts, 17 upazilla's and 647 villages across the country with 5 referral hospitals. The population is divided into 6(six) socioeconomic groups such as Ultra poor (Aw) Poor (Ka) Lower Middle Class (Kha) Middle Class (Ga) Upper Middle Class (Gha) Rich Class (Umo).
UniversePG l www.universepg.com 24 The health care services provided by GK trained health workers called Paramedic. Each paramedic is responsible for total health care of 5000 to 6000 population. Paramedics visit every family once in a month and fill out the event registration forms. The paramedics also provide reproductive and health care and family planning services in its programme areas. These services include (a) registration of pregnant women to provide ANC related services like measurement of height, weight, circumference of the ankle and lower leg, 2-3 inches above the ankle to check the oedema, blood pressure, and check jaundice and anemia. They also test urine for sugar, albumin and examine eyes, ears and teeth, foetal movement and foetal heart sound; (b) They also distribute iron and calcium tablets and immunized pregnant women against tetanus and children under age one year against six deadly diseases: diphtheria, whooping cough, tetanus, polio, tuberculosis and measles; (c) Identification of high-risk mothers through regular follow-up for the referral to medical professional as an when needed; (d) They also suggested the family members of the mal nutrients and lactating pregnant women for balanced diet; (e) They arrange meeting with family members and villagers about the possible causes of maternal death and how maternal death could have been prevented; (f) Organize special camps for treatment of pregnant women.
The works of paramedics are verified by the field monitoring officer in a routine basis. They also manually prepare a list of those events and send it to Savar office for the documentation and preparation of monthly statistical report. If needed the health workers visit more frequently. Ante Natal Care, Postnatal care are very important component of universal PHC Services. During ANC, the paramedics identify highrisk pregnant women. She is given extra care and attention. A medical doctor will see all high-risk mother at least once in their gestation period either in the clinic or in the community, 76% newborn babies checked by paramedics within first seven days of delivery, supervisors could check 50% of new born within first week of birth. Physician usually could visit 30% newborn in their neonatal period.
ANC and PNC is a very important component of GK's service. GK's trained personnel conduct over 70% delivery in GK service area. Most paramedics are young women with 8-12 years of education. GK brought Traditional Birth Attendants (TBAs) in the mainstream of its health service delivery system which further enriched MCH care. Health education with community participation is one of the major activities of GK. Every infant and maternal death is discussed in the community to draw lesson to improve health service and social and household community action. Besides integrated health care programmes (Homeopathy, Traditional system of medicine-Ayurvedh and Physiotherapy (non drug therapy) basic School, women skill development and health orientated publiccations, GK runs a number of manufacturing industries (essential drug related). Profits are invested in social development programme. GK also provides both home based and hospital based care. On the basis of statistical report field monitoring officer immediately visit each village of the events collected to check the inconsistency if any. Moreover, after completion of entry of vital events data across checking is done with statistical report to see any omission or addition of births, deaths, including neonatal/infant and maternal deaths.
In this study the maternal mortality data used for a period of 11 years from the 14 th April, 2008 to 13 th April 2018 of the G.K health services programme areas covered 13 districts, 17 upazillas and 647 villages is now one of the largest health service provider's outside the Govt. of Bangladesh (BDS Paper no-14 Dhaka, 2007). The study explains the GK's experience in primary health care and examines its impact on reduction of maternal mortality on the years. This kind of study on maternal mortality is rare in Bangladesh that used longitudinal data, in which several cohorts were followed from the time of conceptions until the outcome of pregnancies.

RESULTS:
In the present study       If any complication be seen, at once they take necessary steps to solve the problems of pregnant mothers and her children. As a result both of the mother and her children saved from death. The MMR in 2016-17 was 156.79 increased to 40.47 percent from the preceding year. The MMR in 2017-18 was 171.74 also increased but the increasing rate is less 9.54% than the preceding year (Fig 1).
The reasons of increasing MMR are given below -1) Increase caesarean section deliveries.
2) Influenced by the broker to go in the private clinic.
3) After conducting Ultra sonography, doctors of that clinic influence the pregnant mother and her guardian at once to conduct caesarean delivery otherwise her patient or her baby may die. It is the business strategy of private clinic. 4) Unskilled doctors conduct caesarean delivery, and sometimes heavy bleeding occurs, which cannot control the unskilled doctor and refer to other hospital, and in maximum cases the patient died on the way. 5) Sometimes trained TBA also takes the pregnant mother to the private clinic or hospital in spite of a chance of normal delivery at home. Because in case of normal delivery at home she may get at best Tk. 500 but if she takes her in the private clinic, the authority of the clinic gives her at least Tk.1000 per delivery. The clinic agents have contact with the TBA in this respect. 6) Now the financial condition of general people has increased; they take decision for caesarean delivery from the beginning. Besides, there are some misconceptions about caesarian delivery and broker or other agents mislead the mother and her guardian. This is one of the main reasons of increasing MMR.              (Table 11). Table 12 Shows the number of live birth and maternal death during the last eleven years from1414 to 1424. Within these eleven years, total live births and maternal deaths were 146561 and 205 respectively.

Table 25
Shows that total 48 mothers died during and or after caesarean section deliveries and the cost of deliveries according to their socio-economic status (SES). Among them there were 29 from poor, 16 from lower, 3 from middle class family's respectively. Analyzing the delivery cost it is also found that one mother did not get any treatment and the remaining 47 mothers' treatment costs were Tk. 1000-5000 for 5, Tk.6000-15000 for 12, Tk.15001-25000 for 9, Tk.26000-50000 for another 9 and Tk.50000 and above for 12 mothers.                                                 household is likely to be positively associated with maternal mortality as the mother of a well off households are suppose to be more aware of risk of pregnancies than the poor mothers. Moreover, the former is more likely to have utilized ANC and PNC services than the latter because of their greater awareness and afford-ability.
A pregnant mother is more vulnerable to a deadly disease like tetanus, particularly in poor sanitary condition in many developing countries like Bangladesh. The tetanus vaccinations are used for the safe guard of mother. Moreover, in rural areas of Bangladesh there has been a common practice to cut the umbilical cord using steel blade (not boiled) or blade made of bamboo and paste cow dung on the cord. This unhygienic method causes the risk of tetanus infection. The data in Table 49 confirm the result that the vaccinated women have considerably lower rate of mortality than those women who have not vaccinated. Educated pregnant women are more conscious for taking and utilizing antenatal and post natal care services than the women who have no formal education. The other cause of maternal mortality is severe anemia. It is observed and estimated that a pregnant women's blood volume increases almost 50 percent, although the amount of plasma is disproportionately greater than blood volume. As a result the fall in the hemoglobin level below the normal level may expose pregnant women to a higher risk of death. To save the mother GK workers treat with iron supplementation.
In Bangladesh there has been a decline of 40% maternal mortality over a period of 9 years from 2001 to 2010. However the maternal mortality due to indirect causes somewhat increased (BMMS, 2010). In this respect the researchers opined that the indirect causes of maternal mortality include diabetes, high blood pressure, heart disease, cancer, tuberculosis, anemia, hepatitis 'B', HIV Aids and Malaria. The age of conception of women either too early or too late also the causes of maternal deaths. One of the members of the Bangladesh maternal mortality and health care survey, 2010 suggests that during and after conception of women if the following measures are taken in the Govt. save motherhood campaign programme to reduce the indirect causes of maternal deaths such as: a) to identify the mother who has been suffering from the diseases mentioned above; b) Cancer vaccination has been given or not. Gonoshasthaya Kendra provides reproductive and child health care as well as family planning services with other services to its catchments villages. Among other things, these are: 1. Planning for a healthy pregnancy-GK health workers regularly go to the villages, find out eligible couple and provide consultation to them about family planning and nutritional matters. Especially, new couple who do not wish to take baby immediately after marry. To identify all eligible couple and inform them about the necessary to accept family planning. Besides, if anyone needs to take any family planning method with the help of government family planning department, then maintain a liaison with them and to provide instrument of family planning methods. If any woman of eligible couple didn`t take TT vaccine before, then give her TT vaccine and ensured that she has accepted full course of TT vaccine.

Care during pregnancy (Antenatal Care)-
Firstly, identify pregnant woman, enlisted and make a follow-up card. The provided health care's are regularly recorded in the follow-up card. Generally, four times antenatal follow-up provides to a normal pregnant woman, but in case of sick, risky and complicated pregnant, antenatal follow-up may be more times. Examining their health condition such as edema, blood pressure, jaundice, anemia etc. At the same time health workers also observe eyes, nose, teeth and stomach height of the pregnant mother. They also observe the movement and heart beat of the womb baby and test urine albumin of the mother. If anyone needs to take nutrition then provide Iron, calcium, vitamin-A and also provide consultation to eat proper nutritious (vegetables) food and minavit for filling up malnutrition.
To register the pregnant mother and recorded various ANC related services, such; (a) height and weight, edema; (b) BP measurement, examining jaundice and anemia; (c) Urine test to iden-tify sugar and albumin; (d) Examine eyes, ear and teeth; (e) Pregnant cervical height measurement and observe heart beat and movement of the womb baby. To teach the pregnant mother to realize about fetus movement. Encourage the pregnant mother to take Iron and Calcium tablet. Provide TT vaccine to the pregnant mothers. Measuring (Pregnant camp, yard meeting and immunization center) blood grouping of all pregnant mothers. It is also identified some relatives of the pregnant of same blood group from beginning, if blood is required during delivery. If blood is needed, from the close relatives, voluntary blood donor groups (Bondhon, Sondhani) and blood banks are collected the blood and after cross-matching, the blood has to be circulated. Sometimes in need have blood, to announce locally using mosque mike to collect blood. Ensure to identify high risk pregnant, conduct regular follow-up, arrange medicine and timely refer system to the certain place. After identifying pregnant women, firstly attached her with a nearest skilled TBA and provide her/ family members the mobile number of the project manager/health in charge/supervisor so that they can communicate with them at any time finding any danger sign of the pregnant.

Care during Labour and Delivery: Delivery time-
Hearing the news of delivery pain of the woman, at once the trained TBA goes to their home. Most of the time the family member of the pregnant informs GK health workers by phone. 1). It is actual pregnant related pain or not; 2). Due to actual labor, the duration of the contraction will increase and reduce the contraction time from one contraction to the next. If the contraction does not start, the mother is prohibited from pressing, and it is said to make walking, it is said to take long breathing and also said to eat light hot liquids and soft foods. After 2 hours, it is said to urinate; 3). Examine vaginal path, (a) Watch (Slippery fluid content is seen in the vagina with a finger), (b) Whether the uterus has opened and how many fingers it has, (c) Whether the water has broken, the presence of the baby in the womb is diagnosed, (d) Whether there is water colour and smell, (e) Monitoring delivery progress (child movements, checking the heart beat of the child), mother's pulse motion and blood pressure are tested through partograph, (f) Perineal guard is used to protect perineal tear, (g) The child is caught for not geting hurt as the child falls.

The problems which can be performing due to home delivery are as follows
• There are no facilities of Oxygen, Nebulizer or suction if needed. • If perineum tear and/or heavy bleeding occur after delivery there is no way to provide emergency treatment. • During delivery pain many of the villagers call quack. Before water leakage the unskilled village doctors push injection for increasing unnecessary pain. As a result still birth may occur, Uterus may be tearing and heavy bleeding occurs and placenta may not be come out smoothly. For that reason many other problems can be seen and at once the patient need to take in the hospital emergency. The conditions of the pregnant mother then become very risky. • Generally the cultures in our country especially in the community, during the 1st delivery of pregnant mother have to send to her parent's house. During delivery pain, generally unskilled relatives are called to attend delivery who usually don`t properly understand. At the time of delivery sometime it is seen that the baby was in breech position. The canal of the uterus was narrow and the unskilled TBA pulled the baby with force, as a result tear the membrane and heavy bleeding occurs. If they fail to stop bleeding then the pregnant mother may be died.

Solution
• Delivery should be conducted by the trained TBA and health workers. • If the sign and Symptom identified complicated from the beginning, then after starting delivery pain at once the mother have to send in hospital or any health center for safe delivery. • If any health worker of GK get news of delivery pain from any guardian in village, at once the health worker go to the spot along with doctor and necessary instruments. If they find complication, they bring her to the GK hospital. Besides, they refer the patient to the nearest Govt. hospital or other health centers.
• If any skilled TBA finds complication of the pregnant mother, then she sends her as early as possible to nearest hospital. In this way such problems can be solved. (1) Keep the baby a little below at the parallel of the mother's stomach, then the umbilical cord is cremated several times till 2-3 minutes like milking a cow, and is given her directly to mothers breast; (2) After a few minutes, the umbilical cord is bound by three hurdles, then keep the two binding with the baby and cut the umbilical cord between two to three number binding. The cord side of the mother is tied with mother's thyroid. The cord side of the mother is tied with mother's thyroid. It is mentionable that there will not be any cloths to make barrier among mother and baby`s skin. It is to keep the baby on the mother's breast for suckling cholesterol. Mothers Placenta is thrown out. It turns out that the placenta is completely untouched. Generally the placenta come out after 30 minutes of delivery, then examine the mothers vaginal path (1) whether it is being tear, (2) Whether excess bleeding is occurring, (3)the uterus is contracted, (4) whether the uterus come down, (5) whether another baby is in the womb. After ensuring positive all, two mesoprostol tablet may be give her through oral or vagina for protecting excess bleeding.

For mother and child after birth-
After childbirth, the mother and child are kept in constant monitoring for two hours so that the mother and the baby can be identified immediately and take proper step to solve the identifying problem. After delivery, at least 3 Post Natal Care (PNC) needed. First visit starts within first week of delivery, but it would be better from first 12 to 24 hours.
Baby and mothers health condition is observed from this visit. 2 nd visit is starts after 2 nd week of delivery. Advice to give the baby vitamin -A capsule and again examine mother and child health condition. 3 rd visit is to be complete within six week after delivery. In this visit, generally encourage mother for immunization of her baby and accept family planning. At the same time encourage other members of the family to provide balance diet to the mother.
When needs to refer 1) Being Eclampsia 2) Excess bleeding 3) Oedema 4) Blurred vision 5) If the baby is at land shape 6) If baby come out with uterus bag. 7) Whether the baby die in the womb of mother. Pregnant pain is zero but water is broken. 8) If uterus come out after delivery. 9) If the child throat is trapped.
After delivery, if the baby don`t cry, the color of the child becomes red-blue then at once have to refer to the suitable health center.

The following matters are taught to the birth attendants during training
Hand washing (practically), Nails cutting, Communication, Counseling, Pregnant care (Safe delivery, normal sign of the womb, danger sign at pre, present and post delivery, primary management and about referring systems), Neonatal care, advantages of cholesterol, Certain time of breast feeding, the way of feeding baby, balance diet for mother and baby, Family planning methods, Immunization etc. Especially, teaches them, how to refer in the emergency situation. Some drugs were taught to them (Iron, Calcium, Paracetamol, Antacid, Vitamin B-Complex, ORS, Messoprostol and about minavit). Maternal death meeting: Maternal death meeting is started at 1990. Super visors as well as health in charge with paramedic have to present in such meeting. Besides, union parishad members, government worker and local well-known persons are requested to join the meeting. At that meeting, the causes of death are discussed with the family members and other attendants. At the same time, it is to provide consultation to the attendants and local community about their duties in such a situation in future.
In this way, the paramedic acquired knowledge to prevent the maternal death. In every monthly meeting, paramedics illustrate their success and failure. The function of various paramedics in the meeting was judged in the best measure. In the next month, again check up the matter of maternal and infant death and try to find out the reasons of it. At the end of the year, paramedic's promotion and salary increase depends on this evaluation. All paramedics of Gonoshasthaya Kendra are dedicated to their responsibility and are sincere in providing services. As a result, their popularity and acceptance is in-creasing day by day in the villages and clinic level. A matter is needed to mention here that, Gonoshasthaya Kendra never thought against village doctor and dhai, otherwise always tried to train them.

CONCLUSION:
The result of this study suggests that the tetanus vaccination reduce maternal mortality. Iron supplementation will also reduce the high risk of maternal deaths. Increased age at marriage of women will increase the age of conception and maternal death will be declined. If the following measures are taken in the Govt. "Save the motherhood campaign programmers" will help to reduce the indirect causes of maternal deaths. Of the direct causes of maternal deaths, a) Home delivery with untrained dhai, b) Early marriage and conception, c) Not taking proper health care before, during and after delivery, d) Malnutrition, e) Mental and physical torture of pregnant mother. To reduce the indirect or direct causes of maternal mortality, mothers' and guardians awareness must be build up through different Govt. non Govt. Organizations either National or International and also mass media can play vital role how to take proper care of mother during pregnancy and after delivery. Moreover, pregnant mother and her family members should take care about the following four topics to reduce the maternal deaths: o Pregnant mother have to eat again and again a little amount of nutritious food, not at the end of all members, always try to eat firstly with other children. o Have to take rest (two hours after lunch and eight hours after dinner) o Cleanliness (takes care of personal cleanliness and breast) o Provide cholesterol and exclusive breast feeding after delivery the baby.
Advice to take pre-preparation before delivery: ▪ To select neat and clean place where adequate light and air are available (clean wealth cloth and rexin sheet). ▪ Germfree yarn, blade and hand washing soap, covered clean pot for boiling water. ▪ For taking the baby in lap and wrapping her, need to collect clean dry cloths.

ACKNOWLEDGEMENT:
I am greatly indebted to the mother organization, Gonostasthaya Kendra of Gono Bishwabidyalay for providing me with the data and all financial support for collecting and analyzing the data. I express my profound gratitude to Dr. Zafrullah Chowdhury Founder and Trustee of Gonoshasthaya Kendra for his cooperation and support for this study. I am also thankful to Rehana Sultana, Sr. Research Assistant and Md. Sadequl Islam, Programmer for their assistance in preparing the data files.

CONFLICTS OF INTEREST:
The author declares there is no conflict of interest to publish it.