Ruby Akthar can still remember the agony of her first labour. Nestled away in one of Bangladesh’s many urban slums—aged just 20—a frightened Akthar attempted to deliver her first baby at home without medical assistance. But following hours of agony due to the baby being in a difficult position, she and a family member bundled into a taxi and crossed a stiflingly humid Dhaka to seek medical help from a NGO health centre. Now a proud mother Akthar smiles; thinking of her six year old daughter, but without medical assistance during the birth it is possible that neither mother nor daughter would be here today.
WHO estimates that in 2016, 830 women died everyday as a result of childbirth. In Bangladesh, the combination of high rates of poverty, poor access to medical resources, elevated cases of child marriage and deep-rooted attitudes towards gender roles means that in 2016, somewhere between 6,000 and 7,000 mothers died. But Bangladesh, one of the poorest and most densely populated countries in the world, is full of surprises.
A 2016 Unicef report claims that the nation has the second highest rate of child marriage in the world—in its rural areas 74 percent of young women are married before their 18th birthday. Early marriage puts young women’s health under immense risk. Premature and closely spaced multiple pregnancies increase the likelihood of uterine prolapse and obstetric fistula; a complication during birth which causes the reproductive organs, bladder and rectum to split, leaving women incontinent. This condition can potentially lead to abandonment from their husbands, ostracisation from their communities and if severe, death.
In some communities, notably rural, women who seek Western medical care are shamed and shy away from openly discussing their pregnancy or any worrying symptoms. Expectant mothers, often under pressure from village elders, follow traditional birthing rituals. “I would hold a round or a cylindrical object every evening after dinner and make 7 rounds in the small courtyard outside our home,” said Ruksana Khatun. According to the family myth, performing this ritual assures one of a healthy son. Khatun later aborted her child after discovering she was carrying a daughter. During the labour itself, expectant mothers may be violently shaken by traditional birthing attendants to allegedly assist in releasing the baby—running a high risk of hemorrhaging, uterine prolapse and damage to the child.
In spite of such horror stories surrounding maternal health, impressive change is already underway across the nation. The alleged source of this transformation has come as a surprise to many. Doctor Zafrullah Chowdhury, founder of one of Bangladesh's oldest NGOs, Gonoshasta Kendra (GK), argues that sexual violence committed during the 1971 Bangladesh War of Independence with Pakistan resulted in hundreds of thousands of Bangladeshi women demanding access to family planning services. "Many of the medical developments came during the war ... our war changed our attitude," he explained, "Culture has not changed, religion has not changed - but attitude has changed." This demand for family planning—notably abortion, meant that swarms of health workers headed into rural communities and entered into conversation with villages about women’s health, rights and safety.
Hot on the heels of this widespread overhaul on women’s health, the Bangladesh Rural Advancement Committee (BRAC)—the world’s largest NGO—created the Improving Maternal, Neonatal and Child Survival (IMNCS) project in 2005. This initiative aims to reduce maternal, neonatal and infant mortality, notably in poorer, more secluded villages and reaches over 25 million people in 14 of the country’s regions. BRAC’s workforce—70 percent female—trains and works in their local communities, meaning that health workers on the programme get closer access to expectant mothers. Local women are taught skills required to work as Community Health Workers (CHW), Newborn Health Workers (NHW) and Community Skilled Birth Attendants (CSBA). These women make regular home visits to mothers before, during and after the birth. Their services have assisted in bridging the gap between the current capacity of public government health services and the needs of an ever-growing population.
Perhaps such initiatives are what has led to Bangladesh being one of only a few countries to achieve the United Nations' Millennium Development Goal (MDG) number four and five, which aimed to lower the infant mortality and maternal mortality rate (MMR)—the number of mothers who die per 100,000 live births. The country’s current MMR is about 170 maternal deaths per 100,000 live births, but between 1998-2001 this averaged 322 per year. Evident progress has clearly been made over the past 16 years, and the nation is currently well ahead of its neighbours India and Pakistan regarding maternal health.
Bangladesh still has a long way to go; for one in two women, medical decisions regarding her pregnancy are made by her husband. Still, this small nation has shown that medically training local women to tackle the issues surrounding maternal health is an effective way to improve mother’s lives. As Dr. Chowdhury said: "For any maternal mortality theme, or any subject you want to take, the key is the women."