1

Baseline Findings: Project of ‘Improving Sexual, Reproductive Health and Rights Including Maternal and Newborn Health in ’ in Five Districts 2 Background of the Study

UNICEF in collaboration with Bangladesh government launched a project “Improving Sexual, Reproductive Health and Rights including Maternal and Newborn Health in Bangladesh” to improve integrated sexual and reproductive health and rights including maternal, newborn, child and adolescent health in 5 districts.

Before implementation of the project a baseline study in 5 project districts (Patuakhali, Rangamati, , Jamalpur and ) with 4 comparison districts (Barguna, Khagrachhari, Lalmonirhat and ), implemented by UNICEF and conducted by SURCH between 9th May and 18th August 2018 3 Objectives of the baseline study

Overall objective: Collect baseline information of study area, living conditions of study population, their knowledge on & practices of key MNCH care and knowledge on adolescent sexual & reproductive health and rights (ASRHR), and other factors affecting health and nutrition of children and women, and to identify gaps between the real need and services in the study districts to design a package of cost-effective intervention in project area. Specific objectives: ▪ To design a methodology that would allow the project to estimate the impact of its interventions ▪ Provide information to make concrete recommendations for improving MNH & ASRHR activities ▪ Identify coverage of key health, nutrition and adolescent health interventions at district and levels ▪ Identify impact level indicators, i.e. neonatal & under-5 mortality rates and adolescent fertility rates ▪ Identify key barriers to access or acquire services in both public and private facilities 4 Study Methodology

Study Design Quasi Experimental Design : Pre-Post with Intervention and Comparison areas 5 Intervention (project) districts- Patuakhali, Rangamati, Sirajganj, Jamalpur and Moulvibazar 4 comparison districts- Barguna, Khagrachhari, Lalmonirhat and Sylhet

Quantitative method Qualitative methods

➢ Household Survey ➢ Focus Group Discussions (FGD) ➢ Health Facility Survey ➢ Key Informant Interviews (KII) ➢ Health facility mapping by GPS reading ➢ Review of Documents 5 Methodology : Household Survey Sample Size and Sampling Design Two stage cluster sampling design was followed First stage: 78 segments (clusters) with 100 HHs in each, selected following PPS sampling method in each of the project and control districts Second stage: Selected 25 HHs per cluster • Required sample size for each district: 1950 HHs (25 HHs×78 clusters)

• The study targeted 17550 HHs [(1950x5)+(1950x4)] in 9 districts.

• However, successfully covered 17329 households (Project: 9608; Control: 7721)(98.74% completion rate). 6 Methodology : Health Facility Survey

Public facility:

▪ District and Upazila levels: All ▪ Union level: 2 unions per upazila selected randomly, where - all government health facilities, i.e. FWCs, upgraded UH&FWCs, RDs, USCs and CCs in the selected unions listed and surveyed. Private and NGO facilities: ▪ All private and NGO-run facilities (10+ beds)

Total - 715 health facilities, Project- 441 and Control- 274 (public 554 +private 161= 715) 7 Methodology : Health Facility Survey Coverage: Public, private and NGO health facilities ▪ Medical College Hospitals (MCHs) ▪ District General Hospitals (DGHs) ▪ Maternal and Child Welfare Centers (MCWCs) ▪ Upazila Health Complexes (UHCs) ▪ Upgraded Union Health and Family Welfare Centers (upgraded UH&FWCs) ▪ Family Welfare Centers (FWCs) ▪ Union Sub-Centers (USCs) ▪ Rural Dispensaries (RDs) ▪ Community Clinics (CCs) ▪ Other government facilities(Kalapara 20 Bed, Ullapara 30 Bed & Angorpota-Dahagram 10 Bed Hospitals) ▪ Private hospitals/clinics ▪ NGO-run hospitals/clinics 8 Methodology : Health Facility Survey

Gathered data to assess: ▪ Availability and quality of health facilities ▪ Health services including key MNH and SRHR including FP service and ▪ Capacity of service providers at community and facility levels Techniques applied: ▪ Review of records ▪ Observations ▪ Interview with service providers/key officials ▪ GPS reading based mapping of health facilities and services for GIS 9 Methodology : GPS reading for GIS Public facility: ▪ All facilities at district, upazila and union levels

Private and NGO facilities: ▪ All private and NGO-run facilities

GPS reading of all health facilities in project and comparison areas- Except 40 facilities (mainly in Rangamati & Khagrachhari) due to lack of uninterrupted internet connectivity

Total- 675 health facilities 10 Methodology : Qualitative Methods

20 Focus Group Discussions (FGD) with ▪ Husbands and mothers-in-law of community women ▪ members of Community Groups (CGs) and Community Support Groups (CSGs) 30 Key informant interviews (KII) with ▪ Civil Surgeons ▪ Superintendents ▪ Deputy Directors of Family Planning (DDFP) ▪ UH&FPO , UFPO and RMO And Document Review 11

Household Survey Findings

Household Population 12 Household composition

Percent distribution of households by sex of household heads and household size Percent Characteristics Project area Comparison area Sex of household heads Male 89.2 87.2 Female 10.8 12.8 Total 100.0 100.0 Household size Average (mean) number of household members 4.5 4.6 n (number of households) 9608 7721

Findings: Mostly male headed households: Project 89.2%, Control 87.2% Average number of household members: Project 4.5, Control 4.6, nationally: 4.5 persons (BDHS 2014) 13

Maternal Care (of women age 15-49 years with a live birth in last two years prior to survey) 14 Antenatal care (at least one ANC from any source or from MTP) Antenatal Care

100 88.3 88.9 90 87.7 85.3 87.4 82.1 81.7 83.2 81.5 82.0 76.4 77.6 78.4 80 72.9 69.0 70 62.4 63.9 58.9 60 52.7 50 45.7 44.7 40 30 20 10 0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Barguna Khagrachhari Sylhet Lalmonirhat BDHS2014 BDHS2017 Project area Comparison area National

At least one ANC from any source At least one ANC from MTP

Note: Medically trained provider (MTP) includes qualified doctor, nurse, midwife, paramedics, sub assistant community medical officer, family welfare visitor and community skilled birth attendant 15 Number of ANC visits to any provider Antenatal Care 100% 11.7 12.3 14.7 90% 16.8 18.8 21.4 No ANC 80% 14.9 22.3 47.3 19.6 ANC1 70% 27.0 18.4 17.9 15.2 60% ANC2 23.0 18.1 15.9 16.2 50% 18.1 19.9 16.3 ANC3 40% 11.5 13.6 13.2 15.3 10.4 30% 13.2 ANC4+ 20% 39.5 13.1 34.0 33.3 27.7 28.0 31.3 10% 10.1 0% Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj BDHS2014 Project area Comparison area National

4+ ANC: Nationally 47% according to BDHS2017 16 Consumption of IFA supplements Antenatal Care

Consumed or not consumed Consumed 100 or more

100% 0.9 0.5 1.0 0.0 0.2 0.3 100.0 90% Can't recall Consumed 100+ 90.0 82.0 80% 80.0 70% 65.4 67.0 70.0 64.0 70.4 73.1 68.7 69.6 60% Consumed 60.0 50% 50.0

40% 40.0 31.6 30% 30.0 25.2 24.8 19.8 20% Not 34.6 32.8 consumed 20.0 14.0 14.7 28.7 26.4 30.3 30.1 10% 10.0

0% 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Patuakhali RangamatiMaulvibazar Jamalpur Sirajganj BDHS2014 BDHS2017 Project area Comparison Project area Comparison area National area 17 Birth preparedness (plan for place of delivery: home or facility or no plan) Birth preparedness

100.0 90.0 80.0

70.0

62.7

58.0 57.3

60.0 56.2 51.9

50.0 45.0 44.2

40.0 31.9

30.0 26.9

22.9 22.9

21.5

20.9

20.5 19.8

20.0 16.2 10.9 10.0 10.4 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Project area Comparison area

Nothing planned Planned home delivery Planned facility delivery 18 Birth preparedness (MTP to assist delivery, transport, money, cloth, blood donor)

100.0 89.1 90.3 90.0 87.2 80.9 77.2 80.0 74.3 74.8 69.6 69.8 70.0 58.8 60.0 51.8 50.0 43.8 40.8 40.0 30.0 22.6 22.5 25.2 24.0 19.1 20.6 15.6 17.0 16.0 20.0 13.6 12.7 8.5 9.4 8.4 10.5 10.1 10.0 7.1 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Project area Comparison area Selected MTP to assist delivery Arranged transport Saved money Arranged two pieces of cloth Selected blood donor MTP includes qualified doctor/nurse/SACMO/paramedic/MA/FWV/CSBA/midwife 19 Place of last delivery, and delivery by C-section Delivery Care

100.0

90.0 81.4 80.0

70.0 70.5

63.3

62.2

60.1 56.3

60.0 55.5

50.0 50.0

50.0 44.5

43.7

39.9 37.4

40.0 36.7

33.0

30.2 30.1

30.0 29.5

24.4

22.9

19.8 18.6 20.0 18.1 10.0 10.1 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj BDHS2014 BDHS2017 Project area Comparison National area Home Facility Delivery by C-section

Facility delivery includes deliveries at public, private and NGO-run facilities 20 Delivery assisted by Delivery assisted by

Untrained TTBA Nurse/paramedic/SACMO/FWV/CSBA/Midwife Qualified doctor 100% 90% 80% 35.3 39.2 40.1 47.4 47.7 70% 62.2 63.6 60% 17.4 7.4 50% 13.1 15.0 10.2 23.7 40% 18.2 14.1 5.8 11.2 30% 18.9 8.9 16.9 20% 29.1 6.3 29.7 32.7 30.9 10% 21.7 20.7 12.6 0% Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj BDHS2014 Project area Comparison area National

Nationally (BDHS2017-18: qualified doctor-38%, Nurse/paramedic/SACMO/FWV/CSBA- 14%) 21 PNC for mothers in 2 days of delivery Postnatal care

100.0 From any provider From MTP 90.0

80.0 73.6

70.0 60.1

60.0 59.1

52.8

52.0 49.5

50.0 48.3

42.8 36.8

40.0 36.4

34.7 31.1

30.0 25.5 19.4

20.0 16.3 10.0 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj BDHS2014 BDHS2017 Project area Comparison National area 22 PNC for newborn in 2 days of birth Postnatal care

100.0 From any provider From MTP 90.0 84.1 81.3 80.0 70.0 61.4 59.9 62.4 60.0 54.3 50.0 44.4 39.1 38.6 40.0 33.5 30.5 31.5 30.0 27.2 20.0 17.8 10.0 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj BDHS2014 Project area Comparison area National 23 Delivery by skilled person with mothers’/newborn’s PNC within 2 days after birth

100.0 Delivery by skilled person and mother's PNC in 2 days 90.0 Delivery by skilled person and newborn's PNC in 2 days 80.0 70.0 60.0 48.6 48.7 50.0 45.3 45.5 40.9 42.9 40.0 33.9 34.6 28.5 29.1 30.0 20.0 17.1 17.2 10.0 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Project area Comparison area

Skilled person: qualified doctor, nurse, paramedic, FWV, CSBA and midwife 24 Major maternal complications in ANC/pregnancy period & care seeking for complications

100.0 Women with complication did not seek care Faced any major complication in pregnancy period Women with complication sought care from non-MTP 90.0 Women with complication sought care from MTP 100% 80.0 4.1 12.5 16.3 16.8 90% 9.4 20.3 22.2 70.0 80% 14.2 5.4 12.4 8.9 60.0 10.2 70%

50.0 60%

40.0 50% 31.7 86.5 28.4 28.5 40% 30.0 73.3 74.3 74.3 67.6 71.3 21.2 19.6 30% 20.0 12.4 20% 10.0 10%

0.0 0% Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Project area Comparison area Project area Comparison area 25 Facing major maternal complications during delivery & care seeking for complications

Women with complications during delivery did not seek care 100.0 Faced any of major complications in delivery period Women with complications in delivery sought care from non-MTP 90.0 Women with complications in delivery sought care from MTP 100% 80.0 15.4 16.7 13.3 13.8 90% 22.2 33.3 7.8 70.0 80% 8.3 17.8 23.1 60.0 70% 24.1 50.0 60% 16.7 50% 40.0 40% 75.0 78.9 30.0 68.4 30% 61.5 53.7 20.0 50.0 15.6 14.1 14.5 15.0 20% 9.3 10.1 10.0 10%

0.0 0% Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Project area Comparison Project area Comparison area area 26 Facing major complications within 42 days of delivery and care seeking behavior

100.0 Women with complication in 42 days of delivery did not seek care Women faced any of major complications within 42 days of Women with complication in 42 days of delivery sought care from non-MTP 90.0 delivery Women with complications in 42 days of delivery sought care from MTP 100% 80.0 90% 27.3 26.0 27.8 70.0 34.0 80% 36.0 60.0 70% 57.1 18.2 50.0 60% 17.0 30.8 40.0 50% 50.0 27.5 40% 30.0 27.1 14.3 20.6 30% 54.5 20.0 15.5 15.8 15.3 49.1 13.1 41.4 20% 36.5 10.0 28.6 10% 24.0

0.0 0% Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Project area Comparison Project area Comparison area area

Nationally complication after delivery:21% (BMMS 2016) 27 Knowledge on danger signs during pregnancy period Danger sign knowledge

Excessive Severe Headache Know 3+ Areas Districts vaginal High fever Convulsion/fit abdominal and/or blurred danger signs bleeding pain vision

Patuakhali 29.7 25.3 47.3 24.5 53.9 22.2

Rangamati 19.9 36.9 16.8 40.0 51.3 23.3

Project area Maulvibazar 36.9 31.1 33.3 26.1 49.2 22.3

Jamalpur 33.3 29.5 71.5 38.7 52.9 43.2

Sirajganj 41.4 24.7 42.6 40.0 51.2 29.9

Comparison area 35.7 35.2 43.2 31.7 61.9 35.9 28 Knowledge on danger signs during delivery period Danger sign knowledge

Prolonged Convulsion/ Baby’s hands Premature Excessive labour pain Retained un- and feet come Know 3+ Areas Districts rupture of vaginal (for 13+ years) placenta consciousness first danger signs membranes bleeding

Patuakhali 18.9 22.6 17.4 41.0 15.7 24.9 8.1

Rangamati 18.6 11.0 0.8 11.3 8.0 17.0 1.6

Project districts Maulvibazar 24.5 7.0 2.9 25.9 7.7 32.9 0.3

Jamalpur 23.0 34.1 0.4 65 28 33.6 13.6

Sirajganj 26.8 20.9 4.4 42.6 17.7 32.7 6.1

Comparison districts 33.2 19.1 9.1 33.2 26.2 27.1 11.0 29 Knowledge on danger signs immediately after delivery Danger sign knowledge

Headache/ blurry Severe Edema Excessive Difficulty Know 3+ vision/ Convulsion High lower Faint Areas Districts in vaginal in danger high /shivering fever abdominal /senselessness face/leg bleeding breathing signs blood pain pressure

Patuakhali 23.2 43.4 54.1 25.7 23.5 21.6 13.7 12.1 36.6

Rangamati 33.9 15.3 14.5 26.9 12.5 31.9 11.5 4.8 31.0 Project Maulvibazar 23.7 13.5 27.0 28 23.9 26.8 13.7 3.8 23.9 area Jamalpur 24.5 24.7 79.8 30.5 28.4 34.3 12.0 10.3 50.8

Sirajganj 31.5 18.9 46.6 30.2 31.9 34.9 22.0 11.7 46.0

Comparison area 28.8 27.1 39.3 32.1 27.0 27.1 14.3 11.7 45.1 30 Knowledge on any FP method and 4+ modern methods

100.0 95.1 94.0 92.9 90.5 86.7 90.0 82.1 80.0 70.0 60.0 50.0 40.0 30.0 17.5 15.6 20.0 12.5 15.0 6.7 10.0 2.6 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Project area Comparison area

Have any knowledge on FP method Know 4+ modern FP method 31 Current prevalence of any FP method and modern FP method

100.0 Currently use no method Currently use any FP method Currently use any modern method 90.0 80.0 68.9 68.9 70.0 66.6 66.3 65.1 63.1 63.0 63.5 62.4 62.0 58.9 59.2 60.0 54.0 54.1 52.0 48.8 50.0 46.0 40.0 37.0 36.5 37.6 38.0 31.1 33.4 31.1 30.0 20.0 10.0 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj BDHS2014 BDHS2017 Project area Comparison National area 32 Modern method-users’ knowledge on side effects of FP methods

100.0 90.0 Modern method-users had knowledge on side effect of FP method 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.8 9.6 8.2 10.0 4.2 4.3 6.4 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Project area Comparison area 33 Women counseled on PPFP

100.0 Women counseled on PPFP 90.0 80.0 70.0 60.0 50.0 41.5 40.0 28.9 30.0 26.3 25.0 19.0 20.0 14.9 10.0 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Project area Comparison area 34

Neonatal Healthcare Practices 35 Essential Newborn Care by area

100.0 91.6 90.0 83.8 83.1 78.5 80.0 70.0 66.9 60.0 57.2 52.4 50.0 39.5 38.7 40.0 34.3 29.0 30.0 26.6 20.0 10.0 6.1 0.4 0.2 0.0 0.7 0.0 0.0 0.0 Project area Comparison area BDHS2014 Nothing applied Applied chlorhexidine Dried within 10 minutes Skin-to-skin initiated in 10 minutes lasted for 1+ hour Breastfed in 1 hour of birth Delayed bath at 72+ hours after birth All 5 ENC (nothingOrChlorhex, drying, skin-to-skin, BF, delyed bath) According to BDHS 2014: dried within 0-4 minutes; all ENC refers to instrument boiled before cord cutting, drying in 0-4 minutes, nothing applied, delayed bath at 72+ hours and immediate breastfeeding in 1 hour 36 Essential Newborn Care by district Neonatal Healthcare Practices

100.0

89.2

89.0

88.8

88.1 87.9 90.0 87.7

80.0 77.9

73.7

73.3 66.9 70.0 65.7

60.0 57.2

52.4 51.5 50.0

40.0 40.0

34.3

29.5

28.2

26.9 26.6

30.0 25.9

23.9 22.1

20.0 13.0

10.0 6.1

0.7

0.6 0.6

0.5

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj BDHS2014 Project area National Nothing applied Applied chlorhexidine Dried within 10 minutes Skin-to-skin in 10 minutes for 1+ hour Breastfed in 1 hour of birth Delayed bath at 72+ hours after birth All 5 ENC (nothingOrChlorhex, drying, skin-to-skin, BF, delyed bath)

According to BDHS 2014: dried within 0-4 minutes; all ENC refers to instrument boiled before cord cutting, drying in 0-4 minutes, nothing applied, delayed bath at 72+ hours and immediate breastfeeding in 1 hour 37

Newborn with complications in 1 month after birth and care Neonatal Healthcare seeking behavior Practices

Newborn with complications did not seek care Newborn with complications sought care from non-MTP 100 Newborn with complications in 1 month of birth Newborn with complications sought care from MTP 90 100% 2.8 6.7 10.0 14.1 14.7 80 90% 23.3 24.8 70 80% 33.6 60 70% 46.7 33.6 45.4 60% 32.6 50 45.8 42.8 42.9 40.7 50% 40 32.6 33.2 40% 30 72.3 30% 56.4 20 46.7 51.7 20% 44.2 40.5 10 10% 0 0% Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Project area Comparison area Project area Comparison area 38 Neonatal Healthcare Mothers’/Caretaker’s knowledge on newborn danger signs Practices

Know 3+ Difficult/fast Poor Convulsion/ Feel Areas Districts Pneumonia Lethargy danger breathing sucking shivering fever/cool signs

Patuakhali 28.4 69.4 5.0 12.7 43.0 2.2 14.3

Rangamati 19.5 38.8 15.1 3.1 27.6 1.5 14.7

Project area Maulvibazar 16.3 48.6 6.8 2.8 55.9 0.7 7.2

Jamalpur 24.1 75.0 11.6 28.4 46.7 1.6 23.8

Sirajganj 24.4 70.0 5.3 10.7 49.1 3.5 16.3

Comparison area 33.3 65.3 12.7 15.9 36.7 2.8 22.5 39

Infant and Young Child Feeding (IYCF) Practices 40 IYCF practice & Newborn, young child nutrition care practice through breastfeeding child care

Exclusively breastfed children (0-5 months) Innitiated complementary food to children (6-8 months) Continued breastfeeding to children (20-23 months) 100.0 89.3 88.8 90.0 86.7 86.0 84.7 86.7 87.3 80.9 81.8 76.9 80.0 72.9 69.6 68.3 70.0 64.5 59.4 60.0 60.0 54.5 56.7 55.3 50.0 38.4 40.0 35.5 30.0 20.0 10.0 0.0 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj BDHS2014 Project area Comparison area National 41

Child Health, Morbidity and Mortality 42

Fertility, Child Health, Community level suspected pneumonia among children 0-59 months Morbidity and Mortality

100.0 90.0 80.0 70.0 Children with suspected pneumonia 60.0 50.0 40.0 30.0 20.0 10.0 5.4 2.7 1.9 3.4 3.7 3.2 2.2 0.0 Paruakhali Rangamati Maulvibazar Jamalpur Sirajganj BDHS2014 Project area Comparison area National 43

Fertility, Child Health, Community level management of children 0-59 months with suspected pneumonia Morbidity and Mortality

100.0 100.0 100.0 93.8 91.8 89.4 90.0

80.0 71.9 70.0 60.0

50.0 42.0 35.4 40.0 31.6 34.7 34.2 30.0 20.0 15.6 15.6 11.1 8.6 6.1 6.3 10.0 2.9 2.0 0.0 Maulvibazar Jamalpur Sirajganj BDHS2014 Comparison area National

Received treatment from any provider Received treatment from MTP Consumed antibiotics from MTP Consumed full course of antbiotics 44 Child Health, Morbidity and Neonatal and childhood mortality rates Mortality

Neonatal, post-neonatal, infant, child, and under-five mortality rates for five-year periods preceding the survey (Sample sizes: 9083 and 7353 ever married women age 15-49 in Project and Comparison areas respectively) Project area Comparison area Years Post- Post- preceding Neonatal Infant Child Under-5 Neonatal Infant Child Under-5 neonatal neonatal the survey mortality mortality mortality mortality mortality mortality mortality mortality mortality mortality

0-4 28 10 38 7 45 25 8 33 10 42

5-9 40 10 50 6 56 32 15 47 13 59

10-14 39 11 50 12 62 30 21 51 14 64

Nationally (death per 1000 live birth in last 5 years)(BDHS 2014 and BDHS 2017-2018 respectively): neonatal mortality rates- 28 and 30, infant mortality rates- 38 both, and under-5 mortality rates- 46 and 45 45

Adolescent Sexual and Reproductive Health and Rights (ASRHR) related advice or services to adolescents 46 ASRHR related advice/services: adolescents’ knowledge on place and receiving service from that place with ease

100.0 Adolescents know any place where from can receive ASRHR services 90.0 Adolescents feel easy to receive ASRHR service from the place 80.0 Adolescents ever received ASRHR services from the place 70.0 60.0 50.0

40.0 35.9

27.2 26.9

30.0 25.8

23.3

20.1

19.7

19.3

17.9

17.7

16.8

15.8 15.7

20.0 14.2

13.6

13.0

12.9

12.7

12.6

10.7

10.6

10.4

9.9

9.7

8.7

8.5

8.3

7.8

6.6

6.1 6.1

5.6

5.4 5.4

5.1 4.7

10.0 4.2

3.8

3.7

3.5

3.4

3.3

3.0

2.6 2.6

2.4

2.0

1.9

1.8

1.4

1.2 1.2

0.9 0.6 0.0 Boy Girl Both Boy Girl Both Boy Girl Both Boy Girl Both Boy Girl Both Boy Girl Both Patuakhali Rangamati Moulvibazar Jamalpur Sirajganj Project area Comparison area 47

Maternal-Newborn-Healthcare Services in Health Facilities 48 Sample coverage of health facilities Health Facility Survey

Project area Comparison area

Type of facility Number of Number of Number of Number of available facilities surveyed facilities available facilities surveyed facilities

District and upazila public facilities MCH 0 0 1 1 DH 5 5 4 4 MCWC 5 5 4 4 UHC 35 35 26 26 Other government facilities 2 2 1 1 Union level public facilities UHFWC/FWC/USC/RD 352 69 233 46 Community Clinic 931 218 544 138 Private facilities Private clinic/hospital 202 103 73 54 Total 1534 437 886 274 49 Average Number of Sanctioned, Employed and Vacant Posts for Doctors Health Facility Survey

40 Average No. of sanctioned posts for doctors Average No. of employed posts for doctors 35 Average No. of vacant posts for doctors 31 30 30 28

22 22 21 20 19 19

Average number Average 16 15 13 11 11 10 10 9 10 8 8 8 8 6 7 7 7 7 5 5 3 3 3 2 1 1 1 1 1 1 1 1 1 0 0 0 0 0 DH MCWC UHC DH MCWC UHC DH MCWC UHC DH MCWC UHC DH MCWC UHC Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj

Number of UHCs in Patuakhali- 6, Rangamati-9, Maulvibazar-6, Jamalpur-6 and Sirajganj-8 50

Doctors not available at facility on survey date (among employed posts) Health Facility Survey

30 Average No. of employed posts for doctors Average No. of doctor present on survey day Average No. of doctor not available at facility on survey day 22 22 21 21 20 20

16 15 13

10 8 8 8

Average numberof doctor Average 7 7 7 6 6 6 5 5 4 3 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 DH MCWC UHC DH MCWC UHC DH MCWC UHC DH MCWC UHC DH MCWC UHC Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj

Number of UHCs in Patuakhali- 6, Rangamati-9, Maulvibazar-6, Jamalpur-6 and Sirajganj-8 Main reasons for doctors’ unavailability reported: remain on leave, in training, busy with official work 51 Blood Transfusion (screening, collection and transfusion) and CEmOC Services Health Facility Survey

100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

90 83.3 83.3 80

70

60 50.0

50 Percent 40

30

20 16.7

10 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0 DH MCWC UHC DH MCWC UHC DH MCWC UHC DH MCWC UHC DH MCWC UHC Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj

Blood transfusion services available Blood transfusion with CEmOC services available 52 No stock out record of essential medicines in any time in last 3 months Health Facility Survey

prior to survey

100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

90 87.5 77.8

80 77.8

75.0 75.0

66.7 66.7 66.7 70 66.7

60

50 Percent

40 37.5

33.3 33.3 33.3 33.3 33.3

30 16.7

20 16.7 11.1

10

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0 0.0 DH UHC DH UHC DH UHC DH UHC DH UHC Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj

Antibiotic ORS Zinc Oxytocine Mag. Sulphet 53 Functioning communication systems for service recipients (land phone, Health Facility Survey

mobile phone, computer, internet access)

100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

90 83.3 80

70 66.7

60

50.0 50.0

50 50.0

44.4

44.1 Percent

40 33.3

30 25.0

20 16.7 12.5

10

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0 0.0 DH MCWC UHC DH MCWC UHC DH MCWC UHC DH MCWC UHC DH MCWC UHC Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj Landline telephone Mobile phone Computer Internet 54

Power supply systems (electricity, generator, solar system) Health Facility Survey

100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

100 100 100 100 100 100 100

90

80

66.7 66.7 70 66.7

60 50.0

50 50.0

44.4 44.4 Percent

40 33.3 30

20 16.7 12.5

10

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0 0.0 DH MCWC UHC DH MCWC UHC DH MCWC UHC DH MCWC UHC DH MCWC UHC Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj

Access to electricity Functioning Generator Functioning Solar 55

Facilities with Normal Delivery Services Health Facility Survey

100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

100.0 97.6 91.7

90.0 88.9 80.8 80.0

70.0

61.5 61.1 60.0 58.3

Percent 50.0

40.0 40.0 30.0

20.0 19.4 13.6

10.0

2.8

0.0 0.0

0.0 0.0

DH CC DH CC DH CC DH CC DH CC

UHC UHC UHC UHC UHC

FWC FWC FWC FWC FWC

NGO NGO NGO NGO

MCWC MCWC MCWC MCWC MCWC

Private Private Private Private Private Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj 56

Facilities with C-Section and CEmOC Services Health Facility Survey

100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 97.6

90 82.9 80

70

60 57

50.0 50.0

50 46.2 Percent

40 33.3 30

20

10

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0

0 0

DH DH DH DH DH

UHC UHC UHC UHC UHC

NGO NGO NGO NGO

MCWC MCWC MCWC MCWC MCWC

Private Private Private Private Private Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj

Delivery by C-Section Delivery by C-Section with CEmOC services 57

Facility with Midwifery Services Health Facility Survey

100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

100.0 100.0 88.9

90.0 88.9

83.3 83.3

80.0 66.7 70.0 66.7

60.0 50.0

50.0 46.2

38.5

37.5 37.5

40.0 37.5

33.3 33.3

30.0

16.7 16.7 16.7

20.0 16.7

15.4

11.1

8.3 8.3 8.3

10.0 8.3

5.6 5.6

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 DH MCWC UHC FWC DH MCWC UHC FWC DH MCWC UHC FWC DH MCWC UHC FWC DH MCWC UHC FWC Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj

Midwife available Midwife for sexual and reproductive health services Provide service during delivery Conduct MR 58

UHCs with 9 Signal Functions Health Facility Survey

100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

100.0 100.0

88.9

83.3 83.3 83.3 83.3 83.3 83.3 83.3 90.0 83.3

80.0 77.8 66.7 70.0 66.7

60.0 55.6

50.0 50.0

50.0 44.4 37.5

40.0 33.3 33.3

30.0 25.0

22.2 16.7 Percent 20.0

10.0

0.0 0.0 0.0 0.0 0.0 0.0 0.0

0.0 0.0

Conduct C-Section Conduct C-Section Conduct C-Section Conduct C-Section Conduct C-Section Conduct

Administer oxytocin Administer oxytocin Administer oxytocin Administer oxytocin Administer oxytocin Administer

Removal of placenta of Removal placenta of Removal placenta of Removal placenta of Removal placenta of Removal

Administer antibiotics Administer antibiotics Administer antibiotics Administer antibiotics Administer antibiotics Administer

Assisted vaginal delivery vaginalAssisted delivery vaginalAssisted delivery vaginalAssisted delivery vaginalAssisted delivery vaginalAssisted

Administer mag. sulphate mag. Administer sulphate mag. Administer sulphate mag. Administer sulphate mag. Administer sulphate mag. Administer

Blood transfusion service transfusion Blood service transfusion Blood service transfusion Blood service transfusion Blood service transfusion Blood

Resuscitation with bag and mask and bag with Resuscitation mask and bag with Resuscitation mask and bag with Resuscitation mask and bag with Resuscitation mask and bag with Resuscitation

Vaccuum aspiration, antibiotics etc. aspiration, Vaccuum antibiotics etc. aspiration, Vaccuum antibiotics etc. aspiration, Vaccuum antibiotics etc. aspiration, Vaccuum antibiotics etc. aspiration, Vaccuum Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj 59 UHCs with 4+ Signal Functions Health Facility Survey

100.0 100.0 100.0 100.0 100.0 100.0 100.0

90.0 83.3 80.0 75.0 70.0 60.0

50.0 44.4

40.0 33.3 30.0 20.0 10.0 0.0 4+ signal 5+ signal 4+ signal 5+ signal 4+ signal 5+ signal 4+ signal 5+ signal 4+ signal 5+ signal functions out functions out functions out functions out functions out functions out functions out functions out functions out functions out of 7 of 9 of 7 of 9 of 7 of 9 of 7 of 9 of 7 of 9 Patuakhali Rangamati Maulvibazar Jamalpur Sirajganj 60 Health Facilities with SCANU and NSU Health Facility Survey Type of No. of District SCANU NSU Facilities Facilities DH 100.0 0.0 1 Patuakhali UHC 0.0 0.0 6 DH 0.0 0.0 1 Rangamati UHC 0.0 0.0 9 DH 100.0 0.0 1 Maulvibazar UHC 0.0 0.0 6 DH 100.0 100.0 1 Jamalpur UHC 0.0 0.0 6 DH 100.0 0.0 1 Sirajganj UHC 0.0 0.0 8 61 Number of newborns treated at SCANU in last 6 months Health Facility Survey

Districts Number of newborns

Patuakhali 1800

Maulvibazar 1189

Jamalpur 830

Sirajganj 701 62 Quality of MNH services of UHCs based on average scores on 10 EMEN standards

Mean % of scores out of total scores EMEN (Every Mother Every Newborn) Standards for each standard secured by UHCs Project area Comparison area Standard 1 Providing evidence based safe ANC services 54.5 52.4 Standard 2 Evidence-based safe care is provided during labour and child birth (maternal and neonatal) 65.9 66.5

Standard 3 Providing evidence based safe PNC during labour and child birth 68.3 66.8 Providing maternal-&-newborn healthcare to recipients by maintaining fundamental human rights and with Standard 4 75.5 79.7 full dignity and respect to them Availability of governance system (Administrative System) to support the provision of quality maternal and Standard 5 68.8 61.3 newborn care Standard 6 Safe and congenial physical environment of the health facility for providing maternal and newborn care 63.3 61.3 Availability of adequate number of qualified and competent staff to provide safe and quality mother and Standard 7 80.0 72.0 newborn care Consistent availability of essential drugs, supplies, functional equipment, and diagnostic services to provide Standard 8 72.6 64.6 mother-&-newborn care Availability of health information system in the health facility to manage patients’ clinical records and service Standard 9 71.7 75.8 data Standard 10 Availability of services in the health facility to ensure continuity of maternal and newborn care 57.9 61.5 Overall % 66.3 65.3

Note: Each standard has several questions. Each of them had scoring values of 0-2 or 0-1-2 indicating a specific indicator being fully, partially or not-at-all implemented at the surveyed UHCs. 63 Conclusion

• Maternal-newborn-child-healthcare at community level is not promising in both areas; ample scope of improvement • Major sources of healthcare: Public facilities with good share of private facilities in both areas • Low coverage of MNH services and facility delivery

Main reasons: ➢ Lack of easy accessibility to adequate and appropriate health facilities and services with skilled and adequate number of service providers ➢ Lack of awareness of people 64 Conclusion (continued)

Comparative findings show better status in Comparison area in some respects.

Propensity Score Matching (PSM) analysis is planned to make the Project and Comparison areas similar by using Logit or Probit analysis to support impact evaluation of the intervention (estimate of changes due to intervention) at endline controlling background variables included in the survey 65 Acknowledgement UNICEF Bangladesh

❑ Health Section

• Ms. Maya Vandenent, Chief • Dr. Md Ziaul Matin, Health Manager • Dr. Shamina Sharmin, Health Specialist • Dr. Minjoon Kim, Health Specialist ❑ SPEAR Section • Mr. Carlos Acosta, Chief • Ms. Juanita Vasquez Escallon, Research and Evaluation Specialist

Thanks owe to the technical review committee on MNH baseline survey, Civil Surgeons, Deputy Directors Family Planning, Upazila Health & Family Planning Officers, Upazila Family Planning Officers, Residential Medical Officers, Sub-Assistant Community Medical Officers, Family Welfare Visitors, Community Healthcare Promoters of government health facilities and directors/managers/key personnel of NGO and private health facilities. Thanks owe to all participants in the survey and field investigators, without their cooperation this study would not have been possible to implement successfully. 66 Study team SURCH and Institute of Health Economics, University of

Professor Muhammad Shuaib Professor Dr. Sushil Ranjan Hawladar Dr. Nasrin Sultana Dr. Rafia Rahman Dr. Sheikh Tawhidul Islam Dr. Sharmin Afroze MAFM Ahnaf Md. Mokhlesur Rahman Md. Ziaul Hasan Sikder Mohammad Shakwat Hossain Khan Muhammad Rashed Muhammad Sadeq Nailla Ferdousi Haq Laila Begum 67

Thank You