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 Maintaining Momentum Towards the MDGs: An Impact Evaluation of Interventions to Improve Maternal and Child Health and Nutrition Outcomes in Bangladesh
Improving maternal and child health and nutrition is central to development goals.
The importance of these objectives is reflected by their inclusion in poverty-reduction
targets, such as the Millennium Development Goals (MDGs) and Bangladesh’s Interim
Poverty Reduction Strategy Paper, supported by major development partners including the
World Bank and DFID. This report addresses the issue of what publicly-supported programs
and external assistance from the Bank and other agencies can do to accelerate attainment of
targets such as reducing infant mortality by two-thirds. The evidence presented here relates to
Bangladesh, a country which has made spectacular progress but needs to maintain
momentum in order to achieve its own poverty reduction goals.
The report addresses the following issues: (1) What has happened to child health and
nutrition outcomes and fertility in Bangladesh since 1990? Are the poor sharing in the
progress which is being made? (2) What have been the main determinants of MCH outcomes
in Bangladesh over this period? (3) Given these determinants, what can be said about the
impact of publicly and externally-supported programs – notably those of the World Bank and
DFID - to improve health and nutrition? (4) To the extent that interventions have brought
about positive impacts, have they done so in a cost effective manner?
Trends in Under-Five Mortality, Fertility and Nutrition
Despite an inauspicious start coming out of war and famine, Bangladesh has achieved spectacular rates of progress in the last two decades, most notably with respect to fertility decline. Contrary to common perceptions, fertility continued to decline during the 1990s. Under-five mortality has also been reduced at a substantial rate, Bangladesh being one of the few countries to achieve a sufficient rate of reduction to achieve the MDG of a two-thirds decline by 2015. The exception to these successes has been nutrition. Physical measures of nutritional status only began to show some improvement in the 1990s, and malnutrition remains at high levels.
Improvements in these outcomes have been spread across all Bangladeshis. Although children of the poor are more likely to suffer premature death, this gap is narrowing, with
mortality rates falling faster among the poor than the non-poor. Contraceptive use and low
fertility are also common among the poor.
Sources of Under-five Mortality Decline
Analysis of the determinants of mortality using both cross-country and Demographic
and Health Survey (DHS) data shows that a variety of factors have been behind the falling
number of deaths. Improved economic well-being is the most important reason for lower
child mortality, but plays less of a role for infants. Social sector interventions – both health
and education – are also found to matter, with expanded immunization coverage and greater
female enrolment in primary and secondary education both playing a substantial part in
mortality reduction. The results also show a pronounced sex bias in mortality against girls,
especially in the Sylhet and Chittagong divisions.
Analysis of selected interventions reveals
the following:
 Immunization coverage was at less than 2 percent in the early 1980s, but grew in the
latter part of the decade (largely with the support of UNICEF, but later also other
donors including the World Bank) so that by 1990 close to half of all children were
fully vaccinated in their first 12 months. Immunization has averted over 2 million child
deaths in the last two decades, at a cost of between $100 and $300 per life saved.
The World Bank financed the training of approximately 14,000 traditional birth
attendants (TBAs) until the late nineties, at which point training TBAs was abandoned
following a shift in international opinion toward a policy of all births being attended by
Skilled Birth Attendants. However, the evidence presented in this report shows that
training TBAs saved infant lives, at a cost of $220-800 per death averted.
Female secondary schooling expanded rapidly in the 1990s, especially in rural areas
partly as a result of the stipend paid to all female students in grades 6-10 in rural areas
supported by Norwegian aid, the Asian Development Bank, the World Bank and
government. Amongst the benefits of the increase in female secondary schooling are
lower mortality, at a cost of $1,080-US$5,400 per death averted.
Rural electrification, supported through three World Bank programs in the 1980s and 1990s, reduces mortality through income effects, improving health services, making
water sterilization easier and improving access to health information, especially from
TV. Taking these various channels into account means that children in households
receiving electrification have an under-five mortality rate 25 per 1,000 lower than that
of children in non-electrified households. Based on historic costs, this amounts to
$20,000 per life saved, and $40,000 based on current connection costs.
Nutrition
In order to address the poor state of nutrition, the government implemented, with
World Bank assistance, the pilot Bangladesh Integrated Nutrition Project (BINP). The core of
BINP is the Community-Based Nutrition Component (CNBC), which promotes nutritional
counseling to bring about behavior change, complemented by supplementary feeding for
pregnant women and young children.
Analysis of the causal chain from BINP inputs to child anthropometric outcomes
shows the following: (1) there is a weak link in the chain as behavioral change
communication has been excessively focused on mothers, who are often not the main
decision maker for all nutrition-related practices; (2) program coverage is generally high in
project areas, but notably lower in more conservative thanas (sub-districts), especially among
women who live with their mothers-in-law; (3) there are some deficiencies in targeting: (a)
too strict a criterion was applied in admitting malnourished children to supplementary
feeding, while admitting children who were growth faltering but probably well-nourished, (b)
feeding of pregnant women excluded many who were eligible while including a proportion
who were not; (4) a large proportion of mothers of children receiving supplementary feeding
claimed to have not received nutritional counseling; (5) there is a substantial knowledgepractice
gap, whereby women do not turn the advice they receive into practice: economic
resource and time constraints are a major reason for this; and (6) the impact on pregnancy
weight gain is too small to have a substantial impact on birth weight, which is a common
result from similar programs in other countries; mother’s pre-pregnancy nutritional status is a
more important factor in low birth weight than pregnancy weight gain and might therefore
have been a better focus for the project.
The list in the previous paragraph may be read as a list of problems to be fixed in the
project, as to some extent they have been under the expanded National Nutrition Project – the targeting criteria for children’s supplementary feeding have been revised and another attempt
made to reach men with nutritional counseling. But the program has not been a very cost effective means of improving nutritional status – which has improved generally with the acceleration in food availability associated with the yield-driven increase in rice production since the late nineties, and consequent reduction in the real price of rice. Simulations show
that simply giving food to families with children would have had a larger nutritional impact.
The cost per life saved from the hypothetical rice ration is just over $2,000, half the cost of
lives saved by BINP.
Fertility Reduction
The rate of fertility reduction in Bangladesh is shown to exceed that which may be
expected from other socio-economic developments, such as income growth and expanding
female education. While socio-economic developments, including the demographic
transition, explain a part of Bangladesh’s rapid fall in fertility, a large part is attributable to
the country’s family planning service, built up with substantial external support in the years
following liberation in 1971. The continued decline of fertility in the 1990s, driven by rising
contraceptive prevalence, demonstrates the continued effectiveness of this program.
The government’s HNP Strategic Investment Plan highlights the role of increasing
the age at marriage as a means of reducing fertility, and several programs, including the
counseling provided under BINP, promote getting married later. It is a condition of the
female secondary school stipend program, supported by the Bank amongst others, that
recipients remain unmarried. It is true that the age at marriage in Bangladesh is low, with half
of all women marrying by age 14. It is also true that there is a well-established international
pattern whereby increasing the age at marriage drives down fertility. But this pattern should
not be expected to be observed in Bangladesh for two reasons: (1) raising the age at marriage
of girls aged 13 or less has no effect on the age at which they have their first child (so as the
age at marriage has risen the gap from marriage to first birth has fallen), and (2) if a woman
plans to have only 3-4 children, as the majority of Bangladeshi women do, then this can be
accomplished whether child bearing begins at 15 or 20. The direct effect of expanding
secondary education will be muted, as Bangladesh has already attained fertility levels
comparable to those in countries with higher education levels. Hence raising the age at
marriage, while desirable for both maternal and child health (children born to young mothers
have a greater chance of premature death), will have little impact on the number of children
borne by each women during her reproductive years - though there would be a temporary
tempo effect on the total fertility rate, and there will be a second-order effect as the mortality
reducing effect of later births will reduce the desired number of births. Instead high fertility
households should be targeted, partly by an attempt to restore the use of permanent
contraceptive measures to their previous levels. Efforts should also be made to tackle son
preference which creates a barrier to fertility decline. And continued success in reducing
mortality will also help reduce fertility.
Lessons Learned
The following general lessons follow from the analysis in this report:
Externally supported interventions have had a notable impact on MCH-related outcomes
in Bangladesh. Immunization has proved particularly cost effective, and has saved the
lives of up to two million children under the age of five.
World Bank support to sectors outside of health has contributed to better child health outcomes.
Small amounts of money save lives…though the amount varies significantly by
intervention.
Although interventions from many sectors affect maternal and child health outcomes, this fact need not imply that multi-sectoral interventions are always needed.
World Bank support for training traditional birth attendants has reduced neonatal mortality…but this program has now been abandoned following the international trend
toward support for skilled birth attendants.
Programs should be based on local evidence, rather than general conventional wisdom.
Gender issues are central to health strategies in Bangladesh. More attention is needed to redressing gender biases to maintain momentum in mortality decline and fertility
reduction. But traditional attitudes are not the absolute constraint on service provision
which is sometimes suggested.
The Bank’s BINP has improved nutritional status, but not by much less than planned. Serious attention needs to be given to ways of improving both the efficacy and efficiency
of the program - or if not possible then to consider alternatives to scaling up.
Rigorous impact evaluation can show which government programs and external support
are contributing most to meeting poverty reduction goals.
National surveys can be used for evaluation purposes, but some adaptations would make them more powerful, notably a more detailed community questionnaire.
About IEG
The Independent Evaluation Group (IEG) is an independent unit within the World Bank; it reports directly to the Bank's Board of Executive Directors. IEG assesses what works, and what does not; how a borrower plans to run and maintain a project; and the lasting contribution of the Bank to a country's overall development. The goals of evaluation are to learn from experience, to provide an objective basis for assessing the results of the Bank's work, and to provide accountability in the achievement of its objectives. It also improves Bank work by identifying and disseminating the lessons learned from experience and by framing recommendations drawn from evaluation findings. |
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