# **1. Introduction**

## **1.1    Why is investing in priority determinants important for RMNCH-N utilization and outcomes in low- and middle-income countries?**

Globally, the performance trajectory of countries in improving reproductive, maternal, neonatal, child health, and nutrition (RMNCH-N) outcomes over the last few decades highlights a number of exemplary pathways.<sup>1–5</sup> First, global evidence shows that timely and appropriate RMNCH-N service utilization is the foremost key to improving the RMNCH-N outcomes.<sup>5</sup> Specifically, countries that invested in enhancing utilization have achieved further improvements in RMNCH-N outcomes. A second pivotal step in improving RMNCH-N service utilization is by addressing its determinants. Third, both the demand- and supply-side determinants are equally relevant in boosting RMNCH-N service utilization in a timely manner. The relative importance of the various determinants, however, changes at different phases of the progress trajectory. Fourth, the determinants of RMNCH-N service utilization and outcomes are context-specific (i.e., country or region-specific) and time-specific.<sup>1</sup> For instance, certain demand-side determinants (e.g., cultural factors) are more dominant in the early stages of progress and sometimes, new determinants may arise (e.g., mass media influence). However, it is difficult to predict the role and magnitude of such determinants unless they are regularly assessed. Fifth, global evidence shows that countries can make more rapid progress when they make specific investments in priority determinants of RMNCH-N service utilization, rather than relying on generic strategies and interventions. For example, a recent global assessment has shown that interventions specifically addressing the priority (i.e., context and time-specific) RMNCH-N service determinants could reduce the fertility rate to 2.5 in certain Asian settings compared to generic interventions.<sup>1</sup> Another <mark>study of diarrhea and pneumonia interventions observed that 15 highly costeffective interventions addressing the top RMNCH-N service utilization determinants – if implemented at scale – would prevent 95 percent of deaths from diarrhea and 67 percent of deaths from pneumonia in under-5 children by 2025.</mark><sup>6</sup> <mark>S</mark> uch specific interventions addressing priority utilization determinants are also proven to be cost effective in improving the RMNCH-N outcomes in a short timeframe. In summary, the existing evidence shows that regular tracking, coupled with prioritized investments in context-specific utilization determinants, can improve RMNCH-N service utilization.

## **1.2 Reproductive, maternal, child health, and nutrition landscape in Bangladesh**

Bangladesh has witnessed significant improvements across key maternal, child health and nutrition indicators over the last few years, with multi-faceted and sector-wide approaches to improving the health of pregnant women and under-five children.<sup>7</sup> Changing fertility behavior, and increased access to and utilization of health services, for example, have been major contributors to the consistent decline in underfive and maternal mortalities.<sup>8</sup> Notwithstanding progress, however, Bangladesh is still far away from reaching a key Sustainable Development Goal (SDG) – “maternal mortality ratio target is 70 deaths per 100,000 live births” (currently at 165).<sup>8</sup> The uptake of certain key maternal and child health (MCH) services has been consistently sub-optimal. For instance, institutional deliveries are only 50% and skilled birth attendance is at 53%.<sup>9</sup> <mark>As per verbal autopsies and household surveys, two-thirds of total maternal deaths occur during the postpartum period, but postnatal care visits are still low at 65%.</mark><sup>10</sup> <mark>There are also</mark> persistent inequities in service utilization and health status among different socio-economic groups. Health indicators and service utilization, for example, are relatively better among the rich, urban and educated groups compared to their counterparts.<sup>11</sup> For 1