instance, under-5 mortality was 55 (out of 1,000 live births) among the lowest quintile compared to 36 among the highest, and perinatal mortality was 52 and 39 respectively <mark>in 2017.</mark> Women in urban areas were more likely to receive quality ANC services than those in rural areas (27% versus 14%) in 2017, and more women with a secondary-level education or higher (33%) reported receiving quality ANC services compared to less-educated women (6%). Only 7% of women from the lowest wealth quintile received quality ANC, compared to 37% from the highest wealth quintile. Similarly, only 21.4% of rural women received quality ANC compared to urban counterparts (34.6%). The status of key RMNCH-N indicators are summarized in Table 1.

**Table 1: Key reproductive, maternal, child and nutrition indicators**

|**Indicators**|**Value**|
|---|---|
|Maternal mortality ratio per 100,000 live births (2017)|173|
|Neonatal Mortality Rate per 1,000 live births (2019)|15|
|Infant Mortality Rate per 1,000 live births (2019)|34|
|Under-five Mortality Rate per 1,000 live births (2019)|40|
|Under-five stunting prevalence moderate & severe (2019)|31|
|Under-five underweight prevalence moderate & severe (2019)|22.6|
|Under-five wasting prevalence moderate & severe (2019)|9.8|
|Under-five overweight prevalence moderate & severe (2019)|2.4|
|Early initiation of breastfeeding (2019)|46.6%|
|Exclusive breastfeeding up to six months (2019)|62.6%|
|Children weighed at birth (2019)|51.9%|
|Delayed bathing (>24 hours after birth) (2019)|80%|
|Under-five received all vaccination (2017)|86%|
|Care-seeking for fever (2019)|55.6%|
|Contraceptive prevalence rate (2019)|70.3%|
|4+antenatal care visits by any provider (2019)|36.9%|
|Institutional deliveries (2019)|53%|
|Skilled birth attendance (2019)|59%|
|Postnatal health check for the mother at least one (2019)|65%|
|Contraceptive prevalence rate among 15-49 age women|62%|

**Sources:** DHS2017<sup>12</sup> ; MICS 2019<sup>9</sup> ; The World Bank 2017<sup>13</sup>

# **1.3 Context for the study**

With considerable investments and noticeable improvements, Bangladesh currently stands at a crucial phase in its RMNCH-N landscape. In order to accelerate achievement of improved RMNCH-N outcomes, global evidence suggests the need for smart and strategic health sector investments and interventions.<sup>1</sup> Further, global evidence also shows that the path to achieving the top RMNCH-N milestones (e.g. SDGs) is more complex and difficult for countries, compared to the earlier milestones (e.g. millennium development goals).<sup>1</sup> Consequently, for Bangladesh, strategic decision-making and investments are necessary.<sup>14</sup> It is already known that investments targeting appropriate RMNCH-N utilization would lead to improved RMNCH-N outcomes.<sup>15,16</sup> However, the success of such investments largely depends on how efficiently and timely (i.e. immediate to short-term) the service utilization determinants are addressed.<sup>14</sup> While there could be several determinants of RMNCH-N utilization, for example, addressing the key ones could be one of the most strategic approaches to ensuring timely progress in the short-term. For instance, while it is known that the quality of maternal, neonatal and child health is low in many countries, it is also known that improving the quality of care would reduce maternal and neonatal deaths. Current global evidence, however, does not establish that improving the quality of care alone would necessarily motivate women to 2