Category: Antenatal care

Bangladesh’s private-sector puzzle: What it will take to introduce a maternal vaccine

Bangladesh often gets held up as one of the great immunisation success stories of the last half-century.

Its Expanded Programme on Immunisation (EPI), launched in 1979, took childhood coverage from around 2 percent at the outset to more than 80 percent today, was certified polio-free in 2014, and has eliminated maternal and neonatal tetanus.

Yet according to Aniqa Tasnim Hossain, an Associate Scientist at the International Centre for Diarrhoeal Disease Research (ICDDR ,B) who has been working on the MIRNA Consortium’s situational analysis for Bangladesh, that record of success masks a structural problem that will shape how, and whether, any new maternal vaccine reaches the women who need it.

“We in Bangladesh, two-thirds of the women actually go to take Antenatal Care (ANC care) from private facilities and they do not go to public facilities,” she explains.

Bangladesh’s Expanded Programme on Immunisation (EPI) system, however extensive its outreach network of more than 130,000 centres, was built around the public sector. If most antenatal care happens somewhere else entirely, a maternal vaccine strategy that ignores private providers is, in effect, designing for a minority of pregnant women.

–Aniqa Tasnim Hossain, an Associate Scientist at the International Centre for Diarrhoeal Disease Research (ICDDR ,B) (Photo: Timon Abuna, WHM)

“At the private facilities there are gaps, and there are a lot of private facilities that are in place,” Hossain says. A 300-facility assessment carried out by the Bangladesh team found shortfalls in both public and private settings, particularly around the accurate recording of gestational age, a detail that matters far beyond bookkeeping, since it determines whether a vaccine like one for respiratory syncytial virus (RSV) is given within its narrow window of effectiveness.

Multiply that gap across thousands of scattered private clinics, and the logistical challenge becomes clear. “So when introducing a vaccine, a maternal vaccine, we have to consider these private facilities,” Hossain notes, “but this is going to be very challenging because providing vaccines to so many ANC clinics would be very difficult.”

This is not a uniquely Bangladeshi dilemma. A recent WHO-supported scoping review of maternal and child health delivery in low- and middle-income countries found that the private-for-profit and NGO sectors are already contributing meaningfully to immunisation delivery, and that in many settings the for-profit sector is often the first to adopt new vaccines and technologies. The same review notes that public health efforts have historically concentrated on the public sector almost by default, even where private provision dominates, precisely the mismatch Hossain describes for Bangladesh. Strengthening both sectors together, rather than treating the private sector as an afterthought, is increasingly recognised as necessary for anything approaching universal coverage.

“Another thing is that more frequently the EPI and ANC are not well integrated or well connected,” Hossain says. “So, they are working in silos. So they need to be sort of linked up.”

This is, in fact, the same structural gap identified by MIRNA’s Pakistan team, where vertically funded, donor-specific programmes have made horizontal integration difficult once systems are already built around separate silos. WHO’s own Maternal Immunisation and Antenatal Care Situational Analysis (MIACSA) project, run with support from the Bill and Melinda Gates Foundation, reached a similar conclusion. This was after mapping tetanus vaccination programmes across multiple LMICs, integration is generally strongest at the point of care, where the same health workers often deliver both antenatal and immunisation services, but weakest at the national and policy level, where separate funding streams and separate lines of accountability pull the two apart. Concerted coordination at the national level, the project concluded, is critical if new maternal vaccines are to be added successfully to existing platforms.

Modelling work following on from that agenda has reinforced the case for closing the gap rather than living with it. Recent analysis of ANC-mediated benefits of maternal immunisation across five LMICs found that integrating vaccination into the antenatal platform produces positive knock-on effects for maternal and child health more broadly and that countries starting from lower baseline coverage, of the kind Bangladesh records for its TT/TD proxy vaccine (currently 58 percent, against roughly 93 percent for at least one ANC visit), stand to gain the most from closing that structural gap.

Yet for all these system-level barriers, Hossain returns repeatedly to a more human factor trust. “Generally, pregnant mothers would accept a vaccine if it is being told by a healthcare provider who they trust,” she says. “So trust is a very big factor here.”

Her team’s work identified distinct dimensions to that trust confidence in the health system as a whole, trust in government, and, crucially, familiarity built through years of contact with the same local vaccinators.

“They trust the system, they have trust in the government, and they also know the provider for a long time,” Hossain says. “So maybe that’s why they trust a lot, so that trust actually supports them to accept the vaccines.”

This chimes closely with WHO’s own Behavioural and Social Drivers of Vaccination (BeSD) framework, developed with SAGE, its Strategic Advisory Group of Experts on Immunisation. The framework identifies “thinking and feeling” including confidence in vaccine safety and in the health system delivering it as one of four core domains shaping uptake, alongside social processes, motivation and practical access.

Reviews applying the BeSD framework across multiple settings have consistently found that health workers are among the most trusted sources of information on immunisation, and that a recommendation from a familiar provider can be decisive in a caregiver’s decision, while poor communication or a rushed encounter can erode confidence quickly, even where baseline trust is high.

For Bangladesh, Hossain’s conclusion draws these threads together into a single, practical instruction for the introduction of any new maternal vaccine. “I think when we’re developing a vaccine demand strategy, we really have to think about that trust and how we build on the introduction of the vaccines using that trust.”

October 23, 2026
Why involving communities in research matters in boosting mother-child health outcomes in Uganda

By morning, Professor Annettee Nakimuli may be teaching the next generation of doctors. By afternoon, she is on a labour ward in Kampala, managing some of the highest-risk pregnancies in East Africa. By night, her mind is often on a genome. Few people move between the delivery room and the genetics laboratory as comfortably as she does, and fewer still have changed what the world knows about a disease because of it.

She is Dean of Makerere University’s School of Medicine, the oldest medical school in East Africa, and President of the East, Central and Southern Africa College of Obstetrics and Gynaecology. Titles like these usually take a clinician away from the bedside. Hers have not. She still practises high-risk obstetrics at Mulago Specialised Women’s and Neonatal Hospital and Kawempe National Referral Hospital, where birth volumes rank among the highest in sub-Saharan Africa.

Then there is her PhD, mentored by Professor Ashley Moffett at the University of Cambridge, she led the first genetic case-control study of pre-eclampsia among indigenous Africans. The findings upended long-held assumptions about why the condition hits African women so hard. Clinician first, scientist always: that double life shapes everything she says about the disease she has spent her career fighting.

–Professor Annette Nakimuli Dean, Makerere University’s School of Medicine, MIRNA Principal Investigator (Photo: Timon Abuna, WHM)

A killer hiding behind late presentation

“I have for over twenty years research been a clinician scientist and researched some of the common problems that affect pregnant women in Africa, where we have the highest burden of maternal death,” she said. “Over 70 per cent of maternal death globally happen in Africa.”

Within that broader crisis, one condition has held her attention above all others. “One of those I have been of very keen interest to address is pre-eclampsia, which generally is the number two, sometimes number one, killer of women in this setting.”

The tragedy, she explained, is compounded by timing. Women often reach care only once the disease has already progressed. “Part of the problem is that they present late to care. So, the late detection makes them get severe complications and sometimes death.”

Clinicians treating severe pre-eclampsia frequently have no choice but to deliver the baby early, whatever the risks of prematurity, in order to save the woman’s life. “We also end up having a lot of their babies either get stillborn or are born prematurely as we try to reverse the disease in the mother, again creating another burden of newborn death from prematurity complications.” A single disease, in other words, generates two overlapping tragedies.

Sorting risk, tailoring care

Faced with a health system that cannot give every pregnant woman the same intensity of monitoring, Professor Nakimuli has focused much of her research on identifying who needs it most. “Part of the work I’ve done was around trying to risk-profile women who are at risk of getting pre-eclampsia,” she said.

“The aim of that is to find which women would benefit from some of the interventions and others that will be discovered, because we know we can’t give every woman the same level of care due to limited resources. So, we need to know who is most at risk, so that we can start those interventions.”

Risk profiling, in her framing, is not merely an academic exercise. It changes what happens in the antenatal clinic and delivery room. “We also offer tailor-made care so that we are able to follow them up more closely in the antenatal clinic and during the time of childbirth, so that they are able to get better outcomes than they currently do if they are not detected early.”

Rewriting the genetics of an African disease

Where Professor Nakimuli’s work has attracted the most international attention is in genetics, a field long weighted towards populations of European descent. She sees that imbalance as a scientific opportunity as much as an injustice. “It’s worldly known that Africa has the biggest genetic diversity. We are the original gene pool, so there are many genetic variants that are yet to be actually discovered.”

Her own research has already begun filling that gap. “The work I did actually identified some very new, what they call novel, genes that are associated with pre-eclampsia, which have actually made the understanding of the disease better, and probably in future inform better intervention and better care.” For a condition that has, in her words, “for a long time been difficult to exactly know why some women get and others don’t,” that shift in understanding carries real weight.

The uncomfortable economics of maternal research

Ask Professor Nakimuli what holds the field back, and she does not hesitate. “Some of the biggest challenges in sustaining maternal health research in Africa in particular is financing. It’s very low on the priority list, funding list, because of other more pressing problems, probably.”

She is careful to note this is not a purely African problem. “This is not a uniquely African problem. We know generally maternal health is not as high priority for funding as things like heart disease, cancer, name it. But it’s much worse here.”

Compounding the shortfall is where the money comes from in the first place. “Most of the funding is not domestic funding. It’s from other international bodies, which may have other priorities.” The practical consequence, she argued, is that Africa’s own distinctive maternal health burdens get squeezed out. “What that has meant is that most of those problems that affect mothers and are uniquely African, such as pre-eclampsia, where it causes a lot of complications, they end up being not at the forefront of research.”

Even when research does happen, African women are frequently under-represented in the resulting evidence base, a gap Professor Nakimuli attributes largely to cost. “The infrastructure is not as fully supportive as it should be. It’s much more expensive to do research in Africa than elsewhere, because we don’t have regional suppliers of laboratory supplies, equipment.”

Turning evidence into practice

For all these obstacles, Professor Nakimuli is precise about how she ensures her findings do not simply sit in journals. It begins, she said, with who is in the room when a study is designed. “I try as much as possible to involve the communities that are most affected, the pregnant women in this case and their families, in designing these studies. We’ve seen that that is usually very helpful. They bring out insights which would not be envisaged if we didn’t, even including how to consent them to participate.”

From there, the circle widens deliberately to include policymakers, clinicians and social scientists alike, each bringing something the others cannot. “It’s a whole chain of involving different stakeholders, starting from designing all the way to the dissemination of findings,” she said. “We try to publish, writing policy briefs, and also trying to make linkages with industry.”

It is a model built on a conviction she has carried since the earliest days of her career: that understanding a disease genetically means little unless that understanding eventually reaches the woman in labour, hundreds of miles from any laboratory, whose life depends on being recognised as at risk before it is too late.

October 23, 2026
Maternal vaccination can close the immunity gap for newborns

Despite remarkable progress in child survival, newborn deaths remain a major challenge in Bangladesh. According to recent estimates , about 60,000 newborns die each year in the country, with nearly three-quarters of these deaths occurring in the first week of life. Many of these deaths are caused by infections that strike before infants are old enough to receive routine vaccines. While Bangladesh expanded childhood immunisation and maternal health services over the past decades, protecting babies in the earliest days of life requires additional strategies. Maternal vaccination, which allows mothers to pass protective antibodies to their babies during pregnancy, offers a promising opportunity to reduce these preventable deaths and strengthen newborn survival. Yet, despite this potential, maternal immunisation remains absent from routine pregnancy care in Bangladesh, reflecting a collaboration gap between antenatal care services and the national immunisation programme.

The recent measles outbreak in Bangladesh, where around 50 children have died and hundreds of cases have been reported this year, serve as a reminder of the risks posed by immunity gaps and the consequences of delayed or incomplete protection against infectious diseases. While measles primarily affects older infants and children, it reflects broader vulnerabilities in maintaining population immunity and protecting those who are too young to be vaccinated. This underscores the importance of complementary strategies such as maternal vaccination, which can provide early protection to newborns and help bridge the critical window before routine vaccination.

Maternal vaccination falls between two health platforms. Vaccine delivery is managed through the Expanded Programme on Immunization (EPI), while pregnancy care is provided through antenatal services. Because these systems often operate in parallel, vaccination is not routinely integrated into antenatal visits, and opportunities to counsel or vaccinate pregnant women may be missed. Bridging this gap will be essential to expand maternal immunisation and prepare for new vaccines that protect mothers and newborns.

Encouragingly, public trust in vaccines remains one of Bangladesh’s greatest strengths. Decades of successful childhood immunisation have built strong confidence among communities, families, and frontline health workers. National immunisation coverage for many childhood vaccines remains above 90 percent, and vaccination has become widely accepted as a normal part of protecting children’s health. Many women, therefore, view vaccination as an important step in safeguarding their own and their babies’ health. In community discussions, participants frequently expressed willingness to accept vaccines when they understand their benefits. As one pregnant woman mentioned during our qualitative fieldwork, “If the doctors or healthcare providers explain that this will help the child and prevent illnesses, of course I will say yes. Why would I want harm?” This deep-rooted trust creates a favourable environment for introducing new maternal vaccines, provided that pregnant women receive clear information and guidance from trusted health providers.

Antenatal care offers one of the most promising platforms for strengthening maternal immunisation in Bangladesh. According to the Bangladesh Demographic and Health Survey 2022, more than 85 percent of women receive at least one antenatal care visit during pregnancy. These contacts provide crucial opportunities to counsel women about vaccination and deliver vaccines at the right time. Timing is particularly critical for maternal vaccines, as they are most effective when administered during specific stages of pregnancy. Accurate assessment of gestational age is therefore essential. Ultrasound examinations, used by 94 percent of women who sought antenatal care during their pregnancies, can help determine gestational age and support the appropriate timing of maternal vaccination. However, a significant proportion, around 70 percent of antenatal care in Bangladesh is delivered through the private sector, where vaccination services are not always systematically integrated with the national immunisation programme. Strengthening coordination among immunisation programmes, public antenatal care services, and private providers could transform routine pregnancy visits into effective opportunities for maternal vaccination.

At the same time, the global maternal immunisation landscape is evolving rapidly. Tetanus toxoid-containing vaccines have long been administered during pregnancy to prevent maternal and neonatal tetanus, and some countries have introduced pertussis vaccination for pregnant women to protect newborns from severe respiratory infection. More recently, maternal vaccines against respiratory syncytial virus (RSV) have emerged as a promising tool to reduce severe illness in early infancy, while vaccines against Group B Streptococcus (GBS) are under development. Importantly, these vaccines are also considered highly cost-effective public health strategies because a single dose given during pregnancy can protect newborns during their most vulnerable months and reduce hospitalisations and healthcare costs. For Bangladesh, these innovations present both opportunities and challenges. While maternal vaccines could significantly strengthen newborn protection, their successful introduction will require preparedness across the health system. Without clear delivery strategies, provider training, and coordination across health services, new vaccines may face delays or low uptake. Planning must begin well before the vaccines arrive.

Research and evidence will play a critical role in guiding this process. The Maternal Immunisation Readiness Network in Africa and Asia (MIRNA), funded by the Gates Foundation, is a nine-country consortium working to strengthen the evidence base for maternal vaccination in low and middle-income countries, including Bangladesh. Through collaborative research, the network aims to understand maternal vaccine demand, acceptance, and implementation challenges across health systems to help policymakers address key questions before introducing new maternal vaccines.

Protecting newborns begins before birth. As maternal vaccines such as those for respiratory syncytial virus (RSV) and Group B Streptococcus (GBS) approach introduction, Bangladesh has an opportunity to prepare its health system now. Recent measles outbreaks point to the need for stronger efforts to close immunity gaps early in life, through routine immunisation, including vaccination during pregnancy. Strengthening coordination across immunisation and maternal health services, engaging both public and private providers, and building on the country’s strong trust in vaccines can make maternal vaccination routine part of pregnancy care and help protect newborns in their most vulnerable early days.

April 4, 2026
Bangladesh needs a national RSV vaccination strategy

Respiratory syncytial virus, known as RSV, is a common virus that most adults mistake for a mild cold when affected. Common symptoms such as a runny nose, slight cough, or a low-grade fever rarely cause concern. But for babies under 12 months of age, RSV can turn deadly. In newborns, severe RSV infection attacks the lungs, causing excessive breathing difficulty and leading to serious illness such as pneumonia and bronchiolitis. As RSV appears more or less harmless in older children and healthy adults, it is frequently underestimated, allowing the virus to spread unnoticed until a baby becomes critically ill.

In early 2025, a premature 10-week-old in Dhaka was rushed to the hospital, struggling to breathe. What began as a mild cold quickly became a medical emergency. Doctors diagnosed RSV, and the baby required oxygen support and intensive care to survive. In one of many similar cases, a six-week-old baby girl in rural Bangladesh fought the virus and narrowly survived after prolonged hospitalisation. These are not isolated cases. Across hospitals in Bangladesh, infants are repeatedly admitted with severe RSV infection, raising serious concern among healthcare providers, yet remaining largely unnoticed beyond hospital walls.

From October to April each year, RSV circulates widely across the country. During this peak season, hospitals admit thousands of infants with severe respiratory illness. Many arrive too late. RSV is now one of the leading viral causes of pneumonia, which remains the leading cause of death among children under five in Bangladesh.

Evidence clearly shows the scale of the problem. Globally, a major international health study published in 2024 by The Lancet, one of the world’s leading medical journals, estimates that RSV infects about 33 million children under five, leading to 3.6 million hospitalisations and more than 118,000 deaths every year. In Bangladesh, the latest Global Burden of Disease estimates indicate that RSV contributes to more than 500 child deaths annually and accounts for over 47,000 years of healthy life lost. Even more concerning is that RSV-related deaths among Bangladeshi children have increased steadily over the past three years.

This virus is especially dangerous because it strikes babies before they are old enough to receive routine childhood vaccines, creating a critical gap in protection. The question, therefore, is not whether RSV is serious, but how we can protect infants during this most vulnerable period of life.

One proven solution is maternal immunisation. When a pregnant woman is vaccinated, her body produces protective antibodies that pass to her baby before birth, providing immediate protection from day one. This approach is not experimental. Bangladesh has already used maternal vaccination to nearly eliminate newborn tetanus. Additionally, many high and low-middle income countries now offer maternal vaccines for whooping cough, influenza, Covid, and, most recently, RSV. Maternal immunisation has become standard public health practice, not an exception.

After decades of research, we now have new tools to prevent RSV. In 2023, the first RSV vaccine for 32-36-week pregnant women was approved for use. In 2025, the World Health Organization (WHO) prequalified this vaccine, confirming that it meets global standards for safety and effectiveness. This creates an important policy opportunity for Bangladesh, with potential financial support from the Global Alliance for Vaccines and Immunization (Gavi), which works to expand access to life-saving vaccines in low-income countries.

Some may also be concerned about whether Bangladesh can deliver vaccines at the correct stage of pregnancy. But Bangladesh already delivers time-sensitive antenatal interventions every day. For example, pregnant women receive tetanus vaccines at specific stages, and antenatal corticosteroid injections are given to mothers at risk of preterm birth to help mature a baby’s lungs before delivery. These services rely on accurate timing and existing antenatal care systems. With appropriate guidance and digital tracking, the same systems can safely support maternal RSV vaccination.

Evidence from real-world settings is compelling. In Argentina’s 2024 RSV vaccine rollout, where about 60 percent of pregnant women were vaccinated, severe RSV illness in infants fell by nearly 75 percent. Hospital admissions dropped sharply, intensive care admissions declined by more than three-quarters, and, notably, all RSV-related infant deaths occurred among babies whose mothers had not been vaccinated. The message is simple and clear: vaccinating mothers saves babies’ lives.

Bangladesh is not starting from scratch. The country is globally well recognised for its Expanded Programme on Immunization (EPI), which has achieved high childhood vaccine coverage and dramatically reduced diseases like measles and polio. The delivery platforms, cold chain systems, trained health workers, and public trust already exist. What is missing is a coordinated maternal immunisation platform that brings pregnancy-based vaccines into routine antenatal care across both public and private sectors.

Digital systems under Bangladesh’s national Health Management Information System (HMIS) are already in place. These systems can register pregnancies, schedule vaccines, and send reminders. With better use of these tools, maternal and child immunisation services can remain closely connected, ensuring no woman or baby is missed. Public awareness is equally important. Expectant parents need to know that maternal vaccines are safe, carefully tested, and designed to protect both mother and child. Bangladesh has shown sustained leadership in public health, from pioneering oral rehydration therapy to achieving high childhood immunisation coverage. Maternal immunisation is the next step in the trajectory.

Policymakers must establish a dedicated platform and formally include RSV vaccination within national immunisation guidelines for pregnancy. Health managers must integrate maternal vaccination into routine antenatal care. Development partners, including Gavi, should align financing to support rapid introduction. Healthcare providers must be trained and supported to counsel and vaccinate pregnant women, even in busy and resource-constrained settings. Delay will cost lives. With the systems, evidence, and experience already in place, Bangladesh has a real chance to protect its newborns and infants before serious illness takes hold. When we vaccinate a mother, we protect two lives and secure the promise of tomorrow.

January 24, 2026