Statistical Yearbook for Asia and the Pacific 2011
 
People - Health
Maternal and reproductive health
Data sources: UN MDG Indicators database. WHO Global Health Observatory Database (WHO/ GHO), World Health Statistics.

The maternal mortality ratio in Asia and the Pacific has dropped by more than 50% in the last two decades; however, maternal deaths continue to take too many lives in the region. The Asia-Pacific region accounted for 136,995 maternal deaths in 2008, nearly 40% of the world total.

The vast majority of maternal deaths occur in Africa (207,796 of the world total 358,773) and in Asia and the Pacific (136,995). Combined, Africa and the Asia-Pacific account for 96% of the maternal deaths with only 75% of the world population.

The 2008 maternal mortality ratio (MMR) of 184 (maternal deaths per 100,000 live births) in the Asia-Pacific region is much lower than the world average of 266. However, it is more than twice the MMR of Latin America and the Caribbean (85), more than 7 times higher than North America (23) and more than 18 times higher than Europe (10). The dramatic reduction of the Asia-Pacific MMR from 372 in 1990 to 184 in 2008 represents more than a 50% decline in MMR and significant progress in achieving Millennium Development Goal 5 (MDG-5) target of a three quarter reduction in MMR between 1990 and 2015. In the region, 177,300 fewer mothers died in childbirth in 2008 than in 1990.

While some Asian and Pacific countries have already achieved the target of MDG-5 (Bhutan, the Islamic Republic of Iran and the Maldives), for others the task will not be easy. In Kyrgyzstan the MMR has increased from 1990 to 2008. The MMR also increased in Singapore, albeit from a much lower base, comparable to European levels. Other countries with a high MMR and a slow pace of reduction (less than 20%) are Afghanistan, the Democratic People’s Republic of Korea, Georgia, Thailand and Turkmenistan.

Although there are MMR differences between the Asia-Pacific subregions, more pronounced differences are associated with economic development. The MMR differences are striking across economic strata, ranging from 517 for low-income countries to 10 for high-income countries. Collectively, the landlocked developing countries of the region have an extremely high MMR at 602 and LDCs are close behind at 550.

Figure I.13 – Maternal mortality ratio, Asia-Pacific subregions, 1990 and 2008

Across the subregions in Asia and the Pacific, the lowest MMR prevails in East and North-East Asia, at 40 per 100,000 live births, followed closely by North and Central Asia at 42. The low subregional average of East and North-East Asia camouflages the very high MMR of 250 in the Democratic People’s Republic of Korea, a statistic that has changed little (by only 7.4%) from 270 in 1990.

South and South-West Asia is the worst off in the region with an average MMR of 269 and six countries (Afghanistan, Bangladesh, Bhutan, India, Nepal and Pakistan) showing a ratio at or above 200. Nevertheless, these figures represent a significant decline since 1990. Afghanistan has the highest MMR in the Asia-Pacific with an MMR of 1,400 per 100,000 live births, signifying that 1.4% of all births end with the mother dying.

In South-East Asia, the average MMR of 164 encompasses countries with extremely high ratios, the highest being the Lao People’s Democratic Republic (580), Timor-Leste (370) and Cambodia (290), and countries with relatively low values, Singapore (9), Brunei Darussalam (21) and Malaysia (31).

The average MMR in the Pacific is 95; however, the calculation is based on only five countries (including Australia and New Zealand). Papua New Guinea has the highest MMR in the subregion (based on available data) at 250. The sparse data in this subregion do not allow for definitive conclusions on the subregion as a whole.

In Asia, the causes of maternal deaths are haemorrhage (accounting for 30.8% – mostly postpartum); hypertensive disorders (9.1%); sepsis/infections (11.6% – mostly soon after delivery); abortion (5.7%); obstructed labour (9.4%); anaemia (12.8% – preventable through iron foliate supplementation during pregnancy); ectopic pregnancy (0.1%); embolism (0.4%); other direct causes (1.6% – including complications related to caesarean section and anaesthesia); other indirect causes (12.5% – including complications related to malaria, cardiovascular disease and other conditions which complicate pregnancy or are aggravated by it); and unclassified (6.1%).1

Prevention

Two critical interventions for combating preventable maternal and neonatal mortality are, first, to ensure access of pregnant women to antenatal care; and second, that women in labour have skilled health personnel in attendance.

The presence of a skilled birth attendant (a doctor, a nurse or a midwife) during the birth is an important determinant of successful childbirth. Similar to the world average, approximately two thirds of all deliveries in Asia and the Pacific were attended by skilled health personnel (SHP) in 2009. Of the world total of unattended births, just over half (23 million of the total 45 million) took place in the Asia-Pacific region in 2009, with South and South-West Asia accounting for 20 million of them.

Upper middle-income countries had almost universal coverage of births attended by SHP (97%) similar to high-income countries (100%); whereas the coverage rate in low-income countries was a very low 37%, with lower middle-income countries at 69%. In South and South-West Asia, births attended by SHP coverage was 50%; in South-East Asia, much higher at 77%. In both East and North-East Asia, and North and Central Asia, almost all births attended by SHP, maintaining a level above 90% with the exception of Azerbaijan and Tajikistan at 88%. In the Pacific subregion, where data are sparse, latest data available show high coverage for most countries (Papua New Guinea is the most notable exception) with the subregional average at 80%. 1 Khalid S. Khan and others, “WHO analysis of causes of maternal death: A systematic review”, Lancet, vol. 367 (2006), pp. 1066-74.

Figure I.14 – Births attended by skilled health personnel, Asia-Pacific subregions, 1990 and 2009

Figure I.14 – Births attended by skilled health personnel, Asia-Pacific subregions, 1990 and 2009

Births attended by SHP coverage in Asia-Pacific subregions shows strong correlation with economic capacity when broken down by income quintiles; differences between coverage in rural and urban areas are also stark. At this level of disaggregation, data are available from most countries in South and South-West Asia, South- East Asia and North and Central Asia; however, data availability in East and North-East Asia and the Pacific is very limited (only Mongolia, Samoa and Vanuatu). The poorest quintiles in South and South-West Asia and South-East Asia showed significantly lower (more than 40 percentage points) births attended by SHP coverage rates as compared to the wealthiest quintiles for 5 of the 7 countries with available data in South-East Asia; and for 4 of the 5 countries with available data in South and South-West Asia. This indicates a high level of inequality in the provision of essential health service. For all Asia-Pacific countries with both income quintile and rural/urban data, the percentage point difference in births attended by SHP by income quintile is greater than the rural/urban difference. However, inequity between rural and urban areas still exists.

Antenatal care (ANC) enables early diagnosis and treatment of infections and potential complications in the mother and is an opportunity to prevent low birth weight and other conditions in the newborn. Approximately four of every five (80%) pregnant women had at least one ANC visit in Asian and Pacific countries in 2009. The unfortunate corollary of this statistic is that approximately 15 million pregnant women did not have a single visit for pregnancy-related care. Furthermore, some women wait until too late during pregnancy for the full benefits of antenatal care to be realized in terms of lives saved, both maternal and newborn.

The WHO recommends four ANC visits. In 18 of the 25 countries with both one visit and four-visit data (same year) available, more than 60% of women who complete one visit will complete the full four visits. Least-developed countries in Asia and the Pacific have an average rate of 37% for four ANC visits, correlating with a high maternal mortality ratio of 550.

The overall trend in the Asia-Pacific region reflects more than a one-third decline in the number of births not attended by skilled health personnel in the past 18 years, from 36 million in 1990 to 23 million in 2009. Although the increase in the proportion of births attended by a skilled birth attendant is impressive, improvement is still needed. Pregnancy care during ANC visits is critical to identify potentially high-risk pregnancies and provide treatment. Clearly opportunities for intervention are being missed here. Insufficient numbers of contacts are taking place during the intra-partum period when possible complications could be identified and addressed.

Figure I.15 – Antenatal care coverage, at least four visits vs. at least one visit, Asia and the Pacific, 2005 to 2010

In addition to ANC and attendance of birth by SHP, family planning can also impact maternal mortality. Maternal mortality is affected greatly by the use of family planning – fewer pregnancies and births and greater spacing of births put mothers at less risk of dying during pregnancy and childbirth.

One of the MDG-5 targets is universal access to reproductive health services, for which the contraceptive prevalence rate (CPR) – defined as current contraceptive use (any method) among married women of 15 to 49 years old – has been identified as a proxy indicator. In East and North-East Asia all countries (with available data) have a CPR above 50%. Using the years for which the latest data are available for each country, the lowest CPRs are found in Afghanistan (23%, 2008), Pakistan (27%, 2008), Samoa (29%, 2009) and Timor-Leste (22%, 2010).

Community-based services for reducing maternal deaths

Each year many women die unnecessarily simply as a consequence of lack of healthcare during pregnancy and childbirth. This can be averted through appropriate contact with the health system, by facility or provider, during pregnancy and delivery with such interventions as antenatal care, skilled birth attendance and appropriate postpartum care.

Demographic and health survey data show that most poor women in developing countries deliver their babies at home.2 Given that most maternal deaths also occur at home,2 community-based interventions aimed at making home births safer could have an enormous benefit. This may take the form of traditional birth attendants or midwives with sufficient training and supervision who can ensure healthcare during pregnancy and at birth.

Part of the challenge for Asian and Pacific countries in combating maternal mortality is related to scaling up community-based approaches. For particular the expansion of training and improved compensation for and retention of trained reproductive health specialists such as birth attendants and midwives. Support for home births should be accompanied wherever possible. This can be done by improved communication to educate and inform women and their families, including household decision-makers, on the benefits and necessity of appropriate health care during pregnancy and delivery. An effective referral system should also be established.


1 Khalid S. Khan and others, “WHO analysis of causes of maternal death: A systematic review”, Lancet, vol. 367 (2006), pp. 1066-74.

2 Dominic Montagu and others, “Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data”, PLoS ONE 2011, vol. 6, no. 2 (2011), c17155.

 
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Table I.14 Maternal mortality and birth attendance
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Table I.15 Maternal mortality, birth attendance and antenatal care women affected
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Table I.16 Use of contraceptives and antenatal care coverage rate
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