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
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. |
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Maternal and reproductive health
