Statistical Yearbook for Asia and the Pacific 2012
 
   
B. Health
 
B.2. Maternal and reproductive health

No woman should die giving birth. Yet, every day about 800 women die giving birth around the globe and more than one third of these deaths occur in the Asian and Pacific region, the majority of which are in South Asia. Great efforts have been made in the last decades to reduce maternal mortality in the region and, while certain progress has been achieved, Asia and the Pacific is still lagging behind in achieving Millennium Development Goal 5 in the areas of maternal mortality, skilled birth attendance, antenatal care and access to sexual and reproductive health. The vast majority of maternal deaths are preventable, and stronger action and bolder policies need to be pursued if the region as a whole aims to achieve Millennium Development Goal 5 by 2015.

288 women in Asia and the Pacific die every day due to complications during pregnancy or at childbirth

The maternal mortality ratio in Asia and the Pacific was 142 per 100,000 live births in 2010, equivalent to a total of 105,012 maternal deaths. This means that, on average, 288 women in Asia and the Pacific die every day due to complications during pregnancy or at childbirth. However, the 2010 maternal mortality ratio in the region has reduced almost 62 per cent from the 1990 level of 369 deaths per 100,000 live births. In comparison the global reduction in maternal mortality ratio over the two decades was 46 per cent. In the region in 2010, the maternal mortality ratio ranged from levels as high as 470 deaths per 100,000 live births in the Lao People’s and 460 in Afghanistan (levels similar to the African average of 463) to levels as low as 3 in Singapore, 5 in Japan and 7 in Australia, which are comparable to the European average of just under 11. The most common causes behind maternal mortality are complications during pregnancy or at childbirth, such as haemorrhages and infections.1 It is for this reason that skilled care during childbirth, especially emergency obstetric care, is key to reducing maternal mortality. Bhutan has managed to reduce maternal mortality by more than three quarters since 1990. This reduction is thanks to an increase in the births attended by skilled health personnel, from 24 per cent in 2000 to 65 per cent in 2010.

It is important to underline that a reduction in maternal deaths does not necessarily require a high national income. Lower-middle-income economies such as Bhutan and Maldives have managed some of the largest reductions in maternal mortality through the improvement of their health systems and the increase in access to family planning and skilled health personnel. Even Cambodia, a low-income economy, is a success story, having been able to reduce maternal mortality from 830 deaths per 100,000 live births in 1990 to 250 deaths per 100,000 live births in 2010. In the mid-2000s, Cambodia undertook a systematic upgrading of its public health facilities, making maternity services more accessible and increasing the antenatal care coverage of at least one visit, from only 38 per cent of pregnant women in 2000 to 89 per cent in 2010.

Figure B.2-1
Maternal mortality, Asian and Pacific subregions, 1990-2010

Figure B.2-1 Maternal mortality, Asian and Pacific subregions, 1990-2010

Despite overall progress, differentials between subregions remain, with the highest maternal mortality occurring in South Asia.

South and South-West Asia has the highest maternal mortality ratios of all subregions in Asia and the Pacific, at 203 deaths per 100,000 live births, as opposed to 158 in South-East Asia and 37 in East and North-East Asia (excluding Japan). Because of the size of the population in this subregion, it also has the highest absolute number of maternal deaths, at over 77,700 in 2010. While having achieved some progress, the most populous countries of this subregion, namely Bangladesh, India and Pakistan, continue to struggle in reducing the number of maternal deaths due to a lack of skilled attendance at birth.

Slightly more than half of all births in South and South-West Asia are attended by skilled health personnel. This amounts to about 18 million births that are not attended by a skilled professional in the subregion, which is close to 88 per cent of total unattended births in Asia and the Pacific. At the country level, the figures for Bangladesh and Nepal were 32 per cent and 36 per cent, respectively, in 2011. Conversely, for the subregions of East and North-East Asia (excluding Japan) and South-East Asia, the figures were 99 per cent and 81 per cent, respectively.

More work needs to be done to reduce maternal mortality in Asia and the Pacific. Governments need to reinforce their commitment to improve their health systems by addressing the main challenges that slow progress. Such challenges include inadequate human resource capacities, a lack of essential tools and equipment, poor prioritization of maternal health policies and planning, as well as limited access to these systems due to high user fees for the poor and other cultural or social barriers women face.

Box B.2-1
Disparities within countries are still significant, even in those that have made good progress

Just as advancements differ within regions and subregions, improvement at the national level does not imply advancement for the whole country. When considering the two different stories of Cambodia and Timor-Leste,a it can be observed that not everyone benefits equally from improvement at the country level. Between 2000 and 2010, Cambodia increased the number of births attended by skilled health personnel by more than 100 per cent. In Timor-Leste, on the other hand, the proportion of births attended by skilled health personnel increased from 25.8 per cent in 1997 to 29.3 per cent in 2010. However, subnational data reveal wide gaps between the different geographical areas and wealth quintiles within each of these countries.

In the case of Cambodia, pregnant mothers in urban areas and in the richest wealth quintile had almost complete access to attended skilled health personnel during childbirth. In contrast, only two thirds of pregnant mothers in rural areas could benefit from such services, and only half of those in the poorest wealth quintile could give birth to a child with the support of health personnel. These disparities are more evident in the case of Timor-Leste, where women in the richest quintile are seven times more likely to give birth with the support of a skilled health professional than women in the poorest quintile. While the result is not surprising, what is notable is the wide gap between subgroups.

Births attended by skilled health personnel in Cambodia by subgroup in 2000 and 2010

Births attended by skilled health personnel in Cambodia by subgroup in 2000 and 2010

Births attended by skilled health personnel in Timor- Leste by subgroup in 2010

Births attended by skilled health personnel in Timor- Leste by subgroup in 2010

Source: Data repository WHO, GHO available at www.who.int/gho/database/en/
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a Cambodia has a GDP per capita in purchasing power parity terms 1.4 times as high as that of Timor-Leste.
The lack of support for women’s access to sexual and reproductive health is an obstacle in reducing maternal mortality.

In terms of saving mothers’ lives, one main area often overlooked is the right to sexual and reproductive health. Based on one estimate, 41 per cent of all pregnancies are unintended at the global level and 38 per cent in Asia, which is equivalent to 45.1 million unintended pregnancies in the region.2 At the global level, about half of these unintended pregnancies end up in abortions and approximately 13 per cent in miscarriages.3 More important is the fact that most young women are the ones who are affected by an unintended pregnancy. All women should have the right to decide whether and when to have children. According to the United Nations Population Fund, access to voluntary family planning alone could reduce maternal deaths by more than one third and child deaths by as much as 20 per cent.4 In South Asia, complications during pregnancy and childbirth are the leading causes of death for women of childbearing age. For these reasons, it is very important to improve women’s access to family planning. According to the most recent figures available, contraceptive prevalence among women aged 15-49 years in Asia and the Pacific varies widely, from about 20 per cent in Afghanistan and Timor-Leste, to about 80 per cent in China and Thailand. Related to this, the unmet need for family planning is another indicator that identifies the demand for increased family planning and services.

Regarding this unmet need, there is a significant gap between (a) countries such as China and Thailand, with about 3 per cent, and Viet Nam, with 6.6 per cent, and (b) countries such as Cambodia, the Lao People’s Democratic Republic and Timor-Leste, with about 30 per cent.5 This demonstrates the clear need to raise awareness and to provide women with better information and services in order to ensure their health and that of their families.

Figure B.2-2
Unmet need for family planning, selected Asian and Pacific countries, latest year (percentage)

Figure B.2-2 Unmet need for family planning, selected Asian and Pacific countries, latest year (percentage)

Source: ICF International, Measure DHS STATCompiler (2012) (accessed 4 July 2013).

Further reading

United Nations Population Fund. Giving birth should not be a matter of life and death. Fact sheet. 2012.

–––––––. State of World Population: By Choice Not By Chance – Family Planning, Human Rights and Development. 2012.

World Health Organization. Maternal Health. Available from www.who.int/topics/maternal_health/ en/index.html.

World Health Organization, United Nations Children’s Fund, United Nations Population Fund and World Bank. Trends in Maternal Mortality: 1990 to 2010. 2012.

Technical notes

Maternal mortality (deaths per 100,000 live births, number of deaths)
Maternal mortality is the death of a woman while pregnant or within 42 days after termination of pregnancy, irrespective of the duration and location (domestic or abroad) of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Aggregate calculations: Millennium Development Goal aggregation and imputation methods; weighted averages using the number of live births (WPP2012) as weight (per 100,000 live births); sum of individual country values (number of deaths).

Births attended by skilled health personnel: total (percentage of live births)
Births attended by skilled health personnel (doctors, nurses or midwives) are deliveries attended by personnel trained in (a) providing life-saving obstetric care, including giving the necessary supervision, care and advice to women during pregnancy, labour and the post-partum period, (b) conducting deliveries on their own and (c) caring for newborns. Traditional birth attendants, even if they have received a short training course, are not included. Poorest and richest quintiles of the population are based on income data. Aggregate calculations: Millennium Development Goal aggregation and imputation methods; weighted averages using the number of live births (WPP2012) as weight.

Births not attended by skilled health personnel (thousands)
Births not attended by skilled health personnel is calculated for only economic, regional and subregional groupings. Aggregate calculations: The number of births for each economic, regional or subregional grouping multiplied by the percentage of births not attended by skilled health personnel (1 minus the percentage of births attended by skilled health personnel).

Contraceptive prevalence rate, females 15-49 years old (percentage)
The contraceptive prevalence rate is the proportion of women currently using, or whose sexual partner is using, a method of contraception among women of reproductive age (usually aged 15-49 years). In some countries the denominator is married women only, as (reported) sexual activity outside of marriage is considered rare.

Antenatal care coverage: at least four visits, at least one visit (percentage of women with a live birth)
At least four visits: Women aged 15-49 years with a live birth in a given time period who received antenatal care four or more times with any provider (whether skilled or unskilled). At least one visit: Women aged 15-49 years with a live birth in a given time period who received antenatal care provided by skilled health personnel (doctors, nurses or midwives) at least once during pregnancy. A skilled health worker/ attendant is an accredited health professional, such as a midwife, doctor or nurse, who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate post-natal period, and in the identification, management and referral of complications in women and newborns. Both trained and untrained traditional birth attendants are excluded. Aggregate calculations: Millennium Development Goal aggregation and imputation methods; weighted averages using the number of live births (WPP2012) as weight.

Women lacking antenatal care coverage: at least one visit (thousands)
Women lacking antenatal care coverage is calculated for only economic, regional and subregional groupings. Aggregate calculations: The number of women with live births for each economic, regional or subregional grouping multiplied by the percentage of women lacking antenatal care (1 minus the percentage of women with antenatal care coverage).

Source

Source of maternal mortality data: Millennium Indicators Database. Based on data from the World Health Organization (WHO), the United Nations Development Programme, the United Nations Children’s Fund (UNICEF) and the World Bank. Sources and methods used to determine maternal mortality vary by country. Primary sources of data include vital registration systems, household surveys (direct and indirect methods), reproductive-age mortality studies, disease surveillance or sample registration systems, special studies on maternal mortality and national population censuses. Despite being based on established demographic techniques and empirical data from other countries, the countryspecific point estimates obtained through the statistical model do not necessarily represent the true levels of maternal mortality. Data obtained: 2 August 2013.

Source of data on births attended by skilled health personnel: rural, urban, poorest and richest quintiles: WHO Global Health Observatory. Microdata are from nationally representative surveys including demographic and health surveys, fertility and family surveys, reproductive health surveys with assistance from the Centers for Disease Control and Prevention in the United States of America, multiple indicator cluster surveys, and national family planning, or health, or household, or socioeconomic surveys. Survey data from sources other than the national statistical system are included when other data are not available. The data are taken from published survey reports or, in exceptional cases, other published analytic reports. UNICEF and WHO base their estimates on the available data sources and internal verification procedures. Data obtained: 5 July 2012.

Source of data on births attended by skilled health personnel: antenatal care coverage, at least one visit and at least four visits, contraceptive prevalence rate and unmet need for family planning: Millennium Indicators Database. National-level household surveys, including multiple indicator cluster surveys and demographic and health surveys, are the most common sources of data. These surveys are generally conducted every three to five years. UNICEF reviews the data in collaboration with WHO. Data obtained: 2 August 2013.

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1 K.S. Khan and others, “WHO analysis of causes of maternal death: a systematic review”, Lancet, vol. 367, No. 9516 (April 2006), pp. 1066-1074. Available from www.ncbi.nlm.nih.gov/pubmed?cmd=Retrieve&list_uids=16581405.
2 See www.escrh.eu/sites/escrh.eu/files/esc_unwanted_pregnancy_slides1.pdf.
3 Ibid.
4 See www.unfpa.org/webdav/site/global/shared/factsheets/srh/EN-SRH%20fact%20sheet-LifeandDeath.pdf.
5 ICF International, Measure DHS STATCompiler (2012) (accessed 4 July 2013).
 
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