Progress towards achieving Millennium Development Goal 5 in South-East Asia

DOI:.1111/j.1471-528.211.38.x www.bjog.org Commentary Progress towards achieving Millennium Development Goal 5 in South-East Asia M Islam Family Health and Research, World Health Organisation, South East Asia Regional Office, New Delhi, India Correspondence: Dr M Islam, Director, Family Health and Research, World Health Organisation, South East Asia Regional Office, New Delhi, India. Email islamm@whosea.org Accepted 21 July 211. Please cite this paper as: Islam M. Progress towards achieving Millennium Development Goal 5 in South-East Asia. BJOG 211; 118 (Suppl. 2): 6 11. Progress towards achieving Millennium Development Goal (MDG) 5A Every year almost half a million pregnant women die globally. The South-East Asia region (SEAR) alone is accountable for approximately 32% of the global maternal deaths, which equated to an estimated 1 mothers lost in 25. In the region, India, Bangladesh, Nepal, Indonesia and Myanmar together contribute to almost 98% of these deaths due to their large country population size and high maternal mortality risks. Thailand, Sri Lanka, the Democratic People s Republic of Korea (DPRK) and the Maldives are countries which have maintained low maternal mortality rates (MMRs) over the previous decades. At the UN last year Bangladesh and Nepal received the UN Secretary General s awards for their significant progress and for being on track to achieve MDGs 4 and 5. However, overall in the region movement towards the MDG 5 target of reducing maternal mortality has shown slow progress as the MMR remains high in many countries of the region including 6 per live births in Timor-Leste, and above in Myanmar, Indonesia and India (see national estimates, Table 1). The major causes of maternal deaths remain: haemorrhage, sepsis, hypertensive disorders, unsafe abortion and prolonged or obstructed labour complications that can be effectively treated in health facilities that provide obstetric care. Most of these deaths occur around childbirth and could have been prevented if deliveries were assisted by a health provider with midwifery skills backed up with an effective referral system. Although substantial efforts have been undertaken, still many countries of the region have a high proportion of home deliveries without the presence of skilled birth attendants. DPRK, Sri Lanka and Thailand have almost universal coverage of deliveries with skilled attendants and the Maldives report 84% coverage, which positively correlates with the remarkable reductions in the maternal mortality in these countries. According to the World Health Statistics 29, in Timor-Leste, Bangladesh and Nepal the proportion of women who deliver with a skilled birth attendant is <2%, while Myanmar, Bhutan and India are yet to reach the goal of % which was set for the year 2. Table 2 depicts data on the MDG 5A target: MMRs in the base year of 19, current levels and the expected levels in 215 as well as the proportion of deliveries assisted by a skilled birth attendant. Skilled birth attendants or skilled attendants are health care providers (particularly those who work at primary care level) with competencies in core midwifery skills. Traditional birth attendants, although trained, are not included in the skilled birth attendant category. It is apparent that eight countries are likely to fail to reach the target of MDG 5A. Maternal and neonatal health are interrelated. The persistent burden of maternal and neonatal health globally, and in the SEAR in particular, has been a major challenge to the achievement of both MDGs 4 and 5 as high rates of neonatal deaths contribute to infant and under-5 mortality inhibiting progress towards the MDG 4 target of reducing child mortality by two-thirds between 19 and 215. The number of neonatal deaths (deaths of infants within 28 days of life) in the region was 1.3 million 1 according to the 25 WHO estimates, which corresponded to 35% of all global neonatal deaths. Figure 1 shows the neonatal mortality rates for the SEAR countries. Three countries (Sri Lanka, Thailand and Indonesia) had neonatal mortality rates of <2 per live births in 24, while rates for DPRK, Maldives, Timor- Leste and Bhutan ranged from 22 to per live births and Nepal, Bangladesh, India and Myanmar rates were 32 49 per live births. Figure 2 shows the trends for the percentage of neonates protected at birth against neonatal tetanus from 19 to 6 ª 211 The Author BJOG An International Journal of Obstetrics and Gynaecology ª 211 RCOG

MDG 5 in the South-East Asia Region Table 1. Comparison of maternal mortality ratio (deaths per live births) in SEAR countries global and national estimates Global estimate (25)* Absolute numbers of deaths National estimate 26 through tetanus toxoid immunisation. Almost all countries had achieved more than 8%, except Timor- Leste. Many countries report that the incidence of neonatal tetanus is decreasing in countries with a high proportion of deliveries assisted by a skilled attendant. Progress towards MDG 5B National sources Bangladesh 5 21 194 Household Survey Report 211. Survey Sample Vital Registration system (BBS, 28) Bhutan 4 28 255 National Health Survey 2 DPRK 3 97 Central Bureau of Statistics, DPRK, 22 India 4 117 1 Sample registration system Indonesia 42 19 7 Progress to MDG report 24 Maldives 12 12 72 Ministry of Planning and National Development, Statistical Yearbook 26 Myanmar 38 316 Progress to MDG report 25 Nepal 8 281 Nepal Demographic and Health Survey 26, recent survey indicates 231 Sri Lanka 58 1 43 MDG report 25 Thailand 1 1 2.63 21 National Data Timor-Leste 38 1 6 Timor-Leste 26 Country Health statistics report *Source of global estimates, maternal mortality in 25: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organisation, 27. The MDG 5 target B of achieving universal access to reproductive health by 215 was adopted by the 62nd United Nations General Assembly in October 27. It embraces the core principles of the ICPD Programme of Action and recognises the centrality of reproductive health and reproductive rights in improving maternal and infant health and in reducing poverty. The four key indicators of progress are contraceptive prevalence rate (CPR), adolescent birth rate, antenatal care coverage ( at least one visit and at least four visits ) and unmet need for family planning. Contraceptive prevalence In general, countries of the SEAR have made steady progress in increasing the availability and use of modern contraceptive methods (Figure 3), which allows individuals and couples to exercise their rights to decide for themselves the size of their family and the number and timing of their children, including birth spacing and birth limiting. Consequently the use of contraception reduces the number of unwanted pregnancies, and thus the risks of pregnancy and abortion complications. However, the issues of availability of contraceptive choices, their acceptability (such as the use of male contraceptive methods) and accessibility still inhibit widespread use. Adverse effects also are known to result in discontinuation of contraceptive methods if these are not properly managed. Timor-Leste is an example of a country where major barriers to the use of contraception exist. As a consequence, the country s CPR remains low (at %) and the total fertility rate is marks the highest (7.8) around the globe. Bhutan, Myanmar, Maldives and Nepal had a CPR of <% in 28, while in the rest of the countries the CPR ranges from 56% to 72%. Adolescent birth rate Adolescent pregnancy remains a great challenge in the region, especially in countries with an early age of marriage, which increases the risks of adverse maternal and newborn conditions. Early teenage pregnancy has been associated with higher risks including poor maternal weight gain, anaemia, obstetric complications (i.e. pregnancyinduced hypertension and prolonged labour), as well as low birthweight babies and prematurity. For both physiological and social reasons, girls aged 15 19 are twice as likely to die in childbirth as those in their 2s and may have increased risks of poor pregnancy outcomes, such as newborn morbidity and mortality. Often, age-disaggregated data are not readily available in these countries, including data on age-specific fertility rates. The estimates of the 25 World Population Data, however, show an overall decline in teenage fertility rate (Figure 4) for all countries except Timor-Leste, which had an alarming rise in teenage fertility from 47 in 1995 to 182 live births per women 15 19 years of age in 25. Teenage fertility has declined in Bangladesh, India, Maldives and Indonesia, reaching 132, 8, and 55 per women live births respectively in 25. In Nepal, the data on teenage fertility rate did not reflect any significant changes over the past few decades, still remaining above ª 211 The Author BJOG An International Journal of Obstetrics and Gynaecology ª 211 RCOG 7

Islam Table 2. Maternal health indicators of member countries of SEAR Number of maternal deaths (s), 25 Maternal mortality ratio (per live births) 19* Latest (year)* MDG 215* Deliveries by skilled birth attendants** (%), 2 26 Progress toward the MDG target Bangladesh 21 574 38 (22) 143 2 Significant progress Bhutan 28 5 255 (2) 1 51 Insufficient DPRK 5 (1996) 97 (22) 97 NA India 117 437 1 (25 6) 9 47 Insufficient Indonesia 19 3 7 (22) 66 Insufficient Maldives 12 72 (25) 125 84 On track Myanmar 232 38 (22 3) 63 57 Insufficient Nepal 515 281 (25) 134 19 Significant progress Sri Lanka 1 92 47 (21) 36 97 On track Thailand 1 36 14 (23) 9 97 On track Timor-Leste 1 NA 42 8 (22) 252 19 Insufficient MDG, millennium development goal; NA, not available. Source: WHO, UNICEF, UNFPA, WB. Maternal mortality ratio in 25. *WHO/SEAR. 11 health questions about 11 SEAR countries, New Delhi 27. **World Health Statistics 29. MMR 49 IND 39 BAN 36 NEP 32 BHU TLS MAV 24 29 KRD 22 INO 17 THA 9 SRL 8 2 Source: World Health Statistics, 29, WHO Figure 1. Neonatal mortality rate (per live births) in SEAR countries, 24. Source: World Health Statistics, 29, WHO. 12 live births per women aged 15 19 years. The lowest teenage fertility rates were in DPRK (2), Sri Lanka (2) and Myanmar (21). Early sexual initiation is an increasing tendency in many countries. This may lead to early teenage and unwanted pregnancy, as access to family planning information and services is limited for adolescents, especially when they are unmarried. A proportion of these adolescents will seek unsafe abortion services, which places them at a higher risk of maternal death. Figure 5 highlights the situation in some countries of the region. More than 68% of girls in Bangladesh, 51.4% in Nepal, 47.4% in India and about 24% in Indonesia are married by the time they are 18 years of age. Moreover, more than 37% of Bangladeshi girls are married by the age of 15. About 18.2% of girls in India and.2% girls in Nepal are married by 15 years of age. Antenatal care coverage Antenatal care provides an opportunity for educating mothers about proper care during pregnancy and birth, as well as about emergency preparedness and postpartum care. In addition to checking mother and fetal health, provision of necessary interventions, identification of problems and treatment of these problems are key components of antenatal care. Thus, antenatal care is an important point of contact between mothers and health providers to ensure the welfare of mothers and fetus. WHO recommends at least four antenatal visits to a woman during her pregnancy in the absence of any complications. Subsequently countries are encouraged to measure antenatal care coverage for at least one and for at least four consecutive antenatal visits to a pregnant woman during her pregnancy. 8 ª 211 The Author BJOG An International Journal of Obstetrics and Gynaecology ª 211 RCOG

MDG 5 in the South-East Asia Region 8 DPR Korea Maldives Sri Lanka India Thailand Bangladesh Indonesia Bhutan Myanmar 86 85 81 75 64 63 62 95 88 86 85 82 81 64 62 58 94 92 88 88 87 86 84 83 83 63 Timor Leste 44 Nepal 35 19 2 26 Figure 2. Trends in neonates protected at birth against neonatal tetanus (%): 19 26. 2 8 2 72 71.5 66 62 59 68.8 62.3 57 58 56.3 55.8 48 49 48 43 39 39 25 23 14 42 39.8 37 37 33 19.7 19 2 25 28 THA SRL KRD INO IND BAN NEP MAV MMR BHU TLS Source: World population policies 25; World population data sheet 26; Family planning worldwise 28 data sheet Figure 3. Trends in contraceptive prevalence rate in SEAR countries 19 28. Source: World Population Policies 25; World Population Data Sheet 26; Family Planning Worldwise 28 Data Sheet. TFR 2 Bangladesh 2 India Maldives 1 Nepal Indonesia Myanmar Bhutan Thailand Timor Leste Sri Lanka DPR Korea 1975 1985 1995 25 Year Source: World population data, 25 Figure 4. Teenage fertility rate (per women aged 15 19 years), SEAR, 1975 25. Source: World Population Data, 25. ª 211 The Author BJOG An International Journal of Obstetrics and Gynaecology ª 211 RCOG 9

Islam 8 2 Percent 68.4 88.7 47.4 64.6 24.2 Bangladesh India Indonesia Nepal Sri Lanka 46.8 51.4 65 2 24 44 Source: Bangladesh DHS 24; India NFHS-III 25-6 ; Indonesia DHS 22-3; Nepal-DHS 26; Sri Lanka DHS 2 Figure 5. Percentage married by age 18 among females aged 2 24 and 44 years. Source: Bangladesh DHS 24; India NFHS-III 25 6; Indonesia DHS 22 3; Nepal DHS 26; Sri Lanka DHS 2..1 ANC coverage at least one visit, % ANC coverage at least four visits, % 95.4 97 99 99.4 93 91 8 64.6 71.8 77 81 52 57 49.8 2 2.6 34.5 BAN TLS MMR BHU NEP IND INO THA SRL KRD MAV Source: IND: NFHS 25-6; BAN: BAN DHS 27; TLS: TLS Annual Health Report 28; MMR: HMIS, Dept of Health Planning; NEP: Annual Report 26-7; KRD: RH Survey 26; SRL: DHS 26; MAV: MAV RHS 24; THA: THA MCHS 26 Figure 6. Antenatal coverage in SEAR countries in 24 8. Source: India NFHS 25 6; Bangladesh DHS 27; TLS Annual Health Report 28; MMR, HMIS, Department of Health Planning; Nepal Annual Report 26 7; KRD RH Survey 26; Sri Lanka DHS 26; MAV RHS 24; Thailand THA MCHS 26. Table 3. Unmet need for family planning in SEAR countries Countries Unmet need for family planning Bangladesh, 23 15.3 Bhutan NA DPRK, 23 16.7 India, 23 15.8 Indonesia, 23 8.6 Maldives, 23 34 Myanmar, 1997 2 Nepal 28 Sri Lanka, 2 8 Thailand 5.9 Timor-Leste NA Source: Family Planning Saves Lives! An Investment in Development, WHO/SEARO, 25. In general, antenatal care data in countries show better coverage than for access to skilled care at birth. However, the data on antenatal coverage with at least four visits is yet to be routinely available for most countries and in those where the data are already available it shows a much lower proportion of pregnant women continuing to attend antenatal care after their first visit. This is particularly the case in countries where maternal health status is low, such as Bangladesh, Nepal, India and Timor-Leste (Figure 6). Usually this is due to low quality of care and an insufficient number of health facilities providing maternal and neonatal health care at community level or their being overburdened with other public health tasks, as well as socio-cultural barriers. Unmet need for family planning The unmet need for family planning reflects the level of missed opportunity for family planning services for women ª 211 The Author BJOG An International Journal of Obstetrics and Gynaecology ª 211 RCOG

MDG 5 in the South-East Asia Region who do not want to get pregnant anymore or want to postpone the next pregnancy. Table 3 shows that the unmet need for family planning is still high in the Maldives, Nepal, Myanmar, DPRK, India and Bangladesh. In these countries, it is expected that unsafe abortion still remains a major challenge and usually contributes significantly to maternal mortality. Conclusion Unless extraordinary efforts are made, at the current pace not all countries of the SEAR will be able to attain the MDG 5 targets of reducing MMR by 75% and achieving universal access to reproductive health between 19 and 215. This has implications for the reduction of neonatal mortality and thus further reduction of under-5 child mortality to achieve MDG 4, which requires at least a % reduction of neonatal mortality. Disclosure of interests No competing interests to disclose. Funding None j References 1 WHO. Neonatal and Perinatal Mortality 24: Country, Regional and Global Estimates. Geneva: WHO, 27 [http://whqlibdoc.who.int/ publications/27/9789241596145_eng.pdf]. Accessed 16 August 211. 2 World Health Organisation. Measles and Rubella Serology (IgM) Results SEAR. Geneva, Switzerland: WHO, 2 [http://www.searo.who.int/ vaccine/linkfiles/meavpd/mealab2.pdf] 19 August 211. ª 211 The Author BJOG An International Journal of Obstetrics and Gynaecology ª 211 RCOG 11