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Abstract

  1. Top of page
  2. Abstract
  3. Progress towards achieving Millennium Development Goal (MDG) 5A
  4. Progress towards MDG 5B
  5. Contraceptive prevalence
  6. Adolescent birth rate
  7. Antenatal care coverage
  8. Unmet need for family planning
  9. Conclusion
  10. References

Please cite this paper as: Islam M. Progress towards achieving Millennium Development Goal 5 in South-East Asia. BJOG 2011; 118 (Suppl. 2): 6–11.


Progress towards achieving Millennium Development Goal (MDG) 5A

  1. Top of page
  2. Abstract
  3. Progress towards achieving Millennium Development Goal (MDG) 5A
  4. Progress towards MDG 5B
  5. Contraceptive prevalence
  6. Adolescent birth rate
  7. Antenatal care coverage
  8. Unmet need for family planning
  9. Conclusion
  10. References

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 170 000 mothers lost in 2005. 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 660 per 100 000 live births in Timor-Leste, and above 300 in Myanmar, Indonesia and India (see national estimates, Table 1).

Table 1.   Comparison of maternal mortality ratio (deaths per 100 000 live births) in SEAR countries—global and national estimates
 Global estimate (2005)*Absolute numbers of deathsNational estimateNational sources
  1. *Source of global estimates, maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva, World Health Organisation, 2007.

Bangladesh57021 000194Household Survey Report 2011. Survey Sample Vital Registration system (BBS, 2008)
Bhutan440280255National Health Survey 2000
DPRK370130097Central Bureau of Statistics, DPRK, 2002
India450117 000301Sample registration system
Indonesia42019 000307Progress to MDG report 2004
Maldives1201272Ministry of Planning and National Development, Statistical Yearbook 2006
Myanmar3803700316Progress to MDG report 2005
Nepal8306500281Nepal Demographic and Health Survey 2006, recent survey indicates 231
Sri Lanka5819043MDG report 2005
Thailand110110020.632001 National Data
Timor-Leste380190660Timor-Leste 2006 Country Health statistics report

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 2009, in Timor-Leste, Bangladesh and Nepal the proportion of women who deliver with a skilled birth attendant is <20%, while Myanmar, Bhutan and India are yet to reach the goal of 60% which was set for the year 2010.

Table 2 depicts data on the MDG 5A target: MMRs in the base year of 1990, current levels and the expected levels in 2015 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.

Table 2.   Maternal health indicators of member countries of SEAR
 Number of maternal deaths (000s), 2005Maternal mortality ratio (per 100 000 live births)Deliveries by skilled birth attendants** (%), 2000–2006Progress toward the MDG target
1990*Latest (year)*MDG 2015*
  1. MDG, millennium development goal; NA, not available.

  2. Source: WHO, UNICEF, UNFPA, WB. Maternal mortality ratio in 2005.

  3. *WHO/SEAR. 11 health questions about 11 SEAR countries, New Delhi 2007.

  4. **World Health Statistics 2009.

Bangladesh21 000574380 (2002)14320Significant progress
Bhutan280560255 (2000)14051Insufficient
DPRK1300105 (1996)97 (2002)3097NA
India117 000437301 (2005–6)10947Insufficient
Indonesia19 000390307 (2002)10066Insufficient
Maldives1250072 (2005)12584On track
Myanmar3700232380 (2002–3)6357Insufficient
Nepal6500515281 (2005)13419Significant progress
Sri Lanka1909247 (2001)3697On track
Thailand11003614 (2003)997On track
Timor-Leste190NA420–800 (2002)25219Insufficient

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 1990 and 2015. The number of neonatal deaths (deaths of infants within 28 days of life) in the region was 1.3 million1 according to the 2005 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 <20 per 1000 live births in 2004, while rates for DPRK, Maldives, Timor-Leste and Bhutan ranged from 22 to 30 per 1000 live births and Nepal, Bangladesh, India and Myanmar rates were 32–49 per 1000 live births.

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Figure 1.  Neonatal mortality rate (per 1000 live births) in SEAR countries, 2004. Source: World Health Statistics, 2009, WHO.

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Figure 2 shows the trends for the percentage of neonates protected at birth against neonatal tetanus from 1990 to 2006 through tetanus toxoid immunisation. Almost all countries had achieved more than 80%, 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.

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Figure 2.  Trends in neonates protected at birth against neonatal tetanus (%): 1990–2006.2

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Progress towards MDG 5B

  1. Top of page
  2. Abstract
  3. Progress towards achieving Millennium Development Goal (MDG) 5A
  4. Progress towards MDG 5B
  5. Contraceptive prevalence
  6. Adolescent birth rate
  7. Antenatal care coverage
  8. Unmet need for family planning
  9. Conclusion
  10. References

The MDG 5 target B of achieving universal access to reproductive health by 2015 was adopted by the 62nd United Nations General Assembly in October 2007. 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

  1. Top of page
  2. Abstract
  3. Progress towards achieving Millennium Development Goal (MDG) 5A
  4. Progress towards MDG 5B
  5. Contraceptive prevalence
  6. Adolescent birth rate
  7. Antenatal care coverage
  8. Unmet need for family planning
  9. Conclusion
  10. References

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 10%) and the total fertility rate is marks the highest (7.8) around the globe. Bhutan, Myanmar, Maldives and Nepal had a CPR of <50% in 2008, while in the rest of the countries the CPR ranges from 56% to 72%.

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Figure 3.  Trends in contraceptive prevalence rate in SEAR countries 1990–2008. Source: World Population Policies 2005; World Population Data Sheet 2006; Family Planning Worldwise 2008 Data Sheet.

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Adolescent birth rate

  1. Top of page
  2. Abstract
  3. Progress towards achieving Millennium Development Goal (MDG) 5A
  4. Progress towards MDG 5B
  5. Contraceptive prevalence
  6. Adolescent birth rate
  7. Antenatal care coverage
  8. Unmet need for family planning
  9. Conclusion
  10. References

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. pregnancy-induced 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 20s 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 2005 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 1000 women 15–19 years of age in 2005. Teenage fertility has declined in Bangladesh, India, Maldives and Indonesia, reaching 132, 80, 70 and 55 per 1000 women live births respectively in 2005. In Nepal, the data on teenage fertility rate did not reflect any significant changes over the past few decades, still remaining above 120 live births per 1000 women aged 15–19 years. The lowest teenage fertility rates were in DPRK (2), Sri Lanka (20) and Myanmar (21).

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Figure 4.  Teenage fertility rate (per 1000 women aged 15–19 years), SEAR, 1975–2005. Source: World Population Data, 2005.

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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 10.2% girls in Nepal are married by 15 years of age.

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Figure 5.  Percentage married by age 18 among females aged 20–24 and 40–44 years. Source: Bangladesh DHS 2004; India NFHS-III 2005–6; Indonesia DHS 2002–3; Nepal DHS 2006; Sri Lanka DHS 2000.

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Antenatal care coverage

  1. Top of page
  2. Abstract
  3. Progress towards achieving Millennium Development Goal (MDG) 5A
  4. Progress towards MDG 5B
  5. Contraceptive prevalence
  6. Adolescent birth rate
  7. Antenatal care coverage
  8. Unmet need for family planning
  9. Conclusion
  10. References

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.

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.

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Figure 6.  Antenatal coverage in SEAR countries in 2004–8. Source: India NFHS 2005–6; Bangladesh DHS 2007; TLS Annual Health Report 2008; MMR, HMIS, Department of Health Planning; Nepal Annual Report 2006–7; KRD RH Survey 2006; Sri Lanka DHS 2006; MAV RHS 2004; Thailand THA MCHS 2006.

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Unmet need for family planning

  1. Top of page
  2. Abstract
  3. Progress towards achieving Millennium Development Goal (MDG) 5A
  4. Progress towards MDG 5B
  5. Contraceptive prevalence
  6. Adolescent birth rate
  7. Antenatal care coverage
  8. Unmet need for family planning
  9. Conclusion
  10. References

The unmet need for family planning reflects the level of missed opportunity for family planning services for women 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.

Table 3.   Unmet need for family planning in SEAR countries
CountriesUnmet need for family planning
  1. Source: Family Planning Saves Lives! An Investment in Development, WHO/SEARO, 2005.

Bangladesh, 200315.3
BhutanNA
DPRK, 200316.7
India, 200315.8
Indonesia, 20038.6
Maldives, 200334
Myanmar, 199720
Nepal28
Sri Lanka, 20008
Thailand5.9
Timor-LesteNA

Conclusion

  1. Top of page
  2. Abstract
  3. Progress towards achieving Millennium Development Goal (MDG) 5A
  4. Progress towards MDG 5B
  5. Contraceptive prevalence
  6. Adolescent birth rate
  7. Antenatal care coverage
  8. Unmet need for family planning
  9. Conclusion
  10. References

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 1990 and 2015. 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 50% reduction of neonatal mortality.

Disclosure of interests

No competing interests to disclose.

Funding

None

References

  1. Top of page
  2. Abstract
  3. Progress towards achieving Millennium Development Goal (MDG) 5A
  4. Progress towards MDG 5B
  5. Contraceptive prevalence
  6. Adolescent birth rate
  7. Antenatal care coverage
  8. Unmet need for family planning
  9. Conclusion
  10. References