Goal 5: Improve Maternal Health

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1 107 In the Asia and Pacific region, maternal mortality ranges from 1 per 100,000 live births in Hong Kong, China to 1,800 in Afghanistan. The People s Republic of China (PRC) has a rather low rate of 45 but over 300 women die in childbirth per 100,000 live births in Bangladesh, India, Indonesia, and Pakistan. There is fairly strong evidence that maternal mortality ratios are reduced when a trained health worker is present. Adolescent birth rates have generally been falling since 1990 and in some cases the falls have been dramatic. But seven economies reported increases. Introduction Goal 5 has two targets: 5.A: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio. This ratio is calculated as the number of deaths in child birth per 100,000 live births. It is not yet possible to assess progress toward this target because data for earlier and more recent years are not sufficiently comparable for a number of economies. A related indicator is the number of births that are attended to by a health worker who has been trained to conduct deliveries and care for newborns. MILLENNIUM DEVELOPMENT GOALS 5.B: Achieve, by 2015, universal access to reproductive health. These services should cover advice on contraceptive methods and family planning, antenatal care, and advice on transmission of HIV/AIDS and other sexually transmitted diseases. This is a new target introduced in the revised MDG framework. Key Trends Maternal mortality is unacceptably high in many countries. Figure 5.1 shows the number of maternal deaths per 100,000 live births in Afghanistan had an extremely high ratio of 1,800. Of the five most populous economies, the People s Republic of China (PRC) has by far the lowest ratio: 45 per 100,000 live births in Bangladesh, India, Indonesia, and Pakistan all have maternal mortality ratios well above 300 per 100,000 live births. Other economies showing relatively high mortality ratios over 500 were Cambodia, Lao People s Democratic Republic, and Nepal. In many of these countries, tradition encourages young girls to marry at ages when their bodies are not yet fit for the rigors of childbirth. The richer economies of Brunei Darussalam; Hong Kong, China; Republic of Korea; Singapore; and Taipei,China reported less than 15 maternal deaths per 100,000 live births, with Hong Kong, China having the lowest ratio of 1. By comparison, maternal mortality rates for the developed countries of Western Europe and North America are rarely over 10 per 100,000 live births. Figure 5.1 Maternal Mortality Ratio, 2005 or Latest Year (per 100,000 live births) Hong Kong, China Taipei,China Brunei Darussalam Singapore Korea, Rep. of Uzbekistan China, People's Rep. of Mongolia Sri Lanka Malaysia Georgia Armenia Azerbaijan Thailand Maldives Turkmenistan Kazakhstan Viet Nam Kyrgyz Republic Tajikistan Fiji Islands Solomon Islands Philippines Pakistan Timor-Leste Myanmar Indonesia Bhutan India Papua New Guinea Cambodia Bangladesh Lao PDR Nepal Afghanistan Source: Table 5.1.

2 108 Properly trained midwives are scarce in many countries. Figure 5.2 shows that in the latest year for which data are available, skilled health personnel assisted in 90% or more of childbirths in 17 of the 38 economies; of these, nine economies reported that % of births were professionally attended. Of the five most populous economies, the PRC reported that 98% of births were professionally attended. For Indonesia, the figure was 73%. The others were much lower: India 47%, Pakistan 39%, and Bangladesh 18%, which is the lowest in the region apart from Afghanistan. In 2006, the percentages were higher or remained the same in 28 economies, compared with those in Sharp rises occurred in Bhutan, Indonesia, and Pakistan. On the other hand, 10 countries reported falling percentages. These were usually quite small but larger falls were reported by Azerbaijan, Papua New Guinea, and Timor-Leste. Figure 5.2 Births Attended by Skilled Health Personnel, 1995 and 2006 or Nearest Years (percent) Tuvalu Palau Uzbekistan Kazakhstan Turkmenistan Mongolia Fiji Islands Brunei Darussalam Sri Lanka Georgia Cook Islands Malaysia China, People's Rep. of Armenia Kyrgyz Republic Thailand Tonga Vanuatu Azerbaijan Micronesia, Fed. States of Viet Nam Solomon Islands Kiribati Maldives Tajikistan Indonesia Philippines Myanmar Bhutan India Cambodia Papua New Guinea Pakistan Lao PDR Nepal Timor-Leste Bangladesh Afghanistan Maternal deaths are reduced when a trained health worker is present. Figure 5.3 plots maternal deaths per 100,000 live births against the percentage of births attended by skilled health personnel for 30 selected member countries that have data for both variables for recent years. (The dates of the two variables are fairly close but not identical.) The linear regression suggests that over 80% of the variation in maternal mortality ratios between economies is explained by whether or not skilled health personnel are in attendance. The regression results also suggest that maternal mortality ratios fall by about 6.5 per 100,000 live births for every percentage point increase in the percentage of births attended by skilled health personnel. Maternal Deaths (per 100,000 live births) Figure 5.3 Maternal Mortality and Births Attended by Skilled Health Personnel, 2006 or Latest Year Source: Derived from Table 5.1. y = x R 2 = Percent of births attended by skilled health personnel Source: Table 5.1.

3 109 Adolescent births show that in many countries, young women are still poorly advised about reproductive health. Figure 5.4 shows the number of adolescent births as a percentage of the female population aged years. This is taken as an indicator of the extent to which women have access to good reproductive health care, including advice on family planning and modern contraceptive methods. Most of the 43 economies shown in Figure 5.4 have seen reductions in adolescent births since 1990, and in several countries the falls have been dramatic. The number per thousand women of childbearing age fell by 30 or more in nine economies, including Bangladesh, India, and Pakistan. Seven countries, however, reported increases, including Nepal, Philippines, and Thailand. In the latest year available (mostly in 2005 or 2006) six economies had rates below 10 but three had rates of 100 or higher. Among the most populous countries, the PRC reported the lowest rate (5). Pakistan s rate was also quite low (20). Much higher rates were reported by India (45), Indonesia (51), and Bangladesh (127). Figure 5.4 Adolescent Birth Rate, 1990 and 2007 or Nearest Years (per thousand women aged 15 19) Korea, Rep. of Hong Kong, China China, People's Rep. of Singapore Taipei,China Maldives Malaysia Tonga Mongolia Turkmenistan Pakistan Tuvalu Armenia Uzbekistan Brunei Darussalam Tajikistan Sri Lanka Kyrgyz Republic Samoa Kazakhstan Myanmar Fiji Islands Palau Viet Nam Georgia Kiribati Azerbaijan India Thailand Bhutan Cook Islands Indonesia Micronesia, Fed. States of Cambodia Philippines Timor-Leste Nauru Papua New Guinea Solomon Islands Marshall Islands Nepal Lao PDR Bangladesh MILLENNIUM DEVELOPMENT GOALS Source: Table 5.2. Data Issues and Comparability The most reliable information on maternal mortality comes from vital registration records or other administrative sources. In many developing economies, however, registration records are not well maintained, with many births taking place at home rather than in clinics, and many not being attended to by trained health workers. Mortality ratios for these economies are based on household surveys of varying reliability. Unfortunately, it is not possible to calculate the progress of many economies toward achieving the target because the maternal mortality ratios are not comparable, having been estimated using different methodologies. There is only 1 year data available for earlier years. Data on the proportion of births attended by skilled health personnel are collected through national household surveys. However, it is difficult to standardize the definition of skilled health personnel due to the differences in the training of health personnel in different countries. Data on the adolescent birth rate are derived from vital registration systems or household surveys. Data derived using both sources may suffer from limitations such as the misreporting of the mother s age and exclusion of previous births.

4 110 Goal 5 Targets and Indicators Table 5.1 Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio 5.1 Maternal Mortality Ratio 5.2 Proportion of Births Attended (per 100,000 live births) by Skilled Health Personnel (percent) Developing Member Countries Central and West Asia Afghanistan (2000) 14 (2003) Armenia (1997) 98 (2005) Azerbaijan (1998) 88 Georgia (1998) 98 (2005) Kazakhstan Kyrgyz Republic (1997) 98 Pakistan (1991) 39 (2007) Tajikistan (1996) 83 (2005) Turkmenistan (1996) 100 Uzbekistan (1996) 100 East Asia China, People s Rep. of Hong Kong, China 1 (2007) Korea, Rep. of 14 Mongolia (1998) 99 Taipei,China 7 (2007) South Asia Bangladesh (1994) 18 (2007) Bhutan (1994) 56 (2003) India (1993) 47 Maldives (1994) 84 (2004) Nepal (1996) 19 Sri Lanka (1993) 99 (2007) Southeast Asia Brunei Darussalam a (1994) 99 (1999) Cambodia (1998) 44 (2005) Indonesia (2007) Lao PDR (2001) 20 Malaysia (2005) Myanmar (1997) 57 (2001) Philippines (1998) 60 (2003) Singapore (1998) Thailand (2000) 97 Viet Nam (1997) 88 The Pacific Cook Islands (1998) 98 (2001) Fiji Islands (1998) 99 (2000) Kiribati 72 (1994) 85 (1998) Marshall Islands 95 (1998) Micronesia, Fed. States of 93 (1999) 88 (2001) Nauru Palau 100 (1998) 100 (2002) Papua New Guinea (1996) 41 (2000) Samoa 100 (1998) Solomon Islands (1994) 85 (1999) Timor-Leste (1997) 18 (2003) Tonga 92 (1991) 95 (2000) Tuvalu 99 (1997) 100 (2002) Vanuatu (1999) Developed Member Countries Australia (1999) Japan (1996) New Zealand a Brunei Darussalam is a regional member of ADB, but it is not classified as a developing member country. Sources: Millennium Indicators Database Online (UNSD 2009); for Hong Kong, China and Taipei,China: economy sources.

5 111 Table 5.2 Target 5.B: Achieve, by 2015, universal access to reproductive health Goal 5 Targets and Indicators 5.3 Contraceptive Prevalence Rate 5.4 Adolescent Birth Rate (percent of married women years) (per 1,000 women years) 1995 Latest Year Developing Member Countries Central and West Asia Afghanistan 5 (2000) 19 (2006) 151 (2001) Armenia 61 (2000) 53 (2005) (2006) Azerbaijan 55 (2000) 51 (2006) (2006) Georgia 41 (2000) 47 (2005) (2006) Kazakhstan (2006) Kyrgyz Republic 60 (1997) 48 (2006) (2006) Pakistan (2007) 73 (1992) 20 (2005) Tajikistan 34 (2000) 38 (2005) (2005) Turkmenistan 62 (2000) (2003) Uzbekistan 56 (1996) 65 (2006) (2006) East Asia China, People s Rep. of 84 (1997) 87 (2001) 16 5 (2006) Hong Kong, China 86 (1997) 84 (2002) 6 4 (2006) Korea, Rep. of 77 (1994) 80 (2005) 4 2 (2006) Mongolia 57 (1994) 66 (2006) Taipei,China 17 6 MILLENNIUM DEVELOPMENT GOALS South Asia Bangladesh 45 (1994) 56 (2007) (2005) Bhutan 19 (1994) 31 (2000) 120 (1993) 46 (2005) India 41 (1993) 56 (2006) 76 (1991) 45 (2006) Maldives 42 (1999) 39 (2004) (2006) Nepal 29 (1996) 48 (2006) (2004) Sri Lanka 66 (1993) 68 (2007) 33 (1991) 28 (2005) Southeast Asia Brunei Darussalam a (2002) Cambodia (2005) 90 (1993) 52 (2003) Indonesia (2007) 63 (1992) 51 (2006) Lao PDR 19 (1993) 32 (2000) 115 (1992) 110 (2005) Malaysia 55 (1994) (2004) Myanmar 33 (1997) 37 (2001) (1999) Philippines (2006) (2001) Singapore 65 (1992) 62 (1997) 8 6 (2006) Thailand 72 (1997) 81 (2006) (2005) Viet Nam 65 (1994) 79 (2007) 38 (1991) 35 The Pacific Cook Islands 63 (1996) 43 (1999) 82 (1996) 47 (2001) Fiji Islands (2004) Kiribati 36 (2000) (2005) Marshall Islands 105 (1995) 88 (2006) Micronesia, Fed. States of 54 (1994) 51 (2003) Nauru 36 (2007) 70 (1992) 69 (2006) Palau 33 (2003) (2005) Papua New Guinea 26 (1996) 77 (1994) 70 (2000) Samoa 25 (1998) 25 (1991) 29 (2006) Solomon Islands 72 (1998) 80 (1999) Timor-Leste 23 (1994) 10 (2003) 49 (1993) 59 (2004) Tonga (2006) Tuvalu 41 (1991) 22 (2005) Vanuatu (1999) Developed Member Countries Australia (2002) Japan 59 (1994) 54 (2005) 4 5 (2006) New Zealand (2006) continued.

6 112 Goal 5 Targets and Indicators Table 5.2 Target 5.B: Achieve, by 2015, universal access to reproductive health (continued) 5.5 Antenatal Care Coverage 5.6 Unmet Need for Family Planning (percent of live births ) (percent of women aged years who are married or in consensual union) One Visit Four Visits Earliest Year Latest Year Developing Member Countries Central and West Asia Afghanistan 16 (2003) Armenia 93 (2005) 71 (2005) 12 (2000) 13 (2005) Azerbaijan 77 (2006) 45 (2006) 12 (2001) 23 (2006) Georgia 94 (2005) 75 (2005) 24 (2000) 16 (2005) Kazakhstan 100 (2006) 70 (1999) 16 (1995) 9 (1999) Kyrgyz Republic 97 (2006) 81 (1997) 12 (1997) Pakistan 61 (2007) 28 (2007) 32 (1991) 25 (2007) Tajikistan 77 (2005) Turkmenistan 99 (2006) 83 (2000) 10 (2000) Uzbekistan 99 (2006) 79 (1996) 14 (1996) East Asia China, People s Rep. of 90 (2006) 3 (1992) 2 (2001) Hong Kong, China Korea, Rep. of Mongolia 99 (2006) 10 (1998) 5 (2003) Taipei,China South Asia Bangladesh 51 (2007) 21 (2007) 19 (1994) 17 (2007) Bhutan 88 (2007) India 74 (2006) 51 (2006) 17 (1993) 13 (2006) Maldives 81 (2001) Nepal 44 (2006) 29 (2006) 28 (1991) 25 (2006) Sri Lanka 99 (2007) 18 (2000) Southeast Asia Brunei Darussalam a 100 (1994) Cambodia 69 (2005) 27 (2005) 33 (2000) 25 (2005) Indonesia 93 (2007) 81 (2002) 13 (1991) 9 (2007) Lao PDR 35 (2006) 40 (2000) Malaysia 79 (2005) Myanmar 76 (2001) 21 (1991) 19 (2001) Philippines 88 (2003) 70 (2003) 26 (1993) 17 (2003) Singapore Thailand 98 (2006) 3 (2006) Viet Nam 91 (2006) 29 (2002) 7 (1997) 5 (2002) The Pacific Cook Islands Fiji Islands Kiribati 88 (1994) Marshall Islands Micronesia, Fed. States of Nauru Palau Papua New Guinea 78 (1996) Samoa Solomon Islands Timor-Leste 61 (2003) 30 (2003) 18 (1991) 4 (2003) Tonga Tuvalu Vanuatu Developed Member Countries Australia 100 (1991) Japan New Zealand 95 (1994) a Brunei Darussalam is a regional member of ADB, but it is not classified as a developing member country. Sources: Millennium Indicators Database Online (UNSD 2009); for Taipei,China: Directorate-General of Budget, Accounting and Statistics.

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