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Making
Pregnancy Safer in South-East Asia
Dr N Kumara Rai*, Dr Sanu Maiyan Dali**
Introduction
Of
the many health indicators that demonstrate comparison between developed and
developing countries, maternal mortality shows the greatest disparity. Every
year, eight million women suffer severe complications as a consequence of pregnancy, childbirth and unsafe abortion. Over half a million1,
99% from poor countries, die. Each year, globally, 40-60 million women seek
termination of an unwanted pregnancy under unsafe conditions. Worldwide,
almost 20 million unsafe abortions occur each year, of which 95% take place
in the developing world. Globally one in eight pregnancy-related deaths, an estimated 13% are due to unsafe abortions2.
Poor maternal health also affects the chances of survival of the newborn.
Although progress in infant and child survival has been made, an estimated 9.4 million babies still die shortly before or after their birth3
(perinatal period).
Compounding
these problems, epi-demics such as HIV/AIDS,
malaria and tuberculosis began to emerge or re-emerge, further complicating
the world's under-privileged. In sub-Saharan Africa, with high prevalence of
HIV/AIDS, maternal to child transmission of HIV is reversing the gains made
in infant and child survival in the last decades.
Maternal
mortality in South-East
Asia
accounts for about 40% of global deaths. Over 50 per cent of infant deaths in
the Region occur during the neonatal period; nearly two-thirds within the first week of birth, mostly due to perinatal causes4.
The
South-East Asia Region is home to nearly half of the world's poor, and women
are especially affected by poverty. Globally, women from the poorest
households, with a daily income of less than US$1, are at least 300 times
more likely to die due to pregnancy-related causes than their better-off counterparts5.
Despite
the establishment of an impressive health infrastructure, countries of South-East Asia are often not able to provide
life-saving emergency obstetric care. A large majority of women, particularly
the poor and the marginalized, do not have easy access to such life-saving
technologies.
There
is a complex interplay of socioeconomic, environmental, and cultural factors
that contribute to this situation in reproductive ill-health. The low social
status of women, the historical gender bias against women, their lack of
decision-making power in the family, poverty, ignorance, illiteracy and
malnutrition, unequal access to resources, and, in some settings, harmful
traditional practicesmilitate against survival.
More
direct determining factors are the age at marriage and pregnancy, the number
of births and frequency of childbearing, unwanted pregnancies and unsafe
abortions.
Health
systems in many countries have failed not only in addressing these issues,
but also in providing the basic minimum requirements of skilled attendance at
delivery and rapid access to quality care in the event of an emergency.
Dr
Brundtland, the Director-General of WHO, has aptly
stated, "Maternal mortality is an indicator not only of women’s health,
but also of access, integrity and effectiveness of the health sector".
Situation Analysis
In
the countries of the South-East Asia Region, although significant improvement
in child survival and reduction in infant mortality have been observed,
maternal mortality remains high. Though safe motherhood is a high priority
programme, most deliveries still occur at home and are attended by
traditional birth attendants. DPR Korea, Sri Lanka and Thailand have been able to successfully
address these issues, thereby substantially decreasing maternal mortality.
1. Maternal
Mortality Ratio
In
South-East
Asia,
maternal deaths are grossly under-reported, mainly due to non-registration
and misclassification. The estimated maternal mortality ratio (MMR) in
the Region varies between countries from 23 (Sri Lanka) to 539 (Nepal) per 100 000 live births.
Let us look at the scenario of the Maternal Mortality Ratio of the Member
Countries. In Bangladesh, MMR is 390, Bhutan 380, DPR Korea 105, India
407, Indonesia 373, Maldives 200, Myanmar 180, Nepal 539, Sri Lanka 23 and Thailand 446
Hence, it clearly shows that eight Member Countries have an MMR of above 100.
2. Infant
Mortality Rate
The
Infant Mortality Rate (IMR) in countries of the SEA Region ranges from 18 (Sri Lanka ) to 83 (Nepal) /1 000 live births as shown in
Fig.1. IMR in Member Countries is as follows: 79 in Bangladesh, 63 in Bhutan, 22 in DPR Korea, 72 in India, 48 in Indonesia, 50 in Maldives, 79 in Myanmar, 83 in Nepal,18 in Sri Lanka and 29 in Thailand6. IMR had
shown a considerable decrease from 142 to 18 in the last two decades (Fig 1).
Figure 1: Infant Mortality Rate South East Asia
Region,
1978 and 1988.
3) Perinatal Mortality
Rate
As
shown in Fig 2, the perinatal mortality rate (PNMR)
is considerably high in seven Member Countries. The World PNMR is 52/1 000
live births, whereas it was 85 in Myanmar, 80 in Bangladesh, 75 in Bhutan and
Maldives, 70 in India and Nepal, 60 in DPR Korea, 40 in Indonesia, 30 in Sri Lanka and 20 in Thailand7.
Figure
2 : Estimated perinatal monthly rates
in SEAR countries, 1999
(4) Births assisted by Skilled Health Personnel
The
percentage of all births attended by skilled health workers is considered to
be the most appropriate process indicator. It is closely related with
maternal mortality and is readily measurable (Fig 3). Current estimates
indicate that globally, only 56% of births are assisted by a skilled person.
In
the Region, in 1998, as per the country reports, DPR Korea has the highest
rate of attendance, followed by Sri Lanka, and Thailand. The higher the births attended
by trained health personnel, the lower the maternal mortality, except in Maldives. Maldives has some peculiarities: the rate
of trained health personnel attendance and MMR as per the country reports are
both high6 (95% and 200 respectively).
Figure
3: The relationship between MMR and % age of births attended by trained
health personnel in countries of the SEA Region ( 1998 )
Source: Health Situation in South-East Asia,
Basic Indicators 2000 (WHO, SEA-2000)
The direct indicator, the maternal mortality data, could
be used for monitoring the progress achieved in reducing maternal mortality
only for countries with compre-hensive vital
registration systems. However, other countries will have to depend on the
process indicator, data on skilled attendant at delivery.
Characteristics of Maternal Death
Research shows that most of the obstetric complications
cannot be predicted. Obstetric complications develop in 15 to 20 percent of
pregnancies. A major portion of these deaths occur either at home or in
transit.
A pregnant adolescent (10 to 19 years old) is two to
five times more likely to die than a woman between 20 and 25 years of age. In
some countries of the Region, 40 to 50 per cent of girls are married and
become pregnant before they reach the age of 208.
Causes of Maternal and Infant deaths
Globally,
80% of maternal deaths are due to direct obstetric complications: haemorrhage (25%), sepsis (15%), unsafe abortion (13%),
hypertensive disorders of pregnancy, eclampsia
(12%) and obstructed labour (8%), other direct
causes like ectopic pregnancy, embolism, and anaesthetic-related (8%) and indirect causes like malaria,
anaemia and heart disease9(8%).
Information
about the causes of maternal and neonatal deaths are
not available in all Member Countries. Anaemia
during pregnancy is a major contributor to maternal death and low birth
weight. More than 70% of pregnant women in South-East Asia Region suffer from nutritional anaemia8.
An overview of available information on the causes of maternal deaths for
five countries of Region is shown in Table given below. For Myanmar,
the information is hospital-based and abortion was the main cause of maternal
death. In India
and Nepal, it
is based on large-scale sample surveys in some parts of the country and haemorrhage is the main cause of death. Anaemia is responsible for one-fourth of maternal deaths.
In Sri Lanka
and Thailand,
the information is from data collection by health services, and indirect
causes and obstructed labour respectively are the
main causes of maternal deaths.
Death
of newborns during the first week of life is largely the result of inadequate
or inappropriate care during pregnancy, child-birth, or the first critical
hours after birth. The major causes of neonatal mortality are neonatal
infections, birth asphyxia and trauma, preterm birth and/or low birth-weight and congenital anomalies7.
Anaemia may also contribute to perinatal
morbidity and mortality by increasing the likelihood of intrauterine growth retardation and the pre-term delivery8.
The
prevalence of low birth weight varies from 1% (DPR Korea) to 50% (Bangladesh)
in countries of the SEA Region. It is 50 in Bangladesh,
23 in Bhutan,
1 in DPR Korea, 30 in India,
11 in Indonesia,
20 in Maldives,
23 in Myanmar,
25 in Nepal,
18 in Sri Lanka
and 8 in Thailand6. * Director, Dept. of Health Systems and
Community Health, WHO, SEARO, New Delhi
** Regional focal point, Making Pregnancy Safer, WHO, SEARO,
New Delhi 
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