MDG 5: improve maternal health

Target 5.A. Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
Target 5.B. Achieve, by 2015, universal access to reproductive health
More than half a million women die each year in pregnancy and childbirth. Most of them die because there is not enough skilled routine and
emergency care. Some South-East Asian and North African countries with high maternal and newborn mortality, have made progress in
providing skilled care to women during pregnancy and childbirth. However, in sub-Saharan Africa, one in 22 women has the risk of dying during
pregnancy or childbirth over a lifetime, compared with about one in 8000 women in the developed world.
WHO key working areas
* Strengthening health systems and promoting interventions focusing on policies and strategies that work, are pro-poor and cost-effective.
* Monitoring and evaluating the burden of maternal and newborn ill-health and its impact on societies and their socio-economic
development.
* Building effective partnerships in order to make best use of scarce resources and minimize duplication in efforts to improve maternal and
newborn health.
* Advocating for investment in maternal and newborn health by highlighting the social and economic benefits and by emphasizing maternal
mortality as human rights and equity issue.
* Coordinating research, with wide-scale application, that focuses on improving maternal health in pregnancy and during and after childbirth.
MDG 5: Improve Maternal Health
Target 5a: Reduce by three quarters the maternal mortality ratio
Target 5b: Achieve, by 2015, universal access to reproductive health
Disclaimer: Some of the MDG data presented in this website have been adjusted by the responsible specialized agencies to ensure international
comparability, in compliance with their shared mandate to assess progress towards the MDGs at the regional and global levels.[1]
Indicators (United Nations)
5.1 Maternal mortality ratio (MMR):
a. 2000: 200[2]
b. 2005: 230[3]
c. 2008:
A maternal death is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of
the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes.”[4] According to
the 2005 WHO/UNICEF/UNFPA maternal mortality estimates, most of the countries in the Asian region have not reduced the maternal
mortality by three quarters as stated in the MDG Goal.[5]
Philippines record a high maternal mortality ratio of 230 per 100,000 live births in 2005[6]. This maternal mortality ratio in the Philippines
remains stagnant, in comparison to 238 in 1995, and 200 in 2000.
According to the ICPD+15 draft country report submitted by Likhaan (ARROW partner in the Philippines), MMR dropped from 209 (in 1993)[7]
to 172 (in 1998)[8] to 162 (in 2006)[9]. The latter drop is deemed “insignificant” by the National Statistics Office. In 2000, the WHO corrected
the 1998 estimates upward to 200[10], a figure that seems to correspond more to alternative indicators. Using MMR of 200 for 2008, the
University of the Philippines Population Institute and the Guttmacher Institute projected annual maternal deaths to be about 4,700 or 12
deaths/day.
Critical indicators to comprehensively monitor maternal mortality
5.1.1 Lifetime Risk of Maternal DeathThe concept of adult lifetime risk of maternal death measured as the probability of dying from a maternal
cause during a woman’s reproductive lifespan[11], is more holistic in comparison to maternal mortality ratio (MM Ratio) and maternal mortality
rate (MM Rate). Whereas the MMRatio and the MMRate are measures of the frequency of maternal death in relation to the number of live
births or to the female population of reproductive age, the lifetime risk of maternal mortality describes the cumulative loss of human life due to
maternal death over the female life course. Because it is expressed in terms of the female life course, the lifetime risk is often preferred to the
MMRatio or MMRate as a summary measure of the impact of maternal mortality[12].
The lifetime risk of maternal death is 1 in 140, as compared to 1 in 1 300 in China, which shows the extent of risk to the life and well being of
Filipino women in reproductive age group, which is indicative of inequity.
5.1.2 Maternal deaths due to unsafe abortion
Unsafe abortion continues to be a major factor in maternal deaths in the region. Mortality due to unsafe abortion for the South-east Asia is
estimated at 14% of all maternal deaths.[13]
In the Philippines, pregnancy with abortive outcome contributed to nine percent of maternal deaths in 2000.[14] Laws in the Philippines restrict
access to safe abortion services and it is important to understand that providing access to safe abortion services is a critical intervention to
reduce maternal deaths in these contexts.
Voices on the ground:
News/Magazine articles:
a. This article is based on the story of Mrs X (not real name) in Philippines. If she had a choice, she would have taken other roads but
inevitably took the maternity death road because options of alternative ‘routes’ were not availed to her. This was because she was poor, lived
in an inaccessible area and she was in poor health. She had no access to the ‘escape routes’ that would enable her to acquire full quality
information that would enable her avoid unwanted pregnancies, space her pregnancies and plan her family. She had no access to quality health
services or trained birth attendants. Read the article here
b. “Giving midwives access to further training in life-saving skills could prevent up to 80 percent of maternal deaths in Philippines.” This would
especially be effective in the areas that are hard to reach or disadvantaged and where doctors and nurses are scarce. Read the article here
c. More and more Filipino women are dying due to child birth related complications. Causes of these deaths and other birth related
complications are haemorrhage, obstructed labour, complications of unsafe abortion and many others. Unfortunately, most of these deaths
and complications are preventable with proper diagnosis and access to better health care and facilities. However, there is no sufficient progress
in the reducing of the maternal deaths. Read the article here
Videos:
a. Video highlighting the risks pregnant and postpartum women face during times of disaster such as flooding in Philippines. It also highlights
how UNFPA helps these women in various ways, for example, after a disaster UNFPA handed out kits for maternal health and hygiene. Medical
missions are conducted in partnership with NGOs and are used to hand out kits to pregnant, delivering and postpartum women. NGOs conduct
prenatal and post partum checkups, hold information sessions and distribute clean delivery kits among other things. With the provision of this
much needed reproductive health services, the high likelihood of maternal deaths could be averted. Watch the video. Part 1 of 2 and Part 2 of
2
Study:
1. ‘A Study of Knowledge, Attitudes and Understanding of Legal Professionals about Safe Abortion as a Women’s Right’ was conducted by
ASAP in 2008-2009. The study was conducted with local partner Philippines (Women LEAD). The court is a powerful arena to effect changes in
society. Through the avenue of the courts, restrictive laws may be stricken down as invalid; failure to implement the law by state agents, may
hold these state agents liable, in their official as well as personal capacity; refusal to heed the requirements of the law, may also compel the
courts to enforce compliance by these state agents. Legal profession, when used in this study, however, does not simply refer to those who
have had formal schooling in law and are bestowed the titles as such. This study adopts an expanded definition of the legal profession and
includes also legislators, high ranking police personnel, jailers, medical practitioners, head of hospitals, and other persons who are tasked with
the implementation of the law, as well as those whose opinion and experience may be given weight in legal and policy advocacy. While the
members of the legal profession are important agents of change in society, they cannot effect lasting change on their own. We recognize that
these changes in the field of law and policy need to be propelled and informed by the experiences and wisdom of those at the ground level in
the implementation of the law. The study findings are expected to help in a greater understanding of the perspectives of this group and will
inform future capacity building, attitude reconstruction efforts and the development of advocacy tools for action. This study is unique in its
attempt to move beyond the women/community-provider interface and look at gatekeepers outside the service provision field. To read the
study,
5.2 Proportion of births attended by skilled health personnel:
a. 2001: 58.0[15]
b. 2005:
c. 2008: 61.8[16]
A skilled attendant, according to WHO, refers to “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 postnatal period,
and in the identification, management and referral of complications in women and newborns.” Traditional Birth attendants (TBA) either trained
or untrained are excluded from the category of skilled health workers.
Skilled attendants at birth in 2003 in Cambodia were reported to be 59.8[17].
Critical indicators to comprehensively monitor skilled health attendance would include not just skilled birth attendants but also access to basic
and comprehensive emergency obstetric care services and post-partum care
The quality of care provided by skilled attendants at birth is crucial. Particularly when complications occur, skilled personnel need access to
essential drugs, supplies, equipment and emergency obstetric care. They should receive training on required competencies. And they need
supervision that helps ensure high standards of care, which is vitally important[18].
Global and country studies on skilled attendants showed that the overall effectiveness of skilled attendants depends on their access to a
functioning health system with a basic and comprehensive level of obstetric care, including surgery and blood transfusions in case of
complications. The key to maternal death reduction is universal access to emergency obstetric care which is a major challenge in most of the
Asian countries.
It is therefore critical to not just look at skilled attendants at birth, but also look at a) access to emergency obstetric care services and b)
postpartum care so as to reduce maternal deaths meaningfully.
5.2.1 Access to emergency obstetric care
According to the ICPD+15 draft country report submitted by Likhaan (ARROW partner in the Philippines), “The most common life-threatening
complications can all be treated by a package of interventions called Emergency Obstetric Care (EmOC)[19]. Basic EmOC comprises of 6
functions including intramuscular medications and removal of retained products of conception; while Comprehensive EmOC comprises of the 6
BEmOC functions plus blood transfusion and CS. To be able to save women, functional EmOC facilities have to be available in adequate
numbers, in a manner that is accessible to them. At this time, it is not certain whether poor and remote provinces have these necessary
facilities.Caesarean Section (CS) can be used as a proxy indicator for EmOC, esp. CEMOC. It is a life-saving procedure for many obstetric
complications, especially obstructed labor and extensive bleeding. Maternal mortality experts estimate an optimum rate for C-sections of 5 to
15% based on the strict indications[20]. In the Philippines in 2003, only 1.7 of the poorest women and 3.4% of the second poorest had C-
sections; while 20% of the richest women had C-sections, which were not necessary and could have exposed them to surgical and anesthetic
risks.”
5.2.2 Post partum care
A large proportion of maternal deaths occur during the 24 hours after delivery and hence postnatal care constitutes a critical safe pregnancy
intervention. The first two days following delivery are critical for monitoring complications arising from the delivery.
The single most common cause of maternal mortality is obstetric haemorrhage, generally occurring postpartum and accounting for 25—33% of
all maternal deaths. The rate of death due to post partum haemorrhage (PPH) varies widely in the developing world. PPH-related mortality
rates based on hospital studies are estimated to be 25—30% in India, and 43% in Indonesia. However, women who come to a hospital for care
do not represent the general population of women. Because haemorrhage is more apt to occur and more difficult to treat in the community,
studies have suggested higher rates of PPH-related mortality in these areas, but there is comparatively little data available outside of a hospital
setting.[21]
According to the 2003 Philippines National Demographic Health Survey (NDHS), one in three women had a postnatal checkup within two days
of delivery and 17 % of the women received a postnatal checkup from three to six days after delivery, for a total of 51 % of women receiving a
postnatal checkup within seven days of delivery. 38% of women delivered in a health facility (assuming they received postpartum care), a total
of 89 % of women received postnatal care within six days of delivery.
Although postnatal visits have improved in the countries, the quality of postpartum care, diagnosis of complications and transport to a higher
level facility are critical to address postpartum complications.
5.3 Adolescent birth rate (per 1000 women):
a. 2001: 55.0[22]
b. 2006: 53.0[23]
c. 2008:
The adolescent birth rate measures the annual number of births to women 15 to 19 years of age per 1,000 women in that age group. It
represents the risk of childbearing among adolescent women 15 to 19 years of age. It is also referred to as the age-specific fertility rate for
women aged 15-19[24].
The adolescent birth rate has slightly declined 55.0 in 2001 to 53.0 in 2006.
According to the ICPD+15 draft country report submitted by Likhaan (ARROW partner in the Philippines), Adolescent Fertility Rate (the number
of births per 1,000 women aged 15 to 19 constant (from 50 in 2003 to 54 in 2008)- despite slight decline in total fertility rate This means young
women continuing to have unprotected sex before they are ready for the consequences. Dire outcomes include the risk of maternal
complications, onerous parenting obligations, and missed opportunities for education and future employment.
Teenage fertility and pregnancies are a major health concern because teenage mothers and their children are at high risk of reproductive
morbidity and mortality. Early childbearing also impedes the overall development of teenage girls and their access to education and labour
force participation.
Critical indicators to comprehensively monitor adolescent birth rate would look at the median age at marriage, the legal age at marriage and
access to sex and sexuality education
5.3.1 Median age at marriage
The median age for marriage for women aged (25-49) is 22 in the Philippines.
5.3.2 Legal age of marriage
The legal age of marriage in the Philippines is 18 for women and 18 for men. There are also pre-conditions for parental approval. In the
Philippines individuals aged 18–21 need written parental consent and must undergo marriage counselling, and individuals aged 21–25 need
parental advice before getting married.
In the Philippines, under the Civil and Commercial Code, betrothal can occur only when both the man and the woman are at least 17 years of
age; children must obtain the consent of their parents or guardians for the betrothal, and only men can initiate betrothal.[25]
5.3.3 Sex and sexuality education
Sex education is defined as the basic education about reproductive processes, puberty and sexual behaviour. Sex education may include other
information, for example about contraception, protection from sexually transmitted infections and parenthood.[26] Sexuality education is
defined as education about all matters relating to sexuality and its expression. Sexuality education covers the same topics as sex education but
also includes issues such as relationships, attitudes towards sexuality, sexual roles, gender relations and the social pressures to be sexually
active, and it provides information about SRH services. It may also include training in communication and decision-making skills.[27]
Philippines have not started providing sex education in schools as part of the school curriculum. In the Philippines, adolescent reproductive
health (ARH) education is mostly community-based. Some are school based, and a few are implemented in the workplace. Information and
education interventions include lectures, workshops, discussions, trainings, and media-based activities. Most of these programmes are focused
on ARH, sexuality and fertility issues, where counselling is provided.[28] In 1997, the Population Commission of the Philippines, with the
assistance of the national and local governments and NGOs, launched “Hearts and Minds,” a nationwide information, education and
communication (IEC) campaign that teaches young Filipinos about sexual health, responsible adulthood, and parenthood.[29]
However according to the BBC sources, a pilot project teaching sex education in 80 primary schools and 79 secondary schools across Philippines
is being rolled out in the Philippines[30].
5.3.4 Access to reproductive health services for adolescents within the public health system
Data is not easily available.
5.4 Contraceptive prevalence rate (Current contraceptive use among married women 15-49 yrs old any method%:
Contraceptive prevalence rate (Current contraceptive use among married women 15-49 yrs old any method%:
a. 2001: 47.0[31]
b. 2005: 49.3[32]
c. 2008: 50.7[33]
CPR increased from 47.0 (2001) to 49.3 (2005) to 50.7 (2008).
Critical indicators to comprehensively monitor contraceptive prevalence rate would include looking at range of methods available including
access to modern methods and provision of informed choice.
Beyond the numbers for CPR it is essential to look at access to a range of contraceptive services.
5.4.1 Range of contraceptive methods available.
Access to modern methods of contraception seems to be an issue as 32% of all contraceptive users rely on traditional methods for their
contraceptive needs according to the 2003 DHS.
5.4.2 Provision of informed choice service provision.
Informed choice of family planning methods is an important rights indicator. However it has not been commonly regarded as an important
aspect of the service provided with the contraception method. Informed choice includes: information on the full range of methods including
traditional and male methods; information on side-effects of all methods and the appropriate course of action; and information on the efficacy
of each of the methods.[34] However, data is not readily available for the Philippines for this indicator.
Voices from the ground:
ICPD+15 Country Case Study
a. This study looks into the reasons for the low level of contraceptive use among sexually active youth in selected urban poor communities in
Metro Manila, with a focus on the accessibility of young people to family planning information, services and supplies and their knowledge
about contraception. The study also presents the policy and legal situation vis-à-vis raising awareness about young people’s sexual and
reproductive health and rights. The study seeks to establish that lack of effective access to FP information and services among Filipinos in
general and young people in particular are due mainly to the absence of a government policy to provide the full range of safe and legally
acceptable family planning methods. Read the case study
5.5 Unmet Need for contraception:
a. 2003: 17.3[35]
b. 2005:
c. 2008: 22.3[36]
Unmet need increased from 17.3% in 2003 to 22.3% in 2008.
Generally women with lower education or are uneducated, who are poor, who live in remote areas and rural areas face the greatest challenge
in controlling their own fertility. Socio-economic inequities are closely inter-linked with higher rates of unintended births and it is important to
ensure access to contraception to all groups of women.[37]
The accepted definition of “[u]nmet need for contraception is the percentage of fertile, married women of reproductive age who do not want
to become pregnant and are not using contraception.”[38] The concept of unmet need is an important one because it assesses the ‘need’ for
contraception based on whether and when a woman wants a child or another one rather than focusing on government limits on family size.
Another limitation is that it assumes all users as having their need ‘met’ including women with infertility and secondary infertility. But many
women may be using a contraceptive method not of their choice due to provider bias or government policy as earlier discussed and this
constitutes an ‘unmet need’ too. It is also important to keep in mind that contraception is primarily focused on pregnancy prevention. There is
also an urgent unmet need for disease/infection prevention which is not being considered.[39]
Critical indicators to comprehensively monitor unmet need would take into account differences between total and wanted fertility rates and
reasons for non-use of contraception.
5.5.1 Total and Wanted Fertility Rates
Wanted fertility rates compared to Total Fertility Rates
a. Total Fertility Rate (2005): 3.5[40]
b. Wanted Fertility Rate (2005): 2.5[41]
c. % difference: 40%[42]
It is important to look at Wanted Fertility Rates and Total Fertility Rates to also establish unmet need.
In the DHS 2003, the TFR was 3.5 and the WFR was actually 2.5; this means women were having 40% more children than they actually wanted
and this constitutes an unmet need.[43]
5.5.2 Reasons for non-use of contraception
One of the most common reasons given by married women with an unmet need for not using contraception is associated with the supply of
methods and services and within this category, concerns about the side effects, health consequences and inconvenience of methods were the
most prominent reasons. The prevalence of these concerns is particularly high in Southeast Asia.[44]
Apart from the fertility-related reasons, method-related reasons and health concerns, a major reason for non-use of contraception in the
Philippines is ‘fatalism’ (0.9%) i.e. fertility is still seen as something ‘fate’ deals out rather than a matter of exercising choice. In addition,
opposition to use (both own and spousal) constitutes 19.7% and religious prohibition constitutes 6.2% all of which are not being considered in
discussing unmet need.[45]
5.6 Antenatal care coverage:
a. At least one visit (%):
b. At least one visit (%):
Ø 2000: 85.9[46]
Ø 2005:
Ø 2008: 91.0[47]
c. At least four visits(%):
Ø 2001:
Ø 2003: 70.4[48]
Ø 2008:
SOURCES: http://www.mdg5watch.org/index.php?option=com_content&view=article&id=107&Itemid=177