Maternal Mortality in South Asia
- Chantel Lovell
- May 9, 2021
- 6 min read
According to the World Health Organization (WHO) and the United Nations International Children's Emergency Fund (UNICEF), the global maternal mortality ratio has declined by nearly 38% from 2000 to 2017. The maternal mortality ratio (MMR) represents the number of maternal deaths per 100,000 live births during a given time interval. In 2000, the average global MMR was 342, with the most current data estimating an MMR of 211. Sub-Saharan Africa and South Asia face disproportionately higher ratios than the rest of the world, making up around 85% of all maternal-related deaths. In the past three decades, the countries of South Asia- Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka- have experienced a -71% relative change in MMR from 558 to 163, while sub-Saharan Africa ratios decreased from 987 to 533. This essay will examine maternal mortality in South Asia, specifically within Nepal, India, Afghanistan, and Pakistan, related to socioeconomic factors and HIV prevalence. Further, there will be a focus on specific and broad policy implementations contributing to decreasing or stagnant mortality rates.
Maternal Mortality Goals
The Millennium Development Goals (MDG), established in 2000, sought to reach eight specific goals by 2015. Relevant to maternal mortality is MDG four and MDG five. That is, to reduce child mortality and improve maternal health, respectively. Within MDG five, the United Nations (UN) goal was to reduce MMR by three quarters and achieve universal access to reproductive health services. According to WHO, the global decline was only 45% from 1990 to 2013. Major contributors that prevent further decreases in maternal mortality include the three delays: delay in deciding to seek medical assistance, delay in accessing appropriate care, and delay in receiving that care from health centers. Such delays occur for many different reasons, ranging from cultural beliefs to lack of transportation. Often, it boils down to a lack of awareness. Many women are unaware of prenatal care benefits or even the increasing legalization of abortion in certain regions.
The MDG was particularly challenging in Nepal due to gender inequality, economic disparity, politics, and cultural discrimination. Studies revealed such impacts upon women, more specifically among various ethnic groups, concerning their choices to seek or not to seek prenatal care and maternal and child health services (MCHs). For example, large groups of women in Nepal, as of 2008, refuse prenatal care due to the belief that it increases infant mortality in the womb. The general perception of maternal care is often affected by traditional familial beliefs. Additionally, rural populations in Nepal are more likely to trust traditional healers over other health care workers due to reports of staff being unreliable or unavailable. The percentage of mothers seeking prenatal care from skilled birth attendants has, however, increased per annum. It is necessary to recognize culturally significant beliefs when implementing policies to combat maternal mortality. That is, researching for and providing community-based knowledge rather than pushing Western ideals.
Studies of the Mongoloid women indigenous to parts of Asia provide evidence that women’s autonomy and equality can impact mortality rates. They experienced a nearly 50% lower MMR than the orthodox Chettri and Brahmin women of Nepal. When women of any population are pressured into early marriage and experience frequent births, they are at an increased risk for material-related mortality. The United Nations Economic and Social Commission for Asia and the Pacific (ESCAP) states that “Evidence has shown that MM…results from a culmination of violation of decision-making and human rights against women and girls.” (UNESCAP, 2010) Not only should we be investing in training medical professionals to combat maternal mortality, but there should also be more investment in women’s education and rights for developing countries.
Efforts and Interventions
Policy interventions in Nepal include national efforts to prioritize family planning as well as maternal and child health. The government has focused on specific interventions to combat maternal mortality for over five decades, seeking to provide more widespread access to health services for more vulnerable populations. Such interventions have proven successful through studies of socioeconomic status and health outcomes, where the reduction of poverty is associated with increased health status. Nepal adopted a community-based approach to providing appropriate services accommodating cultural differences, welcomed provisions for free or reduced maternal and child healthcare, and trained more women as community health volunteers. They are among ten countries worldwide to have reduced maternal mortality by at least 75% through their efforts to provide equitable access to health treatments. Nearly half of Nepal’s reduction of MMR has come from access to safe abortions. Still, abortion-related complications from women unable to safely receive care for unwanted pregnancies are on the rise. This continual increase is due to barriers that many women face over lack of decision-making autonomy or fear due to stigma.
Access to family planning services and knowledge allows women to prevent unwanted or risky pregnancies, consequently reducing MMR. USAID/Nepal programs seek to educate women as healthcare workers in rural communities with cross-cultural methods that apply to groups of various incomes, ethnicities, and beliefs. Despite efforts for comprehensive services, Nepal faced significant challenges targeting the more disadvantaged groups in need, and want, of access to modern contraceptives and clinics. Task-shifting is highly important to healthcare expansion and reducing maternal and child mortality, where less specialized staff can take on more responsibilities where it is needed.
In India, specifically in Uttar Pradesh/Uttaranchal, Bihar/Jharkhand, and Rajasthan, witnessed the highest MMR reduction at 76.1%. Nonetheless, India still accounted for 17% of maternal mortality rates worldwide as of 2013. Data from 2018 suggests that India is around an MMR of 113, which is a decline in total annual deaths from 33,800 mothers in 2016 to 26,437 mothers. UNICEF recognizes that many direct causes of maternal deaths- including hemorrhaging, anemia, and obstructed labor- are preventable. Indirect causes such as infections and malnutrition are also considered preventable and requiring of attention within the scope of maternal mortality policies. Young reproductive age highly contributes to MMR as this group is even less likely to receive the appropriate prenatal and delivery care. The Ministry of Health and Family Welfare (MoHFW) and state governments in India work alongside UNICEF to expand policy change efforts and formulations relating to maternal health. Further goals include reaching vulnerable communities with higher socioeconomic disparities.
Afghanistan remains the most at-risk country in South Asia for maternal mortality. As of 2017, the MMR was 638. Gender inequalities heavily affect the women in South Asia, which often dampens efforts to reduce maternal mortality. Lady Health Workers is a government program invested in rural areas in Pakistan and Afghanistan. The group focuses on combating the health-hindering inequalities women face. One member, Khalda Perveen, explained that "In remote areas where there are no doctors, Lady Health Workers perform an important role: we go to areas where other health professionals won’t go. But still, some people don’t accept us and think that as women...we shouldn’t be working.”
Alongside the Lady Health Workers is the National Program for Family Planning and Primary Health Care, a Pakistani government-run effort to reach tribal communities affected by strict cultural customs potentially contributing to the women's lack of access to health care and opportunities. The World Health Organization states that this group focuses on Afghanistan in areas most affected by war and where maternal mortality may reach 1,600 deaths per 100,000 live births. The main goal is to spread awareness of ordinary health services, family planning, and to challenge social barriers.
How To Help
It is of importance to recognize that modern medicine is not the end-all-be-all of healthcare. White saviorship and Western beliefs have no place in improving maternal mortality, as it furthers medical distrust and prevents proper policy implementation. Promote access to family planning and the expansion of general prenatal and postnatal knowledge in ways respectful to the communities you are addressing.
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