93604 Knowledge Brief Health, Nutrition and Population Global Practice MALDIVES: MATERNAL AND REPRODUCTIVE HEALTH AT A GLANCE Sameh El-Saharty, Naoko Ohno, Intissar Sarker, Federica Secci, and Somil Nagpal November 2014 Country Context KEY MESSAGES: Maldives is composed of 1,192 small tropical islands with • Maldives, a middle income country, is a diverse marine environment, strategically located along on track to meet most of the Millennium shipping routes. In the early 1980s, Maldives’ population of 156,000 was among the world’s 20 poorest countries. Development Goals (MDGs), while Now, with a population of over 326,000, it is a middle- gender gap requires attention. income country with a GNI per capita of over $7,177. Between 2000 and 2010-11, it averaged 7 percent • Maldives has made great progress in growth, moderating to 3.4 percent and 3.7 percent improving maternal health and has respectively in 2012 and 2013. Some 9 percent of the achieved MDG 5. population lives on less than US$1.25 per day (2013), down from 10 percent in 2003. Youth unemployment is • The total fertility rate has declined to 2.3 high. About 32 percent of youth aged 20-24 are not in 1, 2 in 2012. Contraceptive use has increased school or working. but high unmet need of 28.1 percent is The country is on track to meet most of the Millennium of concern. Skilled birth attendance is Development Goals (MDGs). Maldives met the MDGs on high at 95 percent. eradicating extreme poverty and hunger, achieving universal primary education, reducing child mortality, • Access to maternal health services is improving maternal health, and combating HIV/AIDS, fairly equitable by residence and wealth malaria, and other diseases. quintile, while geographical access to services remains challenging. Also, The gender gap is closing. Maldives ranks 64 of 148 countries in the Gender Inequality Index. Gender parity in unwanted pregnancies among young primary education is 100 percent net enrollment of girls women are on the rise. and boys. At the secondary level, more females are enrolled than males. In 1990, the ratio of women to men • Maldives has initiated a number of with tertiary qualifications was 24 percent compared to 58 interventions to increase adolescents’ percent in 2006. Nonetheless, opportunities for women to needs for sexual and reproductive health work outside the home are limited. Isolation and a lack of services, improve quality of RMNCH access to resources continue to frustrate women’s 1, 2 economic participation. services, and increase utilization of health services at local level. Page 1 HNPGP Knowledge Brief  sterilization (10.1 percent), male condoms (9.3 percent) and the pill (4.6 percent) are the most commonly used form of modern methods. Traditional methods are used by 7.8 percent of currently married women. There is still an 5 unmet need of 28.1 percent. MDG Target 5a: Reduce the MMR by three-quarters, between 1990 and 2015 Maldives has made great progress over the past two decades on maternal health and has achieved MDG 5. The MMR declined from 430 deaths per 100,000 live births in 1990 to 31 in 2013 (figure 1), for an average Early childbearing affects maternal health outcomes; 4 annual decline of 10.8 percent. in Maldives, however, this does not appear to be an issue. The median age at first marriage among women age 25-49 is 19 years and that at first birth among the same cohort is 21.2 years. The share of women age 15- 5 19 that have begun childbearing is only 2.1 percent. The adolescent fertility rate is 4.2 births per 1,000 women age 1 15–19. Pregnancy Outcomes Complete and timely antenatal care (ANC) is a necessary component for positive pregnancy outcomes. As of 2009, 99.2 percent of women sought ANC from a skilled provider; 85.1 percent of women received the recommended four or more ANC visits; 99.6 percent of women had their blood pressure measured (a 5 component in a package of ANC services). Skilled birth attendance (SBA) is critical in reducing maternal deaths. In Maldives, SBA by a skilled provider has historically been high. It increased from 90 percent in 1994 to 94.8 percent in 2009 (figure 3). 1 Ninety-five percent of births are delivered in a health facility (85 Fertility percent in a public sector facility and 10.2 percent in a Fertility has been declining over the past 20 years. 5 private sector facility). Between 1990 and 2012, the total fertility rate declined 1 from 6.1 to 2.3 (figure 2). Postnatal care is another important component for maternal health, especially for managing post- Increased contraceptive use has accompanied fertility delivery complications. It is recommended that decline. The CPR (any method) increased from about 29 postnatal care for mothers occur within the first two days 1 percent in 1991 to 34.7 percent in 2009. Modern of delivery. In Maldives, 67.1 percent of women sought methods are the main choice of contraceptives and are this type of care from a qualified provider within the first used by 27 percent of currently married women. Female 5 two days of delivery. Page 2 HNPGP Knowledge Brief  There is also little variation in SBA. While the gap is While maternal health care utilization is high in slightly higher across residences, it is only a difference of Maldives, problems are still encountered in access to 6 percentage points between urban and rural areas. This health services. Overall, 83 percent of women age 15-49 is, however, negligible as the proportion of SBA is very encountered at least one problem in accessing health 5 high anyways (figure 6). care when sick. The biggest problem identified is the 5 concern of no drugs available (72.2 percent). Equity in Access to Maternal Health Services Access to maternal health services is fairly equitable. Little variation is observed across residence (rural/urban) and wealth quintiles. The CPR shows a difference of only 2 percentage points (33.6 percent and 35.3 percent) 5 (figure 4). The gap is somewhat larger for SBA across wealth quintiles: 88.6 percent of the poorest quintile had SBA compared with 99.3 percent of the richest quintile (figure 7). Again, the proportion of SBA in all wealth quintiles is 5 high. The CPR across wealth quintiles has an unusual pattern. It is higher among the poorest two wealth quintiles than the richest quintile. There is, however, only a difference of about 3 percentage points between the 5 poorest and richest quintiles (figure 5). Page 3 HNPGP Knowledge Brief  Key Strategies to Improve Maternal and Reproductive Health Outcomes Addressing increasing demands from youth/ adolescent: Maldives has initiated a number of interventions to establish youth/adolescent friendly health services in collaboration with other government agencies, such as implementation of Youth Health Strategy, the Standards and Service package for Adolescent Friendly Health Services, and life skills education program in schools. Improving quality of RMNCH services: To ensure quality of RMNCH services, the government has set up and implemented the guidelines and standards and been striving to reduce stock out of life-saving medicines for mothers and babies. In FP, the government has adopted interventions such as sensitization of community and religious leaders on ‘family health’, behavior change, improving quality of Adolescent and Sexual Health FP counseling, reducing commodity stock out, and Meeting the health needs of the youth in Maldives is strengthening linkage between RH and FP services. critical as nearly half the population is under 25 years. For example, 3.2 percent of unmarried women and 9.8 Increasing utilization of peripheral health services: percent of unmarried men age 15-24 have had sexual The government has taken key actions including intercourse. Sexual and reproductive health is an upgrading all atoll hospitals with comprehensive extremely sensitive topic and therefore knowledge and EmONC facilities and striving to ensure availability of access to information is limited. Some 25 percent of medicines and equipment for MNCH. The government never-married female youth and 22 percent of never- is mapping the health facilities using MNCH services as married male youth have reported that they “had not a proxy to understand utilization of health services. talked about reproductive health and sexuality with Rationalization of human resources according to skills anyone”. Preventive care can help meet youth needs. The specification to promote utilization of a 4-tier health current health system, however, is primarily curative. services is also ongoing. Unwanted pregnancies are a problem for young women. Findings from the 2010 Statistical Analysis of the Family Protection Unit (FPU) at the Indira Gandhi Memorial Hospital (IGMH) in Malé show that out of a total of 620 References: cases attended to by the unit in the analysis period (since 1 World Bank. World Development Indicators 2014: Accessed 19 May 2014 its establishment om 2005), 121 cases were pregnancies 2 Maldives: Country Program Snapshot. March 2014, the World outside marriage and the majority of those cases were Bank 6 among young women ages 18 – 24. 3 UNDP. 2013 Human Development Report Gender Inequality Index 4 WHO, UNICEF, UNFPA and The World Bank. 2014. Trends in Maternal Mortality: 1990 to 2013: World Health Organization 5 Ministry of Health and Family (MOHF) [Maldives] and ICF Macro. 2010. Maldives Demographic and Health Survey 2009. Calverton, Maryland: MOHF and ICF Macro. 6 UNFPA. Reproductive Health Knowledge and Behavior of Young Unmarried Women in the Maldives. UNFPA; Malé, Maldives. September 2011. For more information on this topic, go to: www.worldbank.org/health. Page 4