93552 Knowledge Brief Health, Nutrition and Population Global Practice SOUTH ASIA: MATERNAL AND REPRODUCTIVE HEALTH AT A GLANCE Sameh El-Saharty, Naoko Ohno, Intissar Sarker, and Federica Secci September 2014 Regional Context KEY MESSAGES: The South Asia Region (SAR) includes Afghanistan, • The South Asia Region (SAR) has the Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, second highest share of maternal mortality in and Sri Lanka. With over 1.6 billion people, it is the most the world behind Sub-Saharan Africa. densely populated region in the world. The populations vary from 400,000 in the Maldives to 1.2 billion in India. • Skilled birth attendance increased from 36.2 The economies range from fragile and low-income to percent in 2000 to 49.8 percent in 2010, but middle-income countries. lags behind all other regions except Sub- SAR experienced 20 years of robust economic Saharan Africa. growth, averaging 6 percent a year. Growth resulted in declining poverty and impressive improvements in human • Early marriage and pregnancy rates are high development. More than 42 percent of the developing and negatively affect maternal health world’s poor live in SAR, where about 500 million people survive on less than $1.25 a day. outcomes. The region’s GDP growth rose to an estimated 4.6 • While contraceptive prevalence has percent in 2013 from 4.2 percent in 2012. It is projected increased, there is still an unmet need for to rise to 5.7 percent in 2014, 6.3 percent in 2015, and 6.7 percent in 2016. Remittances declined to an estimated contraception. 6.8 percent in 2013 from 9.7 percent in 2012. India was • Inequity in access to maternal health the largest recipient in absolute terms, but Bangladesh, Nepal, Pakistan, and Sri Lanka’s remittances were larger services is a barrier to achieving MDG 5 relative to GDP. whether in urban vs. rural access or across SAR’s child mortality and malnutrition outcomes are wealth quintiles. close to lower middle-income averages and slightly better than those in Sub-Saharan Africa. Significant • SAR has the largest young working-age progress has been made in basic education, but female population and needs greater access to adult literacy is the worst among all regions. Gender reproductive health services tailored to their inequality persists in every domain. The world’s largest needs. young working-age population portends a demographic dividend and high economic growth. Considerable • Gender inequality still persists in every investments in human development are necessary to domain in South Asia. meet the growing basic health and education needs of the population. Page 1 HNPGP Knowledge Brief  MDG Target 5a: Reduce the MMR by three-quarters, between 1990 and 2015 South Asia has made sterling progress in reducing maternal mortality. The MMR declined from 550 deaths per 100,000 live births in 1990 to 190 in 2013 (figure 1). Other regions also saw reduced maternal mortality: 56 percent in East Asia and the Pacific; 54 percent in Europe and Central Asia; 51 percent in the Middle East and North Africa; 49 percent in Sub-Saharan Africa; and 40 percent in Latin America and the Caribbean (figure 3). Maternal Health around the World Between 1990 and 2013, South Asia experienced the world’s sharpest fall in maternal mortality (65 percent) with an average annual decline of 4.4 percent. But it carries the second highest share of maternal mortality in South Asia is close to reaching replacement fertility. the world behind Sub-Saharan Africa (figure 2). The total fertility rate (TFR) declined from 4.2 in 1990 to 2.6 in 2012. The contraceptive prevalence (CPR) rate increased from 41.3 percent to 52.3 percent between 1990 and 2010 (figure 4). Page 2 HNPGP Knowledge Brief  Four countries in South Asia have achieved replacement level fertility of 2.3: Bangladesh (2.2), Bhutan (2.3), Maldives (2.3), and Sri Lanka (2.3). India and Nepal are close to doing so. Afghanistan has a TFR of 5.1, the highest in the region. Contraceptive prevalence South Asia lags, however, behind all but one other is high in the region. Bangladesh (61.2 percent), Bhutan regions in skilled birth attendance (SBA). While it has (65.6 percent), and Sri Lanka (68.4 percent) have the increased from 36.2 percent in 2000 to 49.8 percent in highest CPRs. Afghanistan has the lowest at 21.2 percent 2010, further progress is needed (figure 5). (figure 7). Early marriage and pregnancy affect maternal health outcomes in South Asia. Bangladesh has the lowest median age at first marriage (15.5 years) and at first birth (18.1 years). The adolescent fertility rate (AFR) for South Maternal Health in South Asian Countries Asia is 38.8 births per 1,000 women age 15-19. AFR is The MMR in South Asia is 190 deaths per 100,000 live highest in Afghanistan and Bangladesh (86.8 and 80.6 births. Afghanistan has the highest ratio in the region at births per 1,000 women age 15-19, respectively). AFR is 400. Sri Lanka and the Maldives have the lowest, at 29 lowest in Maldives (4.2). and 31 (figure 6). While contraceptive prevalence has increased throughout the region, there is still an unmet need for contraception. Unmet need is highest in Maldives (28.1 Page 3 HNPGP Knowledge Brief  percent) and lowest in Sri Lanka (7.3 percent). For the Disparities in access to SBA also exist by residence. rest of the region it is: Bangladesh (13.5 percent), Bhutan The largest gaps between urban and rural access are in (11.7 percent), India (12.8 percent), Nepal (27 percent), Afghanistan and Nepal. Urban SBA is almost three times and Pakistan (20.1 percent). that of rural SBA in Afghanistan. Access to SBA is more equitable in Sri Lanka and the Maldives where the gaps Sri Lanka (99.4 percent), Maldives (99.1 percent), and are negligible (figure 9). Bhutan (97.3 percent) have the highest antenatal care coverage in the region. In Afghanistan it is 47.9 percent, the region’s lowest. SBA is highest in Sri Lanka (98.6 percent) and the Maldives (94.8 percent). While Bangladesh has one of the highest CPRs in the region, it is lowest in SBA (31.7 percent) (figure 8). References: Afghan Public Health Institute, Ministry of Public Health (APHI/MoPH) [Afghanistan], Central Statistics Organization (CSO) [Afghanistan], ICF Macro, Indian Institute of Health Management Research (IIHMR) [India], and World Health Organization Regional Office Equality in Access to Maternal Health for the Eastern Mediterranean (WHO/EMRO [Egypt]. 2011. Afghanistan Mortality Survey 2010. Calverton, Maryland, USA: APHI/MoPH, CSO, ICF Macro, IIHMR and Services WHO/EMRO. Bhutan Multiple Indicator Survey, May 2011, National Statistics Bureau, Thimphu, Bhutan Inequity in access to maternal health services is a Department of Census and Statistics (DCS) and Ministry of Healthcare and Nutrition barrier to MDG 5. SBA has increased, but wide (MOH). 2009. Sri Lanka Demographic and Health Survey 2006-07. Colombo, Sri Lanka: DCS and MOH. disparities remain, especially across wealth quintiles. The International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005–06: India: Vol. I. Mumbai: IIPS. largest gaps between the richest and poorest are in Ministry of Health and Family (MOHF) [Maldives] and ICF Macro. 2010. Maldives Nepal, India, and Afghanistan. Sri Lanka has a very Demographic and Health Survey 2009. Calverton, MD: MOHF and ICF Macro. Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. equitable distribution of SBA with only 2 percentage 2012. Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of points separating the poorest from the richest (table 1). Health and Population, New ERA, and ICF International, Calverton, MD, USA. National Institute of Population Research and Training (NIPORT), Mitra and Associates, and ICF International. 2013. Bangladesh Demographic and Health Survey 2011. Dhaka, Bangladesh and Calverton, MD, USA: NIPORT, Mitra and Associates, and ICF International. National Institute of Population Studies (NIPS) [Pakistan] and ICF International. 2013. Pakistan Demographic and Health Survey 2012-13. Islamabad, Pakistan, and Calverton, MD, USA: NIPS and ICF International. WHO, UNICEF, UNFPA and The World Bank. 2014. Trends in Maternal Mortality: 1990 to 2013: World Health Organization. World Bank. 2012. South Asia Regional Brief. http://www.worldbank.org/en/news/feature/2012/09/25/south-Asia-Regional-Brief _____. 2012 South Asia Strategy Update. http://siteresources.worldbank.org/INDIAEXTN/Resources/295583- 1328744264781/RegionalUpdate2012.pdf _____. 2014 South Asia Strategy Update _____. World Development Indicators 2014: Accessed 19 May 2014 For more information on this topic, go to: www.worldbank.org/health. Page 4