Maternal and child health: is South Asia ready for change?BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7443.816 (Published 01 April 2004) Cite this as: BMJ 2004;328:816
- Zulfiqar A Bhutta (), Husein Lalji Dewraj professor of paediatrics and child health1,
- Indu Gupta, professor of obstetrics and gynaecology2,
- Harendra de'Silva, professor of paediatrics3,
- Dharma Manandhar, professor of paediatrics4,
- Shally Awasthi, professor of paediatrics5,
- S M Moazzem Hossain, project officer6,
- M A Salam, director7
- 1 Aga Khan University, Karachi 74800, Pakistan
- 2 Institute of Postgraduate Education and Research, Chandigarh, India
- 3 Sri Lanka College of Paediatricians, Colombo 7, Sri Lanka
- 4 Department of Paediatrics, Kathmandu Medical College, Kathmandu, Nepal
- 5 Institute of Clinical Epidemiology, King George's Medical University, Lucknow (UP), India
- 6 MCHC Section, Unicef, Saudi Pak Tower, Blue Area, Islamabad, Pakistan
- 7 Clinical Sciences Division, ICDDR, B: Centre for Health and Population Research, Dhaka 1212, Bangladesh
- Correspondence to: Zulfiqar A Bhutta
- Accepted 8 March 2004
South Asia still has a long way to go to meet the United Nations' millennium development goals for maternal and child mortality
A review of maternal and child health in South Asia a few years ago revealed a sorry picture.1 The region had persistently high rates of maternal and infant mortality that had largely remained resilient to change. In recent years, several countries in the region have seen relative prosperity, middle class affluence, and unprecedented economic development.w1 It is uncertain, however, whether this has been associated with improvements in health, especially that of women and children, and whether the underlying determinants of ill health have changed. We review current maternal and child health in South Asia and suggest interventions that may make a difference.
We reviewed all available information on maternal and child health indicators in the South Asian region (Bangladesh, Bhutan, India, Nepal, Pakistan, Sri Lanka, and the Maldives). We also included Afghanistan, which is technically not part of the South Asian Association for Regional Cooperation, because of its strategic and geographical location. In addition to locally available published data and reports, we reviewed the available information from the World Health Organization, Unicef, and the World Bank. We also reviewed data on mortality and interventions from the Bellagio Child Survival Group and other recent intervention studies in the region.
A global review of child deaths by the Bellagio Child Survival Group showed that 34% of child deaths occur in South Asia and that the region has almost two thirds of the global burden of malnutrition.2 Of an estimated half a million maternal deaths worldwide, almost half occur in South and Southeast Asia.3 Maternal mortality ratios range from 23/100 000 live births in Sri Lanka to 539/100 000 in Nepal.4 Given the close relation between maternal and perinatal mortality, it is not surprising that perinatal mortality rates in the region also rank among the highest in the world. Table 1 summa-rises the current data on maternal and child health indicators in the regionw2-w5 and the figure gives mortality data for babies and young children in key countries in the region.
The close relation between maternal and neonatal mortality is explained by the paucity of primary care services, antenatal care, and intrapartum care. The main causes of maternal mortality thus include haemorrhage, obstructed labour, and a relatively high burden of infectious diseases.w6 Major causes of neonatal mortality in the region include birth asphyxia, low birth weight, and high prevalence of serious infections such as neonatal tetanus, sepsis, and pneumonia.5–7
Although large scale food shortages and famines are now uncommon, rates of maternal malnutrition in the region rate among the highest in the world. These are reflected as overt malnutrition with low body mass index as well as widespread subclinical micronutrient deficiencies.8 Interventions directed at these micronutrient deficiencies have been shown to significantly reduce maternal9 as well as infant mortality.10 11 These findings may have important long term implications for health and development. Micronutrient malnutrition, such as iron and iodine deficiency during early childhood, may affect immunity, learning ability, and mental development in later life.
Maternal malnutrition has also been shown to be associated with fetal malnutrition, and estimates of intrauterine growth retardation in the region range from 25% to 50%.w7 Although a correlation has been shown between maternal malnutrition, placental volume, and birth weight,12 this relation may be multi-factorial. Low birth weight has been shown to be associated with poor maternal intake of green leafy vegetables and relatively high maternal energy expenditure and work load.13
High rates of maternal malnutrition and low birth weight may also underlie the high burden of non-communicable diseases in adult life, such as coronary artery disease, hypertension, and diabetes. In a recent landmark study of a birth cohort in Delhi followed until the age of 26 years, Bhargava et al showed that thinness in infancy followed by rapid weight gain in later childhood is associated with impaired glucose tolerance in adult life.14 Thus the growing epidemic of chronic non-communicable diseases among adults in South Asia may have its origins in widespread malnutrition among women and children and changing lifestyles of the population.
Outside the critical period of childbirth, a large proportion of child deaths are related to infectious diseases. WHO estimates that children under 15 years of age contributed 36% of total loss of years of healthy life globally in 2002, while children under 5 years accounted for 90% of these deaths.w8 A large proportion (60%) of these deaths are related to communicable and vaccine preventable diseases. Although reported coverage rates for most vaccines included in WHO's expanded programme on immunisation (EPI) range from 67% to 99% in Southeast Asian countries,w9 in reality vaccination coverage rates are much lower. The persistently high burden of diphtheria and whooping cough in the region reflects the poor ability of health systems to deliver vaccines. More importantly, in the context of the global polio eradication programme, the main residual pockets of polio in the world are in South Asia, with Pakistan and India reporting 90 and 1600 cases respectively in 2002.w10
The burden of diseases that are preventable by EPI vaccination pales in the wake of other childhood illnesses such as serious infections due to Haemophilus influenzae type B, Streptococcus pneumoniae, and hepatitis B virus. Although vaccines against these illnesses are available in most developed countries, they are a long way off being included in public health vaccination programmes in South Asia. In addition, recent threats of emerging infections such as dengue fever or multidrug resistant typhoid fever add another dimension to the existing burden of infections among young children.15
Determinants of maternal and child morbidity and mortality
The persisting high burdens of diarrhoeal disorders, acute respiratory infections, and hepatitis A and E in South Asia reflect the poor state of basic public health services, especially clean water and sanitation, and a general lack of hygiene awareness. Indoor air pollution due to poor housing, overcrowding, and use of organic fuels in confined spaces greatly contributes to respiratory infections among women and children in rural populations. Recognition is also increasing of the role of environmental degradation in South Asia and its contribution to adverse health outcomes. Rates of industrial pollution are high, with poor regulatory mechanisms and legislation for control measures. This is illustrated by reports of lead poisoning in some urban areas16 and high rates of pesticide misuse and exposure in rural settings.
The immediate causes of high rates of poor maternal and child health in South Asia, however, are underlain by more basic determinants. These include the poor status of women in society and the roles of poverty, illiteracy, and social inequity. Sri Lanka remains a remarkable exception as a result of the large and sustained investments it has made in providing primary health care and education to its population. This is especially reflected in the status of maternal health, with almost 94% of births in Sri Lanka attended by skilled health workers.w11 In contrast 64% women in India do not receive any form of antenatal care and only 18% deliver in health facilities.w12
Despite improved economic conditions in South Asia, most countries continue to have high maternal and child mortality
Malnutrition, especially micronutrient deficiency, is widespread
Underlying determinants such as female illiteracy, poverty, and lack of empowerment of women are major barriers to improvements
Substantial improvements have been achieved in some places by focusing resources on low cost primary care strategies and tackling socioeconomic issues
Such interventions need to be extended to whole health systems
The poor social status of women and lack of empowerment contribute greatly to lack of fertility regulation and burgeoning population growth rates. This “feminisation of poverty” in South Asia is a fundamental anomaly that has impaired social development in the region. Sex inequity in health indictors is an almost universal phenomenon in the region and is evident in careseeking practices, referral patterns, and mortality indicators. In particular, recent demographic shifts in the population in north India indicate an unrecognised but important effect of abortion of female fetuses since ultrasonography became generally available in pregnancy.w13 w14 These social barriers to development are compounded by the lack of safety nets and dysfunctional health systems that fail to provide basic services at grass root levels. In most instances widespread corruption, relatively centralised health policy making, and poor devolution to local governments lie at the core of the problem.
In some parts of South Asia, these social issues have been compounded by conflict and upheaval. The war in Afghanistan spanning 25 years, the Maoist uprising in Nepal, smouldering civil war in Sri Lanka, and the longstanding feuds between Pakistan and India have had huge impacts on the lives of people in the region. Though the war in Afghanistan had a direct effect on child mortality and displacement of large sectors of the population,17 18 the disruption of families and forceful conscription as child soldiers in Sri Lanka's civil war has been equally disastrous. These children of war have the makings of a future generation that is at great risk of social dysfunction and impaired psychological development.w15
Despite these sobering issues that affect over 1.5 billion people, South Asia spends far more in arms and weapons than on health and education (table 2).w2 A large proportion of the population still continues to pay directly for basic health care, and public sector spending on health and nutrition remains abysmally low.
Can something be done?
Although the current picture is gloomy, the resilience of the South Asian people and their ability to find solutions that may work for them gives cause for hope. The fundamental obstacle remains the willingness of the governments and policy makers to give due importance to and apportion resources for human development and public health. Investment in maternal and child health as a central focus of public health policy is critical and must lead to the development of evidence based policies and interventions.
All the countries of south Asia are signatories to the millennium development goal targets of reducing maternal and infant mortality by 66-75% by the year 2015.w16 Given the recent progress and trends of investments in this area, it is unlikely that these targets can be met without a concerted effort. Lack of material resources cannot be regarded as the sole obstacle. Sufficient indigenous resources are available within the region, and a willing population can be targeted to tackle priority issues in public health. Some impressive examples from the region, such as Kerala and Sri Lanka, indicate that it is possible to improve maternal and child health.
A recent review of the evidence on interventions also suggested that existing cost effective strategies can help reach the millennium development goals of the region.19–20 These include strategies to provide key micronutrients to mothers and infants,9–11 effective breastfeeding and appropriate complementary feeding promotion strategies,21 and community based models of perinatal and newborn care.7 There are no quick fixes, however; sustained long term investment is needed to reduce the burden of morbidity and mortality among women and children. It is also important that these strategies be firmly based on the best available evidence about what is both cost effective and practical in the existing health systems. The table on bmj.com gives some examples of simple strategies that can help achieve the millennium development goals for South Asia.
Gillespie S, ed. Nutrition in South Asia: a regional profile. Kathmandu: Unicef Regional Office for South Asia, 1997.
Moss W, Darmstadt GL, Marsh DR, Black RE, Santosham M. Research priorities for the reduction of perinatal and neonatal morbidity and mortality in developing country communities. J Perinatol 2002;22: 484-95.
WHO Health Statistics. www.who.int/whosis
The issues of access to services by poor women and children, and the equitable distribution of resources between urban and rural populations are fundamental to the success of such ventures. As India's second national family health survey suggests,w12 providing contraception, improving the status and decision making power of women, counselling by peers, and improving quality of services are critical. Concerted implementation of cost effective interventions in a sustained manner may allow most countries of South Asia to reduce maternal and child mortality and morbidity to those observed in Sri Lanka and other parts of Southeast Asia.
References w1-w16 and a table of effective interventions are on bmj.com
Contributors and sources All authors are actively involved in maternal and child health issues in South Asia. This article resulted from discussions between all authors and contributions based on reviews of the following areas: perinatal and newborn care, maternal health, malnutrition, infectious diseases, war and conflict, investments, and statistical trends.
Competing interests None declared.