Progress in maternal and child health: how has South Asia fared?BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1608 (Published 11 April 2017) Cite this as: BMJ 2017;357:j1608
- Nadia Akseer, statistician1 2,
- Mahdis Kamali, research assistant1,
- Shams E Arifeen, senior scientist3,
- Ashar Malik, senior instructor4,
- Zaid Bhatti, statistician4,
- Naveen Thacker, consultant, paediatrician5 ,
- Mahesh Maksey, head of foundation6,
- Harendra D’Silva, professor7,
- Inacio CM da Silva, epidemiologist,8 ,
- Zulfiqar A Bhutta, professor1 2 4
- 1Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- 2Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- 3Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)
- 4Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
- 5Deep Children Hospital and Research Centre, Gandhidham, Gujrat, India
- 6Nepal Public Health Foundation, Kathmandu, Nepal
- 7Faculty of Medicine, University of Colombo, Sri Lanka
- 8International Center for Equity in Health, Federal University of Pelotas, Brazil
- Correspondence to: Z A Bhutta
In our review of the state of maternal and child health in South Asia published in The BMJ 12 years ago,1 we highlighted rampant poverty, malnutrition, and lack of female empowerment as key barriers to change. Since then, the region has seen much focus on the millennium development goals related to maternal and child health as well as economic development. This article explores the progress and current state of reproductive, maternal, newborn and child health throughout South Asia, and presents a snapshot of the region’s preparedness for the sustainable development goals.2
Methods and data sources
Our analysis focuses on countries that are active members of the South Asian Association for Regional Cooperation: Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. We used national and global data sources to assess maternal mortality,3 child mortality,4 and stillbirths5 as well as causes of death.678
We calculated coverage rates for interventions and health indicators for mothers, infants, and children in South Asia from UN, World Bank, and WHO sources.8910111213 Full definitions of the variables and details of the methods are provided in the appendix on bmj.com.
Mortality trends and causes of death
Globally, maternal mortality ratio dropped from 385 to 216 deaths per 100 000 live births between 1990 and 2015, a 44% reduction.3 Nevertheless, around 303 000 mothers die every year, about 22% of whom are in South Asia, with India accounting for the bulk of these deaths. Maternal mortality fell substantially in all South Asian countries during this period (ranging from a 59% reduction in Pakistan and Sri Lanka to 90% in the Maldives), with an overall reduction of 68% (fig 1⇓). Afghanistan had the highest maternal mortality ratio in the region in 1990 (1340/100 000 births) and still had the highest ratio in 2015 despite a 70% fall. The main causes of maternal death vary across South Asia (appendix), though maternal haemorrhage, hypertensive disorders, obstructed labour and uterine rupture, abortion, miscarriage, or ectopic pregnancy are leading causes in many countries.
Globally mortality among children under 5 years reduced by about half from 1990 to 2015 (91 to 43 deaths per 1000 live births) and by 60% in South Asia (from 129/1000 to 53/1000).4 Of the 5.9 million children under 5 who died in 2015, almost 1.9 million (31%) were in South Asia. Pneumonia and diarrhoea related illness are the two leading preventable causes of child mortality in South Asia (appendix), leading to about half of all child deaths in most countries. Injuries are responsible for at least a further 10%. In Sri Lanka and Maldives congenital anomalies cause a third of child deaths.
Over half (57%) of deaths among children under 5 in South Asia occur in the first 28 days of life; this amounts to more than 1 million newborns dying every year in the region.4 Moreover, of the 2.6 million stillbirths that occur globally every year, about 37% (almost 1 million) are in South Asia.5 Newborn mortality rates fell from 1990 to 2015; stillbirth rates also fell, although more slowly (appendix). Newborn mortality rates continue to be highest in Pakistan (45.5 deaths per 1000 live births) and Afghanistan (35.5). The main causes of newborn death are fairly consistent across the region, with preterm birth causing about one third of deaths and intrapartum related events; infections, including sepsis and meningitis; and congenital anomalies each contributing about one fifth of deaths (appendix). Some variation exists across countries. Robust data on causes of stillbirths were not available for comparison.
Coverage of essential interventions
We explored a range of evidence based essential interventions for mothers and children that are associated with improved child and maternal survival (see appendix for detailed list). Figure 2⇓ shows the wide differences in coverage across the region. Contraceptive use is about 55% on average and is lowest in Afghanistan (31%) and highest in Sri Lanka and Bhutan (about 70%). About 70% of women have at least one antenatal visit in most countries, reaching almost 100% in Sri Lanka and Bhutan. Coverage drops for four or more antenatal care visits and skilled birth attendance; these interventions have the widest variation across countries, ranging from 23% in Afghanistan to 93% in Sri Lanka. The provision of postnatal care within two days for both the newborn and mother is low in the region (30-40% median) with some variation across countries. Data for Sri Lanka were not available.
Breastfeeding interventions (including early initiation and exclusive breastfeeding for six months) have about 50% regional coverage, with a gap of 40% between the highest (Sri Lanka, Bhutan for early initiation; Afghanistan for exclusive breastfeeding) and lowest (Pakistan) countries. The region performs well in the provision of child vaccinations, with about 90% coverage on average for tetanus, Hib3, measles, and DPT3. Country coverage ranges from about 70% to 100%, with Afghanistan and Pakistan among the lowest and Sri Lanka consistently the highest.
Access to treatment for children with diarrhoea and pneumonia is moderate in the region (50-60%). Oral rehydration solutions (ORS) and ORS with continued feeding are least used in India and Pakistan, and coverage rates are highest in Bangladesh. Conversely, care seeking for pneumonia is highest in India and Maldives (almost 80% coverage) and lowest in Bangladesh (41%).
Coverage inequalities within countries
We analysed socioeconomic and residence inequalities for two key interventions (skilled birth attendance and measles vaccination) as they represent opposite ends of the continuum of care and diverse delivery strategies (fig 3⇓). Coverage gaps for skilled birth attendance between the richest and poorest quintiles and between urban and rural residents are evident in most countries, with gaps of at least 70% in India, Nepal, and Bhutan. Sri Lanka and Maldives have minimal to no gaps. Inequities in measles vaccination were greatest for Pakistan, India, and Afghanistan, with lowest coverage rates among the poorest populations and those living in rural areas.
Access to improved water and sanitation
Equitable and sustainable access to safe water and improved sanitation and hygiene can improve outcomes in many ways through its implications for environmental cleanliness, health, reduced poverty, and equity.15 About 8% of maternal deaths worldwide are attributable to infections that can be directly linked to unhygienic conditions during labour and to poor hygiene practices in the six weeks after birth.1617 The availability of improved water is almost universal throughout the region except in Afghanistan, where only 55% of the population has access (see appendix on bmj.com).18 Improved sanitation facilities are less available in the region (about 55% regional median), varying from 32% in Afghanistan to over 90% in Sri Lanka and Maldives.
Malnutrition of children and women remains a problem in South Asia (fig 4⇓). Since the early 2000s, the prevalence of under 5 stunting has dropped by about one third in Afghanistan, Bangladesh, India, Nepal, and Maldives. Pakistan, however, experienced an increase over this period (from 42% to 45%). Despite progress, current levels of stunting are more than 30% in most countries in the region, except Sri Lanka (15%) and Maldives (20%). Currently around a third of children are underweight in most countries except Bhutan (13%) and Maldives (18%) (appendix). Prevalence of wasting has hardly changed over the decade, and currently ranges from 6% in Bhutan to 21% in Sri Lanka.
Both overnutrition and undernutrition are concerns among women age 15-49 years in South Asia (fig 4⇑). Maternal underweight (defined as body mass index< 18.5) is prevalent in about 36% of women in India—about double that in the next highest countries (Nepal 18% and Bangladesh 19%). Obesity (BMI≥30) is highest in Pakistan (15%) and Maldives (13%).
Empowerment of girls and women
Empowered girls and women are more inclined to seek healthcare when in need and consequently have improved health outcomes and survival. Empowered females are more educated, delay marriage, postpone childbearing, and have fewer and spaced pregnancies, all of which are known to improve maternal and child health.20
All countries in the region have experienced an overall reduction in fertility rates since 2004, ranging between 9% and 36% (table 1⇓). Current fertility rates are highest in Afghanistan and Pakistan. Births among adolescent girls (age 15-19 years) have declined more than 50% in Bhutan, Maldives, and India. Pakistan has made the least progress in reducing fertility among adolescent girls (11% reduction). Average age at first marriage is lowest in Bangladesh (19.2 years), and highest in Sri Lanka (23.6 years). Although most countries have increased the average age of marriage by 2%-7%, Afghanistan had the fastest rate of change over the past decade (from 15.0 years in 2006 to 21.2 years in 2011).
Literacy of women (age ≥15 years) is greater than 90% in Sri Lanka (92%) and the Maldives (99%), and about half in other South Asian nations except Afghanistan where only 24% of women are literate. Literacy of young women (age 15-24 years) is >85% in all countries except Pakistan (67%) and Afghanistan (46%).
Investments in health systems
The density of healthcare staff, including physicians, nurses, and midwives, varies widely across the region. South Asia has seen various health system and outreach innovations targeted at marginalised populations with poor access to health services. These have included deployment of community health workers through non-governmental health workers in Bangladesh 21 to public sector workers such as lady health workers in Pakistan 22 or accredited social health activists (ASHA) in India.23
There have also been large scale experiments with community engagement through women’s groups24 as well and financial incentive programmes, both conditional on recipients’ health behaviour, such as India’s Janani Suraksha Yojana programme supporting facility births,25 and unconditional, such as the income support programme in Pakistan targeting women.26
Table 2⇓ lists the key health initiatives implemented in South Asia during the period of the millennium development goals. Common features of such programmes include adaptation of a basic package of healthcare services and strategies to expand universally, contracting out delivery of healthcare services to non-governmental organisations to enable rapid scale-up, financial incentive programmes or abolishing user fees, and community based healthcare initiatives and training of midwives.
High out-of-pocket health expenditures annually drag about 4% of the population into poverty in the three most populous countries of the region: India, Bangladesh, and Pakistan (table 3⇓). Only four countries had data available for spending on maternal and child health. The proportion of total health expenditure was 9.8% in Sri-Lanka, 12% in Bangladesh, 16% in Afghanistan, and 21% in Pakistan.
Despite wide variations, South Asia has made impressive progress in maternal and child health over the past decade. In many countries with widespread conflict and grinding poverty, notably Nepal and Afghanistan, these gains are remarkable. Although countries have used different approaches to achieve these reductions, many have involved community based programmes to manage demand and deliver services.
Nepal invested heavily in community based approaches to increase detection of serious childhood illnesses and management of pneumonia.37 A range of innovative approaches for addressing maternal health and nutrition through women’s groups provided some of the first evidence on the role of community empowerment in rural Makwanpur, Nepal.38 Bangladesh also used interventions including community empowerment, investments in education and young women, and national roll-out of community health workers through non-governmental organisations such as BRAC. It was able to rapidly roll-out interventions through a range of community outreach programmes.3940 However, the reductions in maternal mortality in Bangladesh far outstripped the gains in skilled birth attendance coverage and facility births.41 The innovative deployment of public sector community health workers in Pakistan,42 as well as India,43 suggest that such strategies could be deployed at scale.
Similarly, reductions in child mortality (and especially from diarrhoeal diseases) have been notable, but while there have been major gains in use of oral rehydration therapy, care seeking for childhood pneumonia is low and rates of childhood undernutrition are still high.44 Investments in social determinants and non-health sectors such as education, especially girls’ education and female empowerment to reduce early marriages and high fertility rates, as well as effective communication strategies are likely to be especially important to improve and sustain gains in maternal and child health.
In war ravaged Afghanistan, because of the shortage of skilled public sector workers, the government adopted contracted non-governmental organisations to provide a basic package of primary care services.45 Although the transaction costs were relatively high, there were limited alternatives and the model allowed for rapid population coverage in difficult to reach rural populations.
High rates of newborn mortality and intrapartum stillbirths are a major challenge across the region, and are associated with poor quality of care in both community and facility settings.46 Further reductions in under 5 mortality will require action on the dual challenge of improving care during pregnancy and childbirth in community settings and facilitation of facility births, as well as improving care of newborns in referral facilities. Pakistan invested in a major national programme of primary care using “lady health workers,” who now number over 100 000 and cover almost two thirds of the rural population,47 and India has also introduced a major public sector programme of community based health workers. Evidence shows that there is considerable opportunity for innovations in facilitating the work of frontline workers to improve mother and child health.22434849 In other regions of South Asia where there have been relatively rapid gains, we need to invest in strategies to improve the quality of care in referral facilities, especially those responsible for secondary care.
Major challenges remain. The rapid growth of urban slums—often home to over a third of the population of megacities—poses huge challenges to effective care and governance. These and other marginalised populations, including indigenous groups and those relegated on the basis of ethnicity, religion, or caste systems, will require innovative targeting to reduce inequities. Furthermore, reaching the poorest and remote populations in countries where care is focused on rich and urban populations such as Afghanistan and Pakistan, is critical. Recent reviews have highlighted innovative strategies for reducing such inequities to improve maternal and child health.50
Finally, the state and international partners must support and protect women and children who are at risk of gender based violence, lack of economic security, and physical immobility. High rates of maternal and adolescent malnutrition remain tenacious underlying risk factors for ill health and mortality in the region. Direct policies and initiatives to improve nutrition of all populations are critical for health gains in South Asia. Low rates of breastfeeding and complementary feeding are a concern and should be prioritised for large scale intervention. Quality and timely data are vital for effective monitoring, evaluation, and rapid feedback. Countries should focus on efforts to enhance administrative databases, health management information systems, birth and death registries, and national surveys on health and wellbeing to track progress towards the sustainable development goals.
South Asia comprises a substantial chunk of the global population and contains some of the highest maternal and child mortality rates worldwide. Gains over the past decade provide evidence that progress is possible, but much more can be done with focus on scaling up evidence based interventions and addressing barriers as key investments in reaching the sustainable development goals.
While South Asia has reduced maternal mortality ratio across the region, mortality remains high in many countries including Afghanistan, Pakistan, and Nepal
Despite progress in delivering antenatal care and vaccinations, wide disparities exist across wealth groups and between rural and urban populations in many countries
Social determinants and health systems or policies are important contributors to observed improvement and differentials in the region
Ongoing challenges include conflict or insecurity, malnutrition, encouraging empowerment of girls and women, and supporting better and timely data collection
Contributors and sources: This consortium of authors have diverse subject expertise related to maternal, newborn and child health among countries in the region. Drs Bhutta, Arifeen and Nadia Akseer have undertaken Countdown country case studies in the region. The review was conceived in a planning meeting for the special South Asia collection in Dubai in January 2016.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; externally peer reviewed.