Thailand

Disclaimer: Some of the MDG data presented in this website have been adjusted by the responsible specialized agencies to ensure international comparability, in compliance with their shared mandate to assess progress towards the MDGs at the regional and global levels.^[1] 

 

Indicators (United Nations)

 

5.1 Maternal mortality ratio (MMR):

a.    2000: 44^[2]

b.    2005: 110^[3]

c.    2005-8:

 

A maternal death is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes.”^[4] According to the 2005 WHO/UNICEF/UNFPA maternal mortality estimates, most of the countries in the Asian region have not reduced the maternal mortality  by three quarters as stated in the MDG Goal.^[5] 

Thailand records a high maternal mortality ratio of 110 per 100,000 live births in 2005^[6]. In fact based on the WHO estimates, maternal mortality has increased dramatically since 1995 in Thailand from 44 per 100,000 live births in 1995 to 110 per 100,000 live births in 2005.

 

National estimates on maternal mortality ratio, or MMR, reported by the Bureau of Health Promotion (BHP) (2006), shows different maternal mortality ratios reported by different national sources. The Bureau of Health Promotion (BHP), Ministry of Public Health, Thailand, reports an MMR of 18.2 in 2005, and Bureau of Policy and Strategy, Thailand, reports an MMR of 12.2.   In Thailand, the statistical system is decentralized. Each public organization conducts its own data collection system and the production of statistical reports. When the definition of a statistic is unclear or ambiguous, two public organizations can end up with two varying statistics for a single variable^[7].

 

This inconsistency in estimates calls for a through look at the actual status of MMR in Thailand.

 

Critical indicators to comprehensively monitor maternal mortality

5.1.1 Lifetime Risk of Maternal Death

The concept of adult lifetime risk of maternal death measured as the probability of dying from a maternal cause during a woman’s reproductive lifespan^[8], is more holistic in comparison to maternal mortality ratio (MM Ratio) and maternal mortality rate (MM Rate). Whereas the MMRatio and the MMRate are measures of the frequency of maternal death in relation to the number of live births or to the female population of reproductive age, the lifetime risk of maternal mortality describes the cumulative loss of human life due to maternal death over the female life course. Because it is expressed in terms of the female life course, the lifetime risk is often preferred to the MMRatio or MMRate as a summary measure of the impact of maternal mortality^[9].

 

The lifetime risk of maternal death is 1 in 500, as compared to 1 in 1 300 in China.

 

5.1.2 Maternal deaths due to unsafe abortion

 

Unsafe abortion continues to be a major factor in maternal deaths in the region. Mortality due to unsafe abortion for the South-east Asia is estimated at 14% of all maternal deaths.^[10] 

It was only in 2005, that the Medical Council amended a regulation governing the medical profession’s conduct with regard to abortion. “The regulation provides a standard interpretation of the criminal law provision on abortion, which permits the procedure when a woman’s life or health is in danger and in cases of rape. According to the new regulation, “health” is defined to include mental health as well as physical health. The regulation clarifies that abortion may be performed in public or private health facilities not only to protect a woman’s life and physical health and in cases of rape, but also when a pregnancy causes harm to a woman’s mental health and in cases of foetal impairment.”^[11] 

It is important to understand that providing access to safe abortion services is a critical intervention to reduce maternal deaths in these contexts.

 

5.2 Proportion of births attended by skilled health personnel:

 

a.    2001: 99.3^[12]

b.    2006: 97.3^[13]

c.    2005-8:

 

A skilled attendant, according to WHO, refers to “an accredited health professional-such as a midwife, doctor or nurse- who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.” Traditional Birth attendants (TBA) either trained or untrained are excluded from the category of skilled health workers.

The percentage of skilled attendants at birth in 2006 in Thailand is reported as 97.2^[14].

 

Critical indicators to comprehensively monitor skilled health attendance would include not just skilled birth attendants but also access to basic and comprehensive emergency obstetric care services and post-partum care 

The quality of care provided by skilled attendants at birth is crucial. Particularly when complications occur, skilled personnel need access to essential drugs, supplies, equipment and emergency obstetric care. They should receive training on required competencies. And they need supervision that helps ensure high standards of care, which is vitally important^[15].

Global and country studies on skilled attendants showed that the overall effectiveness of skilled attendants depends on their access to a functioning health system with a basic and comprehensive level of obstetric care, including surgery and blood transfusions  in case of complications. The key to maternal death reduction is universal access to  emergency obstetric care which is a major challenge in most of the Asian countries.

It is therefore critical to not just look at skilled attendants at birth, but also look at a) access to emergency obstetric care services and b) postpartum care so as to reduce maternal deaths meaningfully.

5.2.1 Access to emergency obstetric care

Data is not easily available for this indicator.

 

5.2.2 Post partum care

 

A large proportion of maternal deaths occur during the 24 hours after delivery and hence postnatal care constitutes a critical safe pregnancy intervention. The first two days following delivery are critical for monitoring complications arising from the delivery.

 

5.3 Adolescent birth rate (per 1000 women):

a.    2001: 33.6^[16]

b.    2006: 43.3^[17]

c.    2005-8:

 

The adolescent birth rate measures the annual number of births to women 15 to 19 years of age per 1,000 women in that age group. It represents the risk of childbearing among adolescent women 15 to 19 years of age. It is also referred to as the age-specific fertility rate for women aged 15-19^[18].

The adolescent birth rate in 2001 was reported as 33.6, and this has increased to 43.3 in 2006^[19].

 

Teenage fertility and pregnancies are a major health concern because teenage mothers and their children are at high risk of reproductive morbidity and mortality. Early childbearing  also impedes the overall development of teenage girls and their access to education and labour force participation.

 

Critical indicators to comprehensively monitor adolescent birth rate would look at the median age at marriage,  the legal age at marriage and access to sex and sexuality education

5.3.1 Median age at marriage

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5.3.2 Legal age of marriage 

The legal age of marriage in Thailand is 17 for women and 17 for men.

In Thailand, if a man “mistakenly has sexual relations with a girl over age 13 but under age 15, with the consent of the girl or her parents, the Criminal Law allows the Court to permit the couple to marry without the man being prosecuted.”^[20]   

5.3.3 Sex and sexuality education

Sex education is defined as the basic education about reproductive processes, puberty and sexual behaviour. Sex education may include other information, for example about contraception, protection from sexually transmitted infections and parenthood.^[21] Sexuality education is defined as education about all matters relating to sexuality and its expression. Sexuality education covers the same topics as sex education but also includes issues such as relationships, attitudes towards sexuality, sexual roles, gender relations and the social pressures to be sexually active, and it provides information about SRH services. It may also include training in communication and decision-making skills.^[22] 

Only in Thailand has there been progress on sex education, with the boundaries being pushed forward with each revision of the curriculum. Thailand has already introduced sexuality education. The first national policy on sexuality education in schools was announced in 1938, but sex education was not taught in schools until 1978. Then it was called “Life and Family Studies,” and its content consisted of issues related to the reproductive system and personal hygiene. The education curriculum has been revised several times, involving efforts from both government and non-government sectors and sex education has been accepted as a problem solving tool for adolescent SRH issues. This has been a consequence of educational reform following the National Education Act B.E. 2542, increasing awareness of problems related to adolescents’ sexual practices, and the emergence of women’s sexuality, and queer movements. The most remarkable new approach in sexuality education curricula in Thailand has been the Teenpath Project developed by PATH, Thailand. PATH has also succeeded in institutionalizing sexuality education curricula in schools since 2003.^[23] 

5.3.4 Access to reproductive health services for adolescents within the public health system

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Voices from the ground: 

News/Magazine articles:

a.    “A comprehensive sex education program covers love and relationships, healthy communication and emotional responses that can occur within relationships, such as heartbreaks and jealousy, besides teaching about the biology and physiology of sex”. Read more

 b.    This article highlights how the importance of sex education has been ignored leading to unwanted pregnancies and HIV infections. Read the article here

 

ICPD+15 Country Case Study:

a.   The Thailand case study aims to examine the situations of sexuality education and sexual harassment in workplaces and in educational institutions in Thailand. It also aims to evaluate the status of the program of action undertaken by the government and the concerned NGOs in the field of sexuality education and sexual harassment in workplaces and in educational institutions and discusses obstacles that hinder the progress of actions in enforcing respective laws and implementing policies and interventions.The findings of the study note while that sex education is more comprehensive than before, gaps  do exist in implementing comprehensive sexuality education in school systems. In the area of sexual harassment findings point to widespread sexual harassment embedded in Thai patriarchal culture. Sexual harassment in Thailand have not yet been inclusively defined and standardized, resulting in inconsistent law enforcement, interpretation, and public concern toward the problem. Read it here

 

5.4 Contraceptive prevalence rate (Current contraceptive use among married women 15-49 yrs old any method%:

 

a.    2001: 77.8^[27]

b.    2005: 73.8^[28]

c.    2005-8: 81.1^[29]

 

Thailand has a high CPR: 77.8 (2001) which dropped to 73.8 (2005) and rose to 81.1 (2008).

 

Critical indicators to comprehensively monitor contraceptive prevalence rate would include looking at range of methods available including access to modern methods and provision of informed choice.

Beyond the numbers for CPR it is essential to look at access to a range of contraceptive services.

 

 

5.4.1 Range of contraceptive methods available.

In Thailand, according to the World Contraceptive Use 2007 report, pill users accounted for 43.21% of all methods and female sterilization accounted for 34.26% of all contraceptive methods. In comparison, male sterilization accounted for a mere 1.39% of all methods. Permanent methods are highly used and targets of permanent methods are mainly women.

 

5.4.2 Provision of informed choice service provision. 

Informed choice of family planning methods is an important rights indicator. However it has not been commonly regarded as an important aspect of the service provided with the contraception method. Informed choice includes: information on the full range of methods including traditional and male methods; information on side-effects of all methods and the appropriate course of action; and information on the efficacy of each of the methods.^[30] Providers’ biases appear to affect the availability of information to users in Thailand: “in some cases, women’s choices have been found to be steered by the health personnel involved in distributing the contraceptives or determined by the method being campaigned by the Government at that time.”^[31]

 

 

5.5 Unmet Need for contraception:

 

a.    2003:

b.    2005:

c.    2006: 3.1^[32]

 

Unmet need is low in Thailand at 3.1%.

The accepted definition of “[u]nmet need for contraception is the percentage of fertile, married women of reproductive age who do not want to become pregnant and are not using contraception.”^[33] The concept of unmet need is an important one because it assesses the ‘need’ for contraception based on whether and when a woman wants a child or another one rather than focusing on government limits on family size. The limitation, currently, is that the DHS calculates unmet need based on a sample of married, heterosexual women and not single, unmarried women and this does not accurately capture the extent of unmet need in a country. Another limitation is that it assumes all users as having their need ‘met’ including women with infertility and secondary infertility. But many women may be using a contraceptive method not of their choice due to provider bias or government policy as earlier discussed and this constitutes an ‘unmet need’ too. It is also important to keep in mind that contraception is primarily focused on pregnancy prevention. There is also an urgent unmet need for disease/infection prevention which is not being considered.^[34]

 

Critical indicators to comprehensively monitor unmet need would take into account differences between total and wanted fertility rates and reasons for non-use of contraception.

5.5.1 Total and Wanted Fertility Rates

Wanted fertility rates compared to Total Fertility Rates

 

a.    Total Fertility Rate (2005): 1.8^[35]

b.    Wanted Fertility Rate (2005):

c.    % difference:

 

It is important to look at Wanted Fertility Rates and Total Fertility Rates to also establish unmet need.

Data is not available for wanted fertility rates in Thailand.^[36]

 

5.5.2 Reasons for non-use of contraception

One of the most common reasons given by married women with an unmet need for not using contraception is associated with the supply of methods and services and within this category, concerns about the side effects, health consequences and inconvenience of methods were the most prominent reasons. The prevalence of these concerns is particularly high in Southeast Asia.^[37]

 

5.6 Antenatal care coverage

a.    At least one visit (%):

Ø  2000: 91.8^[38]

Ø  2006: 97.8^[39]

Ø  2005-8:

b.    At least four visits(%):

Ø  2001:

Ø  2003:

Ø  2005-8: