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MDG 5: Improve Maternal Health

Target 5a: Reduce by three quarters the maternal mortality ratio

Target 5b: Achieve, by 2015, universal access to reproductive health

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: 450[2]

b.    2005: 540[3]

c.    After 2005:

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] 

Cambodia records a high maternal mortality ratio of 540 per 100,000 live births in 2005. The Cambodia Demographic Heath Survey (2005) estimates the maternal mortality at a slightly lower measure of 472 per 100,000 live births.  Maternal deaths accounted for 17 percent of all deaths to women age 15-49; in other words, about one in six Cambodian women who died in the seven years preceding the survey died from pregnancy or pregnancy-related causes. This stagnation and widespread maternal deaths in Cambodia is a serious issue, which needs attention from stakeholders involved, as Cambodia falls short of meeting the MDG goal of reducing maternal mortality by three quarters between 1990 and 2015

 

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[6], 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.[7] 

 

The lifetime risk of maternal death is 1 in 48, as compared to 1 in 1 300 in China, which shows the extent of risk to the life and well being of Cambodian women in reproductive age group, which is indicative of inequity.

 

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.[8] 

In Cambodia, in 1997, concerned with the high MMR brought about by the unsafe conditions in which illegal abortions were generally being performed, the government decided to introduce abortion legislation to regulate the procedure formally.  It hoped that the legislation would reduce the MMR by one half by 2010. Moreover, it depicted its proposed legislation as a measure designed to improve the social welfare of the population. Despite some opposition from those who argued that the country’s Buddhist traditions do not allow the legalization of abortion, the proposed legislation was enacted in early October 1997.[9] 

Lack of service facilities and staff trained in abortion methods is an issue in Cambodia, although the law is liberal. Health services in Cambodia are not highly developed and much of the population lacks adequate access to these, particularly at the in-patient level.  Additional health personnel who have the proper training to perform abortions safely are also needed.  With such obstacles to overcome, it is likely that, at least in the short run, many abortions will still be performed in unsafe conditions by unskilled persons.[10] 

It is important to understand that providing access to safe abortion services is a critical intervention to reduce maternal deaths in these contexts and liberal laws on abortion must be backed up by safe abortion service provision.

 

 

5.2 Proportion of births attended by skilled health personnel:

a.    2000: 31.8[11]

b.    2005: 43.8[12]

c.    After 2005:

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.

Skilled attendants at birth in 2005 in Cambodia were reported to be 43.8[13].Forty-four percent of births are delivered with the assistance of a trained health professional, (i.e., a doctor, nurse, or midwife), an increase from 32 percent in 2000. Over half of births (55 percent) are delivered with the assistance of a traditional birth attendant (TBA). First births are more likely to be assisted by a trained health professional (54 percent) than subsequent births. Urban women are much more likely (70 percent) to receive assistance from a trained health professional during childbirth than rural women (39 percent).

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[14].

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.

5.2.1 Access to emergency obstetric care

The Cambodia Demographic Health Survey 2005, does not have any data that talks about access to emergency obstetric care. Although there has been an increase in the skilled birth attendants from 32 percent in 2000, the maternal mortality remained stagnant in Cambodia, which needs to be thought about

 

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.

 

The single most common cause of maternal mortality is obstetric haemorrhage, generally occurring postpartum and accounting for 25—33% of all maternal deaths. The rate of death due to post partum haemorrhage (PPH) varies widely in the developing world. PPH-related mortality rates based on hospital studies are estimated to be 25—30% in India, and 43% in Indonesia. However, women who come to a hospital for care do not represent the general population of women. Because haemorrhage is more apt to occur and more difficult to treat in the community, studies have suggested higher rates of PPH-related mortality in these areas, but there is comparatively little data available outside of a hospital setting.[15] 

According to the Cambodia Demographic Heath Survey (CDHS 2005), “Thirty percent of women received no postnatal care. 64 % of mothers received postnatal care within the crucial first two days of delivery, with 32 % receiving care within four hours of delivery. Urban women are more likely to receive postnatal care (74 %) than rural women during the first two days after delivery (62 %). More than one third of women (37 %) who did not deliver in a health facility did not receive a postnatal checkup.[16]

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.

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

a.    2000: 23.8[25]

b.    2005: 40.0[26]

c.    After 2005:

CPR increased from 23.8 in 2000 to 40.0 in 2005.

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.

Access to modern methods of contraception is still an issue as 32% of all contraceptive users still rely on traditional methods for their contraceptive needs. Pill users (27.5%) and injectable users (19.75%) form almost half of all contraceptive users.

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.[27] However, data is not readily available for Cambodia for this indicator.

 

Voices from the ground:

ICPD+15 Country Case Study:

a.    This is the country case study by ARROW’S ICPD Partner in Cambodia – Reproductive Health Association of Cambodia.  The study recommends that the Ministry of Health should continue to fund interventions that target contraceptive services; provide continued education on contraceptive counseling and provision for birth spacing to health care providers; and undertake mass media campaigns to correct misconceptions among the general public, and among health care providers at large, regarding the characteristics and safety of modern contraceptive methods. These interventions will go a long way to reduce the high maternal deaths in Cambodia. Read the study here  

 

 

5.5 Unmet Need for contraception:

 

a.    2000: 32.6[28]

b.    2005: 25.1[29]

c.    After 2005:

Unmet need decreased from 32.6 in 2000 to 25.1 in 2006. Unmet need is almost uniform across all age groups.[30]

Generally, women with lower education or are uneducated, who are poor, who live in remote areas and rural areas face the greatest challenge in controlling their own fertility. Socio-economic inequities are closely inter-linked with higher rates of unintended births and it is important to ensure access to contraception to all groups of women.[31]

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.”[32] 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. Cambodia is one of the few countries in Asia which includes unmarried women within the DHS survey. 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.[33]

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) : 3.4[34]

b.    Wanted Fertility Rate (2005): 2.8[35]

c.    % difference: 21%[36]

 

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

In the CDHS 2005, the TFR was 3.4 and the WFR was actually 2.8; this means women were having 21% more children than they actually wanted and this constitutes an unmet need.[37]

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.[38]

Apart from the fertility-related reasons, method-related reasons and health concerns, another reason for non-use of contraception in Cambodia is opposition to use (both own and spousal)  – 2% which is not being considered in discussing unmet need.[39]

 

 

5.6 Antenatal care coverage

a.    At least one visit (%):

Ø  2000: 37.7[40]

Ø  2005: 69.3[41]

Ø  After 2005:

b.    At least four visits(%):

Ø  2000: 8.9[42]

Ø  2005: 27.0[43]

Ø  After 2005:

 

 

 

[1] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[2] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[3] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[4] The International Classification of Diseases, Injuries and Causes of Death – 9th revision (ICD9) defines a maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.” These are subdivided into Direct, Indirect, and Fortuitous, but only Direct and Indirect deaths are counted for statistical purposes. The latest revision, ICD10, recognises that some women die as a consequence of Direct or Indirect obstetric causes after this period, and has introduced a category for Late maternal deaths defined as “those deaths occurring between 42 days and one year after abortion, miscarriage or delivery that are due to Direct or Indirect maternal causes.” The ICD 10 further defines direct maternal deaths as those resulting from obstetric complications of the pregnant state (pregnancy, labour, and puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above. Indirect deaths are those resulting from previous existing disease, or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiological effects of pregnancy.  Late deaths are those occurring between 42 days and one year after abortion, miscarriage, or delivery that are due to Direct or Indirect maternal causes. Please refer to ICD-10, WHO. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Geneva, World Health Organization (WHO).

[5] World Health Organization (WHO); United Nations Chidlren’s Fund (UNICEF); United Nations Population Fund (UNFPA); The World Bank. (2007). Maternal Mortality in 2005. Estimates developed by WHO,UNICEF and UNFPA. Geneva, Switzerland: WHO.

[6] World Health Organization (WHO); United Nations Chidlren’s Fund (UNICEF); United Nations Population Fund (UNFPA); The World Bank. (2007). Maternal Mortality in 2005. Estimates developed by WHO,UNICEF and UNFPA. Geneva, Switzerland: WHO.

[7].John Wilmoth . (2009). The lifetime risk of maternal mortality: concept and measurement. . Published online: 13 February 2009 World Health Organization  (WHO)

[8] Excludes Singapore, Vietnam and Turkey.

[9] Department of Economic and Social Affairs: Population Division. (2007). World Abortion Policies 2007, retrieved 29 July 2009 from United Nations Web site: http://www.un.org/esa/population/publications/abortion/doc/cambod1.doc

[10] Department of Economic and Social Affairs: Population Division. (2007). World Abortion Policies 2007.  Retrieved  July 29, 2009 from United Nations Web site: http://www.un.org/esa/population/publications/abortion/doc/cambod1.doc

[11] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[12]Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[13] Department of Reproductive Health and Research, World Health Organization (WHO). (2008). Proportion of Births Attended by a Skilled Health Worker 2008 Updates Factsheet. Geneva, Switzerland: WHO

[14] Monitoring the Situation of Children and Women. (2009). Retrieved August 12, 2010, from Childinfo.org: Statistics by Area Web site: http://www.childinfo.org/delivery_care.html

[15] Geller E; Adams,  M.G; Kelly,  P.J; Kodkany, B.S;, Derman R.J. (2006). Postpartum hemorrhage in resource-poor settings. In International Journal of Gynecology and Obstetrics Vol. 92 Issue 3 (pp. 202-211). Maryland, USA:  Elsevier Inc. 

[16] National Institute of Public Health; National Institute of Statistics; Macro ORC. (2006). Cambodia Demographic and Health Survey 2005. Cambodia: National Institute of Public Health; National Institute of Statistics; Macro ORC.

[17] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[18] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[19] http://unstats.un.org/unsd/mdg/Metadata.aspx?IndicatorId=0&SeriesId=761

[20] National Institute of Public Health; National Institute of Statistics; Macro ORC. (2006). Cambodia Demographic and Health Survey 2005. Cambodia: National Institute of Public Health; National Institute of Statistics; Macro ORC.

[21] Cambodian NGO Committee on CEDAW 2001; Cambodian Committee of Women (CAMBOW). (2006). Joint Coalition Shadow Report for the CEDAW Committee, Report on Elimination of all forms of Discrimination against Women In Cambodia. (p.79) Cambodia; Cambodian NGO Committee on CEDAW 2001; CAMBOW

[22] Glossary. (2009). Retrieved September 29, 2009, from International Planned Parenthood (IPPF)/ Western Hemisphere Region Web site: http://www.ippfwhr.org/en/resources/glossary#S#ixzz0RtBLHMT9

[23] Glossary Browser. (2009). Retrieved September 29, 2009, from International Planned Parenthood (IPPF) Web site:  http://glossary.ippf.org/GlossaryBrowser.aspx

[24] United Nations Population Fund (UNFPA) Population, Gender and Reproductive Health. (2005). Cambodia at a Glance. Cambodia: UNFPA.

[25] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[26] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[27] Thanenthiran, S; Racherla S.J. (2009).  Reclaiming & Redefining Rights – ICPD+15: Status of Sexual and Reproductive Health and Rights in Asia. Kuala Lumpur, Malaysia: The Asian-Pacific Resource & Research Centre for Women (ARROW).

[28] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[29] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[30] National Institute of Public Health; National Institute of Statistics; Macro ORC. (2006). Cambodia Demographic and Health Survey 2005. Cambodia: National Institute of Public Health; National Institute of Statistics; Macro ORC.

[31] Thanenthiran, S; Racherla S.J. (2009).  Reclaiming & Redefining Rights – ICPD+15: Status of Sexual and Reproductive Health and Rights in Asia. Kuala Lumpur, Malaysia: The Asian-Pacific Resource & Research Centre for Women (ARROW).

[32] % of Married Women Ages 15-49, Unmet Need for Contraception Statistics, Countries Compared. (2005). Retrieved August 6, 2009, from Nationmaster.com Web site: http://www.nationmaster.com/graph/hea_unm_nee_for_con_of_mar_wom_age_1549-married-women-ages-15-49

[33] Thanenthiran, S; Racherla S.J. (2009).  Reclaiming & Redefining Rights – ICPD+15: Status of Sexual and Reproductive Health and Rights in Asia. Kuala Lumpur, Malaysia: The Asian-Pacific Resource & Research Centre for Women (ARROW).

[34] National Institute of Public Health; National Institute of Statistics; Macro ORC. (2006).  Cambodia Demographic and Health Survey 2005. Cambodia: National Institute of Public Health; National Institute of Statistics; Macro ORC.

[35] National Institute of Public Health; National Institute of Statistics; Macro ORC. (2006).  Cambodia Demographic and Health Survey 2005. Cambodia: National Institute of Public Health; National Institute of Statistics; Macro ORC.

[36] National Institute of Public Health; National Institute of Statistics; Macro ORC. (2006).  Cambodia Demographic and Health Survey 2005. Cambodia: National Institute of Public Health; National Institute of Statistics; Macro ORC.

[37] Thanenthiran, S; Racherla S.J. (2009).  Reclaiming & Redefining Rights – ICPD+15: Status of Sexual and Reproductive Health and Rights in Asia. Kuala Lumpur, Malaysia: The Asian-Pacific Resource & Research Centre for Women (ARROW).

[38] Sedgh G; Hussain R; Bankole A; Singh S. (2007). Women with an Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method. Occasional Report No. 37.

Retrieved October 1, 2009, from Guttmacher Institute Web site: http://www.guttmacher.org/pubs/2007/07/09/or37.pdf

[39] Thanenthiran, S; Racherla S.J. (2009).  Reclaiming & Redefining Rights – ICPD+15: Status of Sexual and Reproductive Health and Rights in Asia. Kuala Lumpur, Malaysia: The Asian-Pacific Resource & Research Centre for Women (ARROW).

[40] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[41] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[42] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[43] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

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