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www.wvasiapacific.org/maternalhealth

Maternal survival
How many deaths?
zz In South and East Asia and the Pacific 232,000 women die a year from maternal deaths.1 This equates to one mother dying every 2.3 minutes from maternal related causes. zz 2007 figures show that in South Asia 50% of all births were unregistered (as few as seven percent of births are registered in Bangladesh).2 South Asias registered maternal death total of 96,505 in 2007 is therefore also likely to be much lower than the real toll. zz Access to medical care - in South Asia only 35% of pregnant women give birth in a medical facility, and over half of all births occur at home without any skilled professional present.7 zz High birth frequency, which through custom, ignorance or powerlessness, puts women at greater risk statistically of dying from pregnancy-related causes. Of all the people in the world who require family planning services, but do not have access to them, 55% live in Asia and the Pacific.8 zz Low reproductive knowledge - countries with low levels of gender inclusion in primary and secondary education have the highest levels of maternal deaths.

Who?
zz The highest maternal death rate in the Asia Pacific region occurs in Cambodia, with 470 out of 100,000 mothers dying during pregnancy, birth, or the first 42 days after delivery.3 zz Massive discrepancies exist between countries in the region. Cambodia loses 1,795 women to maternal death each year, while neighbour Thailand, with a population four times greater than Cambodia, loses 12.4

Maternal death reduction strategies

Invest in facilities, training and education on maternal health as a priority: zz Public health expenditure remains well below the world average on 5.1 per cent, with South Asia spending only 1.1 per cent of GDP and 1.9 per cent being spent in the rest of Asia-Pacific.9 zz Countries like Thailand, Malaysia and the Republic of Korea (South Korea) experienced massive economic growth in the last quarter of last century. As these countries strengthened economically, they invested in policies to improve services for both mothers and children. The same cannot be said of India, whose thriving economy is in stark contrast to its public health spending, among the lowest in the world per capita. The public health care system, which provides the only health care access for the poor, has only two physicians and eight nurses per 10,000 population10 - very few of these medical staff have training specific to midwifery. zz A country does not need to be wealthy to show commitment to reducing maternal deaths. Over 40 years ago, Sri Lanka began to expand ante-natal and
7 http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.p 8  http://www.adb.org/Documents/Brochures/Maternal-ChildHealth/Investing-Maternal-Child-Health.pdf 9 http://www.thaindian.com/newsportal/lifestyle/india-china-hold key-to-world-meetingmillenium-development-goals-unicef_ 10080148.html 10 http://www.searo.who.int/en/Section313/Section1519.htm

Why?
The seven biggest maternal killers in Asia are: haemorrhaging (31%), ectopic pregnancy, embolism or other complications (15%), anaemia (13%), sepsis, infections (including AIDS-related deaths) (12%), hypertensive disorders (9%), obstructed labour (9%), and complications with abortions (6%). 5 Underlying causes include: zz Under-nutrition in mothers, which makes them weak in withstanding neonatal infections. As a result of under-nutrition more than half the women in reproductive age are anaemic in South and Southeast Asia, and this number shows no sign of declining.6
1 http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf 2 http://www.unicef.org/policyanalysis/files/FactsheetInvesting.pdf 3 http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf 4 http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf 5 Camilla 6  http://www.adb.org/documents/periodicals/ADR/pdf/ADR-Vol17Mason-Hunt-Parker-Jonsson.pdf

Together we can end preventable deaths

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neo-natal services. Even though around one third of its population lives under the poverty line, Sri Lanka has now successfully decreased its maternal death rate, from 340 per 100,000 births in 1960 to just 43 in 2004. 98% of all births are now performed in a medical facility.11
11 http://www.unicef.org/devpro/46000_48498.html

Together we can end preventable deaths

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Child survival
How many deaths?
zz Every year an estimated 3.8 million children in South and South East Asia die before their fifth birthday. (South Asia - 2.98 million / East Asia 799,000).12 This amounts to a child dying every 8.3 seconds, or the casualty equivalent of 1,264 September 11s. zz Of these 3.8 milllion children, around 2.1 die within the first 28 days. (East Asia 535,914 / South Asia 1,557426)13 zz In 2006, 2.5 million child deaths occurred in just two countries - India (2.1m) and China (415,000), together accounting for nearly a third of all child deaths worldwide.14 zz Vaccination against childhood illness overall in the Asia Pacific, at 78%, is slightly under the global average of 80%. In some countries, however, vaccination levels are decreasing; Myanmars has fallen from 90% in 1990 to 78% in 2006, and Indias has steadily decreased since 1996.15 Underlying causes include: zz Neonatal: Most deaths of under-fives occur in the first hours or days of a childs life, mainly due to deliveries at home with no access to skilled professionals who can identify illness or perform emergency treatment. . zz Low birthweight or low immunity, due to maternal malnutrition: Food shortages affect women more than men, especially in countries with low gender parity. In India, where around 350 million people go short of food every day, resultant anaemia in pregnant women can be linked to around 20% of infant deaths.19 zz Insufficient breastfeeding denies a child natural immunity, especially if the first vital colostorum is missed. As well, exposure to gastric illness through dirty water (including when mixed with baby formula) is especially dangerous for a child under 6 months of age, and can wreak permanent damage to infant intestinal tracts. zz Respiratory infections, usually linked to malnutrition because of an infants low immunity from birth, are one of the biggest causes of death between 2 and 28 days. Effective post-natal monitoring can recognise and treat respiratory problems, but is underresourced in most Asian countries. zz Preventable causes: for children under five, especially children who are malnourished, diarrhoea, malaria and other fevers quickly become life threatening.

Who?
zz Myanmar has the highest child mortality rate in the Asia-Pacific region.16 At least one in ten children will die before the age of five three quarters of them before the age of one. At the heart of these statistics is malnutrition. zz In India, where malnutrition in mothers causes nearly one third of babies to be born with low birth weight, around one in 12 die in their first five years.17 One in five children who dies globally is an Indian child.

Child death reduction strategies

zz Targeted health spending: In Malaysia both maternal mortality and neonatal deaths have gone down significantly since the government introduced widespread access to skilled birth attendants. 20 zz Immunisation: DPT3, a three dosage immunisation that protects against diphtheria, pertussis and tetanus, is a countrys usual indicator of child routine immmunisation. Of the estimated 24 million children globally that have not received DPT3, 9.7 million are Indian, 0.4 million are from Bangladesh, 1.1 million from Indonesia and 1.2 million in China. Indias DPT3 vaccination rate peaked in 1995 and has since declined to around 62%. 21
19 20 21 http://www.wfp.org/countries/india http://www.unicef.org/vietnam/media_983.html http://www.adb.org/Documents/Books/Key_Indicators/2008/ pdf/Goal-04.pdf

Why?
The biggest killer of children under 5 in East Asia and the Pacific is inadequate birthing conditions (45%), including low birthweight as well as birth trauma or asphyxiation. Other leading causes of death are diarrhoea (17%), acute respiratory infections (16%), accidents (8%), vaccine preventable diseases including measles and TB (7%), and vector borne diseases e.g. malaria. Malnutrition is a contributory factor in more than half of all deaths under 5.18
12 13 14 15 16 17 18 http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf http://www.adb.org/Documents/Books/Key_Indicators/2008/pdf/ Goal-04.pdf http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf http://www.unicef.org/vietnam/media_983.html

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zz Cleaner water, better sanitation: Children contract diarrhoea from contaminated water or from inadequate toilet hygiene. East and South-East Asia have markedly improved both access to clean water and to toilets over the last 20 years, but one in five people in the region still uses a toilet that does not meet minimum hygiene standards of separating human waste from the possibility of human contact. 22 In South Asia, two out of three people do not use hygienic toilets. 23
22 http://www.unicef.org/eapro/wes_revised_factsheet_2009.pdf 23 http://www.who.int/water_sanitation_health/monitoring/jmp 2008.pdf

Together we can end preventable deaths

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zz Protection from malaria, dengue and other vector-borne diseases: Sleeping under a mosquito net, removing stagnant water from near households, and treating fever symptoms effectively, are three important solutions to reduce malaria and dengue deaths, but are dependent on community knowledge and will. Public health campaigns are urgently needed to combat these preventable deaths.

Maternal and child nutrition

How many affected?
zz Around 30% of women in the Asia region are underweight.24 zz A high rate of anaemia in pregnant and breastfeeding mothers affects the nutrition of their children. Anaemia in women, usually linked to diet, ranges from 13.4% in Thailand to 87% in India.25 zz An estimated 120 million children are malnourished in South and Southeast Asia.26 zz In East Asia and Pacific 11% of under-fives are moderately to severely undernourished. In South Asia the figure is 41% (thats over two out of five). 27 zz Stunting in children under five as a result of malnourishment is almost equal between the two sub-regions; 18% in South Asia , 16% in East Asia. 28 inadequate harvests, natural disasters or unequal food access. Last year, a survey of children in the Indonesian province of West Timor found up to 60% of children were malnourished.31 zz In urban areas, malnutrition can be driven by food costs, where household income in poor communities does not increase in line with the cost of living. In the last two years, rising food costs in megacities like Manila, Jakarta and Dhaka have almost certainly led to increased malnutrition in millions of children under five.32 zz Knowledge and availability of nutritious food poses a challenge to childrens health, especially in communities where mothers have not attended school or had other exposure to the concept of nutrition. What is traditionally grown and cooked by communities may not contain a full spectrum of nutritional requirements. zz Insufficient breastfeeding when babies are moved from breast milk to low nutrition rice porridges their weight and health drops dramatically. In Vietnam only 17% of children are breastfed to six months; as a result, one quarter of children are underweight, despite the relative food security of this prospering nation.33 zz Intestinal parasites affect up to 90% of children in poor communities across the Asia Pacific region, including hookworms or roundworms. Infected children are nearly four times more likely to be stunted and to suffer learning disabilities and underperform academically.34

Who?
zz 2 million children are suffering from undernourishment in Bangladesh today. 500,000 of these children have been diagnosed with severe acute malnutrition.29 zz Timor-Leste currently faces a massive 49% malnutrition in its children, due in part to food shortages and in part to lack of knowledge of maternal and child health including birth spacing.30

Why?
zz In remote or protected areas like outlying Indonesia, rural Myanmar or most of DPRK, malnutrition is linked to food shortages, caused by
24 25 26 27 28 29 30 http://www.searo.who.int/LinkFiles/FCH_SEA-CHD-7.pdf p.13 http://www.searo.who.int/LinkFiles/FCH_SEA-CHD-7.pdf p.13 http://www.adb.org/documents/periodicals/ADR/pdf/ADR-Vol17Mason-Hunt-Parker-Jonsson.pdf http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf http://www.un.org/apps/news/story.asp?NewsID=30329&Cr= bangladesh&Cr1 http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf

31 32 33 34

http://www.alertnet.org/thenews/fromthefield/284081/ 121146418139.htm http://www.reuters.com/article/homepageCrisis/idUSDEL457287. _CH_.2400 http://www.wpro.who.int/vietnam/sites/dhp/nutrition/ http://www.wpro.who.int/media_centre/press_releases/pr_ 20020912.htm

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Maternal and child malnutrition reduction strategies
zz Improving family nutrition need not be expensive. The PD (or Positive Deviance) Hearth model starts by teaching mothers the basics of family healthcare with a strong emphasis on nutrition. After this, mothers whose children show good nutritional results take on the responsibility of training others, by sharing their own good practice. World Visions PD Hearth programmes have shown good results in diverse contexts and cultures across Asia and the Pacific and have proven to be sustainable without the need for ongoing funding.35
35 http://www.positivedeviance.org/about_pd/impact.html

Together we can end preventable deaths

World Vision is a Christian relief, development and advocacy organisation dedicated to working with children, families and communities to overcome poverty and injustice. Motivated by our Christian faith, World Vision works with the worlds most vulnerable people. World Vision serves all people regardless of religion, race, ethnicity or gender. http://wvasiapacific.org

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zz In 2005 a concerted effort in Cambodia saw the Ministry of Health partner with WHO and UNICEF to deliver deworming treatment to nearly 3 million children. Health workers targeted 24 provinces through schools with deworming pills, education posters and pamphlets for teachers as well as games and pictures for children. The campaign cost 6 US cents per child.36

36 http://whqlibdoc.who.int/hq/2005/WHO_CDS_CPE_PVC_ 2005.14.pdf

Terms and definitions

Child mortality usually refers to deaths in the underfive age group. Within this group lies: zz Infant mortality or deaths in children before the age of one year; and zz Neonatal mortality or deaths in children during the first 28 days after birth Maternal deaths are deaths occurring to women during pregnancy, childbirth or within 42 days of delivery. Malnutrition can occur to both adults and children. At any age, malnutrition will reduce immunity and resilience to other health conditions. In children, especially under the age of five, malnutrition can lead to permanent and devastating damage. Stunting, reduced brain size, skin conditions, bone diseases (for instance rickets) are all caused by malnutrition. As well, children are more susceptible to diseases. Stunting measures height against age: usually caused by long-term insufficient nutrient intake or frequent infections. Stunting generally occurs before the age of two; effects are largely irreversible. Wasting measures weight against height in all ages: usually an indicator of acute food shortage and/or disease. A high prevalence of wasting usually correlates with a high under-five mortality rate. Underweight measures weight against age: the indicator used to determine malnutrition in children under five. Usually reversible, as opposed to stunted growth caused by being underweight.

Recommended further references

For country comparative statistics on maternal and child health: The State of the Worlds Children 2009: Maternal and Newborn Health, UNICEF 2009 For funding and policy briefing statistics: Investing in Maternal, Newborn and Child Health; the Case for Asia and the Pacific, Asian Development Bank and partners 2007
http://www.adb.org/Documents/Brochures/Maternal-ChildHealth/Investing-Maternal-Child-Health.pdf

http://www.unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf

For country comparative statistics on water and sanitation: Progress on Drinking-Water and Sanitation, WHO/ UNICEF Joint Monitoring Project 2008

http://www.who.int/water_sanitation_health/monitoring/jmp2008/ en/index.html