Sparing Lives: Better Reproductive Health for Poor Women
Sparing Lives: Better Reproducative Health for Poor Women in South Asia
(March 5, 2009) South Asia must improve the reproductive health of poor women to break the inter-generational cycle of poverty and achieve the Millennium Development Goals.
Facts: -Less than half of all pregnant women in the region receive antenatal care with the exception of Sri Lanka. -In Sri Lanka, almost all births take place in institutions. In India and Pakistan this number is below 40%. It drops to less than 20% in Bangladesh and Nepal. -In industrialized countries, the risk of dying during childbirth is 1 in 4000; In South Asia, the risk is almost 100 times higher.
The report highlights that the region faces enormous challenges in addressing inequalities in reproductive health of poor women, and focuses on the risks they face. This phenomenon perpetuates an inter-generational cycle of poverty. Nearly 185,000 women in South Asia die from causes related to pregnancy every year, and millions more are affected by acute or chronic illnesses as a result of childbearing. Widespread gender discrimination also adversely impacts poor women's health in the region.
The report calls for an integration of reproductive health services and decentralized planning to target poor geographic areas and finding innovative ways of financing reproductive health. The region may not achieve the Millennium Development Goals for maternal and child health unless these issues are addressed.
1. Provide a single window for reproductive health services
Poor women need to be provided health care through a 'single window' as they do not often have the resources to approach different providers for issues such as family planning, childbirth, and nutrition. Outreach services must be targeted to women in the poorest households and villages. Sri Lanka has shown that a well-functioning, integrated primary health network can be very effective in improving the reproductive health of women. Other countries in the region are developing these networks as well but need to address significant gaps.
2. Step up antenatal care and skilled birth attendance
Antenatal care and institutional deliveries defined as the presence of a skilled birth attendant during childbirth can make a critical difference to the survival of mothers and babies. Yet, less than half of all pregnant women in the region receive antenatal care. It is only in Sri Lanka that the vast majority of births take place in institutions. To increase the use of these services by poor women, they need to be made aware of the benefits of good care during pregnancy. Government-run institutions need to integrate these services while improving quality and provding incentives to poor women to use them.
3. Train and equip more female health personnel
All countries in the region face acute shortages of female health workers, nurses, and doctors. They must train larger numbers with the appropriate skills to meet growing demand. The field of rural health services needs to be made more competitive with incentives provided to staff for good performance. Services can also be given to the poor through private providers through effective public-private partnerships. Sri Lanka's Public Health Midwives are better trained and provide a higher level of service than their counterparts in neighboring countries.
4. Increase focus on young adolescents
Early marriage and childbearing are widespread in India, Nepal, and Bangladesh where 1/3 to 1/2 of all adolescent girls (15-19 year-olds) are married. However, knowledge about reproduction and contraception among adolescents remains low. Health services must proactively provide adolescents with much-needed information and counseling on sex and reproduction. Nepal appears to be addressing its adolescent population in important areas such as HIV/AIDS awareness. Pakistan and Sri Lanka have effectively increased the marriage age of girls and most children in these countries are now born to mothers between the ages of 25 and 29.
5. Improve nutrition, especially for girls
Over 40% of children under five in South Asia are malnourished, with malnutrition being high in all five countries. Prevention of malnutrition must begin with the mother and continue through infancy and childhood. Good nutrition for women must be sustained throughout the reproductive period with health workers playing a key role in increasing awareness and action.
6. Emphasize secondary education for girls and improve the status of women
The education of women clearly impacts all facets of reproductive health. However, female literacy remains low in all countries except Sri Lanka and a few Indian states. Increasing secondary education for girls will have a strong impact on the health of women. The more mobility women have outside the home, the more likely they are to utilize contraceptives, antenatal care, immunizations, and skilled birth attendance. Bangladesh, India, and Nepal need to expand efforts in these areas immensely.
Planning should be decentralized. Incorporating the involvement of poor women, local governments, and health staff in the planning process will increase effectiveness and accountability. Given the scarcity of human and financial resources, these resources need to be tailored to meet the needs of poor local women. Sri Lanka's efficient and equitable use of resources in contrast to higher per capita spending offers useful lessons.
8. Spend more and spend it efficiently
Allocations to mother and child health services in public hospitals need to be increased from the current low levels, with a focus on efficient spending. Public money could also be used to provide the poor with vouchers, reimbursement, insurance, or social marketing schemes to enable them to use private services.
Total Fertility Rates (2006): Pakistan: 4.1; Nepal 3.1; Bangladesh 2.7; India 2.7; Sri Lanka 2.4
Female Deficit: In all countries except Sri Lanka, there is a deficit of females in the population, especially among the youngest (0-6 years) age-group.
Early Marriage and Childbearing: Between 1/3 to 1/2 of adolescent girls (15-19 year-old) are married and on the brink of childbearing in Bangladesh, India, and Nepal. In Pakistan, this number has been reduced to 15%, while in Sri Lanka it is as low as 2%
Skilled Birth Attendance: About one in three women deliver their babies in the presence of skilled birth attedants in Bangladesh, India, Nepal, and Pakistan.
Maternal Mortality Ratio (in every 100,000 live births): India: 301; Nepal: 281; Pakistan: 276; Sri Lanka (2005): 58; Bangladesh (2001): 320
Contraception: Nearly one-fifth of all births in the region are unwanted or mistimed.
More Resources on South Asia
World Bank Program in South Asia Launching pad to all information on World Bank activities in Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka.