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Goal 5.
Improve maternal health
5.1. Introduction Goal 5 refers to improvement of maternal health. It translates in two targets aiming to diminish maternal mortality ratio and provision of universal access to reproductive health. Progress is measured through six (6) indicators. Maternal mortality, as well as prevalence of its determining factors, is considered as a severe problem in public health and indicates deep inequalities in life conditions of the population as well as in the health of women in reproductive age. While maternal mortality has an impact on all layers of society, it is specially affects women living in poverty who have limited access to health, low quality in the care they have access to, and lack of antenatal control and attention to obstetric emergencies (United Nations, 20081).
Consolidated List of Goals and Target Indicators 5 Goal 5. Improve maternal health Target 5.A. Reduce by tree quarters, between 1990 and 2015, the maternal mortality ratio Type of Indicator
N°
Name of the Indicator
Official
5.1
Maternal mortality ratio
Official
5.2
Proportion of births attended by skilled health personnel
Target 5.B. Achieve, by 2015, universal access to reproductive health Official
5.3
Contraceptive prevalence rate
Official
5.4
Adolescent birth rate
Official
5.5
Antenatal care coverage (at least one visit and at least four visits)
Official
5.6
Unmet need for family planning
5.2. Regular Progress Report on MDG 5 in Latin America and the Caribbean Maternal mortality ratio (indicator 5.1) refers to the number of women who die by any cause deriving from or worsen by pregnancy or birth, or who die before a period of time of 42 days have passed after termination of pregnancy, and it is calculated per 100,000 children born alive. Charts show that in the Latin America and the Caribbean region the maternal mortality ratio has decreased since 1990, from 180 to 130 deaths every 100,000 children born alive. Nevertheless and once 60% of time to reach the Goal of reducing the incidence in three-quarters by 2015 has passed, the achievement percentage in the region as a whole only amounts to 37%. Thus, it is a rather unfavorable situation when compared with
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United Nations (2008). Millennium Development Goals. Progress towards the right to health in Latin America and the Caribbean Santiago, Chile, Economic Commission for Latin America and the Caribbean (ECLAC). 1
www.cepal.org/mdg developed regions where maternal mortality ratio is not greater than 10 deaths every 100,000 children born alive.
Gráfico 1 (indicador 5.1) Tasa de mortalidad materna América Latina y el Caribe (27 países) 1990, 2005 (tm uertes m aternbas por cada 100.000 nacidos vivos) 200
(muertes por cada 100.000 nacidos vivos)
180 160
180
140 120 130 100 80 60 40 20 0 1990
2005
Source: ECLAC on the basis of UNICEF, United Nations Children's Fund: The State of the World's Children 2006 and 2008. On-line database. Information download: August, 2008.
Maternal mortality ratio of the countries in the region is very diverse and trends are diverging: While having very different initial values (1990), 3 countries have exceeded the Goal of reducing the maternal mortality ratio in three quarters: Bahamas, Chile, and Uruguay. These countries, along with Barbados, have reduced the maternal mortality ratio to less than 20, while Costa Rica, Trinidad Tobago, and Cuba, are already below the Goal of 45 which is the value set for the region by 2015.
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Gráfico 2 (indicadr 5.1) Tasa de mortalidad materna Países de América Latina y el Caribe 2000, 2005 (m uertes m aternas por cada 100.000 nacidos vivos) Chile Barbados Bahamas Uruguay Costa Rica Trinidad y Tabago Cuba Belice Venezuela (Rep. Bolivariana de) México Suriname Argentina Brasil Panamá Colombia Paraguay República Dominicana
Ajustada 2005 Ajustada 2000
Nicaragua Jamaica El Salvador Ecuador Perú Honduras Guatemala Bolivia Guyana Haití 0
100
200
300
400
500
600
700
(tasa por cada 100.000 nacidos vivos)
Source: ECLAC on the basis of UNICEF, United Nations Children's Fund: The State of the World's Children 2008. On-line database. Information download: August, 2008.
On the other end, the situation affecting countries like Haiti, Guyana, Bolivia, Guatemala, Honduras, Peru, and Ecuador is observed with concern as maternal mortality ratio continues to be over 200 deaths every 100,000 children born alive. In the case of Haiti, the increase reaches 670, thus producing a marginal reduction since 1990. Lastly, it should also be mentioned that in 8 countries the mortality rate has increased since 1990. This shows important deficiencies in health policies focused on the sexual and reproductive health of such countries. One of the determining factors in maternal mortality is the deficient conditions under which births are practiced, especially in rural areas. Lack of attention by skilled professionals along with lack of appropriate equipment and medication during birth is measured by indicator 5.2 of MDGs which refers to the percentage of births attended by skilled health personnel. Data for this indicator come from health and demographic surveys conducted at country level. Thus, there is not any homologation about the questions of the survey or the date when the survey is applied. Taking these 3
www.cepal.org/mdg limitations into account, it is possible to conclude that Latin America and Caribbean countries have made considerable progress in terms of professional assistance during birth, increasing from 68% in 1990 to 88% in 2006. Data show that in 70% of the 39 countries reporting information, more than 90% of births have this type of assistance2, while 40% of the countries where births are attended by skilled health personnel have already reached the level of developed countries (more than 99%). Ten countries have not overcome as of yet the 90% goal. These are Haiti (26.1%), Guatemala (41.4%), and Bolivia (60.8%), countries which also show the highest ratio for maternal mortality. Another important factor in assistance and care provided to women during pregnancy is the appropriate and timely antenatal care, which is measured on the ratio of pregnant women attending medical visits during pregnancy (indicator 5.5). This indicator includes two sub-indicators: Pregnantt women who at least had one visit and women who at least attended 4 visits during pregnancy. For both the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) this latter sub-indicator is considered as a rather more accurate measurement of antenatal care; however there is not much information available from the countries of the region (www.who.int).
2 The General Assembly of the United Nations set a goal by 2015 of 90% of births attended by skilled health personnel during the period of extraordinary meetings dedicated to the Follow-up of the International Conference on Population and Development, CIPD+5 in 1999.
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Gráfico 3 (indicador 5.2) Proporción de partos con asistencia de personal sanitario especializado Países de América Latina y el Caribe (1990 - 1999) y (2000 - 2006)* (porcentaje)
Santa Lucía /a San Vicente y las Saint Kitts y Nevis Granada Barbados Cuba Antigua y Barbuda Chile Uruguay Argentina Dominica b/ Bahamas Brasil /a /j Jamaica /g Colombia d/ j/ República Dominicana Venezuela Costa Rica Guyana México Panamá Belice /a Ecuador Paraguay Perú /h El Salvador /a Nicaragua /k Honduras /f Bolivia /c /l Guatemala Haití /e /l
Entre el 2000 y 2006 Entre 1990 y 1999
América Latina y el Caribe 0
10
20
30
40
50
60
70
80
90
100
(% ) Notes: * 1990 – 2000 data pertains to WHO, World Health Organization, 2008, World Health Statistics. Year of surveys unknown. Year of survey for 2000 - 2006 data: Nicaragua, 2001; Guatemala 2002; El Salvador 2002 – 2003; Bolivia, Venezuela, 2002; Brazil, Paraguay, Peru, 2004; Argentina, Barbados, Chile, Colombia, Dominica, Ecuador, Grenada, Guyana, Jamaica, Panama, Puerto Rico, Saint Kitts and Nevis, San Vincent and the Grenadines, Saint Lucia, Uruguay, 2005; Anguilla, Antigua and Barbuda, Bahamas, Belize, Costa Rica, Cuba, Mexico, Montserrat, Dominican Republic, 2006; Haiti, Honduras 2005 – 2006. /a Births at institutions /b Estimate /c Excludes partera (6%) /d Includes partera (5.7%) /e Includes auxiliaire (1.4%) /f Includes auxiliar de enfermeria (0.6%) /g Includes auxiliary midwife(8.9%) /h IIncludes sanitario/promotora (2.3%) /i Includes auxiliary midwife (9.3%) Source: ECLAC on the basis of WHO, World Health Organization, Factsheet. Proportion of births attended by a skilled health worker. 2008 updates. www.who.int/reproductive-health.
Since the 1990's Latin America and the Caribbean have shown high rates in antenatal care coverage. In this century, in 23 of the countries for which information is available, 20% have already achieved antenatal coverage for at least one visit of 100% while 17 countries exceed 90% coverage. On the other hand, 4 countries have not yet reached 85% coverage nevertheless showing significant progress in recent years. 5
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Gráfico 4 (indicador 5.5) Cobertura de atención prenatal (al menos 1 consulta) Países de América Latina y el Caribe (1990-1999) (2000 - 2006)* (porcentaje) Saint Kitts y Granada Dominica Cuba Barbados Antigua y Barbuda Santa Lucía Argentina República Brasil San Vicente y las Paraguay Colombia Perú Honduras Costa Rica Suriname Jamaica El Salvador Nicaragua Haití Guatemala Ecuador Bolivia 0
10
20
30
40
50
60
70
80
90
100
(% ) Valor entre 1990 - 1999
Valor entre 2000 - 2006
Notes: * Years of household surveys: Antigua and Barbuda 1998, 2005; Argentina 1992, 2005; Barbados 1999, 2004; Belize 1999; Brazil 1996, 2004; Bolivia 1998, 2003; Colombia 1995 , 2005; Costa Rica 1999, 2004; Cuba 1998, 2005; Dominica 1999, 2004; Ecuador 1998, 2004; El Salvador 1998, 2003; Grenada 1999, 2005; Guatemala 1999, 2002; Guyana 2003; Haiti 1995, 2006; Honduras 1996, 2006; Jamaica 1997, 2005; Mexico, 1995; Nicaragua 1998, 2001; Paraguay 1998, 2004; Peru 1996, 2004; Dominican Republic1996, 2002; Saint Kitts and Nevis 1990, 2005; San Vincent and the Grenadines 1999, 2005; Saint Lucia 1990, 2004; Suriname 1996, 2000; Trinidad and Tobago 2006. Source: ECLAC on the basis of United Nations Statistics Division. Millennium Development Goals Indicators. Information download: August, 2008.
While coverage for antenatal care has remarkably improved in recent years, it is a well known fact that antenatal care services currently provided in many parts of the world do not meet recommended standards. Thus, there is an enormous undeveloped potential (www.who.int). Eventhough progress has been made in the Latin American and Caribbean region in regard to expanding accessibility and ensuring at least one antenatal visit, the ratio of women with the minimum recommended of four visits is still low. In consequence, it is necessary to continue making progress in this area as to facilitate early diagnosis of problems that might evolve in maternal death during pregnancy.
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www.cepal.org/mdg Tabla 1 (indicador 5.5) Cobertura de atención prenatal al menos 4 consultas Países de América Latina y el Caribe (porcentaje)
República Dominicana Jamaica Perú Colombia Honduras Paraguay Brasil Nicaragua El Salvador Bolivia Ecuador Haití
Valor
Año de la encuesta
93.5 87.2 87 83.1 80.8 78.8 75.9 71.6 71.2 57.9 57.5 53.8
2002 1997 2004 2005 2006 2004 1996 2001 2003 2003 2004 2006
Source: ECLAC on the basis of United Nations Statistics Division. Millennium Development Goals Indicators. Information download: August, 2008.
The use of contraceptive methods in women (indicator 5.3) is another significant factor in reducing maternal mortality. This indicator reflects access to reproductive health which, when absent, originates unwanted and high-risk pregnancy. Information available about this indicator once again shows the existence of important gaps at country level. Countries like Haiti, Guyana, and Trinidad and Tobago have a percentage of use of contraceptives lesser than 40%, and on the other end of the spectrum in countries like Colombia and Uruguay the same indicator is 78.2% and 77%, respectively.
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Gráfico 5 (indicador 5.3) Tasa de uso de anticonceptivos en mujeres de 15 a 49 años Países de América Latina y el Caribe 2000 - 2006* (porcentaje) 80 América Latina y el Caribe 70 60
(%)
50 40 30 20 10
Haití
Guyana
Trinidad y Tabago /a
Suriname
Bolivia
Guatemala
Chile /c
Honduras
El Salvador
Argentina /b
Nicaragua
Jamaica
México
República Dominicana /a
Perú
Ecuador
Cuba
Paraguay
Uruguay
Colombia
0
Notes: *Year of the survey: Cuba, Suriname, Trinidad and Tobago 2000; Argentina, Chile, Nicaragua 2001; Guatemala, Dominican Republic 2002; El Salvador, Jamaica 2002/03; Bolivia 2003/04; Ecuador, Paraguay, Uruguay 2004: Colombia 2004/05; Peru 2004/06; Guyana 2005; Haiti, Honduras, 2005/06; Mexico 2006. a/ Including women in visiting unions, which are non-cohabiting but are nevertheless regular partnerships. b/ Data pertains to sexually active women of reproductive age. c/ Data pertains to men and women of reproductive age who are in union. Source: ECLAC on the basis of United Nations, Department of Economic and Social Affairs, Population Division. Poster Use of Contraceptive methods worldwide 2007.
This indicator is closely related to the occurrence of unwanted pregnancy, as measured by indicator 5.6 and which refers to unmet needs for family planning, and considers women who became pregnant without using any contraception method and who today claim not to want more children. Reproductive health implies that people are free to decide when to reproduce, and includes the fact that women and men have the right to be informed and have the right to have access to safe, effective, and affordable family planning methods. Having access to family planning methods allow women to combine their wish of creating a family along with their ability to work and have access to their own income, or to continue with their education (Zapata, 20073). Notwithstanding recent decades increase in the use of contraceptives, unmet demand for family planning in several countries of the region for which information is available continues to be high. Chart 6 shows the levels of unwanted fertility levels in the countries of the region for which information is available. Values fluctuate from 5% in the case of Ecuador to 37.5% in the case of Haiti. The latter country is 3
Zapata, Daniela (2007). Transversalizando la perspectiva de Género en los Objetivos de Desarrollo del Milenio. Serie Estudios Estadísticos y Prospectivos. División de Estadística y Proyecciones Económicas. Santiago, CEPAL. 8
www.cepal.org/mdg again in a rather unfavorable situation as women living under extreme poverty and, in many cases, youngest women are the most affected. Prevention of unwanted pregnancy in itself could avoid approximately one-fourth of maternal deaths including deaths caused by clandestine abortions (United Nations, 20074). Gráfico 6 (indicador 5.6) Necesidades insatisfechas en materia de planificación familiar 17 países de América Latina y el Caribe (entre el 2000 y el 2007) (porcentaje) 40
37.5 32.5
35 30
19.5
18.9
16.9 14.6
15
14.2 10.9
10
8.9
8.1
7.3
6.6
5.8
5
Ecuador
20.8
20
Colombia
(%)
22.7
Paraguay
23.1
25
Brasil
Perú
El Salvador
República Dominicana
Jamaica a/
Nicaragua
Honduras
México a/
Belice
Bolivia
Guatemala a/
Trinidad y Tabago a/
Haití
0
Venezuela (Rep. Bolivariana de)
5
Notes: a/ The figure refers to women in fertile age who were once married. Source: ECLAC on the basis of United Nations, Department of Economic and Social Affairs, Population Division. Poster Use of Contraceptive methods worldwide 2007.
The fact of not being able to choose contraceptive methods has a profound impact on adolescent population and generates a dramatic increment in early births among young people. Birth rate among adolescents is addressed by indicator 5.4 of MDG 5 and again considers vulnerability of women in some countries of the region. Many research studies show that women who become mothers before aged 20 reach an education level which is much lesser than women who delay making this decision until reaching their 20's (Zapata, 2007). A large number of young women, especially the youngest, face along with their children an increasing risk of death and disability. In Latin America the high rate of births in adolescent mothers which has been prominent since 1990 has not experienced any significant reduction regardless a continuous reduction in total fertility in the region (United Nations, 2007).
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United Nations (2007). Millennium Development Goals. 2007 Report. Nueva York, UN. 9
www.cepal.org/mdg This is a situation of concern all countries in the region have. While some countries show a rather more favorable situation, with rates under 50 (Cuba, Chile, Trinidad and Tobago, Bahamas), the charts also show rates greater than 100 births for every 1,000 adolescent women in Guatemala, Dominican Republic, Honduras, El Salvador, and Ecuador in a situation that raises concerns where over 10% of adolescents become mothers before aged 19. Gráfico 7 (indicador 5.4) Tasa de natalidad entre las adolescentes Países de América Latina y el Caribe entre el 2000 y el 2004 (núm ero de nacim ientos por cada 1.000 m ujeres adolescentes ) Guatemala República Honduras El Salvador Ecuador Boliv ia Méx ico Colombia Guyana Belice Panamá Venezuela (Rep. Costa Rica San Vicente y Brasil Haití Paraguay Jamaica Uruguay Suriname Argentina Perú Granada Santa Lucía Barbados Chile Cuba Bahamas Trinidad y Tabago 0
20 40 60 80 100 (número de nacimientos por cada 1.000 mujeres adolescentes)
120
Notes: *Year of the Survey: Anguilla 2004, Antigua and Barbuda 2001, Argentina 2005, Aruba 2006, Bahamas 2003, Barbados 2003, Belize 2002, Bolivia 2001, Brazil 2006, British Virgin Islands2004, Chile 2004, Costa Rica 2006, Cuba 2006, Dominica 2001, Dominican Republic 2001, Ecuador 2002, El Salvador 2003, Guatemala 2004, Guyana 2003, Haiti 2003, Honduras 2003, Jamaica 2004, Mexico 2006, Netherlands Antilles 2004, Nicaragua 2005, Panama 2006, Paraguay 2003, Puerto Rico 2005, Saint Kitts and Nevis 2001, Saint Lucia 2002, Saint Vincent and the Grenadines 2003, Suriname 2004, Trinidad and Tobago 2002, United States Virgin Islands 2002, Uruguay 2006, Venezuela 2005. a/ 2000 data pertains to year 1999 b/ 2000 data pertains to year 2001 c/ 2000 data pertains to year 2002 Source: ECLAC on the basis of United Nations Statistics Division. Millennium Development Goals Indicators. Information download: August, 2008.
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