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A Review of Progress in Maternal Health in Eastern Europe and Central Asia

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A Review of Progress in Maternal Health in Eastern Europe and Central Asia A Review of Progress in Maternal Health in Eastern Europe and Central Asia INTRODUCTION This report is a summary of the progress that has been achieved in maternal health in 20 countries in Eastern European and Central Asia. The findings may be useful in a number of ways: • to help each country, and the region as a whole, analyse the state of their maternal health; • to promote dialogue in each country about national priorities for maternal health; • to stimulate proposals in each country to further progress in maternal health. The focus of this report is to provide country specific information rather than a regional overview. It is, however, worth pointing out that previous reviews have noted the general decline in maternal mortality across Eastern Europe and Central Asia and also the significant differences among countries in the region. The 2008 Countdown to 2015 Report included Azerbaijan, Turkmenistan and Tajikistan among 68 priority countries that bear the world’s highest burdens of maternal and child mortality. Turkmenistan is deemed to have made good progress against MDG 4 (reduced child mortality) and MDG 5 (improve maternal health), while Azerbaijan and Tajikistan are assessed as having made good progress against MDG 5 but not MDG 4i. While acknowledging the breadth of diversity, it is also important to note some of the shared trends across many countries. The vast majority of countries have made a commitment to reforming their health-care systems and are at varying stages of implementing reforms. The role of induced abortion has been significant in many countries, and in some countries the volume of procedures has had a significant impact on morbidity and mortality figures. Most countries have experienced an increase in the provision and uptake of modern methods of contraception, but for many the range of choice remains limited and the dependency on external funding sources for supplies is an ongoing issue. Many countries are experiencing low or negative growth in population with some having declared a state of demographic crisis; as a result some countries have adopted pronatalist strategies to encourage women to have children. The demographic profile of the majority of countries is further affected by high levels of migration, which also presents operational challenges for delivering health care. In addition, most countries have revised financing mechanisms, some of which have direct implications on access to services; and in many countries, informal out-of-pocket payments (made by patients) present operational challenges as do significant levels of corruption within the health service. FOREWORD The importance of maternal health and universal access to reproductive health, was highlighted in the International Conference on Population and Development (ICPD) Programme of Action in 1994. At that Conference, 179 governments agreed that every person has the right to sexual and reproductive health and that empowering women is both a priority in its own right, as well as critical to advancing the social and economic development of nations. Improving maternal health is the fifth Millenium Development Goal, as adopted by member States in September of 2000. Reducing maternal mortality and achieving universal access to reproductive health care are critical components of meeting this goal. Much progress has been made to advance sexual and reproductive health and reproductive rights since Cairo. Today, the countries of Eastern Europe and Central Asia have almost universal antenatal coverage, and nearly every birth is assisted by skilled health workers. Maternal mortality has been reduced in half. However, despite these successes there are too many women in the region who cannot afford maternal care, or access quality antenatal care. There are women who give birth at home and women who die giving birth at home. The needs and rights to maternal and reproductive health of poor and disadvantaged women, including young girls, migrants, refugees, persons living with HIV and minority groups such as the Roma, have not yet been met. In some cases, their requirements have not even been addressed. It is quite clear that we have not yet reached those who most need us. We hope that the data and information in this report will be used to promote universal access to reproductive health and education and reinforce the political commitment to sexual and reproductive health and rights. We hope that this publication will serve as a reference for future agenda-setting and programming for advancing maternal health throughout the region. Thea Fierens Director, Regional Office for Eastern Europe and Central Asia Contents Acknowledgements ................................................................................................. 2 Acronyms ................................................................................................................ 3 Overview of methodology ........................................................................................ 4 Regional overview of key indicators for and trends in maternal health in Eastern Europe and Central Asia .............................................. 6 A tabular presentation of key indicators and overview of regional variations ........ 13 A snapshot of each country highlighting the main maternal health issues ............ 18 Assessment of challenges and opportunities for advocacy ................................. 123 Annex 2: Questionnaire ...................................................................................... 131 References .......................................................................................................... 134 2 A REVIEW of PROGRESS in MATERNAL HEALTH in EASTERN EUROPE and CENTRAL ASIA ACKNOWLEDGEMENTS This review was commissioned by UNFPA’s Regional Office for Eastern Europe and Central Asia. Consultant, Sue Newport, conducted the desk review and wrote the publication. This publication was edited by Ms. Anne Levin. The author is grateful to all members of UN staff who have supported this review by providing key documents, completing the questionnaire and responding to specific queries and points of clarification. Thank you. The author is particularly grateful to Garik Hayrapetyan and Gulnara Kadyrkulova of UNFPA for their support and assistance throughout the review. In addition, Rita Columbia and Marta Diavolova of UNFPA’s Eastern Europe and Central Asia Regional Office provided invaluable comments on this report. We would also like to thank Nezih Tavlas in the UNFPA Turkey Country Office who facilitated the design and printing of this document. A REVIEW of PROGRESS in MATERNAL HEALTH in EASTERN EUROPE and CENTRAL ASIA 3 Acronyms AIDS Acquired immunodeficiency syndrome ANC Antenatal Care ASRH Adolescents’ Sexual Reproductive Health BEmOC Basic Emergence Obstetric Care CEDAW Convention on the Elimination of All Forms of Discrimination Against Women CEE Central and Eastern Europe CIS Commonwealth of Independent States CPR Contraceptive Prevalence Rate CRC Convention on the Rights of the Child CS Caesarean Section DHS Demographic Health Survey EmOC Emergency Obstetrics Care EU European Union FP Family Planning GDP Gross Domestic Product HFA Health for All (WHO Database) ICPD International Conference on Population Development IEC Information, Education, Communication IMR Infant Mortality Rate IUD Intra Uterine Device MCH Maternal and Child Health MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey MMR Maternal Mortality Rate MoH Ministry of Health MoE Ministry of Education MPS Making Pregnancy Safer (WHO programme) NGO Non-Governmental Organization OB/GYN Obstetrician/Gynaecologist PHC Primary Health Care PRSP Poverty Reduction Strategy Paper RH Reproductive health SEE South Eastern Europe TFR Total Fertility Rate UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United State Agency for International Development WB World Bank WHO World Health Organization WHOSIS WHO Statistical Information System 4 A REVIEW of PROGRESS in MATERNAL HEALTH in EASTERN EUROPE and CENTRAL ASIA Overview of methodology The international community has not agreed to a set of indicators with which to effectively monitor maternal health. Progress toward achieving the Millennium Development Goal (MDG) 5 target of reducing maternal mortality by 75% indicates the state of maternal health. However, its measurement does not include indicators on maternal morbidity and of non- lethal episodes, and to be accurate it relies on comprehensive systems of registration being in place. It is recognised that there is the potential for wide variations and a varying level of certainty in measures of maternal mortality which make them particularly unsuitable for monitoring short term trends. For the purposes of this review the maternal mortality ratio (MMR) reported by each country has been used and, where possible, alternative estimates highlighted including the WHO/UNICEF/UNFPA and World Bank adjusted MMR estimates of 2005. It is acknowledged that the adjusted estimates are now outdated and are not recognized by some countries; however, the estimates have been included to provide a credible alternative data set. Regional figures (based primarily on the WHO categorisations of countries) are provided. It is not the intention to encourage comparison of these rates. Other indicators used to measure maternal health (primarily those defined by WHOii) tend to assess
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