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NATION
The Last Two Minutes for Reducing
Maternal Mortality
Despite its progress to date, the Philippines wants to
redouble its efforts to reduce maternal mortality in line
with the United Nations' Millennium Development Goal
By Pia Rufno
G
lobally, the number of women dying in
pregnancy and childbirth has fallen by
47% in two decades, according to the most
recent World Health Organization (WHO),
United Nations Children's Fund (UNICEF),
United Nations Population Fund (UNFPA)
and the World Bank estimates. The report
Trends in maternal mortality: 1990 to
2010 released in May said the number of
maternal deaths in the world decreased from
543,000 in 1990 to 287,000 in 2010.
Based on the study that presents the
global, regional and country estimates of
maternal death, the maternal mortality ratio
(MMR), or the number of maternal death
per 100,000 live births, in the Philippines
dropped from 170 in 1990 to 99 in 2010--
a decrease of 43% over 20 years. In 2010,
2,300 maternal deaths occurred in the
country. (p. 35)
According to the report, several factors
may have contributed to the global decline,
such as: improvement in health systems
and coverage in health-care interventions,
STRATEGY POINTS
Depending on the source, the local maternal
mortality ratio may have dropped anywhere
from 22.48% in 16 years to 43% in 20 years
Local maternal mortality continues on a
downward trend, but a lot more progress
will be needed to achieve the United Nations'
Millennium Development Goal 5 target of a
75% reduction in maternal mortality ratio
by 2015
Even as the country's likelihood of achieving
Millennium Development Goal 5 is regarded
as slim, the Department of Health has
assembled a public-private coalition to
develop health interventions in priority areas
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The last two minutes for reducing maternal mortality
increased physical accessibility to health
facilities, and factors outside the health
sector, e.g., increased female education,
according to the report. (p. 27)
However, despite substantial reductions
in maternal deaths (except in Southern
Africa, where MMR increased by 19%
from 1990 to 2010), the joint UN report
said all regions are still very unlikely to
achieve the Millennium Development Goal
(MDG) target for improvement in maternal
health. (p. 22)
The Millennium Development Goals are
eight international development goals that
all 193 United Nations member states have
ugreed Lo ucIIeve by zo1. TIe hILI MDG
goal (MDG 5) is improving maternal health,
which calls for the reduction of maternal
deaths by 75% between 1990 and 2015, and
achieving universal access to reproductive
health care by 2015.
Comparing maternal mortality across
southeast Asia. Maternal mortality
across Southeastern Asia dropped by
63% in 20 years. Among southeast Asian
countries, Vietnam has already achieved
75% reduction in maternal deaths from
1990 to 2010, while Laos and Cambodia
both have registered 70% declines. To
achieve a 75% reduction in 20 years would
require a compounded annual average
reduction rate of about 7.0%, while a 70%
reduction over the same period would
require a compounded annual average
reduction rate of about 6.0%.
Alongside the Philippines' MMR of 99
maternal deaths per 100,000 live births,
elsewhere in southeast Asia, the MMRs in
Brunei, Malaysia, Singapore and Thailand
in 2010 are 24, 29, 3, and 48, respectively.
The Philippines, along with Myanmar
and Indonesia, are categorized as
making progress towards improving
maternal health, with average annual
declines in maternal deaths of between
2% and 5.5%, according to the report.
(See table next page)
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Country MMR % change
in MMR
between
1990 and
2010
Average
annual %
change
in MMR
between
1990 and
2010
Range of
uncertanity on
annual % change in
MMR
Progress
towards
improving
maternal
health
1990 1995 2000 2005 2010 Lower
estimate
Upper
estimate
Brunei
Darussalem
29 25 24 25 24 -16 -0.9 -1.6 -0.2
Cambodia 830 750 510 340 250 -70 -5.8 -7.1 -4.7 on track
Indonesia 600 420 340 270 220 -63 -4.9 -5.9 -4.0 making
progress
Lao People's
Democratic
Republic
1600 1200 870 650 470 -70 -5.9 -6.7 -5.1 on track
Malaysia 53 44 39 34 29 -45 -3.0 -8.1 2.2
Myanmar 520 380 300 230 200 -62 -4.8 -5.4 -4.2 making
progress
Philippines 170 140 120 110 99 -43 -2.8 -3.1 -2.5 making
progress
Singapore 6 6 15 9 3 -40 -2.5 -5.9 1.0
Thailand 54 54 66 54 48 -11 -0.6 -1.7 1.1
Vietnam 240 160 100 74 59 -76 -6.9 -12.0 -2.0 on track
MMR= no. of maternal deaths during a given time period per 100,000 live births during the same time period
TRENDS IN ESTIMATES OF MMR IN SOUTHEAST ASIAN COUNTRIES
BY 5-YEAR INTERVALS, 19902010
Source: TCR compilation of data from Trends in maternal mortality: 1990 to 2010,
WHO, UNICEF, UNFPA, and World Bank, May 6, 2012, p. 37-45
Per LIe reporL, counLrIes wILI MMR a1oo
in 1990 are categorized as on track if
MMR has had 5.5% or more average annual
decline; making progress if MMR has
had 2% to 5.5% average annual decline;
InsuIhcIenL progress II MMR Ius Iud
less than 2% average annual decline; and
no progress if MMR has had an average
annual increase. Countries with MMR <100
in 1990 are not categorized.
Countries lack reliable information
on maternal deaths. However, the
joint UN report said a major challenge in
assessing accurately the progress of most
countries towards the MDG 5 is the lack of
reliable information about maternal deaths.
The Philippines is among 88 countries
covered in the study characterized as
lacking good complete civil registration
data but where other sources of national
data are available.
Having a good civil registration system will
tremendously improve the estimation of
maternal mortality and monitoring of the
MDG goal 5, based on the report.
n IucL, LIe hrsL recommenduLIon In LIe
report of the UN Secretary-General's
Commission on Information and
Accountability for Women's and Children's
Health "Keeping Promises, Measuring
Results" calls for all countries to take
sIgnIhcunL sLeps Lo esLubIIsI u sysLem Ior
registration of births, deaths and causes of
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Year MMR
(per 100,000 live births)
Source
1990 209 TWG on Maternal and Child Mortality (MCM),
National Statistical Coordination Board
1991 203 TWG MCM
1992 197 TWG MCM
1993 191 TWG MCM
1994 186 TWG MCM
1991 180 TWG MCM
1993 209 National Demographic and Health Survey (NDHS), National
Statistics Offce (NSO)
1998 172 NDHS
2000 163 Yabut and Yabut (2004 NCS)
2000 96 Civil Registry, NSO
2003 108 Civil Registry, NSO
death, and to have well-functioning
health information systems that combine
data from facilities, administrative sources
and surveys by 2015.
Chaired by the WHO, the commission
was created in 2011 to propose a
framework for global reporting, oversight
and accountability on women's and
children's health.
Philippines has inconsistent maternal
GHDWKJXUHV The 2012 joint UN
reportalso noted that maternal mortality
estimates are not necessarily the same as
oIhcIuI sLuLIsLIcs oI LIe counLrIes. I LIe
WHO, UNICEF, UNFPA and World Bank
MMR estimate in 1990 170 maternal
deaths per 100,000 live births is the basis,
the Philippines should aim for the maternal
mortality ratio of 42.5 deaths per 100,000
live births by 2015.
MeunwIIIe, LIe IuLesL oIhcIuI sLuLIsLIcs on
maternal death in the Philippines provided
by the NuLIonuI SLuLIsLIcs OIhce (NSO)
through its 2006 Family Planning Survey
shows that the MMR in the country declined
from 209 maternal deaths per 100,000
live births in 1990 to 162 in 2006-- 22.48%
decline in 16 years. So for NSO, the MMR
in 2015 should be 52.25. However, it
also said that the MDG target may not be
achievable and maternal health program
implementers need to redouble efforts to
achieve this target.
Figures of maternal deaths in the
country from 1990 to 2006 are compiled
in Indirect Estimates of Maternal
Mortality: Philippines in 2006, a 2007
paper by Benedicta Yabut of the NSO and
Faye Bautista of the Bangko Sentral. (See
table below)
Maternal deaths are obviously
underregistered, because of the rarity of
the event and the hardship in determining
if a death is related to or aggravated by a
pregnancy, according to the study.
MATERNAL DEATHS IN THE PHILIPPINES, 1990 TO 2006
Source: Indirect Estimates of Maternal Mortality: Philippines in 2006
by Benedicta A. Yabut and Faye Y. Bautista
The last two minutes for reducing maternal mortality
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The report further said that assessing the
Philippines' achievement in terms of MDG
goal 5 using data from Technical Working
Group on Maternal and Child Mortality
and from the National Demographic Health
Survey is misleading and tricky since the
two are not comparable.
The former considers
some assumptions; while
the latter, which costs the
government hundreds of
thousands of pesos, still is
not representative of the true
situation because the event
is so rare to be captured only
through a survey.
Meanwhile, a separate study
titled Maternal mortality for
181 Countries, 1980-2008:
A Systematic Analysis of
Progress towards Millennium
Development Goal 5. published in April
2010 in The Lancet, one oI LIe worId`s
leading and oldest general medical journals,
indicates that the country reduced its MMR
by 61% from 1980 to 1990, and by 81% from
1980 to 2008. (The study is available free of
charge, but registration is required.)
In the abstract of the study, the authors said
they constructed a database of observations
of maternal mortality for the countries from
vital registration data, censuses, surveys,
and verbal autopsy studies.
But these estimates are disputed by Junice
Demetrio Melgar and Alfredo Melgar of
IkIuun CenLer Ior Women`s HeuILI, a
non-government organization dedicated
to the promotion of women's health and
empowermenL, wIo suy LIe hndIngs ure
quite far from reality. In a June 2010
letter to The Lancet, the Melgars said it
was unlikely the Philippines achieved a
record-setting decline in MMR amid all
the economic and political problems
during the 1980s.
Citing data from NSO, the
two argues that MMR has
declined only slightly over
the past 25 years. If Hogan
und coIIeugues` esLImuLes
were accurate, the great
mystery is: how was it
ucIIeved? LIey usked.
Other indicators of maternal
health support a scenario of
little progress. For example,
the proportion of deliveries
by health professionals in
the Philippines has risen
very slowlya mere 17%
over 15 years (from 53%
to 62% from 1993 to 2008), the Melgars
wrote in their letter.
DOH, doctors to review maternal
GHDWKJXUHV. Alarming discrepancies
In muLernuI deuLI hgures due Lo dIIIerenL
measurement standards used by
government and private hospitals have led
Department of Health (DOH) Secretary
Enrique Ona and doctors in Northern
Luzon to sLurL un uudIL oI LIe counLry`s
rate of maternal deaths, as reported in the
Philippine Daily Inquirer in May 2011.
According to the report, Ona addressed the
discrepancy after local hospitals and health
centers in Apayao included women who
died outside the province in its maternal
death records in 2010. A public health
oIhcer In Apuyuo suId LIey were InsLrucLed
to use a system that counts the health
The Melgars said
it was unlikely
the Philippines
achieved a record-
setting decline
in MMR amid all
the economic and
political problems
during the 1980s
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The UNFPA's three-pronged strategy to reduce
maternal mortality
According to the United Nations Population Fund (UNFPA), the following three-pronged strategy is the
key to the accomplishment of a 75%-reduction in the maternal mortality ratio between 1990 and 2015:
All women have access to contraception to avoid unintended pregnancies
All pregnant women have access to skilled care at the time of birth
All those with complications have timely access to quality emergency obstetric care
The international development agency
said signifcant declines in maternal
mortality have occurred in several
countries -- China, Cuba, Egypt, Jamaica,
Malaysia, Morocco, Sri Lanka, Thailand
and Tunisia where more women have
gained access to family planning and
skilled birth attendance, while severe
shortages of trained health providers with
midwifery skills are holding back progress
in many countries.
UNICEF Chief of Health Dr. Peter
Salama also stressed the need to
scale up family planning services
according to international policies and
laws and to support antenatal care and
Malaria and HIV programs to decrease
maternal mortality.
We also need to have skilled birth
attendants that can deliver emergency
obstetrics care or certainly be able to
refer women suffering from complications
to emergency obstetric care, he added.
For UNICEF Gender Specialist Noreen
Khan, it is important to educate women
to reduce their risk of death during
pregnancy. Khan said she has observed
that women in Southeast Asia are being
more educated thus making informed
decisions to have a traditional birth
attendant during child delivery. These women respect and uses the information on reproductive health
they acquired from secondary and tertiary secondary education, she added.

UNICEF Chief of Health Dr. Peter Salama said antenatal care,

skilled birth attendants, emergency obstetrics are important
to reduce maternal mortality

UNICEF Gender Specialist Noreen Khan talks about the

importance of education in reducing risks of death in pregnancy
The last two minutes for reducing maternal mortality
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condition of residents hospitalized or
treated outside the province.
Ona also said the country has a lot of
cuLcIIng up Lo do, cILIng zoo6 NSO hgures
that indicated 162 maternal deaths per
100,000 live births in the country.
Maternal mortality and its causes.
The WHO describes maternal death as
the death of a woman while pregnant or
within 42 days of termination of pregnancy,
irrespective of the duration and site of
the pregnancy, from any cause related
to or aggravated by the pregnancy or its
management but not from accidental or
incidental causes.
According to a September 2010 UN
fact sheet, most maternal deaths could
be avoided. More than 80% of maternal
deaths are caused by hemorrhage, sepsis,
unsafe abortion, obstructed labor and
hypertensive diseases of pregnancy.
However, most of these deaths are
preventable with access to adequate
reproductive health services, equipment,
supplies and skilled healthcare workers.
Based on the 2006 records of DOH,
732 died of complications related to
pregnancy occurring in the course of
labor, delivery and puerperium (the time
immediately after the delivery of a baby),
565 died of hypertension complicating
pregnancy, childbirth and puerperium,
261 of postpartum hemorrhage and 163
pregnancies led to abortive outcome.
Philippines unlikely to meet MDG 5
target. As of September 2011, statistics
of the Philippines' progress based on the
MDG indicators, compiled by the National
Statistics Coordinating Board, show that the
counLry`s probubIIILy oI ucIIevIng LIe LurgeL
reduction in maternal mortality is low.
According to National Economic
Development Authority (NEDA)'s Jan. 2010
DevPulse development advocacy fact sheet,
maternal mortality is rooted in poverty and
lack of education. The DOH said maternal
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poverty and poor education are associated
with delays in seeking, reaching, and
receiving appropriate care, the report cited.
Over half of births occurred at home, and
only a third was assisted by skilled birth
attendants, it added.
High fertility rates and high unmet
need for family planning and poor
nutrition of women also lead to poor
pregnancy outcomes and infant deaths.
Data from the NSO have shown that
having too many children and having them
in close succession corresponds to higher
infant, child, and maternal mortality rates,
according to the fact sheet.
Similarly, the country has not been
performing well in terms of contraceptive
prevalence rate from 40% in 1993 the
rate only increased to 51% in 2008,
according to NEDA's own Philippines
Progress Report on the Millenium
Development Goals 2010, which also said
that the 2015 target of 52 maternal deaths
per 100,000 live births is unlikely to be met.
(See graph below)
According to the progress report, the DOH
has shifted from a risk approach that
focuses on identifying pregnant women
at risk to one that considers all pregnant
women at risk to develop complications.
As a result, the DOH strategy will involve
encouraging women to give birth in
conveniently located health facilities that
are equipped to provide basic emergency
obstetric and newborn care,
and implementing the Maternal,
Neonatal and Child Health and Nutrition
(MNCHN) Strategy, which involves a
shift from health programs controlled
at the national-government level to an
250
200
150
100
50
0
209
203
197
191
186
180
172
162
52
1990 1991 1992 1993 1994 1995 1998 2006 2015
1993-2008 data
Current Rate of Progress
Required Rate of Progress
2015 Target
PHILIPPINE MATERNAL MORTALITY RATES, 1993-2006
Source: Philippines Progress Report on the Millenium Development Goals 2010,
National Economic Development Authority, p. 116
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integrated mother-and-child health and
nutrition package administered at the local-
government-unit level.
Launched in 2008, the MNCHN Strategy
aims to ensure that all pregnancies are
wanted, planned, supported, and well-
managed; deliveries are facility-based and
managed by skilled birth attendants; and
all mothers and newborns receive good
postpartum and postnatal care.
Private sector to help government
achieve MDG 5. To reduce maternal deaths
in the country and to achieve benchmarks
for health conditions set in the MDG, the
DOH, through the Bureau of Local Health
Development, formed a multisectoral
consortium called 162-52 Coalition, which
encourages public-private partnerships to
develop health interventions in priority
areas in the country and deliver better
maternal services.
The coalition is the outcome of the Third
Philippine Health Outlook Forum, held
in December 2011. The forum, an annual
activity of the Zuellig Family Foundation,
brought government and private-sector
stakeholders together to discuss the state
of health in the country, and to form
partnerships to address the health inequities.
The lead convenors of the 162-52
Coalition include: Philippine Health
Insurance Corporation; ZuelligFamily
Foundation; League of Provinces of the
Philippines; Union of Local Authorities of
]the Philippines; Dr. Jaime GalvezTan;
Philippine Business for Social Progress;
Ayala TBI/ACCESS Health Philippines; and
Sunoh-uvenLIs PIIIIppInes.
The priority areas of the coalition comprise
20 provinces and the National Capital
Region, which account for 42% of the
population and 47% of the poorest families.
These priority areas contribute 39% of the
maternal deaths in the country. The coalition
created a framework for action in developing
interventions for the priority areas with three
major components:
eudersIIp -- responsIve IocuI governmenL
units and support groups
Demund sIde - beLLer-IeuILI-seekIng
behavior
SuppIy-sIde - uccessIbIe und uIIordubIe
services, facilities, personnel, essential
medicines and commodities
To take part in the multisectoral effort,
Smart Communications Inc developed
Secured Health Information Network and
Exchange (SHINE), a web- and mobile-based
platform for use by health-care workers, for
addressing the lack of interconnected health
data, as reported in the Inquirer on May 12.
SHINE uses mobile and ICT technologies
to create electronic medical records for
u convenIenL und eIhcIenL meLIod oI
recordIng, sLorIng und upduLIng puLIenLs`
reports and consultations, based on the
report.
It might be the proverbial last two
minutes for the country in terms of
trying to achieve the Millennium
Development Goal of reducing the
maternal mortality ratio by 75% by
2015, but given that the game will not
end in 2015, the continuing sense of
urgency is somewhat warranted, if not
actually welcome.
The last two minutes for reducing maternal mortality
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