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Reproductive health in Southeast Asian women: current situation and the influence factors
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B RIDGING B ELT & R OAD C OUNTRIES Reproductive health in Southeast Asian women: current situation and the influence factors Chenyang Feng1, Yingsi Lai1, 2, Ruixue Li1, Yijing Wang1, Jing Gu1, 2, Chun Hao1, 2, Dong (Roman) Xu1, 2, Yuantao Hao1, 2* 1 Department of Medical Statistic and Epidemiology, School of Public Health, Sun Yat-sen University, 74 Zhong Shan 2nd Road, Guangzhou 510080, China 2 Sun Yat-sen Global Health Institute, Sun Yat-sen University, 135 Xin Gang Xi Road, Guangzhou 510275, China
Abstract Background: The reproductive health addresses the reproductive processes, functions and system at all stages of life. Enhancing the level of global reproductive health is the goal of sustained attention and struggle by the international community. The social and economic development in Southeast Asia is lagging behind, and its female reproductive health is worrying, while the differences of female reproductive health among different regions are significant. Objective: To obtains the necessity and urgency of strengthening the reproductive health level of Southeast Asian countries, so as to provide the basis for the priorities and target to policy-makers and health administrators to improve reproductive health. Methods: Literature review were searched in PubMed, Web of Science databases, Google Scholar database, and WHO’s webpages. Maternal mortality ratio, contraceptive rates, unmet need for family planning, antenatal and postnatal care coverage, and sexually transmitted disease were the five key indicators and the influence factors for female reproductive health status in Southeast Asian countries. Results: The reproductive health of Southeast Asian women were still at a lower level overall and varied in different regions and conntries. Women’s education and attitude, accessibility of service, socioeconomic and cultural factors, etc. were the potential influencing factors. Conclusion: There is left quite large space for improvement to the reproductive health in Southeast Asian countries and efficient interventions can be achieved for the key and easier-improved risk factors such as education and in high-risk areas. Keywords: reproductive health; Southeast Asia; female; review
*Correspondence: [email protected] PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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Background Reproductive Health (RH) has been listed in the Programme of Action of The International Conference on Population and Development in 1994 [1], within the framework of the World Health Organization’s (WHO) definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health addresses the reproductive processes, functions and system at all stages of life [2]. In 1995, International Conference on Population and Development stressed the importance of reproductive health again and introduced the target of “Achieve universal access to reproductive health by the year 2015”, which also been committed in the Millennium Development Goals (MDGs) [3]. Since then, reproductive health has attracted wide attention and input from the international community, and the level of RH around the world has been improve at different degrees [4]. On 25 September 2015, the United Nations General Assembly adopted the new development agenda “Transforming our world: the 2030 agenda for sustainable development”, the Sustainable Development Goals (SDGs) in short, which built upon and extended the MDGs. Several targets in SDGs has been devoted specifically to reproductive health, in reducing maternal mortality and ensuring universal access to sexual and reproductive health-care services [5]. Generally speaking, female reproductive health is not optimistic in the global situation, especially in developing countries. According to the statistics from WHO, the risk of a woman in a developing country dying from a maternal-related cause during her lifetime is about 33 times higher in comparison with a woman living in a developed country [6]. About 287,000 women die of the complications of pregnancy and delivery, 99% of whom are from developing countries. In 2011, about 820,000 women and men aged 15–24 in low- and middle-income countries are newly infected with HIV and more than 60% of them are women. As the second most common type of woman’s cancer in the world, almost all cervical cancer patients are related to sexually transmitted infections of the human papilloma virus (HPV). More than 90% of deaths occur among women in low- and middle-income
countries due to poor access to screening and treatment services [7]. The South-East Asia Region (SEA) of the World Health Organization, divided by WHO, was established in 1948 and was the one of first six regions set up. SEA is the sub region of Asia, consisting of Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, TimorLeste [8]. Most of SEA countries were under colonial rule before Second World War. Widespread poverty, higher illiteracy rate, poor housing conditions, overcrowding and undernutrition or malnutrition attacked these countries. Coupled with this, hot and humid climate of the tropics in which most of the countries are situated, created a favorable environment most of the infectious organisms can survive and thrive. Although some progress to improve states has been made during the MDG era, SEA countries still have gaps with other countries in the world [9]. According to the United Nations, almost half of the SEA countries, Bangladesh, Bhutan, Myanmar, Nepal, Timor-Leste were classified as the Least Developed Countries [10]. All of SEA countries are developing countries. Women’s rights and reproductive health in these countries deserve special attention. So we analyzed the present situation of female reproductive health in Southeast Asian countries, summarized the influencing factors, thus to obtain the necessity and urgency of strengthening the reproductive health level of Southeast Asian countries, so as to provide the basis for the priorities and target to policy-makers and health administrators to improve reproductive health.
Methods A two-step process was used to conduct the literature search. First, we searched for relevant publications about female reproductive health and indicators concerned and its influencing factors in PubMed, Web of Science and Google Scholar databases before April 2018. The search terms were followed: reproduc*/maternal mortality ratio/ MMR, sexually transmit/STD/STI, contracept*/family planning, antenatal care/ANC, postnatal care, births attended by skill, woman/female, southeast Asia (as well as SEA, Bangladesh, Bhutan, Democratic People’s Republic of Korea/North Korea, India, Indonesia, PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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Maldives, Myanmar, Nepal, Sri Lanka, Thailand, TimorLeste), influenc*/risk factor/affect/effect. No timeframe was placed on the searches and reviewed publications were limited to those reported in the English language. Besides, we searched the websites of WHO for the authoritative and detailed data and official by applying the key words “reproductive health”. The uncertainty intervals (UI) computed for all the estimates refer to the 80% uncertainty intervals (10th and 90th percentiles of the posterior distributions). This was chosen as opposed to the more standard 95% intervals because of the substantial uncertainty inherent in maternal mortality outcomes.
Female reproductive health situation in SEA Female reproductive health is a relatively large conception and covers many aspects. So how to measure and estimate the state of RH? Different reports use different indicators. A review about research progress on female reproductive health in China use reproductive tract infection rates, knowledge of female physiological, degree of reproductive cleanliness, and access to reproductive health knowledge, etc., to assess the reproductive health of women in urban, rural and floating populations [4]. While another report to study reproductive health of female floating population mentioned that the assessment of the overall status of reproductive health mainly includes reproductive health knowledge, healthy sexual behavior (safe sex, unintentional sexual behavior) and genital tract infection seeking medical behavior [11]. A study discussed improving adolescent reproductive health in Asia and the Pacific, based on two databases Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS), divided the indicators of adolescent reproductive health into 4 categories: sexual and reproductive health, maternal health (such as percentage of births attended by a skilled birth attendant), new born health (such as neonatal mortality rate), access to reproductive and maternal health services (such as contraceptive prevalence) [12]. In short, we can classify these indicators into two categories: one is the direct reproductive health or disease indicator and another is the coverage of reproductive health service, which
can reflect the situation indirectly. In order to state the status of female reproductive health in Southeast Asian countries more clearly and easier to understand, we select the more commonly used and studied RH indicators after doing a review via PubMed, Web of Science and WHO’s webpages.
Reproductive health or disease indicator Maternal mortality ratio (MMR) MMR was commonly used as indicator for assessing female reproductive health in the world, is the annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births, for a specified year. The indicator monitors deaths related to pregnancy and childbirth. It reflects the capacity of the health systems to provide effective health care in preventing and addressing the complications occurring during pregnancy and childbirth [13]. The uncertainty intervals (UI) computed for all the estimates refer to the 80% uncertainty intervals (10th and 90th percentiles of the posterior distributions). This was chosen as opposed to the more standard 95% intervals because of the substantial uncertainty inherent in maternal mortality outcomes. Over the past 25 years, the global MMR fell by nearly 44%, from 385 (UI 359–427) per 100,000 live births in 1990 to 216 (UI 207–249) in 2015. MMR for developing regions were estimated 239 (UI 229–275) in 2015, which was roughly 20 times higher than that of developed regions, which was just 12 (UI 11–14). As for the southern Asia (Afghanistan, Bangladesh, Bhutan, India, Islamic Republic of Iran, Maldives, Nepal, Pakistan, Sri Lanka) and south-eastern Asia (Brunei Darussalam, Cambodia, Indonesia, Lao People’s Democratic Republic, Malaysia, Myanmar, Philippines, Singapore, Thailand, Timor-Leste, Viet Nam) in MDG regions, MMRs were estimated 176 (UI 153–216) and 110 (UI 95–142) respectively [14]. Among them, in 2015, MMR was estimated 258 (UI 176–425) in Nepal [15], 176 (UI 125–280) in Bangladesh [16], 126 (UI 93–179)
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in Indonesia [17], 178 (UI 121–284) in Myanmar [18], 215 (UI 150–300) in Timor-Leste [19], 174 (UI 139 to 217) in India [20]. Comparing with the average data in SEA region, Nepal and Timor-Leste still need more attention. District variation in maternal mortality also exists within a country. A study in India showed that a wide variation of MMR in the five zones between 2005 and 2007 was observed: West India-342; South India-229; East India-709; North East India-709 and North India-814 [21]. Another research presented that in Bangladesh, for MMR, there was greatly varied between different districts, for example, MMR for Dhaka district was 158 per 100,000 live births in 2011, meanwhile which was 782 in the northern coastal regions, with the higher ratio in eastern and northern regions [22]. There were also significant differences between urban and rural areas. According to 2004‒2006 nationally representative survey, three-quarters of maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated live births in India due to lower access and utilization to healthcare services in rural areas than the urban [23]. Some studies have determined accessibility and availability of maternal health care services are very important factors to reduce maternal mortality. An analysis of factors linked to the decline in maternal mortality found that improved utilization of maternity care services seems essential to the decline in maternal mortality in Nepal [24]. A Bangladeshi study considered the key contribution to this decrease was a drop in mortality risk mainly due to improved access to and use of health facilities [25]. Alternately, we should not only pay attention to the availability of health services, but also the quality of services. District Kutai Kartanegara, a rural district of Indonesia, was such a region, where consistently high maternal mortality was observed, despite high rate of delivery by skilled birth attendants. The root causes were found in poor quality of care including inadequate skills, lack of forward planning, ineffective communication, inadequate risk management and so on [26]. Women’s behaviors also were underlying factors to maternal mortality. Antenatal visits less than 4 times and initial visit to antenatal care facilities after the fourth month of pregnancy were determined as the risk factors in Indonesia [27]. An analysis in Matlab, Bangladesh
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found that abortion was associated with higher mortality risk [28]. Another also in Bangladesh including 165,894 pregnancies data shows that the maternal mortality risk was considerably higher for pregnancies that ended in induced abortion, miscarriage or stillbirth [29]. A result from analyzing the determinants of maternal mortality showed safe abortion might have played a significant role in reducing MMR in Nepal [30]. However, in eastern Myanmar, abortion was interestingly not identified as an important contributor to maternal mortality. Uncovered were a number of underlying factors uniquely contributing to maternal mortality in eastern Myanmar, which could be grouped into the following analytical themes: ongoing conflict, health system deficits, and political and socioeconomic influences [31]. The socioeconomic and demographic factors have a stronger statistically significant association with the maternal mortality ratio. The time series and crosssectional analyses reveal that per capita state net domestic product, poverty ratio, total fertility rate contributed to the decline in the maternal mortality ratio in India [32]. The reduction in fertility and improvements in components of the human development index played the same role in Nepal [33]. Another article demonstrated that fertility decline between 1990 and 2008 has made a substantial contribution to the reduction of the MMR in three South Asian countries (India, Pakistan, and Bangladesh) [34], since the two mechanisms the fertility reduction contributed to averting maternal deaths: the larger effect is due to the sheer reduction in number of births, and the smaller due to the change in the age pattern of mothers (towards aged 20‒34 years) and shifts in parity (fewer high parity births) [25]. A woman’s social status, or the position she holds in society, affected her power, education and resources to act autonomously in the interest of her own health. It influenced every aspect of a woman’s reproductive life, including pre-conceptual health, pregnancy planning, pregnancy and childbirth management. Gender inequity, the underestimation of the severity of complications by family members, and perceptions of low-quality delivery services will delay decisions to seek care, thus associated with maternal mortality, founded in in Khargone district in central India [35]. Some studies highlighted PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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that education of women was a strong predictor of the maternal mortality decline [25, 36] through both increased use of health facilities and other pathways. A review summarized cultural influence on maternal mortality in the developing countries, found that cultural customs, practices, beliefs and values profoundly influence women’s behaviors during the perinatal period and in some cases increase the likelihood of maternal death in childbirth [37]. Some customs suggested to limit meat, eggs, and fish during the perinatal period, may leading to underlying anemia and furthering the risk of death after hemorrhage, which was the direct harm to women [38]. Besides, in many cultures, obstetric emergencies are not recognized, but even when they are, cultural beliefs about their causes, treatment and implications often preclude women from seeking life saving help [39]. Women also intentionally avoid formal health care because they fear appearing weak, being subjected to a caesarean section, or experiencing what is perceived as dangerous, corrupt, insensitive, poorly organized, unclean, and untrustworthy care offered by formal health care [40]. More than that, culture affected the formation of social systems and the establishment of social status. A woman may marry at a very young age, have a lack of contraceptive choices, and face societal pressures for male children, all of which may result in a high number of births accompanied by increased risks for morbidity and mortality, a paper explained how social status make an impact to women’s reproductive health [41].
The factors influenced the Indian’s HIV epidemic are the size, behaviors, and disease burdens of highrisk groups, their interaction with bridge populations and general population sexual networks, and migration and mobility of both bridge populations and high-risk groups [44]. Social attitude played an important role on the diagnosis, treatment and even death of STD patients, especially for women and children. In rural India, those women who were known to have contracted HIV were reluctant to access health care for fear of discrimination and marginalization, leading to a disproportionate death rate in HIV women. India is arguably home to the largest number of orphans of the HIV epidemic. These children face an impenetrable barrier in many Indian societies and endure stigmatization. This situation encourages concealment of the disease and discourages children and their guardians from accessing available essential services [45]. The use of condom has been suggested as the only prospective method against STD. Nevertheless, some social factors were associated with non-use of a condom during sexual intercourse: moral values, ethnic and religious factors, gender inequality, lack of a dialogue among partners with regard to condom use, and the stigma attached to the condom [46]. Another systematic review, focus on the utilization of health care services for sexually transmitted infections, highlighted that stigma, embarrassment, illiteracy, lack of privacy, cost of care was found to limit the use of services [47].
Service coverage indicator
Sexually transmitted disease (STD) Globally, the prevalence of STD among women in developing countries is higher than in developed countries. The prevalence of STD in developing countries is relatively serious, especially in Africa, which is estimated to be about 10 times that of developed countries, followed by Asia and Latin America [42]. According to the Report on Global Sexually Transmitted Infection Surveillance in 2015 from WHO, the reported cases of genital ulcer diseases rates in females (per 100,000 adults) in SEA countries were: Bhutan 73.0 (2012), Indonesia 9.8 (2014), Maldives 35.2 (2014), Myanmar 1.8 (2014), Timor-Leste 104.5 (2014). The female syphilis rates are: Indonesia 4.2 (2014), Myanmar 5.7 (2014), Sri Lanka 6.2 (2014) [43].
Contraceptive rates and unmet need for family planning Contraceptive rates and unmet need for family planning are key indicators of progress in reproductive health. It refers to the proportion of women of reproductive age (15–49 years) who are married or in union and who have an unmet need for family planning, i.e. who do not want any more children or want to wait at least two years before having a baby, and yet are not using contraception. Unmet need is a rights-based measure that helps determine how well a country’s health system and social conditions support the ability of women to realize their stated preference to delay or limit births [48]. In all SEA
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countries, more than 50% of women of reproductive age (15–49 years) in all countries have family planning needs [49]. In 2011/2012, 61% of women in Bangladesh were able to use contraception methods, while 12% of women had unmet needs for family planning (11.7% in 2012, 13.5% in 2011, respectively) [16]. In 2011, Nepalese women’s unmet need reached 27% [15]. In Timor-Leste, only 22% women used contraception in 2009/2010, while the rate of unmet need for contraception reached 32% [19]. Antenatal and postnatal care coverage Antenatal care (ANC) coverage is an indicator of access and utilization of care during pregnancy. We use the proportion of women who were attended at least four times during pregnancy by trained health personnel for reasons related to their pregnancy for measuring. This is also one of the process indicators for tracking progress in reducing maternal mortality [50]. In the South-East Asia region in 2012, only three countries have already reached or surpassed the 90% coverage of pregnant women with at least four visits: Sri Lanka, Indonesia, and Democratic People’s Republic of Korea. Bangladesh had the lowest coverage with four visits of less than 30%.the pre-natal care rate in Bangladesh was less than 30% [16], followed by Timor-Leste and Nepal [15, 19]. In 2013, the average postnatal maternal and newborn care rate was 49%, which refers to be visited by trained health personnel within two days of birth. Maldives, Sri Lanka, and Indonesia were above average and Nepal and India were close to average. However, the postnatal care rates for Timor-Leste and Bangladesh were 25% and 27% respectively, less than 30% [49]. Compared with the data of China, the rate of antenatal care reached 96.2% and postpartum visit rate 93.9% in 2014, we can know the level of reproductive health clearly [51]. Births attended by skilled health personnel The proportion of births attended by skilled health personnel is a sub-indicator to monitor progress in reducing maternal mortality. As it is difficult to accurately measure maternal mortality, and model-based estimates of the maternal mortality ratio cannot be used for monitoring short-term trends, the proportion of births attended by skilled health personnel is used as a proxy indicator for
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this purpose. The computing method of this predictor are the number of births attended by skilled health personnel (doctors, nurses or midwives) trained in providing lifesaving obstetric care, including giving the necessary supervision, care and advice to women during pregnancy, childbirth and the post-partum period divide by the total number of live births in the same period [52]. Rural region in Bangladesh were estimated 35.6% (UI 32.3%‒39.1%) and urban region were 60.5% (UI 56.1%‒64.8%) in 2014. In Bhutan in 2010, rural and urban region were estimated 54.2% (UI 50.9%‒57.4%) and 89.4% (UI 85.0%‒92.6%), respectively. In rural region of Myanmar was 57.5% (UI 52.8%‒62.1%) in 2015, which was in urban region 88.5% (UI 82.0%‒92.9%). In Nepal, the proportion were 50.5% (UI 46.4%‒54.5%) in rural and 90.3% (UI 86.0%‒93.5%) in urban region in 2014 respectively [53]. Also, the factors influencing reproductive health service coverage can be classified into several part. The first part is due to women themselves. Many studies have highlighted the importance of women’s education in seeking health service. Lack of reproductive health knowledge and communication ability with husbands and family members, which were impacted potentially by low education, resulted high early childbearing rate among married adolescent girls in Bangladesh [54]. A review, summarizing the factors relating to utilization of facility delivery in rural South Asia, found that socioeconomic and educational status was one of the main factors [55], as well as women’s occupation. A cross-sectional study carried out in rural Nepal found that the woman’s own occupation and ethnicity, were significantly associated with the utilization of postnatal care [56]. Besides, the attitude and awareness are vital for adequate use of health service. The women with a positive attitude toward family planning practiced family planning 3.7 times more than women who had a negative attitude, founded in Hlaing Township, Myanmar [57]. Family influence factors were followed. The husbands’ education level and occupation played also an important role like women’s [56, 58]. A study aiming to evaluate the effect of the woman’s perception of her husband’s approval of family planning, considered that husband’s approval does appear to be a major PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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determinant of contraceptive uptake in Bangladesh and similar developing countries [59]. Several literatures also supported that wealth or household income determining the choices for contraceptive and antenatal cares [58, 60]. As for the community-level, we must draw attention to distance and the accessibility that comes from it. Distance to a health facility also affected the behaviors women giving birth with a health professional, thus affecting maternal mortality, analyzed in Bangladesh and Indonesia. Women who lived further from health centers in both countries were less likely to have their births attended by health professionals than those who lived closer and may only seek professional care in an emergency and may be unable to reach timely care when living far away from a health center [61]. 24-hour availability of family planning services will contribute to family planning practice [57]. Whilst exposure to mass media (especially television and radio) significantly predicted utilization of antenatal care [58] and exposure to family planning messages through radio had a positive effect on modern and traditional method choices [60]. Socioeconomic and cultural factors had overarching influence on the coverage of reproductive health service. Cultural beliefs and ideas about pregnancy also had an influence on antenatal care use. Lack of privacy and exposure of legs and arms are difficult to accept for Muslim women, which is a barrier for them to use reproductive and sexual health services [62]. Besides, Women in some cultures do not use ANC because of the perception that the modern healthcare sector is intended for curative services only [63]. In some places, an adversarial relationship exists between professional health-care providers and the more traditional birth attendants, creating a cultural milieu where distrust, criticism, and self-interest characterize the maternity care offered to women [37], that was how culture affect.
Conclusion Reproductive health is particularly important for people’s quality of life. It is affected by many factors including behaviors, social environment, utilization of health services. Different indicators of reproductive health have potential links and interactions among each other, for example, antenatal and postnatal care coverage
have overarching influence on maternal death. We also found there are some same influencing factors affect all indicators, for example, the education level of women plays a vital and key role. Educated women are more likely to realize the benefits of using maternal healthcare services. Education increases female autonomy, decisionmaking power within the household and builds greater confidence and capability to make decisions regarding their own health [57]. Therefore, improving the rate of literacy must be the priority and efficient way for government to improve female reproductive health, especially in resource-restricted Southeast Asian countries. Utilization of maternal health care services, the most direct method to reduce MMR and achieve SDG goals, has received extensive attention from society. It is worth noting that the accessibility and availability of health service alongside the quality both are the imperative as the reproductive strategies. There is a huge difference in women’s reproductive health status in the world, especially in developing countries because of the backward economy and lack of health services. Southeast Asian countries have their special geographical, socioeconomical environment and cultural background, and their findings also have regional differences. The reproductive health situation of SEA countries was less optimistic overall. Even in the same country, the RH status was uneven in different areas. Limited by short health resources in these developing countries, precise risk area location and efficient intervention are essential to explore. So, estimating the level of reproductive health in all regions of a country is very worthwhile in order to optimize health resources and target interventions in horizontally backward regions. And studies in these developing countries will contribute to achieve the equity of global health and may inspire researchers and policy-makers in other countries.
Additional files Funding This manuscript was supported by CMB (Grant Number 13‒133), Institutional Development of the Department of Global Health at Sun Yat-sen University.
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Competing interests The authors claim that there is no competing interests for this article.
Consent for publication All authors approved the final version of this manuscript.
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2003;8(9):847-52. 28. Rahman M, DaVanzo J, Razzaque A. Pregnancy termination in Matlab, Bangladesh: maternal mortality risks associated with menstrual regulation and abortion. Int Perspect Sex Reprod Health. 2014;40(3):108-18. 29. Rahman M, DaVanzo J, Razzaque A. The role of pregnancy outcomes in the maternal mortality rates of two areas in Matlab, Bangladesh. Int Perspect Sex Reprod Health. 2010;36(4):170-7. 30. Karkee R. How did Nepal reduce the maternal mortality? A result from analysing the determinants of maternal mortality. JNMA J Nepal Med Assoc. 2012;52(186):88-94. 31. Loyer AB, Ali M, Loyer D. New politics, an opportunity for maternal health advancement in eastern myanmar: an integrative review. J Health Popul Nutr. 2014;32(3):471-85. 32. Goli S, Jaleel AC. What is the cause of the decline in maternal mortality in India? Evidence from time series and cross-sectional analyses. J Biosoc Sci. 2014;46(3):351-65. 33. Hussein J, Bell J, Dar Lang M, Mesko N, Amery J, Graham W. An appraisal of the maternal mortality decline in Nepal. PloS One. 2011;6(5):e19898. 34. Jain AK. Measuring the effect of fertility decline on the maternal mortality ratio. Stud Fam Plann. 2011;42(4):247-60. 35. Jat TR, Deo PR, Goicolea I, Hurtig AK, San Sebastian M. Socio-cultural and service delivery dimensions of maternal mortality in rural central India: a qualitative exploration using a human rights lens. Glob Health Action. 2015;8:24976. 36. Chowdhury ME, Ahmed A, Kalim N, Koblinsky M. Causes of maternal mortality decline in Matlab, Bangladesh. J Health Popul Nutr. 2009;27(2):108-23. 37. Evans EC. A review of cultural influence on maternal mortality in the developing world. Midwifery. 2013;29(5):4906. 38. Okafor CB, Rizzuto RR. Women’s and Health-Care Providers’ Views of Maternal Practices and Services in Rural Nigeria. Stud Fam Plann. 1994;25(6 Pt 1):353-61. 39. Kyomuhendo GB. Low use of rural maternity services in Uganda: impact of women’s status, traditional beliefs and limited resources. Reprod Health Matters. 2003;11(21):1626. 40. Sibley LM, Hruschka D, Kalim N, Khan J, Paul M, Edmonds JK, et al. Cultural Theories of Postpartum Bleeding in Matlab, Bangladesh: Implications for Community Health Intervention. J Health Popul Nutr. 2009;27(3):379-90. 41. Geller SE, Adams MG, Kelly PJ, Kodkany BS, Derman RJ. Postpartum hemorrhage in resource-poor settings. Int J Gynaecol Obstet. 2006;92(3):202-11. 42. Bo P. Diseases sexually transmitted and reproductive health of women. J Med Pest Control. 2010;26(7):616-7, 620. (in Chinese) 43. World Health Organization. Report on global sexually transmitted infection surveillance 2015. Geneva: World Health Organization, 2016.
44. Chandrasekaran P, Dallabetta G, Loo V, Rao S, Gayle H, Alexander A. Containing HIV/AIDS in India: the unfinished agenda. Lancet Infect Dis. 2006;6(8):508-21. 45. Mothi SN, Lala MM, Tappuni AR. HIV/AIDS in women and children in India. Oral Dis. 2016;22(Suppl 1):19-24. 46. Sarkar NN. Barriers to condom use. Eur J Contracept Reprod Health Care. 2008;13(2):114-22. 47. Nagarkar A, Mhaskar P. A systematic review on the prevalence and utilization of health care services for reproductive tract infections/sexually transmitted infections: Evidence from India. Indian J Sex Transm Dis AIDS. 2015;36(1):1825. 48. World Health Organization. Unmet need for family planning (%). [cited 2018-03-28]. http://apps.who.int/gho/data/ node.wrapper.imr?x-id=6. 49. Regional Office for South-East Asia, World Health Organization. Measuring core health indicators in the South-East Asia region 2014. [cited 2018-4-28]. http://apps.who.int/ iris/bitstream/handle/10665/152618/9789290224600-HST. pdf?sequence=1&isAllowed=y. 50. World Health Organization. Antenatal care (at least 4 visits). [cited 2018-03-15]. http://www.who.int/gho/urban_health/ services/antenatal_care/en/. 51. Development Planning and Informatization Division for the Health and Family Planning Commission of the People’s Republic of China. Statistical bulletins on the development of health and family planning in 2014 in China. [updated 2015-11-05; cited 2018-03-19]. http://www.moh. gov.cn/guihuaxxs/s10742/201511/191ab1d8c5f240e8b2f5c81524e80f19.shtml. (in Chinese) 52. World Health Organization. Births attended by skilled health personnel (%). [cited 2018-03-29]. http://apps.who. int/gho/data/node.wrapper.imr?x-id=25. 53. World Health Organization. Global Health Observatory data repository. [cited 2018-03-29]. http://apps.who.int/gho/data/ node.home. 54. Shahabuddin AS, Nöstlinger C, Delvaux T, Sarker M, Bardaji A, Brouwere VD, et al. What Influences Adolescent Girls’ Decision-Making Regarding Contraceptive Methods Use and Childbearing? A Qualitative Exploratory Study in Rangpur District, Bangladesh. PloS One. 2016;11(6):e157664. 55. Metcalfe R, Adegoke AA. Strategies to increase facility-based skilled birth attendance in South Asia: a literature review. Int Health. 2013;5(2):96-105. 56. Dhakal S, Chapman GN, Simkhada PP, van Teijlingen ER, Stephens J, Raja AE. Utilisation of postnatal care among rural women in Nepal. BMC Pregnancy Childbirth. 2007;7:19. 57. Lwin MM, Munsawaengsub C, Nanthamongkokchai S. Factors influencing family planning practice among reproductive age married women in Hlaing Township, Myanmar. J Med Assoc Thai. 2013;96(Suppl 5):S98-106.
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58. Simkhada B, Teijlingen ER, Porter M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. J Adv Nurs. 2008;61(3):244-60. 59. Kamal N. The influence of husbands on contraceptive use by Bangladeshi women. Health Policy Plan. 2000;15(1):43-51. 60. De Oliveira IT, Dias JG, Padmadas SS. Dominance of sterilization and alternative choices of contraception in India: an appraisal of the socioeconomic impact. PloS One. 2014;9(1):e86654. 61. Scott S, Chowdhury ME, Pambudi ES, Qomariyah SN,
41 Ronsmans C. Maternal mortality, birth with a health professional and distance to obstetric care in Indonesia and Bangladesh. Trop Med Int Health. 2013;18(10):1193-201. 62. Mishra VK. Muslim/Non-Muslim differentials in fertility and family planning in India. [updated 2004-01; cited 2018-03-19]. https://scholarspace.manoa.hawaii.edu/bitstream/10125/3749/POPwp112.pdf. 63. Magadi MA, Madise NJ, Rodrigues RN. Frequency and timing of antenatal care in Kenya: explaining the variations between women of different communities. Soc Sci Med. 2000;51(4):551-61.
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B RIDGING B ELT & R OAD C OUNTRIES Reproductive health in Southeast Asian women: current situation and the influence factors Chenyang Feng1, Yingsi Lai1, 2, Ruixue Li1, Yijing Wang1, Jing Gu1, 2, Chun Hao1, 2, Dong (Roman) Xu1, 2, Yuantao Hao1, 2* 1 Department of Medical Statistic and Epidemiology, School of Public Health, Sun Yat-sen University, 74 Zhong Shan 2nd Road, Guangzhou 510080, China 2 Sun Yat-sen Global Health Institute, Sun Yat-sen University, 135 Xin Gang Xi Road, Guangzhou 510275, China
Abstract Background: The reproductive health addresses the reproductive processes, functions and system at all stages of life. Enhancing the level of global reproductive health is the goal of sustained attention and struggle by the international community. The social and economic development in Southeast Asia is lagging behind, and its female reproductive health is worrying, while the differences of female reproductive health among different regions are significant. Objective: To obtains the necessity and urgency of strengthening the reproductive health level of Southeast Asian countries, so as to provide the basis for the priorities and target to policy-makers and health administrators to improve reproductive health. Methods: Literature review were searched in PubMed, Web of Science databases, Google Scholar database, and WHO’s webpages. Maternal mortality ratio, contraceptive rates, unmet need for family planning, antenatal and postnatal care coverage, and sexually transmitted disease were the five key indicators and the influence factors for female reproductive health status in Southeast Asian countries. Results: The reproductive health of Southeast Asian women were still at a lower level overall and varied in different regions and conntries. Women’s education and attitude, accessibility of service, socioeconomic and cultural factors, etc. were the potential influencing factors. Conclusion: There is left quite large space for improvement to the reproductive health in Southeast Asian countries and efficient interventions can be achieved for the key and easier-improved risk factors such as education and in high-risk areas. Keywords: reproductive health; Southeast Asia; female; review
*Correspondence: [email protected] PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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Background Reproductive Health (RH) has been listed in the Programme of Action of The International Conference on Population and Development in 1994 [1], within the framework of the World Health Organization’s (WHO) definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health addresses the reproductive processes, functions and system at all stages of life [2]. In 1995, International Conference on Population and Development stressed the importance of reproductive health again and introduced the target of “Achieve universal access to reproductive health by the year 2015”, which also been committed in the Millennium Development Goals (MDGs) [3]. Since then, reproductive health has attracted wide attention and input from the international community, and the level of RH around the world has been improve at different degrees [4]. On 25 September 2015, the United Nations General Assembly adopted the new development agenda “Transforming our world: the 2030 agenda for sustainable development”, the Sustainable Development Goals (SDGs) in short, which built upon and extended the MDGs. Several targets in SDGs has been devoted specifically to reproductive health, in reducing maternal mortality and ensuring universal access to sexual and reproductive health-care services [5]. Generally speaking, female reproductive health is not optimistic in the global situation, especially in developing countries. According to the statistics from WHO, the risk of a woman in a developing country dying from a maternal-related cause during her lifetime is about 33 times higher in comparison with a woman living in a developed country [6]. About 287,000 women die of the complications of pregnancy and delivery, 99% of whom are from developing countries. In 2011, about 820,000 women and men aged 15–24 in low- and middle-income countries are newly infected with HIV and more than 60% of them are women. As the second most common type of woman’s cancer in the world, almost all cervical cancer patients are related to sexually transmitted infections of the human papilloma virus (HPV). More than 90% of deaths occur among women in low- and middle-income
countries due to poor access to screening and treatment services [7]. The South-East Asia Region (SEA) of the World Health Organization, divided by WHO, was established in 1948 and was the one of first six regions set up. SEA is the sub region of Asia, consisting of Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, TimorLeste [8]. Most of SEA countries were under colonial rule before Second World War. Widespread poverty, higher illiteracy rate, poor housing conditions, overcrowding and undernutrition or malnutrition attacked these countries. Coupled with this, hot and humid climate of the tropics in which most of the countries are situated, created a favorable environment most of the infectious organisms can survive and thrive. Although some progress to improve states has been made during the MDG era, SEA countries still have gaps with other countries in the world [9]. According to the United Nations, almost half of the SEA countries, Bangladesh, Bhutan, Myanmar, Nepal, Timor-Leste were classified as the Least Developed Countries [10]. All of SEA countries are developing countries. Women’s rights and reproductive health in these countries deserve special attention. So we analyzed the present situation of female reproductive health in Southeast Asian countries, summarized the influencing factors, thus to obtain the necessity and urgency of strengthening the reproductive health level of Southeast Asian countries, so as to provide the basis for the priorities and target to policy-makers and health administrators to improve reproductive health.
Methods A two-step process was used to conduct the literature search. First, we searched for relevant publications about female reproductive health and indicators concerned and its influencing factors in PubMed, Web of Science and Google Scholar databases before April 2018. The search terms were followed: reproduc*/maternal mortality ratio/ MMR, sexually transmit/STD/STI, contracept*/family planning, antenatal care/ANC, postnatal care, births attended by skill, woman/female, southeast Asia (as well as SEA, Bangladesh, Bhutan, Democratic People’s Republic of Korea/North Korea, India, Indonesia, PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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Maldives, Myanmar, Nepal, Sri Lanka, Thailand, TimorLeste), influenc*/risk factor/affect/effect. No timeframe was placed on the searches and reviewed publications were limited to those reported in the English language. Besides, we searched the websites of WHO for the authoritative and detailed data and official by applying the key words “reproductive health”. The uncertainty intervals (UI) computed for all the estimates refer to the 80% uncertainty intervals (10th and 90th percentiles of the posterior distributions). This was chosen as opposed to the more standard 95% intervals because of the substantial uncertainty inherent in maternal mortality outcomes.
Female reproductive health situation in SEA Female reproductive health is a relatively large conception and covers many aspects. So how to measure and estimate the state of RH? Different reports use different indicators. A review about research progress on female reproductive health in China use reproductive tract infection rates, knowledge of female physiological, degree of reproductive cleanliness, and access to reproductive health knowledge, etc., to assess the reproductive health of women in urban, rural and floating populations [4]. While another report to study reproductive health of female floating population mentioned that the assessment of the overall status of reproductive health mainly includes reproductive health knowledge, healthy sexual behavior (safe sex, unintentional sexual behavior) and genital tract infection seeking medical behavior [11]. A study discussed improving adolescent reproductive health in Asia and the Pacific, based on two databases Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS), divided the indicators of adolescent reproductive health into 4 categories: sexual and reproductive health, maternal health (such as percentage of births attended by a skilled birth attendant), new born health (such as neonatal mortality rate), access to reproductive and maternal health services (such as contraceptive prevalence) [12]. In short, we can classify these indicators into two categories: one is the direct reproductive health or disease indicator and another is the coverage of reproductive health service, which
can reflect the situation indirectly. In order to state the status of female reproductive health in Southeast Asian countries more clearly and easier to understand, we select the more commonly used and studied RH indicators after doing a review via PubMed, Web of Science and WHO’s webpages.
Reproductive health or disease indicator Maternal mortality ratio (MMR) MMR was commonly used as indicator for assessing female reproductive health in the world, is the annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births, for a specified year. The indicator monitors deaths related to pregnancy and childbirth. It reflects the capacity of the health systems to provide effective health care in preventing and addressing the complications occurring during pregnancy and childbirth [13]. The uncertainty intervals (UI) computed for all the estimates refer to the 80% uncertainty intervals (10th and 90th percentiles of the posterior distributions). This was chosen as opposed to the more standard 95% intervals because of the substantial uncertainty inherent in maternal mortality outcomes. Over the past 25 years, the global MMR fell by nearly 44%, from 385 (UI 359–427) per 100,000 live births in 1990 to 216 (UI 207–249) in 2015. MMR for developing regions were estimated 239 (UI 229–275) in 2015, which was roughly 20 times higher than that of developed regions, which was just 12 (UI 11–14). As for the southern Asia (Afghanistan, Bangladesh, Bhutan, India, Islamic Republic of Iran, Maldives, Nepal, Pakistan, Sri Lanka) and south-eastern Asia (Brunei Darussalam, Cambodia, Indonesia, Lao People’s Democratic Republic, Malaysia, Myanmar, Philippines, Singapore, Thailand, Timor-Leste, Viet Nam) in MDG regions, MMRs were estimated 176 (UI 153–216) and 110 (UI 95–142) respectively [14]. Among them, in 2015, MMR was estimated 258 (UI 176–425) in Nepal [15], 176 (UI 125–280) in Bangladesh [16], 126 (UI 93–179)
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in Indonesia [17], 178 (UI 121–284) in Myanmar [18], 215 (UI 150–300) in Timor-Leste [19], 174 (UI 139 to 217) in India [20]. Comparing with the average data in SEA region, Nepal and Timor-Leste still need more attention. District variation in maternal mortality also exists within a country. A study in India showed that a wide variation of MMR in the five zones between 2005 and 2007 was observed: West India-342; South India-229; East India-709; North East India-709 and North India-814 [21]. Another research presented that in Bangladesh, for MMR, there was greatly varied between different districts, for example, MMR for Dhaka district was 158 per 100,000 live births in 2011, meanwhile which was 782 in the northern coastal regions, with the higher ratio in eastern and northern regions [22]. There were also significant differences between urban and rural areas. According to 2004‒2006 nationally representative survey, three-quarters of maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated live births in India due to lower access and utilization to healthcare services in rural areas than the urban [23]. Some studies have determined accessibility and availability of maternal health care services are very important factors to reduce maternal mortality. An analysis of factors linked to the decline in maternal mortality found that improved utilization of maternity care services seems essential to the decline in maternal mortality in Nepal [24]. A Bangladeshi study considered the key contribution to this decrease was a drop in mortality risk mainly due to improved access to and use of health facilities [25]. Alternately, we should not only pay attention to the availability of health services, but also the quality of services. District Kutai Kartanegara, a rural district of Indonesia, was such a region, where consistently high maternal mortality was observed, despite high rate of delivery by skilled birth attendants. The root causes were found in poor quality of care including inadequate skills, lack of forward planning, ineffective communication, inadequate risk management and so on [26]. Women’s behaviors also were underlying factors to maternal mortality. Antenatal visits less than 4 times and initial visit to antenatal care facilities after the fourth month of pregnancy were determined as the risk factors in Indonesia [27]. An analysis in Matlab, Bangladesh
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found that abortion was associated with higher mortality risk [28]. Another also in Bangladesh including 165,894 pregnancies data shows that the maternal mortality risk was considerably higher for pregnancies that ended in induced abortion, miscarriage or stillbirth [29]. A result from analyzing the determinants of maternal mortality showed safe abortion might have played a significant role in reducing MMR in Nepal [30]. However, in eastern Myanmar, abortion was interestingly not identified as an important contributor to maternal mortality. Uncovered were a number of underlying factors uniquely contributing to maternal mortality in eastern Myanmar, which could be grouped into the following analytical themes: ongoing conflict, health system deficits, and political and socioeconomic influences [31]. The socioeconomic and demographic factors have a stronger statistically significant association with the maternal mortality ratio. The time series and crosssectional analyses reveal that per capita state net domestic product, poverty ratio, total fertility rate contributed to the decline in the maternal mortality ratio in India [32]. The reduction in fertility and improvements in components of the human development index played the same role in Nepal [33]. Another article demonstrated that fertility decline between 1990 and 2008 has made a substantial contribution to the reduction of the MMR in three South Asian countries (India, Pakistan, and Bangladesh) [34], since the two mechanisms the fertility reduction contributed to averting maternal deaths: the larger effect is due to the sheer reduction in number of births, and the smaller due to the change in the age pattern of mothers (towards aged 20‒34 years) and shifts in parity (fewer high parity births) [25]. A woman’s social status, or the position she holds in society, affected her power, education and resources to act autonomously in the interest of her own health. It influenced every aspect of a woman’s reproductive life, including pre-conceptual health, pregnancy planning, pregnancy and childbirth management. Gender inequity, the underestimation of the severity of complications by family members, and perceptions of low-quality delivery services will delay decisions to seek care, thus associated with maternal mortality, founded in in Khargone district in central India [35]. Some studies highlighted PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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that education of women was a strong predictor of the maternal mortality decline [25, 36] through both increased use of health facilities and other pathways. A review summarized cultural influence on maternal mortality in the developing countries, found that cultural customs, practices, beliefs and values profoundly influence women’s behaviors during the perinatal period and in some cases increase the likelihood of maternal death in childbirth [37]. Some customs suggested to limit meat, eggs, and fish during the perinatal period, may leading to underlying anemia and furthering the risk of death after hemorrhage, which was the direct harm to women [38]. Besides, in many cultures, obstetric emergencies are not recognized, but even when they are, cultural beliefs about their causes, treatment and implications often preclude women from seeking life saving help [39]. Women also intentionally avoid formal health care because they fear appearing weak, being subjected to a caesarean section, or experiencing what is perceived as dangerous, corrupt, insensitive, poorly organized, unclean, and untrustworthy care offered by formal health care [40]. More than that, culture affected the formation of social systems and the establishment of social status. A woman may marry at a very young age, have a lack of contraceptive choices, and face societal pressures for male children, all of which may result in a high number of births accompanied by increased risks for morbidity and mortality, a paper explained how social status make an impact to women’s reproductive health [41].
The factors influenced the Indian’s HIV epidemic are the size, behaviors, and disease burdens of highrisk groups, their interaction with bridge populations and general population sexual networks, and migration and mobility of both bridge populations and high-risk groups [44]. Social attitude played an important role on the diagnosis, treatment and even death of STD patients, especially for women and children. In rural India, those women who were known to have contracted HIV were reluctant to access health care for fear of discrimination and marginalization, leading to a disproportionate death rate in HIV women. India is arguably home to the largest number of orphans of the HIV epidemic. These children face an impenetrable barrier in many Indian societies and endure stigmatization. This situation encourages concealment of the disease and discourages children and their guardians from accessing available essential services [45]. The use of condom has been suggested as the only prospective method against STD. Nevertheless, some social factors were associated with non-use of a condom during sexual intercourse: moral values, ethnic and religious factors, gender inequality, lack of a dialogue among partners with regard to condom use, and the stigma attached to the condom [46]. Another systematic review, focus on the utilization of health care services for sexually transmitted infections, highlighted that stigma, embarrassment, illiteracy, lack of privacy, cost of care was found to limit the use of services [47].
Service coverage indicator
Sexually transmitted disease (STD) Globally, the prevalence of STD among women in developing countries is higher than in developed countries. The prevalence of STD in developing countries is relatively serious, especially in Africa, which is estimated to be about 10 times that of developed countries, followed by Asia and Latin America [42]. According to the Report on Global Sexually Transmitted Infection Surveillance in 2015 from WHO, the reported cases of genital ulcer diseases rates in females (per 100,000 adults) in SEA countries were: Bhutan 73.0 (2012), Indonesia 9.8 (2014), Maldives 35.2 (2014), Myanmar 1.8 (2014), Timor-Leste 104.5 (2014). The female syphilis rates are: Indonesia 4.2 (2014), Myanmar 5.7 (2014), Sri Lanka 6.2 (2014) [43].
Contraceptive rates and unmet need for family planning Contraceptive rates and unmet need for family planning are key indicators of progress in reproductive health. It refers to the proportion of women of reproductive age (15–49 years) who are married or in union and who have an unmet need for family planning, i.e. who do not want any more children or want to wait at least two years before having a baby, and yet are not using contraception. Unmet need is a rights-based measure that helps determine how well a country’s health system and social conditions support the ability of women to realize their stated preference to delay or limit births [48]. In all SEA
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countries, more than 50% of women of reproductive age (15–49 years) in all countries have family planning needs [49]. In 2011/2012, 61% of women in Bangladesh were able to use contraception methods, while 12% of women had unmet needs for family planning (11.7% in 2012, 13.5% in 2011, respectively) [16]. In 2011, Nepalese women’s unmet need reached 27% [15]. In Timor-Leste, only 22% women used contraception in 2009/2010, while the rate of unmet need for contraception reached 32% [19]. Antenatal and postnatal care coverage Antenatal care (ANC) coverage is an indicator of access and utilization of care during pregnancy. We use the proportion of women who were attended at least four times during pregnancy by trained health personnel for reasons related to their pregnancy for measuring. This is also one of the process indicators for tracking progress in reducing maternal mortality [50]. In the South-East Asia region in 2012, only three countries have already reached or surpassed the 90% coverage of pregnant women with at least four visits: Sri Lanka, Indonesia, and Democratic People’s Republic of Korea. Bangladesh had the lowest coverage with four visits of less than 30%.the pre-natal care rate in Bangladesh was less than 30% [16], followed by Timor-Leste and Nepal [15, 19]. In 2013, the average postnatal maternal and newborn care rate was 49%, which refers to be visited by trained health personnel within two days of birth. Maldives, Sri Lanka, and Indonesia were above average and Nepal and India were close to average. However, the postnatal care rates for Timor-Leste and Bangladesh were 25% and 27% respectively, less than 30% [49]. Compared with the data of China, the rate of antenatal care reached 96.2% and postpartum visit rate 93.9% in 2014, we can know the level of reproductive health clearly [51]. Births attended by skilled health personnel The proportion of births attended by skilled health personnel is a sub-indicator to monitor progress in reducing maternal mortality. As it is difficult to accurately measure maternal mortality, and model-based estimates of the maternal mortality ratio cannot be used for monitoring short-term trends, the proportion of births attended by skilled health personnel is used as a proxy indicator for
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this purpose. The computing method of this predictor are the number of births attended by skilled health personnel (doctors, nurses or midwives) trained in providing lifesaving obstetric care, including giving the necessary supervision, care and advice to women during pregnancy, childbirth and the post-partum period divide by the total number of live births in the same period [52]. Rural region in Bangladesh were estimated 35.6% (UI 32.3%‒39.1%) and urban region were 60.5% (UI 56.1%‒64.8%) in 2014. In Bhutan in 2010, rural and urban region were estimated 54.2% (UI 50.9%‒57.4%) and 89.4% (UI 85.0%‒92.6%), respectively. In rural region of Myanmar was 57.5% (UI 52.8%‒62.1%) in 2015, which was in urban region 88.5% (UI 82.0%‒92.9%). In Nepal, the proportion were 50.5% (UI 46.4%‒54.5%) in rural and 90.3% (UI 86.0%‒93.5%) in urban region in 2014 respectively [53]. Also, the factors influencing reproductive health service coverage can be classified into several part. The first part is due to women themselves. Many studies have highlighted the importance of women’s education in seeking health service. Lack of reproductive health knowledge and communication ability with husbands and family members, which were impacted potentially by low education, resulted high early childbearing rate among married adolescent girls in Bangladesh [54]. A review, summarizing the factors relating to utilization of facility delivery in rural South Asia, found that socioeconomic and educational status was one of the main factors [55], as well as women’s occupation. A cross-sectional study carried out in rural Nepal found that the woman’s own occupation and ethnicity, were significantly associated with the utilization of postnatal care [56]. Besides, the attitude and awareness are vital for adequate use of health service. The women with a positive attitude toward family planning practiced family planning 3.7 times more than women who had a negative attitude, founded in Hlaing Township, Myanmar [57]. Family influence factors were followed. The husbands’ education level and occupation played also an important role like women’s [56, 58]. A study aiming to evaluate the effect of the woman’s perception of her husband’s approval of family planning, considered that husband’s approval does appear to be a major PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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determinant of contraceptive uptake in Bangladesh and similar developing countries [59]. Several literatures also supported that wealth or household income determining the choices for contraceptive and antenatal cares [58, 60]. As for the community-level, we must draw attention to distance and the accessibility that comes from it. Distance to a health facility also affected the behaviors women giving birth with a health professional, thus affecting maternal mortality, analyzed in Bangladesh and Indonesia. Women who lived further from health centers in both countries were less likely to have their births attended by health professionals than those who lived closer and may only seek professional care in an emergency and may be unable to reach timely care when living far away from a health center [61]. 24-hour availability of family planning services will contribute to family planning practice [57]. Whilst exposure to mass media (especially television and radio) significantly predicted utilization of antenatal care [58] and exposure to family planning messages through radio had a positive effect on modern and traditional method choices [60]. Socioeconomic and cultural factors had overarching influence on the coverage of reproductive health service. Cultural beliefs and ideas about pregnancy also had an influence on antenatal care use. Lack of privacy and exposure of legs and arms are difficult to accept for Muslim women, which is a barrier for them to use reproductive and sexual health services [62]. Besides, Women in some cultures do not use ANC because of the perception that the modern healthcare sector is intended for curative services only [63]. In some places, an adversarial relationship exists between professional health-care providers and the more traditional birth attendants, creating a cultural milieu where distrust, criticism, and self-interest characterize the maternity care offered to women [37], that was how culture affect.
Conclusion Reproductive health is particularly important for people’s quality of life. It is affected by many factors including behaviors, social environment, utilization of health services. Different indicators of reproductive health have potential links and interactions among each other, for example, antenatal and postnatal care coverage
have overarching influence on maternal death. We also found there are some same influencing factors affect all indicators, for example, the education level of women plays a vital and key role. Educated women are more likely to realize the benefits of using maternal healthcare services. Education increases female autonomy, decisionmaking power within the household and builds greater confidence and capability to make decisions regarding their own health [57]. Therefore, improving the rate of literacy must be the priority and efficient way for government to improve female reproductive health, especially in resource-restricted Southeast Asian countries. Utilization of maternal health care services, the most direct method to reduce MMR and achieve SDG goals, has received extensive attention from society. It is worth noting that the accessibility and availability of health service alongside the quality both are the imperative as the reproductive strategies. There is a huge difference in women’s reproductive health status in the world, especially in developing countries because of the backward economy and lack of health services. Southeast Asian countries have their special geographical, socioeconomical environment and cultural background, and their findings also have regional differences. The reproductive health situation of SEA countries was less optimistic overall. Even in the same country, the RH status was uneven in different areas. Limited by short health resources in these developing countries, precise risk area location and efficient intervention are essential to explore. So, estimating the level of reproductive health in all regions of a country is very worthwhile in order to optimize health resources and target interventions in horizontally backward regions. And studies in these developing countries will contribute to achieve the equity of global health and may inspire researchers and policy-makers in other countries.
Additional files Funding This manuscript was supported by CMB (Grant Number 13‒133), Institutional Development of the Department of Global Health at Sun Yat-sen University.
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Competing interests The authors claim that there is no competing interests for this article.
Consent for publication All authors approved the final version of this manuscript.
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