Maternal health
Considerable advances in maternal health have been made in the Region of the Americas. These achievements are related to improvements in various dimensions of people’s lives and, in particular, the lives of women, especially pregnant women.
All the countries of the Region improved their human development index (HDI) scores between 1990 and 2014, with a positive impact on maternal health. The HDI is an indicator of three basic dimensions of human development that attempts to give an objective picture of the average results achieved at a national level in terms of long and healthy life, the acquisition of knowledge, and the enjoyment of a decent standard of living, i.e., health, education, and financial situation.
Most of the countries of the Region rank among the top 100 of a total of 188 countries, except for 11 countries with lower rankings () (Table 1). The list includes the United States of America, with a score of 0.915 (8th place) to Haiti, with a score of 0.483 (163rd). Comparing the performance of Latin American and Caribbean (LAC) countries only, Argentina is the highest-ranking country for this indicator (40th place, HDI = 0.836).
Table 1. Selected indicators for LAC countries with the lowest HDI ranking (below 100th place on the Human Development Index).
| Belize | 0.715 | 101 | 0.426 | 90 | > 85.7 | 93.2 | < 68 |
Dominican Rep. | 0.715 | 101 | 0.477 | 104 | 55.7 | > 93.8 | 92 |
Suriname | 0.714 | 103 | 0.463 | 100 | 66.8 | > 93.8 | 155 |
Paraguay | 0.679 | 112 | 0.472 | 101 | 78.3 | > 93.8 | 132 |
El Salvador | 0.666 | 116 | 0.427 | 91 | 74 | > 93.8 | < 68 |
Bolivia | 0.662 | 119 | 0.444 | 94 | 75.7 | 73.5 | 206 |
Guyana | 0.636 | 124 | 0.515 | 114 | > 85.7 | > 93.8 | 229 |
Nicaragua | 0.631 | 125 | 0.449 | 95 | 72 | > 93.8 | 150 |
Guatemala | 0.627 | 128 | 0.533 | 119 | 43 | 62.4 | 88 |
Honduras | 0.606 | 131 | 0.480 | 106 | > 85.7 | 83 | 129 |
Haiti | 0.483 | 163 | 0.603 | 138 | 67 | 50 | 359 |
* The countries of the Americas ranked below 100th place on the HDI were selected from a total of 188 countries.
** Gender inequality index.
*** Maternal mortality ratio.
Sources:
HDI and GII data: UNDP. Human development report 2015: work for human development ().
Institutional antenatal care during childbirth: Pan American Health Organization. Health situation in the Americas: Core indicators 2016
().
MMR: World Health Organization. Trends in maternal mortality: 1990 to 2015 estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division ().
However, the HDI does not differentiate between women and men. In terms of maternal health, it is relevant to consider as an indicator that is able to identify gender differences within an analysis of human development. This is particularly necessary in a region where inequalities between men and women remain significant and have a negative impact on women’s quality of life and their potential for development. The gender inequality index (GII) is an indicator of inequality that attempts to demonstrate the loss of potential human development due to disparities in two dimensions of achievement by men and women: empowerment and labor market participation. It also attempts to reflect a country’s position with respect to the fundamental dimension of women’s reproductive health.
Since no country has perfect gender equality, all nations suffer some loss in terms of achievements obtained in key aspects of human development when gender inequality is taken into account. Unlike the HDI, whose higher values express better conditions for human development, higher GII scores (closer to 1) indicate greater inequality. In general, the countries of our Region show a consistent trend: a poorer HDI ranking usually means a higher GII score. The 11 countries ranked 100 or below on the HDI index have similarly low GII rankings, ranging from Belize (90th, 0.426) to Haiti (138th, 0.603) () (Table 1).
Only four countries, positioned among the top 100 countries on the HDI, are above 90th position in the GII classification: Colombia (92nd, 0.429), Jamaica (93rd, 0.430), Panama (96th, 0.454), and Venezuela (103rd, 0.476).
Improvements in the HDI and the GII reflect advances toward better maternal health. But these improvements have also stimulated demand for better maternal health in almost all the countries of the Americas. The creation of national health insurance programs in the 1990s and early 2000s was accompanied by several conditional cash transfer programs that promoted access to prenatal care and institutional care in childbirth. Noteworthy programs include, among others: Bono Juana Azurduy in Bolivia, Comunidades Solidarias Rurales in El Salvador, Mi Familia Progresa in Guatemala, Bono Social 10,000 in Honduras, Promotion through Health and Education in Jamaica, and Programa Oportunidades in Mexico ().
Prenatal care (with at least four prenatal visits) increased throughout the Americas, from an average of 79.4% in 2005 to 88.2% in 2016. This increase was especially significant considering that prenatal check-up coverage in LAC rose from 72.6% in 2005 to 85.7% in 2016 ().
However, despite increased prenatal coverage in all LAC countries, nine countries remain below the LAC regional average, ranging from 79.5% in Ecuador to 43% in Guatemala (). Eight of these nine countries have low HDI scores and gender inequity. The only one not in that category is Ecuador, with 79.5% national coverage of antenatal care with four or more prenatal check-ups (Table 1).
Access to institutional childbirth has also improved in nearly all countries in the Region. In the period between 2005 and 2015, institutional coverage of childbirth in the Americas increased from 91.3% to 95.6%. In North America (excluding Mexico), coverage remained stable at 99.4%, while institutional coverage of childbirth in LAC increased by 5.9 percentage points from 87.9% to 93.8%–an increase of 7.6% in 10 years ().
As was observed in the case of antenatal care, other countries are below the LAC average for institutional care during childbirth (93.8%). In total, seven countries show figures ranging from 93.2% in Belize to 50% in Haiti ().
Five of those seven countries have a low HDI score and high gender inequality. In turn, four (Bolivia, Guatemala, Haiti, and Honduras) also show low levels of antenatal care. Furthermore, Peru and Panama show institutional levels of care of delivery below the regional average for LAC.
We have seen how HDI, GII, coverage of prenatal care, and institutional care in childbirth have progressed in recent years. Next we will discuss what has happened with the maternal mortality ratio (MMR) and its relationship to the aforementioned indicators.
The degree of progress made in the reduction of maternal mortality has recently been determined with regard to achieving the Millennium Development Goals, in particular Target 5.A (reducing the MMR by three-quarters with respect to 1990). This target, which only nine countries in the world reached, was not achieved by any country in the Americas. Despite very significant reductions, only Peru came close to achieving Target 5.A, with a 72.9% reduction ().
At the world level, mortality was reduced by 44% between 1990 and 2015, while there was a 49% reduction in the Region of the Americas (). The comparative probability of maternal death for a woman in LAC compared to one in Canada or the United States of America was reduced from 12-fold to 5-fold. This outcome was the result of lower maternal mortality in LAC (MMR declined from 135 per 100,000 live births to 67 per 100,000), as well as an increase in the MMR in North America (11 per 100,000 live births in 1990 versus 13 per a 100,000 in 2015 []).
In turn, the disaggregated figures for LAC show better performance in reducing maternal mortality in Latin America (52%) than in the Caribbean (37%) (). From 1990 to 2015, 25 countries showed some reduction in their MMR figures, ranging from the least in Panama (7.8%) to the most in Peru (72.9%). During the same period, Canada showed no change and seven countries registered an increase in maternal mortality, from just 1.1% in Venezuela to 73.9% in Bahamas ().
Although the majority of LAC countries reduced their maternal mortality figures, the MMR in 13 countries remains above the LAC average (68 per 100,000 live births in 2015), with figures ranging from 80 in the Bahamas to 359 in Haiti ().
With regard to the situation in the 11 countries of the Region that rank below 100th position on the HDI, nine of them show the highest levels of maternal mortality. This confirms that maternal mortality is not an isolated phenomenon and that it is clearly linked to education, work, poverty, and gender inequalities, among other factors.
It should also be emphasized that these disparities at the national level are repeated within countries, and there are groups in vulnerable conditions who should receive special attention because their situation remains hidden behind relatively good national averages. Accordingly, the challenge facing the health sector is how to make progress with multisectoral actions targeting groups in vulnerable conditions in order to achieve a two-thirds reduction in maternal mortality figures by 2030 (based on maternal mortality figures for 2010) in every country of the Region, as all its governments have agreed, within the framework of strategies to end preventable maternal mortality and the Global Strategy for Women’s, Children’s and Adolescents’ Health ().
References
1. United Nations Development Program. Human development report 2015. Work for human development. New York: UNDP; 2015. Available from: //hdr.undp.org/sites/default/files/2015_human_development_report.pdf.
2. Maldonado JH, Moreno RP, Giraldo I, Barrera CA. Los programas de transferencias condicionadas: ¿Hacia la inclusión financiera de los pobres en América Latina? (Serie: Análisis Económico, 26). Lima: CIID/Instituto de Estudios Peruanos; 2011. Available from: //www.proyectocapital.org/es/component/phocadownload/category/1-documentos.html?download=185:los-programas-de-tmc-jorge-maldonado-et-al.
3. Pan American Health Organization. Health situation in the Americas: core indicators 2005. Washington, D.C.: PAHO/WHO; 2005. Available from: //www.paho.org/hq/dmdocuments/2009/BI_2005_ENG.pdf.
4. Pan American Health Organization. Health situation in the Americas: core indicators 2016. Washington, D.C.: PAHO/WHO; 2016. Available
from:
//iris.paho.org/xmlui/bitstream/handle/123456789/31289/CoreIndicators2016-eng.pdf?sequence=1&isAllowed=y.
5. Pan American Health Organization. Health situation in the Americas: basic indicators 2015. Washington, D.C.: PAHO; 2015. Available from: www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=31791&Itemid=270&lang=en.
6. World Health Organization. Trends in maternal mortality: 1990 to 2015 estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: WHO; 2015. Available from: //apps.who.int/iris/bitstream/10665/193994/1/WHO_RHR_15.23_eng.pdf?ua=1.
7. World Health Organization. Strategies toward ending preventable maternal mortality (EPMM). Geneva: WHO; 2015. Available at: //apps.who.int/iris/bitstream/10665/153544/1/9789241508483_eng.pdf?ua=1.
8. United Nations. Global Strategy for Women’s, Children’s and Adolescent’s Health (2016-2030). Survive, thrive, transform. New York: UN; 2015. Available at: //www.who.int/life-course/partners/global-strategy/ewec-globalstrategyreport-200915.pdf?ua=1.