32 Global Health Journal / Volume 2, Issue 1, March 2018

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: haoyt@mail.sysu.edu.cn

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countries due to poor access to screening and treatment

Background services [7].
Reproductive Health (RH) has been listed in the The South-East Asia Region (SEA) of the World
Programme of Action of The International Conference Health Organization, divided by WHO, was established
on Population and Development in 1994 [1], within the in 1948 and was the one of first six regions set up. SEA is
framework of the World Health Organization’s (WHO) the sub region of Asia, consisting of Bangladesh, Bhutan,
definition of health as a state of complete physical, Democratic People’s Republic of Korea, India, Indonesia,
mental and social well-being, and not merely the absence Maldives, Myanmar, Nepal, Sri Lanka, Thailand, Timor-
of disease or infirmity, reproductive health addresses Leste [8]. Most of SEA countries were under colonial rule
the reproductive processes, functions and system at all before Second World War. Widespread poverty, higher
stages of life [2]. In 1995, International Conference on illiteracy rate, poor housing conditions, overcrowding and
Population and Development stressed the importance of undernutrition or malnutrition attacked these countries.
reproductive health again and introduced the target of Coupled with this, hot and humid climate of the tropics in
“Achieve universal access to reproductive health by the which most of the countries are situated, created a favorable
year 2015”, which also been committed in the Millennium environment most of the infectious organisms can survive
Development Goals (MDGs) [3]. Since then, reproductive and thrive. Although some progress to improve states has
health has attracted wide attention and input from the been made during the MDG era, SEA countries still have
international community, and the level of RH around the gaps with other countries in the world [9]. According to
world has been improve at different degrees [4]. On 25 the United Nations, almost half of the SEA countries,
September 2015, the United Nations General Assembly Bangladesh, Bhutan, Myanmar, Nepal, Timor-Leste
adopted the new development agenda “Transforming our were classified as the Least Developed Countries [10].
world: the 2030 agenda for sustainable development”, All of SEA countries are developing countries. Women’s
the Sustainable Development Goals (SDGs) in short, rights and reproductive health in these countries deserve
which built upon and extended the MDGs. Several targets special attention. So we analyzed the present situation
in SDGs has been devoted specifically to reproductive of female reproductive health in Southeast Asian
health, in reducing maternal mortality and ensuring countries, summarized the influencing factors, thus to
universal access to sexual and reproductive health-care obtain the necessity and urgency of strengthening the
services [5]. reproductive health level of Southeast Asian countries,
Generally speaking, female reproductive health so as to provide the basis for the priorities and target
is not optimistic in the global situation, especially in to policy-makers and health administrators to improve
developing countries. According to the statistics from reproductive health.
WHO, the risk of a woman in a developing country dying
from a maternal-related cause during her lifetime is about Methods
33 times higher in comparison with a woman living in a A two-step process was used to conduct the literature
developed country [6]. About 287,000 women die of the search. First, we searched for relevant publications about
complications of pregnancy and delivery, 99% of whom female reproductive health and indicators concerned and
are from developing countries. In 2011, about 820,000 its influencing factors in PubMed, Web of Science and
women and men aged 15–24 in low- and middle-income Google Scholar databases before April 2018. The search
countries are newly infected with HIV and more than 60% terms were followed: reproduc*/maternal mortality ratio/
of them are women. As the second most common type of MMR, sexually transmit/STD/STI, contracept*/family
woman’s cancer in the world, almost all cervical cancer planning, antenatal care/ANC, postnatal care, births
patients are related to sexually transmitted infections of attended by skill, woman/female, southeast Asia (as
the human papilloma virus (HPV). More than 90% of well as SEA, Bangladesh, Bhutan, Democratic People’s
deaths occur among women in low- and middle-income Republic of Korea/North Korea, India, Indonesia,

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Maldives, Myanmar, Nepal, Sri Lanka, Thailand, Timor- can reflect the situation indirectly. In order to state the
Leste), influenc*/risk factor/affect/effect. No timeframe status of female reproductive health in Southeast Asian
was placed on the searches and reviewed publications countries more clearly and easier to understand, we select
were limited to those reported in the English language. the more commonly used and studied RH indicators after
Besides, we searched the websites of WHO for the doing a review via PubMed, Web of Science and WHO’s
authoritative and detailed data and official by applying the webpages.
key words “reproductive health”.
The uncertainty intervals (UI) computed for all the Reproductive health or disease indicator
estimates refer to the 80% uncertainty intervals (10th and
Maternal mortality ratio (MMR)
90th percentiles of the posterior distributions). This was
chosen as opposed to the more standard 95% intervals MMR was commonly used as indicator for assessing
because of the substantial uncertainty inherent in maternal female reproductive health in the world, is the annual
mortality outcomes. number of female deaths from any cause related to or
aggravated by pregnancy or its management (excluding
Female reproductive health situation in accidental or incidental causes) during pregnancy and
SEA childbirth or within 42 days of termination of pregnancy,
Female reproductive health is a relatively large irrespective of the duration and site of the pregnancy, per
conception and covers many aspects. So how to measure 100,000 live births, for a specified year. The indicator
and estimate the state of RH? Different reports use monitors deaths related to pregnancy and childbirth. It
different indicators. A review about research progress on reflects the capacity of the health systems to provide
female reproductive health in China use reproductive tract effective health care in preventing and addressing the
infection rates, knowledge of female physiological, degree complications occurring during pregnancy and childbirth
of reproductive cleanliness, and access to reproductive [13]. The uncertainty intervals (UI) computed for all the
health knowledge, etc., to assess the reproductive health estimates refer to the 80% uncertainty intervals (10th and
of women in urban, rural and floating populations [4]. 90th percentiles of the posterior distributions). This was
While another report to study reproductive health of chosen as opposed to the more standard 95% intervals
female floating population mentioned that the assessment because of the substantial uncertainty inherent in maternal
of the overall status of reproductive health mainly mortality outcomes.
includes reproductive health knowledge, healthy sexual Over the past 25 years, the global MMR fell by
behavior (safe sex, unintentional sexual behavior) and nearly 44%, from 385 (UI 359–427) per 100,000 live
genital tract infection seeking medical behavior [11]. births in 1990 to 216 (UI 207–249) in 2015. MMR for
A study discussed improving adolescent reproductive developing regions were estimated 239 (UI 229–275)
health in Asia and the Pacific, based on two databases in 2015, which was roughly 20 times higher than that of
Demographic and Health Survey (DHS) and Multiple developed regions, which was just 12 (UI 11–14).
Indicator Cluster Survey (MICS), divided the indicators As for the southern Asia (Afghanistan, Bangladesh,
of adolescent reproductive health into 4 categories: Bhutan, India, Islamic Republic of Iran, Maldives,
sexual and reproductive health, maternal health (such as Nepal, Pakistan, Sri Lanka) and south-eastern Asia
percentage of births attended by a skilled birth attendant), (Brunei Darussalam, Cambodia, Indonesia, Lao People’s
new born health (such as neonatal mortality rate), access Democratic Republic, Malaysia, Myanmar, Philippines,
to reproductive and maternal health services (such as Singapore, Thailand, Timor-Leste, Viet Nam) in MDG
contraceptive prevalence) [12]. In short, we can classify regions, MMRs were estimated 176 (UI 153–216) and
these indicators into two categories: one is the direct 110 (UI 95–142) respectively [14]. Among them, in 2015,
reproductive health or disease indicator and another MMR was estimated 258 (UI 176–425) in Nepal [15],
is the coverage of reproductive health service, which 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], found that abortion was associated with higher mortality
215 (UI 150–300) in Timor-Leste [19], 174 (UI 139 to risk [28]. Another also in Bangladesh including 165,894
217) in India [20]. Comparing with the average data pregnancies data shows that the maternal mortality risk
in SEA region, Nepal and Timor-Leste still need more was considerably higher for pregnancies that ended in
attention. District variation in maternal mortality also induced abortion, miscarriage or stillbirth [29]. A result
exists within a country. A study in India showed that a from analyzing the determinants of maternal mortality
wide variation of MMR in the five zones between 2005 showed safe abortion might have played a significant role
and 2007 was observed: West India-342; South India-229; in reducing MMR in Nepal [30]. However, in eastern
East India-709; North East India-709 and North India-814 Myanmar, abortion was interestingly not identified
[21]. Another research presented that in Bangladesh, for as an important contributor to maternal mortality.
MMR, there was greatly varied between different districts, Uncovered were a number of underlying factors uniquely
for example, MMR for Dhaka district was 158 per 100,000 contributing to maternal mortality in eastern Myanmar,
live births in 2011, meanwhile which was 782 in the which could be grouped into the following analytical
northern coastal regions, with the higher ratio in eastern themes: ongoing conflict, health system deficits, and
and northern regions [22]. There were also significant political and socioeconomic influences [31].
differences between urban and rural areas. According to The socioeconomic and demographic factors have
2004‒2006 nationally representative survey, three-quarters a stronger statistically significant association with the
of maternal deaths were clustered in rural areas of poorer maternal mortality ratio. The time series and cross-
states, although these regions have only half the estimated sectional analyses reveal that per capita state net domestic
live births in India due to lower access and utilization to product, poverty ratio, total fertility rate contributed to the
healthcare services in rural areas than the urban [23]. decline in the maternal mortality ratio in India [32]. The
Some studies have determined accessibility and reduction in fertility and improvements in components
availability of maternal health care services are very of the human development index played the same role
important factors to reduce maternal mortality. An analysis in Nepal [33]. Another article demonstrated that fertility
of factors linked to the decline in maternal mortality decline between 1990 and 2008 has made a substantial
found that improved utilization of maternity care services contribution to the reduction of the MMR in three South
seems essential to the decline in maternal mortality in Asian countries (India, Pakistan, and Bangladesh)
Nepal [24]. A Bangladeshi study considered the key [34], since the two mechanisms the fertility reduction
contribution to this decrease was a drop in mortality contributed to averting maternal deaths: the larger effect
risk mainly due to improved access to and use of health is due to the sheer reduction in number of births, and the
facilities [25]. Alternately, we should not only pay attention smaller due to the change in the age pattern of mothers
to the availability of health services, but also the quality (towards aged 20‒34 years) and shifts in parity (fewer
of services. District Kutai Kartanegara, a rural district of high parity births) [25].
Indonesia, was such a region, where consistently high A woman’s social status, or the position she holds
maternal mortality was observed, despite high rate of in society, affected her power, education and resources
delivery by skilled birth attendants. The root causes were to act autonomously in the interest of her own health. It
found in poor quality of care including inadequate skills, influenced every aspect of a woman’s reproductive life,
lack of forward planning, ineffective communication, including pre-conceptual health, pregnancy planning,
inadequate risk management and so on [26]. pregnancy and childbirth management. Gender inequity,
Women’s behaviors also were underlying factors the underestimation of the severity of complications by
to maternal mortality. Antenatal visits less than 4 times family members, and perceptions of low-quality delivery
and initial visit to antenatal care facilities after the fourth services will delay decisions to seek care, thus associated
month of pregnancy were determined as the risk factors with maternal mortality, founded in in Khargone
in Indonesia [27]. An analysis in Matlab, Bangladesh district in central India [35]. Some studies highlighted

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that education of women was a strong predictor of the The factors influenced the Indian’s HIV epidemic
maternal mortality decline [25, 36] through both increased are the size, behaviors, and disease burdens of high-
use of health facilities and other pathways. risk groups, their interaction with bridge populations
A review summarized cultural influence on maternal and general population sexual networks, and migration
mortality in the developing countries, found that cultural and mobility of both bridge populations and high-risk
customs, practices, beliefs and values profoundly groups [44]. Social attitude played an important role on
influence women’s behaviors during the perinatal period the diagnosis, treatment and even death of STD patients,
and in some cases increase the likelihood of maternal especially for women and children. In rural India, those
death in childbirth [37]. Some customs suggested to women who were known to have contracted HIV were
limit meat, eggs, and fish during the perinatal period, reluctant to access health care for fear of discrimination
may leading to underlying anemia and furthering the risk and marginalization, leading to a disproportionate death
of death after hemorrhage, which was the direct harm rate in HIV women. India is arguably home to the largest
to women [38]. Besides, in many cultures, obstetric number of orphans of the HIV epidemic. These children
emergencies are not recognized, but even when they face an impenetrable barrier in many Indian societies and
are, cultural beliefs about their causes, treatment and endure stigmatization. This situation encourages concealment
implications often preclude women from seeking life of the disease and discourages children and their guardians
saving help [39]. Women also intentionally avoid formal from accessing available essential services [45]. The use
health care because they fear appearing weak, being of condom has been suggested as the only prospective
subjected to a caesarean section, or experiencing what method against STD. Nevertheless, some social factors
is perceived as dangerous, corrupt, insensitive, poorly were associated with non-use of a condom during sexual
organized, unclean, and untrustworthy care offered by intercourse: moral values, ethnic and religious factors,
formal health care [40]. More than that, culture affected the gender inequality, lack of a dialogue among partners with
formation of social systems and the establishment of social regard to condom use, and the stigma attached to the
status. A woman may marry at a very young age, have a condom [46]. Another systematic review, focus on the
lack of contraceptive choices, and face societal pressures utilization of health care services for sexually transmitted
for male children, all of which may result in a high number infections, highlighted that stigma, embarrassment,
of births accompanied by increased risks for morbidity illiteracy, lack of privacy, cost of care was found to limit
and mortality, a paper explained how social status make an the use of services [47].
impact to women’s reproductive health [41].
Service coverage indicator
Sexually transmitted disease (STD)
Contraceptive rates and unmet need for family
Globally, the prevalence of STD among women in
planning
developing countries is higher than in developed countries.
The prevalence of STD in developing countries is Contraceptive rates and unmet need for family planning
relatively serious, especially in Africa, which is estimated are key indicators of progress in reproductive health. It
to be about 10 times that of developed countries, followed refers to the proportion of women of reproductive age
by Asia and Latin America [42]. According to the Report (15–49 years) who are married or in union and who have
on Global Sexually Transmitted Infection Surveillance an unmet need for family planning, i.e. who do not want
in 2015 from WHO, the reported cases of genital ulcer any more children or want to wait at least two years
diseases rates in females (per 100,000 adults) in SEA before having a baby, and yet are not using contraception.
countries were: Bhutan 73.0 (2012), Indonesia 9.8 (2014), Unmet need is a rights-based measure that helps
Maldives 35.2 (2014), Myanmar 1.8 (2014), Timor-Leste determine how well a country’s health system and social
104.5 (2014). The female syphilis rates are: Indonesia 4.2 conditions support the ability of women to realize their
(2014), Myanmar 5.7 (2014), Sri Lanka 6.2 (2014) [43]. stated preference to delay or limit births [48]. In all SEA

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countries, more than 50% of women of reproductive age this purpose. The computing method of this predictor are
(15–49 years) in all countries have family planning needs the number of births attended by skilled health personnel
[49]. In 2011/2012, 61% of women in Bangladesh were (doctors, nurses or midwives) trained in providing
able to use contraception methods, while 12% of women lifesaving obstetric care, including giving the necessary
had unmet needs for family planning (11.7% in 2012, supervision, care and advice to women during pregnancy,
13.5% in 2011, respectively) [16]. In 2011, Nepalese childbirth and the post-partum period divide by the total
women’s unmet need reached 27% [15]. In Timor-Leste, number of live births in the same period [52].
only 22% women used contraception in 2009/2010, while Rural region in Bangladesh were estimated 35.6%
the rate of unmet need for contraception reached 32% [19]. (UI 32.3%‒39.1%) and urban region were 60.5% (UI
56.1%‒64.8%) in 2014. In Bhutan in 2010, rural and
Antenatal and postnatal care coverage
urban region were estimated 54.2% (UI 50.9%‒57.4%)
Antenatal care (ANC) coverage is an indicator of access and 89.4% (UI 85.0%‒92.6%), respectively. In rural
and utilization of care during pregnancy. We use the region of Myanmar was 57.5% (UI 52.8%‒62.1%)
proportion of women who were attended at least four in 2015, which was in urban region 88.5% (UI
times during pregnancy by trained health personnel for 82.0%‒92.9%). In Nepal, the proportion were 50.5% (UI
reasons related to their pregnancy for measuring. This is 46.4%‒54.5%) in rural and 90.3% (UI 86.0%‒93.5%) in
also one of the process indicators for tracking progress in urban region in 2014 respectively [53].
reducing maternal mortality [50]. In the South-East Asia Also, the factors influencing reproductive health
region in 2012, only three countries have already reached service coverage can be classified into several part. The
or surpassed the 90% coverage of pregnant women with first part is due to women themselves. Many studies
at least four visits: Sri Lanka, Indonesia, and Democratic have highlighted the importance of women’s education
People’s Republic of Korea. Bangladesh had the lowest in seeking health service. Lack of reproductive health
coverage with four visits of less than 30%.the pre-natal knowledge and communication ability with husbands and
care rate in Bangladesh was less than 30% [16], followed family members, which were impacted potentially by low
by Timor-Leste and Nepal [15, 19]. education, resulted high early childbearing rate among
In 2013, the average postnatal maternal and newborn married adolescent girls in Bangladesh [54]. A review,
care rate was 49%, which refers to be visited by trained summarizing the factors relating to utilization of facility
health personnel within two days of birth. Maldives, Sri delivery in rural South Asia, found that socioeconomic
Lanka, and Indonesia were above average and Nepal and and educational status was one of the main factors [55],
India were close to average. However, the postnatal care as well as women’s occupation. A cross-sectional study
rates for Timor-Leste and Bangladesh were 25% and 27% carried out in rural Nepal found that the woman’s own
respectively, less than 30% [49]. Compared with the data occupation and ethnicity, were significantly associated
of China, the rate of antenatal care reached 96.2% and with the utilization of postnatal care [56]. Besides, the
postpartum visit rate 93.9% in 2014, we can know the attitude and awareness are vital for adequate use of health
level of reproductive health clearly [51]. service. The women with a positive attitude toward family
planning practiced family planning 3.7 times more than
Births attended by skilled health personnel
women who had a negative attitude, founded in Hlaing
The proportion of births attended by skilled health Township, Myanmar [57].
personnel is a sub-indicator to monitor progress in Family influence factors were followed. The
reducing maternal mortality. As it is difficult to accurately husbands’ education level and occupation played also
measure maternal mortality, and model-based estimates of an important role like women’s [56, 58]. A study aiming
the maternal mortality ratio cannot be used for monitoring to evaluate the effect of the woman’s perception of her
short-term trends, the proportion of births attended by husband’s approval of family planning, considered
skilled health personnel is used as a proxy indicator for that husband’s approval does appear to be a major

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determinant of contraceptive uptake in Bangladesh and have overarching influence on maternal death. We also
similar developing countries [59]. Several literatures also found there are some same influencing factors affect all
supported that wealth or household income determining indicators, for example, the education level of women
the choices for contraceptive and antenatal cares [58, 60]. plays a vital and key role. Educated women are more
As for the community-level, we must draw attention likely to realize the benefits of using maternal healthcare
to distance and the accessibility that comes from it. services. Education increases female autonomy, decision-
Distance to a health facility also affected the behaviors making power within the household and builds greater
women giving birth with a health professional, thus confidence and capability to make decisions regarding
affecting maternal mortality, analyzed in Bangladesh their own health [57]. Therefore, improving the rate
and Indonesia. Women who lived further from health of literacy must be the priority and efficient way for
centers in both countries were less likely to have their government to improve female reproductive health,
births attended by health professionals than those who especially in resource-restricted Southeast Asian
lived closer and may only seek professional care in countries. Utilization of maternal health care services, the
an emergency and may be unable to reach timely care most direct method to reduce MMR and achieve SDG
when living far away from a health center [61]. 24-hour goals, has received extensive attention from society. It
availability of family planning services will contribute to is worth noting that the accessibility and availability
family planning practice [57]. Whilst exposure to mass of health service alongside the quality both are the
media (especially television and radio) significantly imperative as the reproductive strategies.
predicted utilization of antenatal care [58] and exposure There is a huge difference in women’s reproductive
to family planning messages through radio had a positive health status in the world, especially in developing
effect on modern and traditional method choices [60]. countries because of the backward economy and lack
Socioeconomic and cultural factors had overarching of health services. Southeast Asian countries have their
influence on the coverage of reproductive health service. special geographical, socioeconomical environment
Cultural beliefs and ideas about pregnancy also had and cultural background, and their findings also have
an influence on antenatal care use. Lack of privacy regional differences. The reproductive health situation
and exposure of legs and arms are difficult to accept of SEA countries was less optimistic overall. Even
for Muslim women, which is a barrier for them to use in the same country, the RH status was uneven in
reproductive and sexual health services [62]. Besides, different areas. Limited by short health resources in
Women in some cultures do not use ANC because of these developing countries, precise risk area location
the perception that the modern healthcare sector is and efficient intervention are essential to explore. So,
intended for curative services only [63]. In some places, estimating the level of reproductive health in all regions
an adversarial relationship exists between professional of a country is very worthwhile in order to optimize
health-care providers and the more traditional birth health resources and target interventions in horizontally
attendants, creating a cultural milieu where distrust, backward regions. And studies in these developing
criticism, and self-interest characterize the maternity care countries will contribute to achieve the equity of global
offered to women [37], that was how culture affect. health and may inspire researchers and policy-makers in
other countries.
Conclusion
Reproductive health is particularly important for people’s Additional files
quality of life. It is affected by many factors including
behaviors, social environment, utilization of health Funding
services. Different indicators of reproductive health This manuscript was supported by CMB (Grant Number
have potential links and interactions among each other, 13‒133), Institutional Development of the Department of
for example, antenatal and postnatal care coverage Global Health at Sun Yat-sen University.

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13.　World Health Organization. Maternal mortality ratio (per

Competing interests 100 000 live births). [cited 2018-03-28]. http://apps.who.
int/gho/data/node.wrapper.imr?x-id=26.
The authors claim that there is no competing interests for
14.　World Health Organization, United Nations Children’s
this article. Fund, United Nations Fund for Population Activities, World
Bank Group, United Nations Population Division. Trends
Consent for publication in maternal mortality: 1990 to 2015: estimates by WHO,
All authors approved the final version of this manuscript. UNICEF, UNFRA, World Bank Group and the United
Nations Population Division. Geneva: World Health Orga-
nization, 2015.
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