Despite various attempts by local and international organizations to reduce the number of pregnancy and childbirth related deaths, Maternal Mortality continues to be one of the leading causes of death for many of the member countries in the Asia-Pacific region. In fact, most of these deaths are preventable and solutions for the complications that arise during pregnancy and childbirth are well-established.1, ² In the last two decades, Southeast Asia has seen a healthy decline in the maternal mortality ratio.³ However, as of 2010, the burden of maternal mortality is still high in this region. Every 2 out of 1,000 pregnant women are at risk for death due to prenatal and perinatal complications.⁴ The risk of maternal mortality in the Western Pacific region, as defined by the WHO, is much less, averaging to about 50 deaths per 100,000 live births.⁵ Although the main causes of maternal mortality include excessive haemorrhaging, hypertension, and abortion-related injuries⁶, the underlying factors that predispose women to these circumstances should be viewed as causative agents to maternal mortality. These include inadequate access to health information and services, unaffordable medical costs, poor nutrition, and violence during pregnancy. Therefore, ensuring provision of adequate and affordable access to the healthcare system, especially to vulnerable populations, remains one of the main initiatives in the goal to reducing maternal morbidity and mortality. Maternal mortality rate is highly correlated with the availability of and access to skilled attendants and antenatal care coverage. Overall, as the percentage of births handled by skilled personnel increases, maternal mortality rate decreases. However, an increase in health labour force such as this requires sufficient funding to the health sector, which is not always possible in resource poor countries. Antenatal care typically includes medical care such as the treatment of pre-eclampsia, tetanus immunization, and nutritional support. In Southeast Asia, the average percentage of antenatal care, (which is defined as at least 4 visits), was 80% in 2009.⁷ This figure is much higher in the Western Pacific region; approximately 92% of women aged 15–49 years with a live birth pregnancy during a specified period of time reported that they had at least four antenatal visits.⁸ Afghanistan, Bangladesh, and Lao PDR however, have the lowest rates of antenatal coverage, ranging between 15% and 26%.⁹ Antenatal care alone is not sufficient in preserving the health of mother and child; other services such as post-partum care and the provision of an emergency obstetrics system is also important in reducing the extent of maternal and neonatal mortality.

Access to Safe Abortion Services

One of the major factors contributing maternal mortality and morbidity is unsafe abortion. The incidence of unsafe abortion continues to be high in the Asia Pacific region. Safe abortion services are an essential component of maternal health services. Laws related to abortion are restrictive in several countries making access to safe abortion services for women and girls difficult. Only a few countries in the Asia Pacific region allow for abortion more liberally than others: China, Nepal, Vietnam, Cambodia and India.¹⁰ When laws are restrictive, women often have to access services in unsafe settings as what happens in countries such as Lao PDR, the Philippines, Indonesia, Bangladesh and Pakistan.¹¹ Young women and adolescent girls often have to face additional challenges when accessing safe abortion due to age. It is necessary to have laws and policies which enable women to access safe abortion services, and to ensure that laws and policies are backed by provision of safe services.

Information on and access to safe and modern methods of contraception is also an important factor which helps women exercise control over their fertility, which in turn ensures women can delay childbearing, space their children and prevent unwanted pregnancies and reduce maternal mortality. In the Asia-Pacific region, data on contraceptive prevalence is underestimated as in most countries only married women are surveyed. Lack of data on contraceptive use among young unmarried women is alarming, as this group, in particular, may face additional barriers in gaining access to information about contraception use and choice. Furthermore, a national study conducted in Pakistan in 2005 showed that the decision to use contraception was significantly associated with autonomy and education levels of women.12

Sexually Transmitted Infections, including HIV and AIDS

Apart from factors such as maternal mortality and morbidity and inadequate information and access to contraceptive services, there has also been an increase, both globally and in the Asia-Pacific region, of the incidence of sexually transmitted infections (STIs) including HIV. In Southeast Asia, the total number of new cases of STIs, encompassing the four main curable infections (chlamydia, gonorrhoea, trichomoniasis, and syphilis), was estimated to be 78.5 million.¹³ In 2011, it was estimated that the Asia-Pacific region was home to almost 5 million people living with HIV.¹⁴ Timely treatment and management is important in reducing the risk of HIV and AIDS. It is estimated that 2.4 million people living in Asia and the Pacific were in need of Anti-Retroviral Therapy (ARTs) in 2009; however, the mean coverage in the region is approximately 31%.¹⁵ There are also gender disparities in access to treatment; in Mongolia and Sri Lanka, women are more likely to get treated equally as men, and the situation is reversed in countries such as Pakistan and Papua New Guinea.¹⁶ Women make up 35% of the people living with HIV in Asia, and this figure has remained somewhat constant over the past decade.¹⁷ Furthermore, it was estimated that the majority, over 90%, of women with HIV had contracted it from their husband or long-term partners.¹⁸The combination of lack of access to relevant information surrounding safe sex and protection against STIs, gender inequity, poverty, and rigid social norms surrounding sexual relationships prevent many of these women from getting the help they need to prevent or treat this infection acutely. It is important to have a paradigm shift from disease prevention to safe sex interventions to address STIs and HIV/AIDS in the region.

Young People and Comprehensive Sexuality Education

Globally, about 16 million girls aged 15–19 years give birth each year and these births happen predominantly in developing nations.¹⁹ According to statistics, in developing nations (excluding China) 35% of young women aged 20–24 years marry below the age of 18 years and 12% below the age of 15; in South Asia, early marriage is predominant with almost half of all young women marrying below age 18 and almost one-fifth below age 15.²⁰ Additionally, 20% of young people aged 20–24 years in developing countries (excluding China) had begun child-bearing before they attained the age of 18.²¹ While this data accounts for married young people alone, there would be many other undocumented cases of unmarried young people who may have begun child-bearing before the age of 18 as well. Early marriages often resulting in early child-bearing and unwanted and frequent pregnancies have a long-term and adverse impact on the health of women especially when they are young. Studies report inconsistent use of condoms or other contraceptives; only 15% of young men and women reported the use of a condom in their last sexual encounter in South Asia.22 Despite these statistics, knowledge of and accessibility to reproductive health services are limited especially for young people. In the Asia-Pacific region where sexuality is still taboo, patriarchal norms are still strong, and religious fundamentalisms are on the rise, comprehensive sexuality education which includes not only information on abstinence but also information on universal access to sexual and reproductive health and rights services including the right to access contraception is severely lacking.

Sexual Rights

Sexual rights include among other things, the right of all people to choose whether to be sexually active or not, right to choose one's partner(s), the right to adult consensual sexual relationships, and the right to decide whether and when to have children (or not). Early and forced marriages still remain the norm for many people in the Asia-Pacific region. Early marriages are detrimental to the rights of a child to bodily integrity and the right to decide if, when and who to marry. They hamper the healthy growth of children especially girls who are denied their right to education and the right to employment (should they desire to work) and often lead to early and unwanted pregnancies. Young women in early marriages have less access to reproductive health services as they will invariably be married to older partners, and have limited capacity to make healthy reproductive choices due to gender power imbalances. Interlinked with early and forced marriages; women and girls also have inadequate power to decide if, when and how many children they would like to have thus making them more vulnerable. In the Asia-Pacific region where a number of countries have inherited laws on sodomy from the colonial period, the rights of people with diverse sexual orientation and gender identities are often thwarted. With threats of criminalization from the state as well as unwarranted torture and assaults including sexual assaults by the police as well as members of the community, people with diverse sexual orientation and gender identities often lead lives full of fear and shame. People with diverse genders and sexualities are thus pushed underground and are unable to access SRHR health and other services thus making them more vulnerable to STIs including HIV. Sexual rights also include the rights to bodily integrity, and the right to be safe against sexual violence. Sexual violence may take different forms including sexual assaults and rape, sexual harassment and newer and emerging forms such as harassment over cyberspace. It is important therefore that efforts are made to have good laws and policies in place to mitigate and prevent sexual violence among women.