Abstract
A large international conference was held in London in October 2007 to celebrate 20 years of the Safe Motherhood Initiative. Launched in Nairobi, in 1987 by the WHO, the United Nations Population Fund and the World Bank, and joined by the United Nations Development Programme, the United Nations Children’s Fund, the International Planned Parenthood Federation and the Population Council shortly thereafter, the initiative aimed at addressing the then neglected high maternal death rates in poor countries. Now, 20 years later, we can see that, while some progress has been made, the regions with the poorest maternal health have made the least progress: sub-Saharan Africa and South Asia. The objectives of the London conference were to take stock of the situation, to highlight the global consensus on effective strategies to reduce maternal mortality and, above all, to galvanize political will and commitment to address this scandalous situation. Although technical issues were discussed in a large number of small sessions, in panel after panel participants hammered on the need to create a global movement around maternal and newborn survival. Whether that objective was achieved will be the focus of this paper.
Dying in childbirth is a thing of the past in most developed countries, where only 1% of the total global maternal deaths occur. Pregnancy is perceived as a happy, safe and largely wanted event. A woman’s risk of death in Sierra Leone is one in six, while, by contrast, in Sweden only one woman in 29,800 dies in childbirth. Shattered health systems and high fertility in the former, as opposed to good-quality health and family planning services in the latter, explain the huge difference in the risk incurred, beyond the large gap between these countries in terms of economic and social development.
In the world today, a woman dies every minute of every day from complications of pregnancy and childbirth – almost 540,000 per year. Another 10–20 million women suffer serious or long-term illness or disability each year. The lifetime risk – or the chance that a woman will die in pregnancy or childbirth – has decreased globally from one in 60 in 1990 to one in 74 in 2000. However, in 2005 maternal mortality was still very high in developing regions – at 450 maternal deaths per 100,000 live births – in stark contrast with one in nine in developed regions. Worldwide, only 63% of births are attended by skilled health personnel. So, although the use of antenatal care has increased in the last 20 years in most regions, the use of intrapartum and postpartum care – where most maternal deaths occur – has not increased at the same pace. Furthermore, large inequalities persist in maternal health services: among the wealthiest women over 80% of births were attended by a skilled caregiver, but only 31% among the poorest. There is also considerable regional variation between and within countries.
Despite the lack of overall progress, evidence from several countries’ including, Sri Lanka, Honduras, Vietnam and Bangladesh indicates that lower maternal mortality can be achieved rapidly in poor countries within 10–20 years. The strategies include providing access to comprehensive reproductive health services, ensuring skilled care is provided by midwives, nurses or doctors, as well as providing access to emergency maternal and neonatal care when needed.
The conditions that kill mothers also cause stillbirths and newborn deaths. Each year, approximately 4 million babies die in their first 4 weeks of life and a similar number are stillborn. Along with the main direct causes of maternal death, such as hemorrhage, infection and pregnancy-related hypertension, HIV increases the risk the most by increasing the susceptibility to opportunistic interventions such as pneumonia, tuberculosis and malaria, and is now a major cause of maternal death in sub-Saharan Africa.
Panelists included Asha-Rose Migiro, Deputy Secretary General of the UN; Thoraya Obaid, Executive Director of UNFPA; Margaret Chang, Director General of the WHO; Peter Piot, Executive Director of the Joint UN Programme on HIV/AIDS; and Julio Frenk, former Health Minister of Mexico, under the passionate and informed chairwomanship of Mary Robinson, Director of Realizing Rights. They all deplored the absence of a popular movement for maternal and newborn survival, similar to the vibrant ardent advocacy initiatives that stimulated action on the environment, human rights, child survival and the HIV epidemic. Also lacking are strong coordination and mutual support between the safe motherhood activists and the women’s movement, which was always reluctant to focus on women as mothers.
A total of 70 high-ranking civil servants, mainly health ministers, attended the Ministers Forum and issued a call for establishing a Fund for Women’s Health.
The many breakout sessions addressed issues such as control of postpartum hemorrhage through using misoprostol, the role of mid-level providers in delivering quality care including life-saving obstetric surgery, and the use of maternal death inquiries. The need to strengthen research institutions in developing countries, in addition to the crucial role of private providers as partners for development, were also discussed.
Maternal morbidity was addressed with a special attention to obstetric fistulas, due to the impressive participation of ‘fistula survivors’ – women affected and successfully cured who now work as advocates in their countries and communities. There is now a large global campaign coordinated by UNFPA, active in more than 40 countries, that aims not only to treat patients but also to strengthen national maternal health programs. Other sessions addressed issues as diverse as child marriage, gender-based violence and the role of faith-based associations in healthcare. One major challenge is the acute dearth of qualified health providers, especially female, in poor areas such as rural settings and urban slums.
The key role of global-to-local advocacy was mentioned in sessions organized by the White Ribbon Alliance for Safe Motherhood, who also led an important group of delegates to meet at 10 Downing Street with Sarah Brown, the wife of the British Prime Minister and an emerging champion for safe motherhood. The White Ribbon Alliance for Safe Motherhood is a member of the global Partnership for Maternal, Newborn and Child Health, a broad constituency of more than 80 members representing recipient and donor countries, UN and multilateral organizations, nongovernmental organizations, professional associations, academic institutions and foundations.
Studies find a significant positive relationship between education and the use of contraception as well as the use of maternal care. Women who are employed or have other economic opportunities, such as access to microcredit, also use maternal health services more often. By preventing unwanted or unintended pregnancies, family planning alone could eliminate between 20 and 25% of maternal deaths. However, an estimated 137 million women globally who would like to delay or stop childbearing are unable to do so.
Where women lack education, economic opportunities and power over the decisions that govern their lives, poor maternal health is very prevalent and undermines economic productivity. The world leaders gave a central place to both maternal health and gender equality in the Millennium Development Goals, a set of internationally agreed goals and targets to be achieved by the year 2015. Whether the situation will significantly improve in the most affected countries of Africa and South Asia very much depends on the political leadership in these countries, and the commitment to implement integrated action plans, as well as infrastructure and telecommunications, in a sustained manner over at least 10–20 years. Accelerated access to affordable services for maternal and neonatal health is the cornerstone of the national programs.
For this to happen, as demonstrated by successful social movements, demand from the communities and the public at large is needed. Since poor women and children are largely absent from the public sphere, the message about the problem and how to solve it will have to be conveyed by frontline health personnel or else dedicated advocates. Professional associations with a global reach have a major role to play. They must convince decision makers to create the political and financial space for the basic interventions that will save lives: family planning and spacing, professional, empathic assistance in childbirth for all women, and emergency obstetrical and neonatal care when complications develop. Involving women and young people in policy and program development and evaluation is very important even if they lack the capacity to drive the movement. Increased funding, better information system, and a stronger health force are essential elements of successful programs.
A woman’s health is critical to the wellbeing of her family, not only because she is the main caregiver for children and older family members but also because most of her income is invested in education and the overall welfare of her family. Improving safety in pregnancy and childbirth is also a way to ensure that all women are able to realize their full potential, as mothers, caregivers, workers and citizens, and to deliver for their societies.
Financial & competing interests disclosure
The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.