Maternal Mortality and Morbidity: Is Pregnancy Getting Safer for Women?

This year is the 20th anniversary of the WHO Safe Motherhood Initiative, which was launched in Nairobi in 1987. As RHM’s contribution to the knowledge base to inform safe motherhood programmes in future, we asked whether pregnancy is getting safer for women. The answer in the papers published here is: yes – and no.

“…maternal mortality remains the indicator of population health that reveals most starkly the profound inequities of our time…” (Lynn Freedman)

What are the actual data? Maternal mortality ratios around the year 1990 for the major world regions have been re-estimated using the same method that has just been applied to estimate maternal mortality in 2005, so that the figures are comparable. Iqbal Shah and Lale Say^* summarise these data in a paper in this journal issue, which shows that:

•	In 2005, an estimated 536,000 women died of complications of pregnancy, childbearing or unsafe abortion, which represents a 7% decrease since 1990 in the estimated number of maternal deaths globally.
•	There was a 5.4% decline in the global maternal mortality ratio from 430 to 400 per 100,000 live births in the 15 years from 1990 to 2005.
•	The declines in the number of deaths exceeded 20% in North Africa, Latin America and the Caribbean, Oceania and the more developed regions.
•	Sub-Saharan Africa was the only region in which the number of maternal deaths increased between 1990 and 2005, driven by increasing numbers of births and a negligible decline in the maternal mortality ratio.†

Studies show that some developing countries have dramatically reduced maternal mortality since 1987, including Egypt, Honduras, Malaysia, Sri Lanka and Thailand (Wendy J Graham et al). There is no longer any disagreement that good nutrition and effective treatment during pregnancy for chronic conditions such as anaemia, diabetes, HIV, TB and malaria; delivery with a skilled attendant; and access to timely emergency obstetric care, when required, are the best way to avoid unnecessary deaths and morbidity in women and newborns.

The question then arises: why is change for the better happening so slowly, and what is going wrong in the countries where there has been little or no improvement or where the situation is worsening? This issue of RHM contains a powerful mixture of qualitative, quantitative and programme-related data, based on a rich variety of experience on the ground, to show what is going right and wrong, and why. They illustrate that:

•	changing what happens in health systems is a social intervention, not just a technical one;
•	context is crucial;
•	implementation of changes must be managed; and methods of monitoring and evaluation must allow for learning on the part of those being evaluated in order for change to take place.

Countries seeking to make pregnancy safer will find their problems reflected in some form in these pages, alongside a wealth of practical information about how others have been trying to understand and take action to resolve problems.

Reason to celebrate?

There are many reasons to celebrate. They include the high quality of research that discovered the efficacy of magnesium sulphate for treating eclampsia and severe pre-eclampsia; the ability to control post-partum haemorrhage through active management of the third stage of labour, including with prophylactic misoprostol; safe abortion care using manual vacuum aspiration and mifepristone–misoprostol; and a high quality of evidence on a number of other effective, ineffective and harmful obstetric interventions (Julia Hussein).

At the same time, there are reasons to wring our hands in despair. For example, a recent study in Uganda found that most of the health facilities that were expected to have essential obstetric services lacked basic equipment, infrastructure, running water, electricity and functional operating theatres. Indeed, 97.2% of the health facilities examined were deficient in these respects.¹

Similarly, a study in rural Karnataka, India (Asha George), found that although women with obstetric complications accessed many health providers, they still died, and high levels of maternal mortality persist. Why? Weak information systems, discontinuity in care, unsupported health workers, haphazard referral systems and distorted accountability mechanisms – for a start. Maternal deaths were not being reviewed, antenatal care and institutional delivery were not linked to post-partum or emergency obstetric care, and health workers were using inappropriate injections but did not treat anaemia or sepsis. Lower-level health workers were often blamed, or women themselves, while the role of informal providers was not being addressed. Nor were systemic service delivery constraints and managerial problems being resolved.

The will to act – or handwringing?

The list of direct and indirect causes of maternal deaths is universal and well-known, though the proportions differ in different populations. The recommendations on prevention and treatment and the type of care required are also the same. But the papers in this issue show that the configuration of problems is multi-layered and not the same in any two countries. In addition, the solutions are highly context-specific because they involve the interaction of people with each other as well as in reaction to official policy and programme goals (Loveday Penn-Kekana et al).

What are these problems? First and foremost is the failure to act.

“While socio-economic inequity largely determines which groups of women run the greatest risk when they become pregnant, gender inequity helps make it acceptable to dismiss maternal mortality and morbidity as too rare, too complicated, too stubbornly unchanging and hard to measure for serious attention and investment. The inclusion of maternal mortality ratio as the target for Millennium Development Goal 5 encourages rhetorical handwringing about persistent maternal mortality and ensures that it gets into Road Maps and national plans. But implementation on the ground requires a level of focus, commitment to systemic change, capacity-building, long-term investment and patience that is rarely rewarded in practice.” (Lynn Freedman)

Handwringing indeed, and suddenly there seems to be a great deal of it about at the moment. But now, the money needs to be put on the table and the work put into the hands of the people who can and will make safe pregnancy and delivery, and safe abortion, happen, with urgent attention to the African countries where the situation is getting worse.

Perennial lack of finance

Which raises the second problem – the perennial lack of sufficient finance to do the job right. Long gone are the days when limited training of traditional birth attendants without any other intervention was believed to be the answer. Yet throughout the last 20 years, maternity services in developing countries have probably been the most grossly underfunded global priority the world has ever known.

In Myanmar, one of the world’s poorest countries, a pilot study of prophylactic misoprostol to prevent post-partum haemorrhage, given by midwives during the third stage of labour, found no cases of haemorrhage among either high risk or randomly chosen post-partum women (Thein Thein Htay). The operational feasibility of this simple intervention was shown to be very high. Now, the government needs to find US$1.5 million annually to provide the misoprostol tablets to cover every delivery. If they succeed, it would represent major progress in safety for birthing women. But where should they turn for the funds?

The World Health Report 2005 estimates that scaling up of skilled care at delivery to halve the number of maternal deaths by 2015 in the poorest countries would incur an extra cost to their health budgets of US$0.22–$1.18 per capita. But skilled care at delivery is only one part of the picture. Still, it sounds cheap enough to do, doesn’t it, a few dollars a head to secure the future of the world’s mothers and babies? But multiply that by the tens of millions of heads every year, and all the other aspects that go into making pregnancy safe, and where will it come from?

In fact, the trend in donor financing for maternal health services is falling, according to a recent analysis, and that must be reversed in a major way. In 2004, an estimated US$ 1,990 million was spent on maternal, newborn and child health. This represented only 2% of gross aid disbursements to developing countries, a large proportion of which would have gone on child health rather than mothers.² This is grossly inadequate and puts paid to any thought of achieving Millennium Development Goal 5 on maternal health. Without major injections of funding, perhaps countries would do better to get on with it themselves. Could some of them, at least, manage on their own from their own health budgets, as Brazil and Thailand have done with other public health problems? It would certainly give countries far more control and perhaps greater sustainability in the long run. However, this too is no easy solution. Most resource-poor countries devote far less than 10% of their national budgets to health and may or may not have the will to act.

Health system financing today is a vexed issue, and health systems in resource-starved countries have been grossly abused by so-called global experts forcing them to do it “their way”. User fees, which fund up to 20% of health care in some resource-poor countries, are an important example of this. It is by now a truism that the economic cost to poor families of paying out of pocket for treatment of serious obstetric complications can be catastrophic. Yet many developing country health services now depend on user fees in order to function, not to mention informal payments to providers, whose salaries at least in the public sector are execrably low. Antenatal and delivery care are a good example, e.g. in China, where government funding for services has plummeted (Amanda Harris et al). It is obviously impossible to replace such fees overnight, so maternity care has been made a special case in some countries, in an effort to get more women to deliver with a skilled attendant and come for emergency care before it’s too late. For pregnant and/or delivering women, schemes that have been tried range from vouchers or individual or district-wide exemptions, to community-based insurance and emergency loan funds. For health workers and facilities, various incentives have also been instituted to encourage them to provide good care so that women will want to attend.

A scheme was introduced in Ghana in 2003, for example, to exempt all pregnant women from payments for delivery, in which providers could claim back lost user-fee revenues, according to an agreed tariff (Sophie Witter et al). The exemption mechanism was well accepted, but there were important problems with disbursing and sustaining the funding, and with budgeting and management. Staff workloads increased as more women attended, and compensation for facilities and staff became crucial. Two years later, when the scheme had barely got on its feet, a national health insurance scheme, intended eventually to include full maternal health care cover, was starting up. It was not yet clear how the exemptions scheme would fit in or if it would be abolished. Although such a shift in policy will probably have long-term benefits, it must surely be destabilising for the health system itself to suffer such changes in such a short space of time.

Moreover, it is a matter of some irony that the one health system financing modality that has been shown to be the least expensive and the most equitable – that is, a tax-based, public health system with universal access, free at the point of care – has rarely been attempted by developing countries. Thanks to the dominance of neoliberal economics over public health exigencies, health systems and health financing in both developed and developing countries alike are well on the road to increasing privatisation, an unregulated private sector, commercialisation, failure to sustain and strengthen the public sector and continuing, often huge, inequities in access to health care and in health status.

A reconsideration of funding modalities for health systems is overdue, and priority of place for antenatal, delivery, post-partum and emergency obstetric care within health system strengthening needs to be assured. A move towards results-based donor financing for health system strengthening was suggested earlier this year by Norway. Certainly, based on the experience of the GAVI Alliance and the Global Fund to Fight AIDS, TB and Malaria, targeted funding for detailed programme plans, with funding renewal conditional on results, does mostly get results. This must surely be better than handing over huge amounts of money for general “budgetary support” with no conditions and regardless of evidence of improvement, as Uganda’s still high maternal mortality unhappily illustrates.

With this in mind, and because the WHO-based Partnership for Maternal, Newborn and Child Health does not wish to be a funding body but only to do advocacy, it seemed to me that a Global Fund for Maternal Health might be the way forward. Indeed, I am willing to set it up myself. However, almost everyone I’ve suggested it to has said oh, no, no, no, no, no, not another Global Fund. But what is the alternative if the aim is to get results? This is a discussion that has been begging to take place at national and international levels for a very long time and has become all the more urgent because real funding has suddenly appeared over the horizon.

On 5 September 2007, an International Health Partnership for Achieving the Health Millennium Development Goals was announced.^* As part of this, on 26 September, Norway pledged US$ 1 billion for reducing maternal and child deaths. While child health has always garnered large amounts of money, this is the most important news for maternal health in decades. How this funding (and any that may follow it) will be disbursed and by whom, and what proportion will be for maternal health, remains to be seen as we go to press. Hopefully, unlike the funding that has gone to the MNCH Partnership to date, it will not be more for babies than for the women who give birth to them.

Nevertheless, it is at national level where change will succeed or fail, and where all the other problems that are keeping maternal mortality and morbidity high, and their solution, lie.

Education and training for skilled attendance

National policy often fails to include comprehensive education and clinical training for health professionals who will work in maternity care, my third problem, including for so-called skilled attendants and other cadres who provide maternity services. In Mexico, for example, a research group reviewed the curricula of three representative schools for the education and clinical preparation of obstetric nurses, professional midwives and general physicians (Leslie Cragin et al). They measured curricular materials against the 214 indicators of knowledge and ability included in the International Confederation of Midwives training guidelines for skilled attendance. They found that the midwifery curriculum covered only 83% of the competencies, 93% of basic knowledge and 86% of basic abilities, compared with only 54%, 59% and 64% covered by the obstetric nursing school and 43%, 60% and 36% by the school of medicine, respectively. The curriculum for general physicians covered the fewest skills and least knowledge of the three schools. Yet, general physicians attend most births in Mexico. In contrast, there are only a handful of professional midwives trained each year, and obstetric nurses were not even formally integrated in the public health system to attend deliveries at all until very recently. These findings suggest the need for reviews of education and clinical training for maternity care providers in many more (if not all) countries.

This evidence is just one example of the limited support that exists for the training of skilled midwives and obstetric nurses. Comprehensive training finally needs to be made a reality through better quality training and more training institutions. Furthermore, evaluations of training schemes that have been initiated in recent years need to be carried out and published.

Delivering evidence-based maternity care

Which services are available and accessible, and the quality of care in those services, remains a major area of difficulty, and is the fourth problem on my list. After decades of research, a whole range of evidence-based practices in maternity care have been developed. Yet the failure to implement them and the persistence of practices that are not evidence-based and may even be harmful is still widespread. One example is found in Uttar Pradesh, India, (Patricia Jeffery et al) where unmonitored, intramuscular oxytocin injections were commonly being given to augment and speed up labour during home deliveries, mainly by unregistered local male practitioners and auxiliary nurse-midwives. Sahar Hassan-Bitar and Laura Wick also mention this practice during labour in a large, public referral hospital in the Occupied West Bank, as does Asha George, who found the use of several unspecified injections in rural Karnataka, India.

Some of the other inappropriate maternity care practices during labour that were identified by Hassan-Bitar and Wick were: forbidding women to have female companions, restriction of mobility and frequent vaginal examinations. Magnesium sulphate was not being used for pre-eclampsia or eclampsia, and post-partum haemorrhage was a frequent occurrence. There was severe understaffing of midwives, who had insufficient supervision and a lack of skills, leading to inadequate care. The authors rightly point out that the use of evidence-based practices which promote normal labour is particularly critical in settings where women have large families and where resources are scarce.

Health system strengthening for emergency obstetric care

The fifth problem is weaknesses in the functioning of health systems as a whole, which undermine even sustained efforts to improve maternal health and health care. From all corners, the need for health system strengthening is now being recognised and proposed, though there are few blueprints for how to do this. This journal issue includes two papers from Nepal that describe just such blueprints for emergency obstetric care. Maternity services are what is being strengthened in Nepal, but will they get such a high profile in other countries if and when “big money” is thrown at health system strengthening? Or will maternity care (again) be sidelined, accompanied by the usual handwringing?

Since 1997, Nepal has received evidence-based technical support to strengthen its district health system to increase emergency obstetric care. A five-year project covering 15% of the country succeeded in achieving an average annual increase of 1.3% per year in met need for emergency obstetric care, reaching 14% in public sector facilities in project districts in 2004 (Alison Dembo Rath et al). Infrastructure and equipment were improved, but sustained functioning, availability of a skilled doctor, blood and anaesthesia were greater challenges. In three districts, 70% of emergency procedures were managed by nurses who had been given additional training for this. This is an impressive achievement for these mid-level providers. Several papers summarised in the Round Up in this issue describe similar programmes that are successfully training non-physician clinicians and midwives in Mozambique, Malawi and Tanzania to provide emergency obstetric surgical procedures safely and at a far lower cost, in rural areas where there are no doctors available (Round Up).

In Nepal, resource and staff shortages remain a major constraint, especially in rural areas. Technical support (Carol E Barker et al) aims to build capacity to institute a minimum package of essential maternity services, linking evidence-based policy development with health system strengthening. It has supported long-term planning, working towards skilled attendance at every birth, safe blood supplies, staff training, building management capacity, improving monitoring systems and use of process indicators, promoting dialogue between women and providers on quality of care, increasing equity and access at district level and much more. Access to safe abortion services is also growing at a fast pace since abortion was legalised.

Providing too much, not too little

It is assumed that in most settings where maternal mortality and morbidity are a problem, it is because there is too little of whatever needs to be available: money, training, human resources, supplies and equipment, transport, passable roads and so on. In the last decade and more, however, problem number six, the problem of “too much” in maternity care, has begun to emerge, not just in rich countries but others too. Too many episiotomies and caesarean sections have long been an issue, researched most assiduously perhaps in Brazil.³ The use of too many ultrasound scans, sometimes as the only form of antenatal care provided and as a means of income-generation for both public and private providers, has emerged as a problem in three countries: Syria,⁴ Viet Nam⁵ and now, in this issue, China (Amanda Harris et al). In some parts of China, increased medicalisation and technical intervention in normal births exceed that of most other nations, and normal vaginal delivery is being redefined “as a risk to be managed through increased, routine intervention”. This is the opposite of a bluprint for the future, but in a health system that is increasingly market-driven:

“…in the context of a neo-liberal health economy with poorly developed government regulatory policies, those with the power to pay for maternity care may be vulnerable to a new range of risks to their health from those positioned to make a profit. While poor communities may lack access to basic services, wealthier socio-economic groups may risk an increase in maternal morbidity and mortality through the overuse of avoidable interventions.” (Amanda Harris et al)

Thus, countries need to examine whether growing rates and types of intervention in normal delivery are causing a reversal in the quality of care, and possibly avoidable morbidity, to try and reach a healthy balance.

Integrating HIV and safe motherhood

The attainment of the UNGASS target of reducing HIV infections by 50% by 2010 necessitates that 80% of all pregnant women accessing antenatal care receive services for prevention of mother-to-child transmission (PMTCT) of HIV. However, in 2005, only seven of the 71 countries reviewed by UNICEF and WHO were on track to meet this target. PMTCT coverage increased from 7% in 2004 in 58 countries to 11% in 2005 in 71 countries (Chewe Luo et al). In the 31 countries that had data, however, only 28% of women who received an antiretroviral for PMTCT also reported receiving antiretroviral treatment for their own health. Achieving the UNGASS target, problem number seven, will require substantial investments and commitment to strengthen maternal and child health services, the health workforce and health systems to move from pilot projects to a decentralised, integrated approach.

Maternal health services face human and financial resource shortages which affect their capacity to integrate HIV prevention. Both HIV and maternal health programmes often receive targeted financial and technical assistance that does not take the other into account (Nel Druce and Anne Nolan). However, proposals in 2007 from a number of countries to the Global Fund to Fight AIDS, TB and Malaria incorporate sexual and reproductive health programming that will also have an impact on HIV, including certain maternity services. These can serve as a model for other countries. Moreover, Botswana, Kenya and Rwanda have shown that progress can be made where national commitment and increased resources are enabling maternal and newborn care to address HIV.

Unsafe abortion: the continuing saga

Problem eight is unsafe abortion. A Lancet paper about to be published found that there were an estimated 42 million induced abortions in 2003, compared to 46 million in 1995. The induced abortion rate worldwide was 29 per 1,000 women aged 15–44 in 2003, down from 35 in 1995. In 2003, only 53% of all induced abortions were legal, including most abortions in developed countries. Nearly all abortions in Africa and Latin America were still unsafe, as were two-thirds of abortions in Asia (excluding East Asia) and even 10% of procedures in Europe. About one in five pregnancies worldwide ended in abortion.⁶

Mortality from unsafe abortion appears to be falling slowly, but where abortion remains legally restricted, an estimated five million women are admitted to hospital for treatment of unsafe abortion complications each year. By comparison, in developed countries complications from abortion procedures and hospitalisation are rare.⁷ Nicaragua has just voted as I write to keep abortion entirely illegal, and says it will penalise both women having abortions and providers with prison sentences. Medical professionals found guilty of providing abortions will have their right to practise removed for 2–5 years. We can expect to see deaths from unsafe abortions increasing in Nicaragua, and providers who are too frightened to help women with complications.⁸ This is an appalling, retrograde state of affairs. In Chile, abortion is also not legal even to save a woman’s life or health. This situation creates serious dilemmas and vulnerabilities for both women and medical practitioners (Bonnie Shepard and Lidia Casas Becerra). Abortion incidence has probably decreased since 1990, however, due to increased use of contraception and lower fertility. Deaths and complication rates have fallen as well, though Chilean hospitals are still using D&C to treat incomplete abortions.

The Round Up in this issue summarises a paper from Uruguay where complications of abortion were causing 29% of all maternal deaths, compared to the worldwide figure of 13%. In one public hospital in Montevideo, unsafe abortion was causing 48% of all maternal mortality, which led a group of obstetrician–gynaecologists there to develop a programme in 2004, later officially supported by the Health Ministry, called Public Health Initiative against Unsafe Abortion. The hospital offers a consultation to any woman presenting with an unwanted pregnancy or self-identifying as at risk of unsafe abortion. Women have number of weeks of pregnancy confirmed by ultrasound and are assessed for any legal grounds for termination. In the case of pregnancies that do not meet legal criteria for abortion, women are given accurate information on the relative risks of a range of abortion methods. The information includes the correct doses of misoprostol. Women are encouraged to attend again, either following abortion or for antenatal care. In the case of incomplete abortion, they can have a uterine aspiration (initially recorded in 30% of cases where misoprostol was used, but declining to 18% as the programme continued), and provision of an effective contraceptive method. There have been no maternal deaths or severe complications recorded at the hospital since the programme began.⁹

Research, monitoring and review

Five papers in this journal issue are devoted to research, monitoring and review, and all of them provide excellent examples of why countries need good data and how to use it to improve services, even with limited resources. One paper from Brazil looks at changes in levels and patterns of maternal mortality in Pernambuco, comparing data from 1994 and 2003 (Sandra Valongueiro Alves) which show how things have got better. Maternal mortality declined in the state by 30% over the ten-year period, but the level of misclassification of maternal deaths was still a problem, and the illegal condition of abortion remained an important contributory factor in abortion-related deaths.

A second paper from Brazil summarises a number of studies on near-misses or severe maternal morbidity, and what these can teach. “The versatility of the concept, the greater frequency of cases available for study and the possibility of interviewing the survivors of severe complications all support the value of studying severe maternal morbidity to help guide local efforts to reduce maternal mortality, including monitoring progress, epidemiological surveillance and auditing of health care” (Jose Guillherme Cecatti et al).

The maternity monitoring system in Botswana, developed in 1998, is using maternal death and morbidity reviews to propose improvements at service delivery level (Keitshokile Dintle Mogobe et al). Analysis is done by the National Maternal Mortality Audit Committee of data collected from perinatal reviews and surveys using process indicators. In 2001, 70% of pregnant women attended antenatal care in Botswana but access to emergency obstetric care was uneven. In 2006, 28 facilities with maternity services surveyed were providing 24-hour delivery care, but laboratory, theatre and blood supplies were more limited, and only 50% of doctors and 67% of midwives had life-saving skills. Antibiotics were widely available, but there were shortages of magnesium sulphate, diazepam, oxytocics and manual vacuum aspiration kits.

In the WHO European Region, the use of national-level confidential enquiries into maternal deaths and facility-based near-miss case reviews were introduced to 12 countries in 2004–2005 (Alberta Bacci et al). Moldova was the first to pilot the review process, and the paper contains a detailed description of the process of preparing for and carrying out the reviews there. This included a technical workshop to make detailed plans, training in how to facilitate and carry out a review, and production of clinical guidelines against which the findings of the two types of review could be judged. Near-miss case reviews have been carried out in the three main referral hospitals in Moldova, and a national committee appointed by the Ministry of Health to conduct a confidential enquiry has met twice. Several of the other countries have begun a similar process, but progress may remain slow due to continuing fears among health professionals of punitive action against them if they have a mother or baby die in their care, which was a real threat in former Soviet times.

Lastly, an elegant piece of research from Sweden (Karin Elebro et al) identified cases of maternal mortality among immigrants from the Horn of Africa living in Sweden. The aim was to verify the cause(s) of death and whether they had been classified as maternal deaths in the Swedish Cause of Death Registry. Several new and possible maternal deaths were found. The authors recommend that both cultural and medical competence for European midwives and obstetricians who are caring for non-European immigrant mothers should be given more attention, so that causes of maternal death that have all but disappeared in Europe, such as tuberculosis, are identified in time to save women’s lives.

Reducing maternal deaths is a social intervention, not just a technical one

“Programmes aiming to improve maternal health are not only technical but also social interventions that need to be evaluated as such, using methodologies that have been developed for evaluating complex social interventions whose aim is to bring about change. The components of effective programmes have been defined globally. However, in getting what works to happen, context matters.” (Loveday Penn-Kekana et al)

This paragraph is worth reading and re-reading, like a mantra, until its meaning begins to sink in. It encapsulates perhaps the most important lesson this journal issue has to offer, based on studies in countries as diverse as Bangladesh, Russia, South Africa and Uganda. Here is the ensuing lesson, arising from another South African study (Leena Susan Thomas et al) published in this issue:

“To build a learning organisation, a new culture of monitoring and evaluation, including routine self-evaluation, is required as core skills for all health workers, and data should be used at the point of collection. Changing reporting lines between programme and district managers may improve co-ordination between different authorities, and there is a need to enhance the manner in which staff are assessed, appraised, promoted and rewarded. Professional bodies who oversee training curricula, institutions that offer training, and institutions that provide funding for training and development need to take on the challenge of health systems development and avoid promoting programme-specific interventions only.”

At the same time, the role of the family and the community is a social aspect of maternal health and maternal deaths that may get left out of the equation. The Nepal Safer Motherhood Programme implemented a community information project that is well worth emulating (Rath et al). Until and unless it is accepted in the community, among those who matter, that having good antenatal care, delivering safely in a facility, seeking help immediately when a complication occurs, and having the means to get there, change will at best be slow and the most vulnerable women will continue to die.

The bottom line: valuing women

The bottom line, though, is that reducing maternal mortality is about valuing women. Perhaps the most moving comment in these pages is that of a 17-year-old Palestinian mother (Hassan-Bitar and Wick) who, when asked how she was treated while giving birth, said: “Thank God they didn’t shout at me”, as if somehow that made the rest all right.

The situation of 536,000 women dying in 2005 alone, needlessly, often in agony, remains.

“The women dying are in their prime of life: they are crucial to society and the economy; they sustain the next generation; they make up more than half the workforce… Continuing high levels of mortality in mothers and in babies is a global collective failure.” (Wendy J Graham et al)

17-year-old Mozambican girl who died of eclampsia after being brought to hospital in a critical condition

The need for leadership

According to an historical study of the effectiveness of the Safe Motherhood Initiative since its inception, researchers Jeremy Shiffman and Stephanie Smith concluded that advocates will need to address four political challenges:

•	surmount disagreements among themselves to present a credible voice to international and national political leaders;
•	build effective institutions to guide and sustain the initiative;
•	find a public positioning of the issue that convinces political leaders it deserves priority; and
•	develop strong linkages with initiatives in high maternal mortality countries.”10

Other features

In 1997, the Supreme Court of India recognised sexual harassment in the workplace as a violation of human rights. An article in this issue (Parmita Chaudhuri) reports an exploratory study in 2005–2006 among 135 women doctors, nurses, health care attendants, administrative and other non-medical staff working in four hospitals in Kolkata, West Bengal, India. Instances of verbal and psychological harassment, sexual gestures and exposure, and unwanted touch by male doctors, patients and other staff were reported. The women were reluctant to complain, fearing for their jobs or being stigmatised. These are the same health workers women rely on to prevent maternal deaths. They are women too, and sometimes they have their own survival issues as health workers.

Lastly, Clémentine Rossier describes two paradoxes as regards abortion in Burkina Faso: what prompts women and providers to reveal something they want to be kept totally secret, and how do women keep their abortion secret while nevertheless talking to others about it in order to find a provider.^*

Global theme issue on poverty and human development

This journal issue is being published early for two reasons. The first is that last year, RHM agreed to join an initiative of the Council of Science Editors, along with 230 other journals internationally, in producing a Global Theme Issue on Poverty and Human Development. These journals have all agreed a common release date of 22 October 2007. The second is so that the journal can be distributed at the Women Deliver conference in London, also in October.

Round Ups for this issue on RHM website

Due to the number and length of the papers in this journal issue, it has been impossible to include the usual number of Round Up sections summarising the published literature of the previous six months. Only summaries regarding maternal mortality and morbidity are included. Other Round Ups will be placed on the RHM website at <www.rhmjournal.org.uk> under RHM Journal Round Ups. They will be uploaded the same day the rest of the journal goes up on the Elsevier website.

Acronyms and RHM

The following is the list of acronyms which appeared in the initial submissions of all the papers included in this issue of RHM:

WHO, BTN, MMR, MPS, CEMD, NMCR, MOH, UNFPA, UNICEF, USAID, MCHRI, IMPAC, EOC, SSMP, DFID, DHS, HDI, MNH, UNDP, MoHP, HIS, PMTCT, MCH, ARV, UNGASS, ANC, ART, SRH, TB, MDG, UN, HIV, AIDS, IATT, EC, GFATM, ICPD, STI, RH, FP, USG, UK APPG, PEPFAR, VCT, SWAp, NGO, HRC, GAO, NAC, PSI, FHI, ICD, EmOC, RGI, RMP, PHC, ANM, MO, IIPS, GAVI, CS, GDP, OECD, IV, PPH, WCHD, IMR, EAG, NRHM, UP, SRS, RCH, CSSM, TBA, FRU, CHC, JSY, ASHA, BPL, NFHS, OR, AMTSL, IMNCI, BCC, IEC, CDC, CEE/CIS, HAART, CD4, AZT, 3TC, NVP, sdNVP, MTCT, DBS, PCR, M&E, SMI, MM &M, APH, MVA, SBA, NSMP, MCHW, BEOC, CEOC, VDC, FHD, HMGN, ODC, DRC, INSD, UERD, AGI, D&C, MD, FONASA, CEDAW, ICESCR, PAHO, SERNAM, PMR, MOU, SDA, HW, HWC, HWFC, RPR, HR, ND, SB, CEDEPLAR, RAMOS, GERES, IRB, SIM, SINASC, IBGE, DATASUS, IFES, LTR, TFR, INSP, Ob/Gyn, UNAM, ENEO, SOM, PPT, ON, GP, SSA, ICM, FIGO, IUD, MANA, LEO, UC, HIPC, IMMPACT, KI, RHM.

This is why we ask authors not to use acronyms, or limit themselves only to those that are well known and used universally. It is too much to ask readers to retain the meanings of so many acronyms in paper after paper, and it makes authors sloppy. Acronyms are easier to overuse than the words they stand for, and often their meaning becomes vague. The extent of the use of acronyms in both writing and speaking today is a form of linguistic cancer, and should be avoided.

RHM subscription rates for 2008 are going up

RHM’s subscription rates are going up starting from 2008 for several reasons: 1) we have barely raised them in the past 4–5 years; 2) we were advised by our Elsevier journals manager that given so many increases in costs, we would be making a loss soon, which we cannot sustain; 3) we did some research and discovered that we were priced far below the other journals in our field; 4) we have been producing a supplement and CDs each year for the past few years without charging for them; 5) we will be producing a supplement and probably another CD next year as well; and 6) we are supporting six and soon possibly seven other languages versions of the journal as well as the English. So we felt it was time to raise our rates. We then had to decide how much to increase them, and whether to do it in one go or in stages over several years. We felt that it was better to have a big jump next year and get it over with, and then to increase the rates only with inflation after that. Whether or not this was the best decision, we aren’t sure. However, we can assure readers that even with the new rates, and considering that there have been three issues of the journal per year instead of two, we are still among the least expensive journals in our field. And the policy on supported (free) subscriptions has not changed. We hope we can count on your continuing subscriptions to RHM.

Notes

* Unless otherwise referenced, examples and quotes in this editorial are from articles in this journal issue, indicated by author name.

† The full report will be published in October 2007 in: Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva: WHO, UNICEF, UNFPA, World Bank, 2007.

* The signatories included the UK, Norway, Germany and Canada, UN agencies and other international organisations, several developing country governments and the Gates Foundation.

* Thanks to Paul Van Look, Julia Hussein, Cherry Bird, Simone Diniz and Loveday Penn-Kekana for comments on an earlier draft of this text.