Maternal mortality or women’s health: time for action

This journal issue begins with a poem about the “woman too hapless / to grace dinner-conferences / held in her name / at exclusive venues” (Sebina) because her life – and death – still do not count. Still, by 2008, the maternal mortality ratio had finally begun falling globally.¹ Not enough, or not enough to meet MDG5 targets,² but some – a start! Making change happen is in the air, from the UN Secretary-General down to the most remote village.

Yet, in certain ways, the world is moving backwards when it comes to dealing with women and pregnancy. Simone Diniz calls it a return to “materno-infantilism” – treating pregnant women like children who need looking after and at the same time, as if their only role in life is to have babies. Today, in much of the literature, all pregnant women are called “mothers” whether they've ever had a baby or not. Yet pregnancy has more than one outcome and is not only about women who “deliver”. It's also about women who experience miscarriages, stillbirths, infant deaths, lack of access to contraception, unwanted pregnancies, unsafe abortions, and lifelong obstetric, reproductive and sexual morbidity. Yet these are nearly invisible in PMNCH these days, and safe abortion – an integral part of women's right to decide the number and spacing of their children – may be made invisible in the new family planning initiative due to be announced in July this year as well.³ While there is nothing new in beatific visions of “mothers and babies”, it is surprising and disturbing how easily the terminology of women “giving” or “creating” life has crept into the language of UNFPA and WHO, public health agencies, shifting the focus away from women, and women's health and rights.

This journal issue starts from the premise that maternal deaths constitute a violation of the most basic human right of all – the right to life. The right of women to life. The papers are still about women dying in vain, and how horrific that is, and they still show that the poorest and the youngest women are the ones most at risk of dying as a consequence of gross negligence. But they aren't only calling on someone else to do something about it any longer. Instead, they are about women and their communities, women's health and human rights advocates and organisations, and more and more, about health professionals, governments and inter-governmental agencies taking action – to hold countries, governments, health services, themselves and each other to account.

What is happening in countries: a very mixed picture

The papers here show that some countries are making serious efforts at strengthening and improving their health systems in relation to reproductive health care and maternity services. Based on data that show who is dying and why, they are making policy and programme changes, such as low-cost delivery services for poor and migrant women, opening new obstetric emergency care and referral centres in hospitals, training more health professionals, and providing health education for women, as in Shanghai (Du et al). Others are strengthening the whole public health system, especially in rural areas where most poor women live, ensuring better leadership and governance, increasing health workforce skills, supporting community-based health insurance, and increasing contraceptive services, as in Rwanda (Bucagu et al). They're promoting peace, stability, economic growth, poverty reduction, improved primary education, better roads and communications, access to information on health and health services, and making health care free of cost for the poor, as in Cambodia (Liljestrand & Sambath).

In contrast, in some countries, appalling, chaotic, uneven, negligent and abusive situations persist. Among the 22 million women each year who have unsafe abortions, adolescents suffer the most from complications and have the highest unmet need for contraception (Shah & Åhman). Custom, lack of perceived need, distance, lack of transport, lack of permission from husbands, cost, unwillingness to see a male doctor are still preventing women from seeking antenatal and delivery care, e.g. in northern Nigeria (Doctor et al), but in many places, these services barely exist anyway.

In the poorest of countries, women may have more pressing health needs even than for maternity care, e.g. in Haiti, where women identified access to any affordable health care, potable water, enough food to eat, any employment, sanitation and education as their most crucial problems (Peragallo Urrutia et al).

Even more broadly, lack of national commitment has been identified as critical in 33 sub-Saharan African countries, as well as very low levels of public financing for health and health services (let alone maternity services), poor coordination between key stakeholders and partners, poorly functioning health systems with poor logistics for supply, distribution and management of essential medicines, family planning commodities, and equipment, and a chronic shortage of skilled health professionals, (Ekechi et al). There may be vast differences in type and extent of health worker training, skills, and knowledge, e.g. in rural Tanzania, which result in some health workers being proficient while others make serious practice errors. Competence may be unpredictable; midwives may be more adept than physicians, aides may be able to conduct breech deliveries and manage retained placenta, while clinical officers flounder with post-partum bleeding (Spangler).

The post-partum period is when 60% of maternal deaths and most newborn deaths take place – yet it is barely getting any attention in practice, even in countries that are making substantial improvements in antenatal and normal delivery care. Thus, there are continuing high levels of maternal and neonatal mortality post-partum due to the continuing neglect of emergency obstetric, post-partum and post-natal care (Fort). In several South Asian countries, cash is being given to pregnant women to deliver in facilities, but some studies are finding, e.g. in India, that when women arrive, there is limited or no antenatal care, no birth attendants with midwifery skills, no emergency obstetric care in obvious cases of need, and referrals that never result in treatment (Subha Sri et al). And now, these same women have a sense of entitlement, and they are protesting.

Many forms of action

The papers here describe a range of models for advocacy and taking action to expose violations of human rights, poor public health practices, absence of monitoring and regulation, failure to ensure national accountability for sexual and reproductive rights and to provide remedies and redress in the event of violations (Kismödi et al). Actions taken include: (1) fact-finding visits to investigate maternal deaths, taking findings to district and state health officials to demand change, and following up with further visits to check whether the changes have led to improvements (Subha Sri et al); (2) individuals who have been victims of rights violations using a procedure under CEDAW (Convention on Elimination of All Forms of Discrimination against Women) to bring cases against the State, which in 2011 led to two landmark decisions by the CEDAW Committee in Brazil and Peru: the one in a maternal death case and the other in the case of a young rape victim who became pregnant and was denied legal access to abortion and surgery for injuries sustained because she was pregnant (Kismödi et al).

Ray et al describe a right-to-health approach for learning and capacity building, community networking, popular mobilisation, public protests and demonstrations over avoidable deaths, and legal action in countries, as the HIV movement has so successfully carried out. They show how important confidential enquiries into maternal deaths and shadow reports to UN human rights treaty body country assessment teams can be, and give examples. And they call for advocates to draw attention to the reality in health services of under-resourced services, shortages of supplies such as blood for transfusion, and poor morale among staff, and to develop user-friendly information materials for women and their families, and provide training and support for patients' groups in how to use hospital complaints procedures (Ray et al).

The paper by Kaur and several Round Up summaries offer powerful examples of the use of litigation to seek redress for violations of the reproductive rights of women who have died unattended in childbirth. These expose the socio-economic, cultural, political and legal factors involved in such deaths, and can be used to ensure accountability in further cases – while recognising that social justice will only be achieved through broader social struggle (Kaur).

Research, use of data, and budget analysis to support change

Across several recent issues of RHM, the importance and limitations of Demographic & Health Surveys have emerged, as countries and civil society seek a more in-depth picture (both qualitative and quantitative) of what it's like for women getting pregnant today, whether the pregnancy was intended and wanted or not, and no matter how it ends.

A review paper finds many layers of delay in the “three delays” framework. Combining this framework with the “near-miss” approach and a range of information-gathering methods appears to offer additional means of recognising critical events around childbirth and highlight the systemic weaknesses in obstetric services (Carvalho Pacagnella et al).

There are a number of papers exploring the sources of data and information on maternal deaths, whether policies and programmes are being informed by data, whether data actually flows between decision-makers and local health staff, and whether existing information systems are capable of collecting, processing, analysing and sharing data (Iguiñiz and Palomino). One paper explores a community-based approach to the measurement of maternal mortality that involved local agents in locating and reporting all births and deaths, nurse-midwives doing verbal autopsies, and shifting the task of cause-of-death attribution from physicians to mid-level providers (Prata et al).

And then there is a thought-provoking roundtable of views on pregnancy registration systems: one on the theory of how they should work in South Asia (Labrique et al); one on the logistical constraints such systems face in rural settings and whether their aim in India is for supervision, monitoring and blaming – or for a learning health system (Gaitonde); and one analysing whether or not the new system in Brazil is rights-based, appropriate and relevant to reducing maternal deaths there (Diniz).

Several governments in Latin America may be embarrassed to learn that their levels of budget transparency in spending on specific aspects of maternity care were found to be very low, and that they need better budgeting modalities, better health information systems and guidelines on how they might better capture data on expenditure, in order to track and plan local and national progress (Malajovich et al). The chaos of numerous competing and unlinked data collection systems on maternal deaths in Peru is shown in painful detail by Iguiñiz and Palomino, but the situation is now much improved. Similarly, an assessment of cash transfer and voucher schemes designed to stimulate demand for services and reduce cost barriers to maternity care found increased use of maternity services in several south Asian countries, but also a need for more efficient operational management, financial transparency, plans for sustainability, evidence of equity and, above all, proven impact on quality of care and maternal mortality and morbidity (Jehan et al).

What about the content of services and quality of care?

In spite of all the emphasis being put on maternal and newborn health, however, it seems that the quality of maternity care in low-resource settings is often still very low indeed. Even today, years after it was admitted that traditional birth attendants weren't the answer to safe motherhood, most resource-poor settings do not have fully qualified and skilled midwives, as revealed in the excellent UNFPA/WHO/ICM report State of the World's Midwifery 2011, excerpted here.

Essential interventions are still not always being carried out in a timely way, and there are problems with referrals onwards, often to two or three facilities/hospitals, before help is provided, often too late. Essential medicines such as magnesium sulfate, oxytocin and/or misoprostol are still often not available, or available but not being used, as a Round Up summary shows. And perhaps most egregiously, some women are being sent elsewhere to die, to keep their deaths out of the records, or sent home from the facilities they were encouraged to attend before the greatest risk of post-partum complications has passed.

Only in Brazil, it seems, are feminists still talking about unnecessary interventions taking place, causing a high level of morbidity, talking about women having a birth companion, delivering in the position of their choice, having privacy, being treated well, getting adequate pain relief – that is, about humanising childbirth.

In spite of government expenditure, cash transfer and voucher schemes, donor funding, health equity funds, maternity benefits, community health insurance schemes, and policies of free maternity care, women it seems often still have to pay out of pocket, formally and informally, buy their own medicines, bring their own equipment – or do without. So where is the money actually going?

Many maternal health people don't seem to want to talk about health systems strengthening, as described in ‘Good Health at Low Cost’: 25 years on. What makes a successful health system?, whose introduction is excerpted here. Instead, they focus on narrow interventions and single treatments or cash payments to individual women, as if these could ever overcome the systemic issues that exist. Yes, women need misoprostol at community level for more than one reason. Yes, cash payments are definitely “bringing many women in”, but what about functioning health systems and sustainable, long-term forms of financing – only these will be effective in reducing deaths in the long run.

Use of language that obscures meaning

Terminology is becoming sloppy – antenatal and delivery services are being called “maternal health services”. They are not; maternal health services are supposed to cover much more ground – all the outcomes of pregnancy for women and the continuum of care that should start before pregnancy ever occurs, with sexuality, health and relationships education, contraceptive provision and safe abortion – and for women with wanted pregnancies, proper antenatal care, prevention and management of miscarriage, stillbirths and fetal anomalies, and care and support to achieve a healthy woman and baby throughout and beyond pregnancy and the breastfeeding period.

Linguistically, there seems to be no distinction between post-partum care (for the woman) and post-natal care (for the infant). Yet they are not the same thing, and providing the one does not automatically mean providing the other, nor do the skilled or semi-skilled attendant(s) involved automatically have both sets of skills. Yet the terms are being used interchangeably without being defined or delineated. And as Spangler points out, skilled attendance (which was always meant to be more than a person) has been reduced to mean the presence of a skilled attendant only.

Associated with this lack of precision, acronyms have taken over the literature: ANC, PPN, PPC, SBAs, ANMs, ASHAs, EmOC, BEmOC, CemOC, BEmONC, MCH, MNCH, PMNCH, RMNCH, P4P, PBF, and so on. Using them means not having to think about their content and value, and what they actually stand for.

What have ICPD and the MDGs done for women?

This is an important question and many more of us should consider how to answer it, as it would help us think about the future. Here is one response:

“The ICPD Programme of Action placed maternal health within the broader framework of sexual and reproductive health and rights. The reason this was so important is that two decades of international development aid focusing on “maternal and child health” had done nothing to reduce maternal deaths. The ten-year evaluation of the achievements of the 1987 Safe Motherhood Initiative, for example, found that maternal deaths were not declining in much of the developing world because they could not effectively be tackled alone. The ICPD Programme of Action was based on evidence that women were dying not only because they could not reach appropriate services for pregnancy and childbirth but also because they were poor and malnourished, because they could not afford the means to prevent pregnancies they could not support and did not want, because they lived in countries where safe and legal abortion was not available, and because they could not practise safer sex. The Programme of Action articulated the inseparable relationship between the different aspects of sexual and reproductive health and the broader context of human rights and women's rights, including in relation to intimate partner violence, lack of access to comprehensive sexuality education, lack of availability of well-equipped sexual and reproductive health services with skilled health care workers, and the importance of laws and policies that make universal access to reproductive and sexual health possible.”⁴

Has ICPD failed? I don't think so, it has had too little time to succeed yet. What have the MDGs done in their turn? On the one hand, the interpretation of MDG5 de-politicised reproductive and sexual health, reducing it to a narrow vision of maternal health, as the last issue of RHM showed. The MDGs have also turned working towards its goals into a quantitative measuring exercise, with success or failure pegged to indicators. What do these indicators show as regards MDG5? In an illustrative study of 54 countries, they almost all showed high levels of inequity in provision of care, with the poorest women having least access as regards antenatal visits and skilled birth attendance. The most equitable intervention was early initiation of breastfeeding. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest women than the richest.⁵

On the other hand, many governments have taken the MDGs far more seriously than other UN efforts to make the world a better place. Moreover, the Special Rapporteur on the Right to Health, Anand Grover,⁶ the Human Rights Council, the Office of the UN High Commissioner for Human Rights and the UN Secretary-General himself have taken an important interest in these matters, covering all sexual and reproductive rights and considering unsafe abortion deaths as part of maternal mortality.^7,8 The Report of the UN Secretary-General to the Commission on the Status of Women earlier this year outlined in extensive detail just how much activity there has been at international level to promote these issues, which was greatly heartening,⁹ in spite of their being contested.

With 2015 around the corner, there is a totally understandable push to meet the targets set, feasible or otherwise. Quality of care will surely come with demand – or won't it? Finding out whether the numbers of deaths, near-misses and morbidities are still falling must be left for another day. Maybe that's the way it has to be – chaotic and uneven, not a smooth, coordinated, stepwise progression. Maybe that's how all change happens.

However, it is not just MDG5 that is important for women, but all the MDGs. A study published in 2011 of the decline in maternal mortality in Nepal found that reduction in fertility, changes in education and wealth, improvements in development, gender empowerment and reduction of anaemia each contributed substantially to a decline in maternal deaths.¹⁰ This shows, as do several papers in this journal issue, that achieving all the MDGs matters, and confirms that the social determinants of health are crucial. And in the case of Nepal particularly, the legalisation of abortion and provision of safe abortion services were important factors as well, as a summary in the Law and Policy Round Up shows.

The past gives birth to the future

The two most heartening things about this journal issue are, first, the authors don't just talk about how bad things are and what needs to be done, but describe what is being done to change the situation on the ground. And secondly, activism is emerging in regard to pregnancy, pregnancy outcomes and the need for safe abortion. We are at a crucial juncture, and this work must be expanded.

The MDGs are probably going to be replaced by “Sustainable Development Goals” after 2015, but the rumour as we go to press is that the Rio+20 negotiations may have a big influence on how these are formulated, not least due to the issue of “population”, which remains a highly contentious issue. The risk of going backwards in this area must be resisted. Neither maternal health nor family planning and population initiatives must be allowed to become single issues again, based on vertical programmes, as they were in the 1960s. Sexual and reproductive health and rights, with all their complexity, must never be allowed to fall – or be pushed – off the agenda at country level.

In 1987, the first Safe Motherhood Initiative was launched at a conference in Nairobi. Also in 1987, at the 5th International Women and Health Meeting in San José, advocates of safe pregnancy and childbirth and of safe, legal abortion agreed to launch the International Day of Action for Women's Health on 28 May 1988, with a call to women for action against maternal mortality. In 1994 the ICPD Programme of Action and in 1995 the Beijing Platform for Action were approved by the great majority of governments.

In 2003, the World Health Organization published Safe Abortion: Technical and Policy Guidance for Health Systems. As we go to press, the updated and revised guidance is also about to be published, and text based on the executive summary is included here. Since then, we have seen an unending flow of ground-breaking clinical and social science research, and health policy and programme development in support not only of safe motherhood but also the full range of sexual and reproductive health and rights.

On 28 May 2012, a new International Campaign for Women's Right to Safe Abortion will be launched, to link together and combine existing efforts and create new efforts towards ensuring women's right to safe abortion in every country. These are only a tiny part of the work that is being done to make change happen in support of women's health, which has a long history and a long way to go.

“Motherhood: only if I want, only if I can”. International Day of Action for the Decriminalization of Abortion, Nicaragua, 28 September 2011

Acknowledgements

Thanks to Rajat Kosla, Eszter Kismödi, Julia Hussein, Lisa Hallgarten, Carla Abouzahr, Asha George, TK Sundari Ravindran, Jane Cottingham and many others who helped with comments, text, photos and thinking that went into this editorial and journal issue.