IMPROVING MATERNAL HEALTH IS NOT ROCKET SCIENCE BUT REQUIRES POLITICAL WILL
Is it acceptable for mothers to die of preventable causes during pregnancy because they are poor? Sadly, this is the pattern revealed by the United Nations (UN) statistics which show that dying of preventable causes is still a reality for half a million women every year [1]. These women live in the world’s poorest countries and surprisingly, the numbers of preventable maternal deaths in these regions have not improved significantly over the last decade [1,2,3]. But the picture is much different for women in developed nations where maternal deaths are 400 times less frequent [2]. Addressing these inequalities should be a focus of all governments since the consequences of social inequity and increased numbers of orphaned children in any society are grave. Unfortunately, based on the recent UN update on the Millennium Development Goals (MDG), universal access to reproductive health is still an elusive target after fifteen years of “commitment” to improving accessibility, and remains totally unreachable for the millions of women that are most in need of care [1].
Maternal health refers to the health of women during pregnancy, childbirth and the period after delivering a child. Pregnancy can be a rewarding experience once adequate healthcare is available, however; pregnancy for many women is associated with suffering and often death. Efforts toward improving maternal health began a long time ago at a conference in Kenya, where attention was drawn to the poor maternal health in many developing countries, and the need for countries to address the high rate of maternal-associated deaths [4,5]. These efforts, arising from the launch of the Safe Motherhood Initiative in 1987, were met with grand support by governments and NGOs, and were somewhat successful. Yet maternal death rates did not decline as anticipated [4]. Efforts toward improving maternal health were strengthened again in 2000 when world leaders of 189 member states of the UN made a commitment, through the development of the Millennium Development Goals (MDG), to use stronger efforts to defend the vulnerable. The MDG consist of eight specific, measurable, time-bound goals which should result in a better, more equitable world once achieved [4,5]. There has been significant progress in many of the MDGs but nine years after their generation, and five years prior to the deadline, there has been virtually no progress in the critically important goal improving maternal health.
The grim picture painted in the recent MDG update released in December 2009 points to the existence of inequity that belies the social development and innovation that is so characteristic of this information age. That 536,000 women and girls die as a result of preventable complications during pregnancy, childbirth, or the six weeks following delivery every year is appalling [1]. Half of these deaths (265,000) occur in sub-Saharan Africa and another third (187,000) in Southern Asia, together accounting for 85 % of all maternal deaths [1,2,5]. Incidentally, the main direct causes of death in these regions are described by the UN as “preventable” [1]. More specifically, 34 % of deaths in sub-Saharan Africa result from hemorrhage, with infections, high blood pressure, and prolonged or obstructed labor accounting for the remainder of deaths. Anaemia, which is made worse by the prevalence of malaria, HIV and other conditions, greatly increases the risk of maternal death from haemorrhage [1].
If these deaths are preventable, why then has there not been a decline in the number of maternal deaths in these regions over the past decade? Upon further analysis, the key message being sent by the UN statistics clearly demonstrates that access to reproductive health is a privilege of the rich. That access to reproductive healthcare is directly related to economic status can be seen both between and within countries. This is especially clear when considering the number of maternal deaths per 100,000 live births, or maternal mortality ratio (MMR) between countries. Sub-Saharan Africa for example, suffers from the highest MMR at 920 maternal deaths per 100,000 live births, followed by South Asia, with an MMR of 500. This compares with an average MMR of 8 in industrialized countries [3]. More specifically, in Ireland, women have a 1 in 47,600 lifetime risk of dying during pregnancy or from a birth-related cause; while in Niger 1 in 7 women face lifetime risk [1]. With respect to within country disparities, the same pattern is evident [1,3]. In the United States of America (USA), there a link between economic status and racial background that impacts maternal health care access. For example, despite the fact that black women represent only 32 percent of women, they make up 51 percent of women that are less likely to have access to adequate maternal health care services [6]. They are more likely to die in pregnancy, childbirth, and in high-risk pregnancies than the rest of the population.
There is now “intensified” commitment to improving access to reproductive health. But how will the NGOs, governments, policy makers, and health care providers ensure that this problem is given the required political and financial attention that is necessary to reduce maternal mortality? How will they ensure that the failures of the past no longer haunt future progress? First, policy makers must tackle at least three key factors when addressing maternal health in these regions; accessibility of resources, equity, and financial commitment. According to the UN Children’s Fund (UNICEF) and the World Health Organization (WHO) recommendation, pregnant women should have a minimum of four antenatal visits [1]. These visits provide women with access to important services, such as tetanus vaccinations and screening and treatment for infections, as well as potentially life-saving information on warning signs during pregnancy. The statistics indicate that basic care is still unavailable to many. In Southern Asia and sub-Saharan Africa, more than half of all births still take place without the assistance of trained personnel, demonstrating that this need is unmet [1].
Secondly, global and local leaders, and governments must promote interest in these issues. Improvement of women’s heath is a basic human right, and is absolutely necessary for promoting development. In fact, addressing the issues plaguing pregnant women and their newborns is at the helm of such advancement. Indeed, I would argue that Millennium Development Goal number 5 “Improve maternal health”, should be used as the gauge for measuring overall progress and governments’ commitment to safe, equitable countries with growing economies.
Thirdly, and most importantly, there must be improved and sustained investment in this cause. Since an infant’s risk of dying in his or her first year of life is 60 per cent higher when the mother is under the age of 18 than when the mother is older, educational programs geared to young women can have a significant benefit which may lead to reductions in death [1]. Of utmost importance to improving maternal health in developing countries is high level commitment and sustained funding toward education and family planning. Given that pregnancy early in life contributes to an estimated 70,000 maternal deaths among girls aged 15 to 19; governments in affected countries should commit to family planning and education as the foundation of any successful maternal health program [1]. Interestingly, instead of increasing support in these areas over the past decade, the UN MDG update indicates that there has been diversion of resources from family planning and sex-education, citing funding gaps as the major obstacle accounting for the failure towards progress in this area. Specifically, there has been a greater than 50 percentage reduction in donor assistance for family planning programs per woman aged 15 to 49 between 1996 and 20061. Where the monies are being shifted to is not clear. What is clear is the low concern for women’s health in these societies, and the lack of commitment to improving maternal health.
Targeting these three areas would undoubtedly improve access to reproductive health. Therefore, failure to make progress in all of these areas over a nine year period points to many short-comings, most notably, a lack of political will. This is especially obvious in the Sub Saharan region, where the death toll has remained unchanged over the decades [2]. Granted, many of these countries rely on international aid programs which, when diminished or reneged, result in the closure of relevant programs. Nevertheless, given that most deaths are preventable (over 90%) small measures taken in affected areas are bound to have significant positive effects, which will ultimately lead to a significant decrease in the number of deaths. The lack of political will is also evident internationally, primarily when countries renege on their pledges, or when financial support for maternal programs is absent. This lack of will is at the crux of the battle for improved maternal health. Thus, substantial change will result only when foreign governments and agencies are held accountable and demanded to pay the monies they pledged, and when local governments in affected countries place maternal health at the top of their public health agendas. This will ensure that preventable death is not the outcome for giving life.
There are a few key questions that must be answered before MDG 5 gets off the ground. Firstly, how exactly does political will become strengthened? More importantly, who determines the political will of a government? There are likely many ways to increase political will. But the most remarkable change occurs when issues like universal access to maternal health are considered to be of common interest by “everyday people”. When people are interested they raise their voices, demand accountability, and engage their political leaders, teachers, and press. We must demand vigilance from our press. How often does maternal health appear in the headlines? Yet, every minute of every day, a woman will die because of poor care during or immediately after pregnancy. And for every woman who dies, approximately 20 more suffer injuries, infection and disabilities.
We must also demand vigilance from our educational institutions. What efforts do “world-renowned” institutions make towards addressing such issues? How is the scientific innovation generated at universities translated to influence policy and treatment for women? When relevant drugs are discovered, are they available to the neediest? We live the era of innovation, antibiotics, specific vaccines, pediatric intensive care, biotechnology, and globalization, but these new developments have had very little impact on maternal health, in developing countries. Instead, developed nations have efficiently reduced already low numbers of maternal associated deaths, while the numbers in developing nations remain largely unaltered. How do we disrupt this vicious cycle?
In MDG 5 countries have made commitments to improving maternal health and reduce the global maternal mortality ratio by three quarters between 1990 and 2015. However, very little progress has been made and the maternal mortality ratio declined by only 5% to date. Reaching this goal now requires accelerating progress. Developing countries have many challenges to overcome before their healthcare systems will directly mirror that of developed countries. However, since early pregnancy, insufficient prenatal care, and the unavailability of medicines are three important contributors to death, sustainable intervention on a country-to-country basis must include education, improved access to essential health care and medicines, and development of health care infrastructure. Most importantly, these efforts must be sustained to bear fruit. Science and innovation can improve access to relevant materials but researchers and educators in developed countries and at leading research institutions must commit strongly and entirely to knowledge translation and international development. This will enable policy makers in developing countries to develop more sustainable approaches to improving access to life-saving services. This will also ensure that governments of developing countries maximize their limited resources by focusing on the most efficient medicines and technology. Most significantly, the general public must be stimulated to act on behalf of the vulnerable. Increasing public interest in maternal health may have a strong effect and can ultimately result in faster improvements in reproductive health for all women.
References
1. The United Nations. The Millennium Development Goals Report 2009. Pages 26-32.
Accessed on: 11/12/2009. Last Updated: June 2009
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Accessed on: 28th March, 2010. Last Updated: September 2008
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