Half a million reasons

12 December 2008

Ann Starrs, President of Family Care International, highlights the importance of improving maternal care in developing countries

Women in northern Tanzania have a long tradition of giving birth at home, cared for by village birth attendants who are experienced in traditional practices but have no medical training. In some villages, that tradition is beginning to change: pregnant women are now more likely to receive regular antenatal care and deliver in a clinic or hospital. It is changing because of improved health facilities, better trained health workers, and an intensive effort to teach local women – through village meetings and a mamanju (traditional song and dance festival) that drew 10,000 people – about the importance of giving birth in the care of a skilled attendant. While undramatic, and little noticed outside the region, it has enormous implications for the survival and wellbeing of women in these communities; now, if a woman begins to bleed heavily after giving birth, medical staff at the local health centre can begin emergency treatment and use a two-way radio to call for an ambulance. Before, death from postpartum haemorrhage or other complications was seen by village residents, and by the women themselves, as an inevitable and common risk in the process of giving life; now, women are much more likely to be able to return home with their newborn babies and give their children and families the care they need.

In Europe and North America, the availability of life-saving care for women in pregnancy and childbirth is taken for granted as a basic right. But in many parts of Africa and the rest of the southern hemisphere, this kind of care is all too rare. As a consequence, a woman dies every minute from complications of pregnancy and childbirth in the developing world, and 300 million women are alive but suffering from sometimes debilitating illnesses.

This is one reason why 193 countries participating in the United Nations' Millennium Summit in 2000 included maternal health as one of eight top priority goals for international development, with the target date of 2015. MDG 5 – improve maternal health – sets out two crucial targets: reducing the maternal mortality ratio by three-quarters, and achieving universal access to reproductive healthcare.

From 2000 until 2007, however, MDG 5 and women's health generated little global interest or action. Numerous other global health goals aim at reducing deaths caused by specific diseases, for which the solutions are relatively simple technologies (such as bed nets for malaria) or drugs (for treatment of tuberculosis). Saving mothers' lives is more challenging; it depends on changing fundamental social practices and improving health infrastructure, from the home to the hospital. There is no single drug or procedure that can prevent the multiple medical causes of maternal death – haemorrhage, hypertensive disorders, infection, unsafe abortion, and obstructed labour – each requires different medications and clinical skills, although each can be prevented or treated with solutions that are known and, in the developed world, widely available.

'Countdown to 2015' is a global effort to track progress toward MDG 5 (as well as MDG 4, which aims at the closely related goal of improving child survival) in the 68 countries that account for 95% of maternal and child deaths. The 2008 Countdown Report tells a grim tale: nowhere near enough progress is being made toward achieving MDG 5. Overall, in order to meet MDG 5, maternal mortality would need to fall by 5.5% per year, whereas the current rate of decline is 1%. And most of the progress is being made in Latin America, the Middle East, and parts of Asia; sub-Saharan Africa, which accounts for 14% of the world's population, accounts for 50% of its maternal deaths. On average, one out of every 22 women in Africa will die from pregnancy or childbirth, and in countries with the worst conditions, the risk is as high as one in seven. A woman in Africa is 2,000-3,000 times more likely to die in pregnancy and childbirth than a woman in northern Europe. There is no other health indicator with such an enormous gap between rich and poor countries. The persistence of these inequities is both a source of shame and a call to action.

The solutions are known: most deaths can be prevented through universal access to reproductive healthcare, including family planning and safe abortion services; skilled care during pregnancy and childbirth; access to emergency obstetric care for complications; and reliable follow-up care after delivery. And all of this must occur within the context of a continuum of care that includes mothers, infants, and children. Countdown to 2015 highlighted that these key interventions are reaching far too few women:
• Only 29% of women married or in union were using contraception;
• Only 53% of women gave birth with a skilled birth attendant by their sides;
• Only 49% of mothers had the required four antenatal care visits;
• Only 24% of women had postnatal care visits.

Despite these grim statistics, there are signs of hope, and a new energy surrounds maternal health and the challenge of MDG 5. In October 2007, 2,000 participants from 115 countries came together in London at the Women Deliver conference to tell the world – clearly and passionately – that women's lives matter. The conference looked at the consequences of maternal mortality for children, families, communities, and nations. When a mother dies after giving birth, her newborn infant's death sentence is almost certainly written, and any older children, especially girls, suffer severe hardship. Maternal and newborn deaths have a huge economic cost: globally, the half million mothers and four million newborn babies who die each year lead to an estimated US$15bn in lost productivity.

The theme of the Women Deliver conference, 'Invest in women – it pays', highlighted this critical message: that ensuring the survival and wellbeing of women and mothers makes sound economic sense. There is also growing acceptance that women have a legal and moral right to essential health services. Women's groups and other civil society organisations are increasingly demanding that governments be accountable for their policies and promises.

These demands are being heard at the highest levels. At their July 2008 meeting in Japan, the Group of Eight leading industrialised nations for the first time took up the issue of maternal and child health, noting that progress toward achieving the relevant MDGs was seriously off track and promising to keep the issue on its future agendas. Donor governments such as the UK and Norway have made new and vocal commitments, as have UN agencies and non-governmental partners. In September, a high-level task force was announced, headed by the President of the World Bank and the Prime Minister of the UK, to look at innovative financing mechanisms for strengthening health systems, with MDG 5 as a specific target – a hopeful sign that significantly increased resources will be mobilised. Governments in a number of developing countries have also stepped forward, working more actively and assertively with donors and NGOs to shape investments according to their needs.

Many of these efforts are aimed squarely at the key missing element for MDG 5: the money. Donor funding for maternal, newborn, and child health has increased significantly in the past few years, from US$2.1bn in 2003 to almost US$3.5bn in 2006, but it remains far below the need. An additional US$10bn per year is needed to provide the basic services to achieve MDGs 4 and 5 by 2015. Of this $10bn, half needs to be earmarked for maternal and newborn health, including reproductive health. This additional investment would barely make a dent in the global aid budget; yet no other investment would produce such dramatic and far-reaching returns.

The undramatic story taking place in northern Tanzania is not the result of any miracle drug or massive new initiative – just investment and action. Without that investment, families, communities, and the world will continue to needlessly lose half a million women every year, when losing even one is too many.