Each year, more than 500,000 women die from complications of pregnancy and childbirth. Indeed, in the developing world, pregnancy complications are a leading cause of death among women in their reproductive years. Most of these deaths, as well as the many injuries and disabilities that often afflict women who survive pregnancy, are completely preventable. Yet, precious little progress has been made at the global level since 1985, when the late Allan Rosenfield, dean of the Mailman School of Public Health at Columbia University, shined a spotlight on this overlooked and ongoing tragedy with his seminal article "Where is the M in MCH?"
Fifteen years later, in 2000, the imperative to improve maternal health made it onto the global agenda at the United Nations (UN) Millennium Summit. At this largest-ever gathering of world leaders, 189 nations (including the United States) committed to the Millennium Declaration—a global partnership to fight extreme poverty. The declaration was distilled down to eight Millennium Development Goals (MDGs), establishing time-bound targets to be achieved by 2015 in areas such as hunger, disease, gender equality and environmental sustainability.
The fifth MDG calls for improving maternal health by reducing maternal deaths by three-quarters and achieving universal access to reproductive health. The bad news is that the world is hardly any closer to reaching MDG 5 today than it was at the start of this process. The financial resources and political will needed to promote maternal health have been lagging for many predictable reasons. Among them is the fact that pregnancy starts with sex, and the politics of supporting sexual and reproductive health services still gives pause to too many decision-makers.
Several key global initiatives have sprung up in recent years to jumpstart the effort to make real progress toward achieving MDG 5. Their success will be measured in women's lives saved. And that will depend, in significant part, on how much longer it will take for governments as well as maternal and child health (MCH) advocates to reprioritize sexual and reproductive health services so that more women in the world's poorest countries can prevent unplanned, high-risk pregnancies and will not have to resort to unsafe abortions.
Causes, Consequences, Interventions
A maternal death is defined as one where a woman dies either while pregnant or within six weeks of pregnancy termination not related to accidental or incidental causes. The causes of maternal death and disability are well known and documented, and include severe bleeding, infection, complications of unsafe abortion, hypertensive disorders and obstructed labor. By far, women in Sub-Saharan Africa are at greatest risk: Pregnancy-related death rates in Sub-Saharan Africa are twice those in South Asia and up to nine times those in Latin America and the Caribbean (see chart).
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| Women in Sub-Saharan Africa are far more likely than in other parts of the world to die of pregnancy-related causes. |
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| Note: Maternal mortality ratio is the number of maternal deaths per 100,000 live births. Data are for 2005. Source: World Health Organization, 2007. |
For every maternal death, approximately 30 more women suffer injuries that can be debilitating for life. Anemia, infertility and pelvic inflammatory disease are just a few of the possibilities. One of the most severe pregnancy-related conditions is obstetric fistula, in which pressure from the baby's head creates a hole between the mother's vagina and bladder or rectum. Without treatment, many afflicted women experience serious physical consequences, such as incontinence and infection, which can lead them to be ostracized by their families and communities because of their foul smell and because of their inability to become pregnant again.
A maternal death is tragic not only because it is a waste of a life, but also because it is costly to the woman's family and community. A newborn whose mother dies is 3–10 times more likely than one whose mother survives to die by the age of two. Indeed, the World Health Organization (WHO) views the survival of newborns as integrally linked to the survival of their mothers. In addition, a mother's death can have consequences for the older children she leaves behind. Often, girl children must step into the void to manage the household—forgoing school and limiting their own futures. Indeed, a mother's death affects the entire family, including its income and productivity, which can affect the broader community in which they live.
The ways to prevent these deaths and disabilities are well understood, relatively simple and mostly low cost. Based on the evidence and drawing on the global consensus, Family Care International—a New York–based nongovernmental organization (NGO)—and Women Deliver—a global advocacy initiative—describe "4 Pillars" for saving women's lives:
• family planning and other reproductive health services;
• skilled care during and immediately following pregnancy and childbirth;
• emergency obstetric care when life-threatening complications develop; and
• immediate postnatal care for mothers and newborns.
Included in "other reproductive health services" are prevention and treatment of STIs and, notably, treatment of septic or incomplete abortion and the provision of safe abortion services consistent with individual country law. These interventions are widely accepted, even if not all receive equal attention or support.
Each year, unsafe abortion alone accounts for an estimated 70,000 maternal deaths and tens of thousands more injuries. The ways to prevent unsafe abortion and its consequences are no mystery: help women prevent an unintended pregnancy; provide women who are facing unintended or high-risk pregnancy and who wish to terminate their pregnancy access to safe abortion services; and where providing safe abortion services is not consistent with individual country law, treat women who are suffering from the complications of an incomplete or septic abortion with prompt, high-quality care. Indeed, research shows that up to one-third of all maternal deaths could be avoided, as the Population Reference Bureau notes, by "allowing women to delay motherhood, space births, avoid unintended pregnancies and unsafely performed abortions, and stop childbearing when they have reached their desired family size."
Key Global Initiatives
Long after dying in pregnancy and childbirth has become virtually unheard of in industrialized countries, so much needless maternal death persists in the developing world. There are many explanations. For years, and still to some extent, women's lives have been seen as expendable. Historically, women have had few advocates, representatives in government or other ways to be heard at the country level. Pregnancy is not a disease and therefore governments have not seen it as a problem to be solved. And fundamentally, perhaps, some of the most effective interventions to reduce maternal mortality involve sex and the politics of sex. Most women do want to have children at some point in their lives. However, so many possess neither the power nor the means to time, space and limit their pregnancies to optimize their and their family's health and well-being.
In response, maternal health activists are working through several global initiatives to muster significant increases in financial support and promote effective, high-impact interventions. These collective efforts are designed to better organize and mobilize grassroots support; improve the quality of the data and information about the problem and solutions; increase coordination and accountability at the governmental and global levels; and strengthen advocacy at the national, regional and global levels. Some, however, are more comprehensive in their approach than others.
White Ribbon Alliance for Safe Motherhood (WRA). This NGO based in Washington, DC, was founded in 1999 as "an international coalition of individuals and organizations formed to promote increased public awareness of the need to make pregnancy and childbirth safe for all women and newborns" in developing and developed countries. WRA is leading a grassroots movement to raise awareness, generate support and inspire leadership, including the likes of Sarah Brown, wife of United Kingdom Prime Minister Gordon Brown. (Indeed, Sarah Brown's involvement with WRA led her to supplement the effort with her own global initiative, the Maternal Mortality Campaign, to marshal new sources of funding and recruit prominent new voices to the cause.) Earlier this year, WRA and CARE, an Atlanta-based humanitarian NGO, launched "Mothers Day Every Day" in the United States. This campaign is cochaired by Donna Shalala, secretary of the Department of Health and Human Services under the Clinton administration, and Ann Veneman, executive director of UNICEF, and is designed specifically to raise consciousness and support in the United States for achieving MDG 5 and to attract some unusual suspects to the cause. The cost of winning over unusual suspects such as Veneman, who has generally ignored the sexual and reproductive health agenda while at the helm of UNICEF, and former U.S. Global AIDS Ambassador Mark Dybul, who has been overtly hostile, has been that WRA remains weak with respect to making the links between maternal and reproductive health. WRA does endorse universal access to family planning as one of the high-impact interventions for reducing maternal mortality, but it is circumspect about the role of unsafe abortion as a proximate cause of maternal deaths and is silent about the importance of access to safe abortion services.
Countdown 2015. This initiative started in 2005 and is managed by member governments, institutions and individuals with a special interest in MDG 5, as well as MDG 4 (which aims to reduce child mortality by two-thirds by 2015 from its 1990 level). The main purpose of Countdown is to track progress and use evidence to inform decision-making and to increase and better direct resources at the country level toward achievement of these MDGs. Countdown is looking at a broad array of indicators for measuring progress toward MDGs 4 and 5. Unmet need for family planning services is one of those measures, but the extent of unsafe abortion, admittedly difficult to measure, is not.
Partnership for Maternal, Newborn and Child Health. The Partnership was formed in 2005 and its secretariat is housed at WHO. Its board and general membership include international agencies (World Bank, UNICEF, United Nations Population Fund and WHO) as well as donors, developing country governments and civil society organizations. Its purpose is to accelerate progress toward achievement of MDGs 4 and 5 by raising the prominence of the issues, advocating for resources and improving accountability—all with an emphasis on a "continuum of care" model. This model emphasizes the importance of linking care and services starting before pregnancy and continuing through childbirth, infancy and early childhood. Earlier this year, the Partnership did officially embrace MDG 5 in its entirety, at least conceptually, though it is not yet clear what the breadth and depth of the Partnership's work will be concerning the reproductive health target.
Women Deliver. This global advocacy initiative was launched in 2007, 20 years after the first international conference to promote safe motherhood was held in Nairobi. Family Care International served as the secretariat for the earlier safe motherhood initiative and now is the host organization for Women Deliver. Its individual and institutional members span 115 countries. Women Deliver works to strengthen local advocacy with clear, compelling messages. Its perspective is to "situate maternal survival firmly in the context of broader recognition of women's importance to families, communities and nations, making the argument that investing in women's well-being makes sound economic sense and is a human rights imperative." Women Deliver's "4 Pillars" for saving women's lives encompass a broad sexual and reproductive health approach.
Maternal Health Task Force. This project is just getting off the ground this year. It is being coordinated by the New York–based NGO EngenderHealth and is fully supported by the Bill and Melinda Gates Foundation. The Task Force works closely with stakeholders in related fields, but is dedicated specifically to promoting maternal health. Its primary focus is on the scientific and programmatic challenges to reducing maternal mortality and morbidity. The scope of the issues and interventions that the Task Force will examine still remains to be seen.
The Politics
Although the issue of sexual and reproductive health and rights is so fundamental it deserved an MDG of its own, it is also true that it is so fundamental that virtually none of the eight MDGs can be achieved without investing in it. This is especially the case when it comes to attaining gender equity (MDG 3), reducing child mortality (MDG 4), improving maternal health (MDG 5), combating HIV and AIDS (MDG 6) and ensuring environmental sustainability (MDG 7). "Achieving universal access to reproductive health" did not make it into the MDGs explicitly, however, until the 2005 World Summit at the UN. At that time, it was incorporated into MDG 5 as one of the two targets for achieving maternal health (see box). This development marked an important breakthrough, because donors and recipient countries around the world have been modeling their own funding and programmatic priorities in accordance with meeting the MDGs.
United Nations Targets and Indicators for Achieving MDG 5
Target 5a. Between 1990 and 2015, reduce by three-quarters the maternal mortality ratio (maternal deaths per 100,000 live births)
Indicators:
• Maternal mortality ratio
• Proportion of births attended by skilled health personnel
Target 5b. Achieve universal access to reproductive health by 2015
Indicators:
• Contraceptive prevalence rate
• Adolescent birthrate
• Antenatal care coverage
• Unmet need for family planning
Unlike his predecessor, President Barack Obama has pledged to join the rest of the global development community and align U.S. development assistance with the MDGs. The fact that reproductive health at least is now included explicitly in the MDG construct is important as the United States begins to transition in its approach to development. It is also highly significant that this president and Secretary of State Hillary Rodham Clinton very strongly and clearly support family planning aid, access to safe abortion services where permissible and related reproductive health care in their own right. Equally important, they recognize the positive impact this array of services has on women's health, improved pregnancy outcomes and the greater educational and economic opportunities that accompany women's ability to control their own fertility.
Yet, some key decision-makers and advocates in the United States and at the global level remain hesitant to speak the whole truth about the interdependence of maternal health and sexual and reproductive health. Most of the reluctance likely stems from the residual negative politics perpetrated by the previous U.S. administration, even around family planning. An honest acknowledgment of the toll that unsafe abortion has taken and continues to take in women's lives and health is evidently even more untouchable.
Schisms between maternal health and reproductive health advocates are not limited to the global scene. They have cropped up over the years involving the politics of the U.S. family planning program, too. On the domestic side, however, the MCH community is actively advocating at least for sound family planning policies because they recognize and assert how key this is to improving maternal and child health (see box).
Family Planning and Maternal and Child Health Advocacy in the United States
In 1970, Congress created the first, and still only, federal program dedicated to the provision of family planning services on a nationwide basis. Its main goal was, and is, to help low-income people have the smaller families they desire, by equalizing access to contraceptive services. Over the course of the decade leading up to the enactment of Title X, the evidence had become clear that helping low-income women to avoid unintended pregnancy would help to alleviate poverty and improve the health of women and children.
The MCH rationale for the U.S. family planning program was compelling. The evidence showed that the timing and spacing of pregnancy has an impact on both a woman's health and the health of her newborn. Over the years, however, MCH advocates tended to remain on the sidelines of the political battles over the value of investing in family planning—not because they doubted the evidence or did not support family planning services in practice, but mostly because family planning politics had become so enmeshed in abortion politics. Over time, the situation has changed. Today, the Association of Maternal and Child Health Programs makes clear on its Web site that "family planning is a vital part of assuring healthy women, babies and families. When women plan their pregnancies, they are more likely to seek prenatal care, improving their own health and the health of the baby. Family planning helps women and their partners have children when they are physically, emotionally and financially prepared to take on the responsibility of a child." And earlier this year, the March of Dimes wrote to the Obama administration and to Congress in strong support of expanding eligibility for family planning services under Medicaid because "a central purpose of family planning is to promote healthy births." There is no doubt that the convergence of the maternal and reproductive health communities benefits U.S. policy, programs and the women they serve.
Moving Ahead
In sum, decision-makers in developing and developed countries alike are awakening to the fact that progress toward improving maternal health at the global level is lagging behind all seven other MDGs. A new momentum behind global advocacy efforts may result in the resources and political commitment needed to make a difference. In fact, as recently as early April, UN member states including the United States took some important steps forward. The UN Commission on Population and Development negotiated and adopted a resolution that prioritizes maternal mortality and morbidity and reproductive health overall as increasing emphasis is placed on strengthening health systems. And, for the first time, an intergovernmental statement recognizes both the integral role that achieving sexual and reproductive health and rights plays in accomplishing the MDGs in general, and endorses the importance of attaining universal access to reproductive health to improve maternal health in particular.
The global financial crisis presents a difficult challenge in marshalling the necessary resources to adequately address global health and development needs. Yet, it is precisely because resources are scarce that they must be used wisely and efficiently in a way that serves both humanitarian and economic development goals. Investing in saving women's lives fits this bill. It is time to remember the forgotten MDG 5. And it is past time for governments and MCH advocates in particular to remember that MDG 5 cannot be achieved without acknowledging, funding and committing to sexual and reproductive health services.