In a village in rural Indonesia, a slim young woman lies dying from infection after giving birth, unattended, two days earlier. Just a year earlier, the daughter she had delivered prematurely was stillborn. And the low-birth weight baby she had before that died when he was a week old, too weak to suckle.
Halfway around the world, in Sub-Saharan Africa another mother labors for two days and nights. When her baby is finally born, she suffers a hemorrhage and dies. Her family, which recently lost another daughter in childbirth due to complications of high blood pressure, wonders who will care for this new infant.
Incidents like these are occurring around the developing world with stunning regularity. Every minute a woman dies in pregnancy and childbirth, every year nearly 540,000 women succumb to complications developed during pregnancy and childbirth. The vast majority of these deaths are preventable when women have access to vital healthcare before, during and after childbirth. Since 1987, the year the global Safe Motherhood Initiative was launched, more than 10 million women have died and another 10 to 20 million women have suffered serious or long-term illness or disability each year.
Most of this maternal morbidity and mortality could be stopped with a coordinated set of actions, sufficient resources, strong leadership and political will. Providing access to comprehensive reproductive health services (which include family planning counseling and safe abortion), ensuring skilled care by midwives or other health practitioners during pregnancy, childbirth and the post-partum period, and providing emergency care for all mothers and newborns with complications, would dramatically impact outcomes. So, why has the maternal mortality rate not reduced over the last two decades?
Jeremy Shiffman, Ph.D., a political scientist and researcher at Syracuse University, attempted to answer that question, marking the 20th anniversary of the Safe Motherhood Initiative. In an article (with Stephanie Smith) published in October 2007 in 'The Lancet', Shiffman posited that four key factors were at play: the need for strong institutional and individual leadership; the need to frame maternal health appropriately for both "internal" and "external" audiences; the need for greater political will inspired by compelling framing; and the need to understand the characteristics of the issue per se.
At a recent forum sponsored by the Wilson Center in Washington, D.C., entitled 'Global Health Spending: Why Maternal Health is Not a Political Priority,' Shiffman noted that there is growing policy cohesion but reiterated problems around charismatic leadership, weak mobilization of civil society, and the lack of a unifying "frame" aimed at political commitment and subsequent action. Increasingly that framework is both an economic one as well as one designed to focus on social justice. Every year, according to the U.S. Agency for International Development, an estimated $15.5 billion in potential productivity is lost when mothers and newborns die.
When the World Bank, the World Health Organization (WHO) and the United Nations Population Fund (UNFPA) launched the Global Safe Motherhood Initiative, the goals were to inspire efforts that would reduce maternal mortality by half by the year 2000. In 2000, the United Nations announced a set of Millennium Development Goals (MDGs) aimed at poverty alleviation by 2015. Maternal health got its own MDG with goal number five being the reduction of the global maternal mortality ratio by 75 per cent over 1990 levels by 2015. The consensus today is that MDG-5 has shown the least progress of all the MDGs.
However, the MDGs did stimulate renewed activity. They fostered dialogue among uneasy or competing entities such as abortion advocates, AIDS activists, human rights feminists, and those who focused on public health policy on behalf of women or newborns. The United Kingdom's development agency and other donors increased funds for maternal and newborn health. Political leaders in India and Nigeria talked publicly about MDG-5. But women continued to die in the face of funding shortfalls and lagging political will.
As pressure built to address the continuing tragedy of maternal mortality, critical alliances were formed. Among them, in 2005, was the Partnership for Maternal, Newborn and Child Health (PMNCH), an amalgam of groups committed to the continuum of care. Not without its critics and internal squabbles, PMNCH has nevertheless provided a useful umbrella and other initiatives have followed.
Last year, UNFPA, UNICEF, WHO and the World Bank agreed to organize a concerted, strategic alliance aimed at harmonizing approaches by UN agencies to improve maternal and newborn health at the country level, and to jointly raise necessary resources. And recently the White Ribbon Alliance (WRA) announced its 'Mothers Day Every Day' campaign in partnership with CARE. Sarah Brown, wife of the British prime minister, is an active force in the WRA.
The Washington, D.C.-based NGO Gender Action actively monitors international financial institutions to assess their programmatic work as well as their still insufficient funding of reproductive health.. Meanwhile, Denmark, Sweden, Norway, the Netherlands and Germany are among countries strongly supporting comprehensive reproductive health services and overall health infrastructure in the developing world.
EngenderHealth, an international reproductive health organization in New York, has just received a three-year, $11 million grant from the Bill & Melinda Gates Foundation to coordinate the Maternal Health Task Force Project. Its mandate is to shape collective efforts in improving maternal health worldwide by facilitating dialogue and consensus around programmes and policies, research and evaluation, and advocacy. "This is a process-oriented project," informs Dr Ana Langer, President and CEO of EngenderHealth. "We want to see pragmatic action as a result of targeted debate. We must find ways to translate knowledge into action and to build communities that work well together. The time is right. Governments are feeling the pressure."
Ann Starrs, President of Family Care International in New York, agrees. "While some regions have experienced relatively significant declines in their maternal mortality rates since 1990, it is nowhere near enough. Donors and governments haven't invested sufficient resources in the programmes and strategies that are essential to reducing maternal mortality."
Despite continuing challenges such as those posed by Dr Shiffman and others, and the fact that "this is still seen as a women's issue", Starrs is cautiously optimistic about the future. "There is greater internal cohesion and collaboration around this issue than I've seen in the past 20 years. The last 12 to 18 months have seen a significant change in terms of awareness, high-level political attention, and celebrity engagement.. We're at the cusp of real change," she says.
"The challenge today," Starrs adds, "is how to get the money to where it needs to go - to invest in short- and long-term solutions that we know are essential to reducing maternal mortality. It is unconscionable that one woman out of every seven in Niger will die from pregnancy-related complications compared to one in 48,000 in Ireland. Yes, we're facing a global economic crisis and there are many problems calling for attention. But an investment of $7 or 8 billion per year will save the world $15 billion in productivity that we lose annually through maternal and newborn deaths. That's not charity; it's a smart investment."