Delivering Women from Death,
The Expert View
What kills 342,900 women worldwide every year, while no man is ever at risk of being targeted? Childbirth and pregnancy-related complications, of course. One of the major goals of the Millennium Development Goals (MDGs) that were accepted by 192 governments around the world a decade ago is the reduction by the year 2015, of the Maternal Mortality Rate (MMR) by 75 per cent.
As that deadline nears, researchers are finally reporting a drop in the global MMR figures. Findings of a study published in 'The Lancet' in April reveal that there were 342,900 deaths worldwide in 2008, down from 526,300 in 1980. The study, led by Dr Christopher Murray of the Institute for Health Metrics and Evaluation at the University of Washington, assessed levels and trends in maternal mortality for 181 countries. However, these findings appear to contradict the figures of a World Health Organisation (WHO) study last May, which indicated that mothers and newborns are no more likely to survive now than 20 years ago.
Whatever the figures may be, the fact is that maternal mortality remains a major challenge to health systems worldwide and that only 23 countries are on track to achieving the 75 per cent reduction goal.
At an international symposium held recently at the Harvard Law School in Boston, USA, experts drawn from different continents unanimously conceded that the world seems "woefully far from that target". The office of the UN High Commissioner for Human Rights, UNICEF and the University of Oslo were the co-sponsors of these deliberations.
As Mary Robinson, former President of Ireland and former UN High Commissioner for Human Rights, observed at the symposium, "Becoming pregnant is a health risk! And not addressing the need for reducing maternal deaths amounts to human rights violations, no less." In her plenary address, South African Navanethem Pillay, U.N. High Commissioner for Human Rights, agreed with Robinson: "This is a violation of human rights, the right to life," she declared.
According to WHO estimates, in addition to the women who die in childbirth, a further eight million women experience lifelong health complications following childbirth. Under the MDGs, reducing MMR was one of the eight main areas of action. The statistics are stark and eloquent - while globally the reduction average is now pegged at 35 per cent, as per the latest study, even this modest figure masks the wide disparities among regions and within countries.
India leads the world in MMR with 683,000 annual deaths (the figures have come down marginally as per the latest study). The US has an overall MMR of 13 per 100,000 live births but among women in New York City's Black community, it is 78. Japan has a MMR of 8 and Egypt 84. (By comparison, estimates for India vary from 250 to 450.) The South Asian region reduced MMR from 650 to less than 500 between 1990 and 2010, with a target of 160 set for 2015, which the region has no chance of reaching, given current trends.
Take India's case. The Eleventh Five Year Plan (2008-2012) included a goal of reducing MMR to under-100 per 100,000 live births, but current estimates are much higher. Also, the disaggregated figures for rural areas and tribal communities are higher than those for urban regions, because of the lack of access to medical services. Less than 48 per cent of births in India are attended by skilled personnel but this again masks figures of 84 per cent among the richest 20 per cent of the population, and only 16 per cent among the poorest 20 per cent.
Poverty is one reason for high MMR and reducing poverty is listed as the first goal among the MDGs. But there is more to the pathetic record on maternal mortality than mere lack of resources. Migration of health workers (doctors and nurses) from India and African countries seeking higher earnings in the developed countries is a major factor. WHO is planning to introduce a draft code at the forthcoming World Health Assembly suggesting tighter control on migration/recruitment.
But what happens to the right of a doctor or nurse to seek employment wherever the remuneration is better? The Harvard symposium included discussions on whether the MDGs and Human Rights covenants converge or clash. The consensus was that there need be no contradiction if development got redefined as betterment that went beyond indices of economic growth and increments in money incomes.
When there was a proposal to make a stint in the rural areas mandatory for medical personnel in India, doctors protested widely because they feared their earnings would be badly affected. Ethics therefore comes into the picture, along with the distributive aspects of economic growth. Thanks to lopsided development that has brought sizeable industrial and economic growth but has left the poor poorer, there are state-of-the-art medical facilities in the world's metropolises, even while pregnant women in the interiors die because no medical help is available when complications develop. Interestingly, Tajikistan, with a low per capita income, has reduced MMR from 100 to 8 in a decade, thanks to the dispersion of health workers in all regions of the country.
When we talk of a 75 per cent reduction in MMR, then, are we focusing on the high MMR among rural women or on the relatively better record in the cities? Do averages make sense in societies marked by wide disparities? Distributive justice has been, in fact, identified as the main determinant in achieving the MDGs, rather than just rising incomes.
Reducing MMRs also means exposing women to fewer pregnancies, which in turn means extending their reproductive rights and granting them the right to decide how many children they want, and when. When former US President, George Bush, imposed a gag rule that cut off funding for NGOs overseas that provided abortion options as part of health services, developing countries, especially in Africa, saw a spurt in maternal mortality because women were unable to get abortions and turned to quacks. Women's groups worldwide protested this gag rule. But what has not helped is the confrontation between pro-life and pro-choice lobbies that has been going on for years. Ultimately, it's the women who end up paying with their lives.
So, what needs to be done for expectant women? More doctors and better distribution of medical personnel in the rural areas, better pay for health workers in rural areas, changes in social attitudes, and a stronger political will to ensure increased budget allocation for the health sector, that is what the experts advocated. "When financial companies had to be bailed out during the recent recession, governments had no trouble handing out funds in billions but when it comes to health budgets, there is never enough money," African academic-activist Fantu Cheru, pointed out, during the symposium.
Only a multi-pronged exercise on all fronts can help us get closer to the target of delivering more women all over the world from death.
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