Barbara K. Herz and Anthony R. Measham
Every year about 500,000 women die as a result of complications associated with child-bearing. This would be the number of fatalities if a jumbo jet with 250 women of reproductive age aboard were to crash every four hours every day, an analogy presented at a 1985 meeting arranged by the World Health Organization on the subject of maternal mortality. Almost all of these deaths are preventable. Apart from the emotional loss of so many mothers, many of them still in their teens, the economic losses to their families and the economies of the Third World are enormous.
These concerns led the World Bank, WHO, and the United Nations Fund for Population Activities to sponsor a conference on Safe Motherhood hosted by the Government of Kenya. President Daniel arap Moi opened the Nairobi conference on February 10, 1987 with a speech emphasizing the high priority of maternal health problems for his government. The aims of the conference included drawing attention to maternal health needs in the developing world, devising strategies for improving women’s health, and launching effective and affordable programs toward these ends. The conference was attended by health ministers and senior officials from about 30 developing countries, and representatives from multilateral and bilateral development agencies and nongovernmental organizations.
Maternal mortality and sickness
Maternal mortality is the leading cause of death among young women in many developing countries, accounting for one fourth to one half of deaths among women of child-bearing age. Nearly half these deaths occur in South Asia and some 30 percent in Sub-Saharan Africa. Poor women and their families suffer most from death and illness associated with childbearing. For every woman who dies, there are at least ten others whose health is seriously impaired. At least one child death is also associated with the death of a mother, either the child she is carrying or other young children left without the care of a mother.
The causes of maternal ill-health and death are numerous. Hemorrhage, sepsis, toxemia, obstructed labor, and abortion together account for most maternal deaths in those developing countries where reasonably reliable studies have been conducted. Hemorrhage is generally the leading cause of death, accounting for about one third of deaths in the only study that included rural home deliveries in India and over half of all deaths in studies in Indonesia and Egypt.
The risk of death from each of these causes, in turn, reflects several underlying factors. First, the absence of family planning and prenatal care that could preclude or minimize the emergence of problems such as abortion, sepsis, and obstructed labor, among other difficulties; second, the lack of trained personnel to treat adequately problems such as hemorrhage and septicemia in the home or local health clinic; and third, the speed with which childbirth-related emergencies such as hemorrhage can develop. In addition, the availability and accessibility of community level health facilities, emergency transport, and referral facilities affect maternal mortality.
Poor socioeconomic conditions clearly increase the risk of illness during a woman’s reproductive years and contribute to the causes of pregnancy-related death; nutrition and health status, and educational level indirectly and directly affect the health of women. Underlying these longer-term factors is the status of women in many developing countries, where women tend to be a disadvantaged group, in spite of the fact that they contribute very substantially to the economy directly and indirectly.
Convergence of views
The important role of women in development and the need to set up mechanisms to prevent ill-health and death resulting from childbirth and related factors were stressed in speeches by the President of the Bank, Barber Conable; WHO Director General, Dr. Halfdan Mahler; UNFPA Deputy Executive Director, Dr. Nafis Sadik; and the Administrator of the United Nations Development Programme, William Draper III. In his speech, Mr. Conable noted the Bank’s plans to involve women more fully in the development process and to address women’s issues in policy dialogue with member countries (see excerpts in box).
Summing up the views of participants, the moderator of the conference proceedings, Dr. Fred Sai of the Bank, said “There must be a commitment to stop these deaths. We need to mobilize the political will, to mobilize community involvement among men and women, and to implement specific programs to stop these tragedies from taking place.”
The conference called for action on four fronts.
• First, improve economic opportunities for women. This could be done through income-generating activities, education and training, improved nutrition, and increased production of subsistence crops. Such actions will also assure that the next generation of mothers are stronger, healthier, and more knowledgeable when they enter the child-bearing years.
• Second, strengthen health services at community level—to provide prenatal care, more effective help during delivery, and family planning. Prenatal care can help reduce anemia and otherwise strengthen women; it can also help prevent problems before they become costly and difficult to manage, by identifying women at high risk so that they can be referred to clinical facilities before childbirth.
• Third, strengthen maternal health care at the first referral level of health facilities, usually the district hospital. Women with high-risk pregnancies or women developing serious complications during pregnancy need more advanced medical care, if they are to survive.
• Fourth, develop an “alarm” and transport system that would link the community level and first referral services, so that women with high risk pregnancies or obstetrical complications could be attended to rapidly.
Half the women who would otherwise die in pregnancy could be saved within a decade if all these recommendations were to be put into effect.
The proposed Safe Motherhood health services should cost no more than $2 per capita per annum, compared with about $9 per capita now being spent for all health care in low-income countries. Many countries already provide some of the recommended services so that additional costs would be modest. Other measures—public information campaigns, health education through schools, mobilization of political leadership—would also help.
To help launch a “safe motherhood” initiative, Mr. Conable pledged that the Bank would roughly double its annual lending for population, health and nutrition activities by 1990, reaching up to $500 million, with projects in some 50 countries that would address maternal health along with other health needs. Discussions on projects to use those funds are already under way in many countries in Africa, Asia, and Latin America. The Bank and UNDP announced that each would contribute $1 million toward a $5 million fund for operational research on Safe Motherhood to be managed by WHO.
The Bank is also planning other activities to carry forward the work and aims of the Nairobi Conference. These include seminars for policy makers; an information campaign and public relations work; cooperation with the nongovernmental organizations and research community; and liaison with other agencies.
Overall, the conference exceeded expectations in focusing the attention of developing countries and international donors alike on maternal health. The challenge now is to implement the Conference’s “Call to Action.”
“A new commitment to common decency and common sense”
Excerpts from a speech by Barber B. Conable, President of The World Bank and International Finance Corporation, to the Safe Motherhood Conference, Nairobi, Kenya, February 10, 1987:
We are not here just to publicize a problem. We are here to attack it, to save lives, and to build better ones….
Common decency tells us that it is intolerable that 1,400 women die every day in the process of carrying or delivering their children. And common sense tells us that those needless deaths waste not only precious lives but precious human resources.
All over the world women are the sustaining force of families, communities, nations. In the Third World women must also be full, forceful partners in sustaining development….
The World Bank will do its part. We have already started intensifying staff involvement in issues affecting women. Through the Bank’s advisory, lending, and research efforts, we will place far more emphasis on the role of women in development. In cooperation with our member countries, we will make that emphasis operational.
Let me mention a few specific steps the Bank will undertake.
•We will prepare action plans on women in development for our lending programs in selected countries, so that our agricultural, industrial, educational, and health programs promote women’s progress along with other development goals.
• We will emphasize issues affecting women in our dialogues with member countries.
• We will encourage development policies that provide appropriate incentives for women and ensure that women have the means to respond.
• We will develop program initiatives in agricultural extension and agricultural credit targeted for women, and expand credit and training for women to improve their employment prospects outside agriculture.
• We will help promote both formal and informal education for women and girls.
• And we plan to double our lending for population, health, and nutrition activities….
In addition, we plan to help establish a Safe Motherhood Fund under the management of the World Health Organization to undertake operational research that will support the development of country programs and projects in the maternal health field. We plan a contribution of $1 million toward the proposed three year budget….
Through the joint efforts of the developing countries, the Bank, other donors, nongovernmental organizations and private groups, we can reduce by half the number of women who die in pregnancy or childbirth by the year 2000.
We believe that this initiative will advance the health, the dignity, and the productivity of women in the developing world and the coming generations that depend on them.