Women’s health is a critical factor in development. Some early progress, but the major challenge still lies ahead
Consider the magnitude of these statistics. Every minute of every day a woman dies from complications related to pregnancy or childbirth. This adds up to half a million deaths every year, with 99 percent of these taking place in the developing world. In addition, countless more women suffer from illnesses caused or aggravated by pregnancy, such as anemia and malaria, or sustain permanent disabilities. Both the human suffering and the economic costs associated with these illnesses and deaths are enormous.
In 1987, international and regional agencies and national governments launched the global Safe Motherhood Initiative, with the goal of reducing maternal mortality and morbidity by at least half by the year 2000. Over the last four years, international and national support has certainly been mobilized, and plans and programs have begun to translate rhetoric into action. But the transition from advocacy to implementation has not been an easy one, and a great deal more needs to be done—and quickly—if the Initiative is to succeed.
For a fuller discussion, see “The Safe Motherhood Initiative,” by Barbara Herz and Anthony R. Measham, World Bank Discussion Paper No. 9, May 1987, as well as “Maternal Health and Development,” by Herz and Measham, in Finance & Development, June 1987.
Rationale for the Initiative
Initially, the impetus behind the Safe Motherhood Initiative rested on the high toll that motherhood took on women’s lives in developing countries. Although in recent years, there has been a dramatic decline in the mortality rate of children under five years of age, the gap between maternal mortality ratios (maternal deaths per 100,000 live births) in the developed and developing countries remains wider than for any other health indicator. Certainly, the problem is worst in Africa and South Asia, where the risks of childbearing are compounded by women’s low social and economic status and high fertility, and the period from the first pregnancy to the last often spans more than half a woman’s lifetime. Indeed, African women have a one in 18 lifetime risk of dying from pregnancy-related causes, compared with a one in 10,000 risk for women in northern Europe.
In recent years, it has become increasingly clear that policies and programs to improve maternal health are not only humanitarian but also economically sound. Data on women’s contribution to development, although still sparse, indicate that women are responsible for more than half the food produced in the developing world and constitute one third of the world’s official labor force. They are also responsible for providing 70–80 percent of all health care in developing countries, and, of course, bear principal responsibility for maintaining the home and caring for society’s dependents—children and the elderly.
What we have also come to recognize—as reflected in the inclusion of maternal mortality reduction goals at the World Summit for Children in 1990—is that child survival and well-being begins well before birth, with the health status of the girl who becomes a mother. Not only is maternal health an important priority in its own right, it is also the determining factor for the development prospects of future generations. The death of a mother in a poor family in the developing world is a virtual death sentence for her infant and, often, for her older children (especially if they are girls). A study in Bangladesh, for example, found that—compared to mortality rates of children up to the age of ten years without a parent’s death—the death of a mother was associated with almost a 200 percent increase in the mortality of her sons and a 350 percent increase in the mortality of her daughters. Moreover, when mothers are malnourished, uneducated, and in poor health, their children face a higher risk of either premature death or continuing in a hopeless cycle of poverty.
Fortunately, effective and relatively low-cost approaches exist to prevent and treat the complications of pregnancy and childbirth, so that there is no excuse for development programs to continue to neglect this vital issue, as has been the case in the past. Moreover, a recent Bank study—which compared the range of possible interventions to reduce premature death and the burden of disease among adults and children—shows that maternity care is one of the most cost-effective approaches for adults and children alike. Indeed, it is the second most cost-effective way to improve child health, the first being the immunization of infants against measles.
What exactly do we mean when we talk about safe motherhood? A growing consensus is now developing that it involves a package of interventions, tailored to each country’s conditions, that meets four objectives: preventing unintended pregnancy, managing unwanted pregnancy, reducing the likelihood of complications during pregnancy and labor, and improving the outcome for women who develop such complications. The emphasis should be on selected maternal health care and nutrition measures and an expansion of family planning services. But for lasting gains to be made, these activities must be complemented by efforts to improve women’s general health, education, and socioeconomic status. All safe motherhood programs should include the following four elements:
Family planning. This improves women’s health and reduces maternal mortality by helping women prevent unanticipated and high-risk pregnancies. In Bangladesh, for example, maternal mortality would decrease by an estimated 60 percent if all women who wanted to prevent pregnancy had access to and used contraceptive services. Programs should include education on the health risks of bearing children too early, too frequently, and too late; basic family planning information; a wide variety of contraceptive methods; and information and services related to sexually transmitted diseases.
Management of abortion. Primitive, clandestine, induced abortion is responsible for at least 200,000 deaths annually in the developing world and constitutes the principal cause of maternal death in some countries. In addition to primary prevention through family planning, these deaths could be averted by providing the facilities to treat the complications that result from unsafe, illicit abortions, and by providing access to safe abortions where these services are legal. Efforts to reduce unwanted pregnancies and unsafe abortion could also save billions of dollars in health care costs.
Safe pregnancies. Essential services needed by pregnant women at the local level include community-based prenatal care (e.g., health and nutrition education, and early detection of problems and referral), trained attendance at delivery (e.g., the use of aseptic techniques), and postpartum support and counselling (e.g., advice on early initiation of exclusive breastfeeding and early detection of postpartum complications).
Management of obstetrical emergencies. At a minimum, this includes first-aid measures at the community level, an “alarm” and transfer system to take patients to the nearest center equipped to deal with complications, and a district hospital or health center equipped for essential obstetrical functions.
Progress to date
With only four years since the launching of the Safe Motherhood Initiative, it is too early to expect solid evidence of a reduction in maternal mortality, especially in view of the difficulty of documenting such changes. However, awareness of the magnitude of maternity mortality has increased, and a growing commitment is evident at both the international and national levels, as exemplified by the sharp rise in the number of World Bank-assisted projects with safe motherhood components—from nine in fiscal year 1986 to 65 by fiscal year 1991.
On the international level, most aid agencies and governments, as well as many nongovernmental organizations (NGOs), have now made safe motherhood a priority and are working together to coordinate strategies and exchange information. Building on the success of the international conference in Nairobi, the Bank and its partners have sponsored a series of regional and national conferences on safe motherhood, organized by Family Care International—70 African, Asian, and Middle Eastern countries have participated to date, and the number should approach 100 by the end of 1992, following seminars in Latin America and the Caribbean.
These workshops—combined with international and national commitments to strengthen safe motherhood programs—have already resulted in a substantial increase in maternal health activity by governments, international agencies, and NGOs. For example, a conference in Indonesia in 1988 led to a Ministry of Health initiative to develop a national safe motherhood strategy, involving the training of thousands of midwives for deployment to rural areas, with Bank and other donor assistance. Action plans developed at a regional conference in Niger in 1989 led to strengthened support for maternal health in francophone Africa, including Bank-assisted projects in Benin, Mauritania, Niger, Rwanda, Senegal, and Togo. At a conference in Tanzania in 1990, the Government stated its commitment to modify its national policy requiring pregnant school girls to drop out of school.
Other national initiatives, which reflect the differing needs and priorities of various regions and countries, include:
• in Bangladesh and India, programs are moving beyond family planning to integrated maternal and child health services, emphasizing prenatal care, trained assistance at deliveries, and iron supplementation to reduce anemia;
• in Zimbabwe, thanks to a relatively well-developed infrastructure, the emphasis is on midwifery training and facility-based deliveries; and
• in Northeast Brazil, where per capita expenditure on health is relatively high, the emphasis is on targeting services to low-income areas, along with paying greater attention to broader reproductive issues (e.g., breast and cervical cancers, and sexually transmitted diseases).
NGO activities at the national level have also contributed importantly to the effort. In many countries, local women’s associations have been strengthened and are using their clout to demand increased access to health, education, and financial services, as well as to promote specific safe motherhood activities. In 1989, for example, a consortium of women’s NGOs in Uganda formed the Safe Motherhood Coordinating Board to develop and implement a safe motherhood strategy, which aims to double the number of women who receive adequate prenatal and postnatal care.
In an effort to improve the delivery of these various safe motherhood programs, the Bank and its partners launched the Safe Motherhood Operational Research program three years ago. The program, which is managed by WHO, has developed a series of technical guidelines (on essential obstetric functions, for example) and supports studies on safe motherhood issues. Some of these research efforts have already provided an effective way to involve health planners, clinicians, and families in safe motherhood programs. In Nepal, for example, a study of the dominant role of mothers-in-law in pregnancy-related care resulted in a national seminar in early 1991 and plans for targeted health education programs to improve these women’s understanding of danger signs during pregnancy and labor.
In the process of helping launch such programs, the Bank has increased its understanding of the importance of what works and why. In addition, it has found that the Safe Motherhood Initiative provides a useful framework for stimulating discussion of previously sensitive or neglected subjects, such as adolescent fertility, unsafe abortion, early age of marriage, nutrition and education of girls, and other issues related to women’s social and economic status.
Family planning. While there was ample evidence from research over the last two decades that family planning had a substantial impact on child survival, we now recognize the importance of family planning to the health and well-being of women. For example, a study in Matlab, Bangladesh, showed that after nine years of extensive family planning efforts, the rate of maternal deaths per 100,000 women of reproductive age in the project area was only half as high as in the nearby “control” area. We have also learned that family planning works best when provided as part of a broader approach to women’s health and development. In Sri Lanka, family planning, combined with expanded maternity care and female education, helped reduce maternal mortality from 555 to 90 deaths per 100,000 live births over the last 30 years.
Abortion management. Unsafe conditions are responsible for millions of deaths, and those numbers are increasing in some countries—Brazil, for example. When contraception and abortion were illegal in Romania in 1988, the maternal mortality ratio was estimated at 159 deaths per 100,000 live births, 86 percent caused by complications from unsafe abortion. After legalization, the frequency of abortion persisted due to scarcity of contraceptive information and supplies, although the mortality rate fell by 50 percent in 1990.
Maternity care. We have also begun to examine more closely the cost, effectiveness, and impact of maternal health interventions, in many instances prompting us to rethink the best way to promote safe motherhood. For example, until recently, a great deal of effort was devoted to screening pregnant women to identify those at high risk. But as it turns out, most of the women who die of pregnancy-related causes do so as a result of unanticipated complications, and most who have “risk factors” actually do not develop life-threatening complications. Thus, risk screening is a useful tool, only if it is combined with monitoring, referral, and treatment to deal with complications as they develop, whether predicted or not.
At the same time, we have found that other types of interventions that were not taken seriously merit a second look. This includes community-based approaches in high mortality areas where infrastructure is weak. A recent study in Bangladesh, for example, shows that the posting of trained midwives in villages led to a 68 percent decline in maternal mortality over a three-year period, beyond the reductions achieved during the earlier period due to family planning. The Bangladesh study also underscores another lesson: While maternal health programs may rely primarily on doctors and traditional birth attendants, the trained midwife often plays the critical role in saving mothers’ lives.
Underlying causes. We have learned that maternal mortality results not only from direct medical causes but also from the underlying social, cultural, and economic environment in which women live. Thus, education and services need to be based on an understanding of women’s perceptions and circumstances if we are to improve attitudes and practices at the household level and enhance the utilization of appropriate services. Cultural taboos in parts of South Asia, for example, render the diets of pregnant women deficient in iron and other essential nutrients. Exacerbating matters is the fact that in many countries, it is not the women themselves who decide whether to utilize maternal health services. In Senegal, for example, a study found that only 2 percent of the women interviewed said they would decide for themselves to seek care in the event of obstetric complications—for most, this decision would be made by their husbands.
Integrated approach. While the Initiative resembles the family planning and child survival initiatives in focusing attention on a specific health need, it is taking an integrated rather than more vertical approach, building on the existing systems. This reflects what we have learned about the critical interactions between family planning, women’s overall health and nutrition, and maternal and child health. It also takes into account the linkages between the various levels of the health system, the important role of NGOs, and the need for coordination with other development sectors (e.g., education, transportation, and agriculture). A lack of transport, for example, is often the missing link between an obstetric emergency in the community and life-saving skills at the referral center.
As the Safe Motherhood Initiative moves increasingly from advocacy to implementation, donors and policymakers alike will have to confront several major challenges, some of which can be overcome more easily than others:
• Political commitment must be maintained and expanded and the necessary resources allocated. This requires a focused, goal-oriented plan (with specific indicators of progress toward the maternal mortality reduction goal), as well as a recognition that sustained improvements in maternal health require more than a short-term medical approach;
• There is an urgent need for better data on the extent, causes, and distribution of maternal morbidity and mortality, the social impediments to improvements in women’s health, the status of health delivery systems, and the relative effectiveness, impact, and cost of different interventions; and
• Most important, efforts to plan and implement programs at the field level need to be accelerated.
Complicating matters, safe motherhood will have to be achieved in different ways in different regions. In Africa, the priorities include improving the infrastructure, upgrading family planning information and services, and training maternal care providers, including midwives and more general practitioners. In Asia and parts of North Africa and the Middle East, the pervasive cultural obstacles have to be surmounted. In Latin America, policies and programs should address the increasing problems of adolescent fertility and abortion, along with improving the efficiency and outreach of maternal health and family planning services. Finally, in Eastern Europe, where abortions outnumber births, information on contraception, as well as the contraceptives themselves, must be much more widely disseminated. In all regions, the involvement of NGOs will be important as a complement to governmental efforts.
Although donors can do much to help, in the end, success will mainly rest on the countries themselves—on favorable national policies, the proper setting of priorities, the allocation of necessary resources, and the design of cost-effective programs. The choice as to which programs receive funding and how that funding is targeted within programs will be—for many women—a choice between survival and death.