Scenes like these are repeated around the developing world with stunning regularity. Every minute a woman dies in pregnancy and childbirth; every year nearly 540,000 women los their lives to complications during pregnancy and childbirth. The vast majority of these deaths are preventable when women have access to vital health care before, during and after childbirth.
Most of this maternal morbidity and mortality could be stopped with coordinated action, sufficient resources, strong leadership and political will. Providing access to comprehensive reproductive health services (including family planning and safe abortion), ensuring skilled care by midwives during pregnancy and childbirth, and providing emergency care for all mothers and newborns with complications, would dramatically impact outcomes. So why has the international community not been more successful in reducing the maternal mortality rate over the last two decades?
Jeremy Shiffman, a political scientist at SyracuseUniversity, attempted to answer that question two years ago on the 20th anniversary of the Safe Motherhood Initiative. In an article in The Lancet (Oct. 2007), Shiffman suggested four key factors were at play: the need for strong leadership; the need to frame maternal health appropriately; the need for greater political will; and the need to understand the issue itself.
Recently, Dr. Shiffman noted that there is growing policy cohesion but reiterated problems around leadership, weak mobilization of civil society, and the lack of a unifying "frame" aimed at political commitment and action. Increasingly that frame is an economic one: Every year an estimated $15.5 billion in potential productivity is lost when mothers and newborns die.
When a number of United Nations agencies launched the Global Safe Motherhood Initiative in 1987, its goals were to raise awareness about the half million women dying every year from childbearing and to inspire efforts to reduce maternal mortality by half by the year 2000. Over the next decade, maternal mortality reduction remained high on the rhetorical agenda of the international public health community. Articles were written, conferences held, grants awarded.
In 2000 the United Nations announced the Millennium Development Goals (MDGs) aimed at poverty alleviation by 2015. Maternal health got its own MDG: Goal five was the reduction of the global maternal mortality ratio by 75 percent over 1990 levels by 2015. The consensus today is that MDG-5 has shown the least progress of all the MDGs.
The MDGs did foster dialogue among competing entities such as abortion advocates, AIDS activists, human rights feminists, and those who focused on public health policy on behalf of women vs. newborns. Development agencies and other donors increased funds for maternal and newborn health. Political leaders in India and Nigeria talked publicly about MDG-5. And still women died 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, the Partnership for Maternal, Newborn and Child Health, an amalgam of groups committed to the continuum of care.
In 2007, a global Women Deliver Conference took place in London. Attended by 1500 parliamentarians, donors, public health professionals, and others, it helped establish key linkages between maternal health, reproductive health and choice, education, economics, gender issues, and human rights.
In 2008, UNFPA, UNICEF, WHO and the World Bank agreed to organize a 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.
The White Ribbon Alliance (WRA), an international coalition established in 1999 to advocate for quality health care before, during and after childbirth, recently announced its "Mothers Day Every Day" campaign in partnership with CARE. Sarah Brown, wife of the British prime minister, is an active force in WRA.
EngenderHealth, an international reproductive health organization, 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 programs and policies, research and evaluation, and advocacy. "We must find ways to translate knowledge into action and to build communities that work well together," says Dr. Ana Langer, President of EngenderHealth. "Governments are feeling the pressure."
Ann Starrs, executive vice-president of Family Care International, agrees. "While some regions have experienced declines in their maternal mortality rates since 1990, it is nowhere near enough. Donors and governments haven't invested sufficient resources in the programs and strategies that are essential to reducing maternal mortality. These strategies need to be implemented along with efforts to improve health services overall, and be linked to efforts addressing factors like gender inequality and poverty."
Despite continuing challenges including the fact that "this is still seen as a women's issue," Starrs is optimistic. "There is greater internal cohesion and collaboration around this issue than I've seen in the past twenty years," she says. "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."
"The challenge today," she adds, "is how to get the money to where it needs to go. 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. But an investment of $7 billion per year will save the world $15 billion in lost productivity. That's not charity; it's a smart investment."