Oxfam Brief on Maternal Mortality

Although more than 90 per cent of maternal deaths are preventable, pregnancy remains the leading killer of women in their reproductive years in developing countries. More than half a million women die each year in pregnancy and childbirth. In 2000, the international community signed on to the Millennium Development Goal #5 to reduce maternal mortality by 75 per cent before 2015. That goal is achievable; indeed, it is a conservative target. Many countries, rich and poor alike, have succeeded in lowering maternal mortality rates far more rapidly than that. To bring down the numbers of mothers dying requires action in three crucial areas: 1) significantly higher investment in public health systems, including measures to make primary care free; 2) specific investment in reproductive health services; and 3) measures to enhance gender equality, so that women can make use of improved health services. This brief offers background on the scale of the problem, the causes of maternal mortality and examples of proven solutions, drawing on Oxfam’s experience in more than 100 developing countries. The scale of the problem – some shocking facts • Every minute of every day, a woman dies in pregnancy and childbirth – adding up

to more than half a million deaths each year. For every woman who dies, 30 more suffer chronic illness or disability as a result of pregnancy or childbirth.

• Children without mothers are three times as likely to die before their fifth birthday; they often enrol in school late and leave school early.i

• In some places, maternal mortality is worsening. Liberia’s maternal mortality rates went up by a staggering 71 per cent between 2001 and 2006,ii even while infant mortality rates improved.

• Cost remains a major barrier to care. In Burkina Faso, a normal delivery costs nearly half a poor family’s annual income, a caesarean 138 per cent of yearly income.iii

• Risk is unacceptably high. In Afghanistan, a woman giving birth is more than three times as likely to die as a Canadian soldier in action.

• Change is possible. Sri Lanka, Egypt, Thailand, Malaysia, Nepal and Honduras all slashed their maternal mortality rates in less than 10 years.

• Long-term investment in health care is critical. Just one more midwife could save the lives of 219 women.iv $1 million invested in family planning could avert 360,000 unwanted pregnancies, prevent 150,000 abortions and save the lives of 800 mothers and 11,000 infants.v

• Gender inequality lies at the heart of the problem. Women and girls have less education, assets, services and security; 12 per cent of women suffer domestic violence during pregnancy.vi

Maternal mortality explained The causes of maternal mortality are multi-faceted and deeply engrained in both gender inequalities and decades of under-investment in public health care. Medical diagnosis

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Worldwide, 80 per cent of maternal deaths are caused directly by complications during pregnancy, delivery and after delivery. The four major killers are: bleeding, infections, unsafe abortions and obstructed labour.

The medical solutions to avoiding or managing these four major killers are well known. In most cases, basic health care intervention in the form of a trained midwife, with obstetric equipment and medicines, and a well-equipped referral hospital staffed by trained doctors will save the mother’s life. Severe bleeding in the third stage of labour can kill a healthy woman in just two hours. An injection of the drug oxytocin, given immediately after childbirth, dramatically reduces the risk of bleeding. Risk of infection is significantly reduced if delivery is carried out by a trained midwife in a clean environment. Unsafe abortions are a major cause of maternal deaths (13 per cent). The costs are borne not only by the woman but also by the families and communities left behind. The financial cost of treating the complications of unsafe and illegal abortions is also a burden on the health system. Inequality at the heart of the problem Outside of the four direct causes of women’s death in pregnancy and childbirth, women’s inequality and over representation among the world’s poorest puts them at high risk. Chances of suffering pregnancy complications are increased by:

• Poor nutrition and poor access to basic health care over a lifetime. • HIV and AIDS, which in sub-Saharan Africa disproportionately affects women.vii • Early marriage: Girls 15–19 are twice as likely to die in childbirth as women aged

20–30. • Lack of education: Women who complete primary education marry later, exercise

better birth control and are more likely to use modern health services.viii Progress on achieving gender equality will enable women and men to make informed choices about the size of their families, contributing to lower maternal deaths and to improved health of the population in general. A trained midwife is not a luxury Properly trained, paid and supported, midwives offer the most effective path to universal access to maternal health care. Nowhere is this clearer than in the poor countries that have achieved dramatic improvements in maternal health.

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In Sri Lanka, where most of the population lives below the poverty line, the government made a commitment to strengthen the entire health-care delivery system. This has produced a reliable referral systems for complicated deliveries, with health services, including family planning, offered for free or at very low cost. It also means that 97 per cent of all births are attended by a skilled professional. The graph below starkly illustrates the relationship between number of midwives and maternal deaths comparing Niger and Sri Lanka. The lack of trained midwives in Niger means one in seven women die from pregnancy.

Source: WHO, UNICEF, UNFPA and the World Bank (2005)

The United Nations calculates that 700,000 midwives need to be trained to achieve a rate of 85 per cent skilled birth attendance throughout the world.

Barriers to women’s access to healthcare The major reason why women die of treatable medical complications during pregnancy and childbirth is lack of access to the care they need. The barriers are: • Poor quality care

It can be done The decline in maternal mortality in Malaysia and Sri Lanka in the past 60 years was directly linked to the magnitude of health system expenditures. The main lessons are that a modest investment in maternal health services, combined with other poverty reduction measures, leads to a fairly rapid decline in the maternal mortality ratio (MMR), defined as the number of maternal deaths per 100,000 live births. The strategies of Malaysia and Sri Lanka evolved over time, from an initial emphasis on expanding the provision of services, especially in underserved areas, to increasing utilization and, finally, to emphasizing the improvement of quality. Removing financial barriers to maternal care for women was an important step in both countries. Professional midwives constitute the backbone of maternal care in Malaysia and Sri Lanka. Maternal survival in developing countries is feasible when appropriate policies are adopted, focused wisely, and adapted incrementally in response to women’s needs and systems’ capacity.

Source: World Bank. Investing in maternal health: learning from Malaysia and Sri Lanka, 2003

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Public health facilities are often not equipped or staffed by trained workers or they are too far away. Insufficient trained staff and lack of equipment and medicines are the natural results of lack of investment in health services.

• Lack of family planning services Reproductive health services are often not provided in primary health clinics. Nearly one-third of maternal deaths could be avoided if women had access to family planning.ix • Gender inequality Even when quality services exist, women can be prevented from using them by husbands and fathers. • Cost of care Women bear the greatest burden of user fees. Their reproductive role means that they have the greatest need of health services, but in many societies their low status and lack of income mean they are last in line for medical care. Even where delivery is free, women have to pay to get to the facility and may have to pay for supplies, such as gloves or medicines.

What needs to change? Saving the lives of mothers will require more and better funding from governments and donor countries. It will mean repairing and strengthening health systems, as women need access to a variety of services at primary to tertiary level. It will mean investing in more health workers, especially midwives and obstetricians. It will mean making health services free and accessible. And it will mean making health services work for all. Increase investment in maternal health In 2001, African nations committed to spending 15 per cent of government budgets on health. But nine years later, only two countries so far have reached this target. Ministers of Finance and Ministers of Health across all developing countries must together recommit to this increased spending target and outline clear timetables for achieving it.

When care is ‘free’ but the extras are not “Women are often deterred from seeking skilled care at health facilities because they know that – even when they don’t have to pay for treatment – they do have to bring basic supplies, such as gloves and cotton lint. Midwives and nurses in Tanzania are put in the dreadful position of either turning away women in labour – sending them to buy these supplies – or choosing who is the poorest in order to benefit from the few supplies they do have. “Many other women do not have cash - or their husbands or mothers-in-law control the family cash – needed to get to hospital. “Tragically, to transport the body of a woman who has died home from the hospital can be far more costly than the health care she received there. Families in Orissa, India, can face bankruptcy, loss of their land and children going into bonded labour when faced with these kinds of expenses, on top of the loss of a wife and mother. This is a strong argument for making all health services – including transport – free of charge.”

Brigid McConville, White Ribbon Alliance for Safer Motherhood

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Donors must restore public trust and honour their promises to increase aid spending to 0.7 per cent of Gross National Income (GNI) by 2015. They must act urgently with much sharper annual increases to meet the global estimated financing gap for health care of US$36 billion annually, using much of it to scale up maternal, newborn and child health services. Donors and governments must work together to improve the quality and effectiveness of aid. Aid should be long-term and predictable, and, where possible, provided as direct support to government health budgets so that it can be used for recurrent expenditures that strengthen, operate and expand health service delivery. Following evidence-based policies, investment should prioritize primary care that is strongly supported by effective and accessible referral to secondary and tertiary care for the 15 per cent of pregnancies requiring emergency medical intervention.x The trend of increased investment in unproven and risky private sector solutions should cease until convincing evidence is found to suggest that these can improve equitable access and quality of care for women.xi

Make the best use of aid money for mothers Donor and developing countries together should prioritize:

• Removing user fees so that health care is free for all pregnant woman and children • Training, recruiting and retaining the additional 4.25 million health workers needed

worldwide. This must include the 700,000 midwives needed to achieve a rate of 85 per cent skilled birth attendance.xii

• Upgrading emergency obstetric services to a level of at least four basic health care facilities and one emergency facility for every 500,000 people.xiii

• Ensuring a sustainable supply of affordable medicines, by facilitating the production and export of generic medicines.

• Financing comprehensive reproductive health services.

Redress gender inequality

User fees Although fees rarely contribute more than five per cent of running costs for health systems, they have proliferated in all regions. Studies suggest that user fees result in higher maternal and infant mortality rates — in one Nigerian district, the numbers of women dying in childbirth doubled after fees were introduced for maternal health services, and the number of babies delivered in hospitals declined by half. Similar results have been observed in Tanzania and Zimbabwe. Eighteen-year-old Clémentine, from Cibitoke in Burundi, describes the consequences of not being able to pay user fees: “After the delivery I was presented with a bill for 30,900F (around $30). As I didn’t have anything to pay with, I was imprisoned in the health centre... I remained there for a week, in detention, without care and without food. I was suffering from anemia and my baby had respiratory and digestive problems.”

Source: Oxfam International, In the Public Interest: Health, Education and Water and Sanitation for All (2006)

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Gender inequality lies at the heart of poor progress on maternal health. Redressing it requires high profile political commitment from donors, developing country governments and multilateral institutions alike. Health systems can work to uphold women’s right to health and to safe pregnancy if given the mandate to do so. Accountability: maternal mortality as the measure of health systems Setting maternal mortality rates as the key indicator for health systems will provide accountability on whether a country’s health system is upholding women’s right to health and to a safe pregnancy. It would not only prioritize the world’s biggest health inequity, it would also send the message that women matter. Such an explicit national and international commitment would contribute to alleviating the compounding effects of women’s inequality on their chances of surviving pregnancy. The goal set in 2000 to reduce maternal mortality by 75 per cent before 2015 is achievable. Governments must increase spending on the health sector in general and maternal care in particular. Donor countries must provide coordinated, predictable and long-term assistance. And governments and civil society must challenge the policies and practices that impede women’s access to health services and violate women’s right to health. For more information, please contact: Karen Palmer Media Officer Oxfam Canada 613-240-3047 karenp@oxfam.ca Mark Fried, Policy Coordinator Lina Holguin, directrice des politiques Oxfam Canada Oxfam-Québec 613-237-5236, ext. 2231 819-923-0041 markf@oxfam.ca holguinl@oxfam.qc.ca www.oxfam.ca www.oxfam.qc.ca NOTES i “FY 2002: Program, Performance and Prospects: The Global Health Pillar". U.S. Agency for International Development, 2001 ii Liberia Demographic and Health Survey (LDHS) for the years 2006 to 2007. iii An Evaluation of Skilled Care at Delivery in Burkina Faso, Impact International, 2008 iv WHO 2005 estimates are 700,000 more midwives needed over 10 years to achieve MDG 5, that’s 3,825,000 less deaths prevented (75% of 510,000 annual deaths over 10 years). That’s 5.46 deaths prevented per midwife. Assuming working lifetime is 40 years, that’s 218.57 lives. v DfID http://www.dfid.gov.uk/news/files/pressreleases/maternal-deaths.asp vi WHO multi country study, 2005 vii The World Health Report. Make every mother and every child count. Geneva, World Health Organization, 2005, p. 62. viii Oxfam International, Education Now, 2001 ix http://www.dfid.gov.uk/news/files/pressreleases/UK-gov-women-childbirth.asp x Maine D, Akalin M, Ward M, et al, The design and evaluation of maternal mortality programs. New York Centre for Population and Family Health, School of Public Health, Columbia University, 1997. xi See Oxfam International, “Blind Optimism: Challenging the myths about private health care in poor countries,” 2008. xii http://www.unfpa.org/news/news.cfm?ID=776 xiii WHO, UNICEF and UNFPA 1997 guidelines