Health Systems and Women's Rights: key elements in effectively averting maternal death and disability.

Every day, thousands of women die from pregnancy and childbirth in Asia and the Pacific. 75% of these deaths are from complications directly associated with the process of pregnancy and childbirth, i.e. direct maternal death, such as from bleeding, hypertension-with-convulsion, infection, and unsafe abortion. The rest are from the aggravation of the maternal state by concomitant medical conditions, i.e. indirect maternal death, such as malaria, TB, malnutrition, and HIV/AIDS. (1)

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Of the total 529,000 deaths estimated in 2000, 253,000 are attributed to Asia. (2) The chance of dying in pregnancy and childbirth is especially high in Nepal, Timor-Leste, Lao PDR, India, Pakistan, and Cambodia. Many of the women who die are poor, from minority groups, not well educated, and unable to fight for their own survival. They embrace the notion that harm and death are inextricable parts of pregnancy and birth.

The fatalism, however, is totally unfounded. The development of medical and surgical remedies in the last century has gradually mitigated the harm due to the complications inherent in pregnancy and delivery. The array of life-saving treatments includes simple procedures like intravenous fluids and medicines, removal of retained afterbirth products and forceps delivery. In the case of more serious complications, there is blood transfusion and delivery by surgery (caesarean section). (3) This constellation of remedies is now called Emergency Obstetric Care or EmOC and where readily available and of good quality, the incidence of maternal death is low or reduced. This is the situation in middle economy countries like Japan, South Korea, Singapore, Malaysia, and Thailand. But this is also the case in poorer countries like Sri Lanka and North Korea, so obviously prosperity is not a key element.

If the solution to the maternal mortality problem is known, why is it then that many Asian countries are unable to stem the tide of this tragedy?

Here are two key elements:

1) The first element is the persistence and pervasiveness of what is known as the "risk assessment approach" (4) to maternal care.

In many countries, the standard of maternal care is to screen pregnant women for risks attributed to certain factors, mainly their age, the number and order of the pregnancy, the time interval with preceding pregnancy, the baby's position in the womb and others. Risks are predicted for women deemed 'too young' or 'too old' or have had 'too many pregnancies' or are having their 'first pregnancy', or had 'too short intervals' between pregnancies. 'High risk' pregnancies are referred for management by professional providers--e.g. nurse, doctor or midwife--or in health facilities. Those viewed to be 'low risk' or 'without 'risk' are relegated to non-professional attendants, such as traditional birth attendants (TBAs) or delivery outside health facilities.

The problem is that these predictions do not coincide with the actual delivery outcomes: many 'high risk' pregnancies end up without complication, while many 'low risk' ones encounter life-threatening complications that require skilled and professional help. (5) The scientific explanation for this is that life-threatening complications could develop in 15% of all pregnancies; complications which "cannot be predicted or prevented," but can be treated by EmOC.f With this evidence, the World Health Organisation (WHO) issued an urgent call in April 1997 that "all pregnancies be considered at risk." (6) This new approach calls for the presence of skilled providers who are not only able to deliver babies safely, but also able to diagnose and respond to emergency complications appropriately. (7) In the same breath, the new approach also calls for the availability and accessibility of referral facilities with EmOC capacity. (8)

This new approach requires many things. It requires the availability of an adequate number of capable and well-motivated health professionals who can be available at any time, in the most remote of places. It requires sustained technical, financial and organisational support to these personnel, as well as working and integrated referral facilities. In other words, it requires a health system that is functional, adequately funded and able to respond quickly to the emergency needs of women in the throes of pregnancy and childbirth complications.

There are also specific reproductive health services, not designed to treat complications, but to avert them before they can even emerge. Two of these are contraception and safe abortion. Successful contraception basically prevents pregnancy and, by this effect, nullifies the possibility of pregnancy complications. (9) Moreover, successful contraception extinguishes the recourse to unsafe abortion that happens with many unwanted pregnancies. Contraception is estimated to prevent 20-35% of maternal deaths. (10)

2) A second element would be women's reproductive freedom and their ability to make and enforce decisions on their fertility and reproduction "free from discrimination, coercion and violence." (11)

This is a woman's ability to decide whether or not they want to be pregnant, which includes their having access to the information and technology that will help them enforce their decisions safely. This also implies the elimination of reproductive coercion and prohibition in culture, norms and policies and people's day-to-day practice. This requires the government to have a strong role in the promotion and enforcement of reproductive rights. At present, there are significant gaps in women's decision-making regarding reproduction in the Asia-Pacific region. One sees this in the persistence of arranged child marriages and the pervasive idealisation of pregnancy and childbirth that disregards the dangers to women. In some countries like the Philippines, powerful cultural institutions, like the Catholic Church, are allowed to control government policies on contraception and abortion.

Where governments fails to protect women through access to vital reproductive health care and safe abortion services, they will likely die or suffer permanent disabilities from pregnancy and childbirth. Every woman's death in motherhood depletes society. Infants orphaned by their mothers are unlikely to survive infanthood itself, (12) especially in the critical first month of life. Older children's nutrition and education are compromised with the loss of a primary caregiver. Moreover, the massive scale of death and disability from preventable causes strikes a discordant and discomfiting note in the time of global economic opulence and scientific advance. What human dignity are we talking about if we allow over half a million women to die yearly without the most basic protection?

Currently, expert opinion is agreed on the effective approach to reducing maternal death and disability. Moreover, there are a lot of working models that demonstrate the feasibility of such a project. (13) Malaysia has a strong public health system predating its becoming an economic success. Sri Lanka is one country that, despite its poverty, has invested heavily on health and a core of professional midwives. China, despite its massive population, continues to prioritise health and has developed competent and well-supervised village health workers who are part of the formal health sector.

The effective approach will require a lot of effort, resources and political commitment. Retooling of the health system and human resource development will have to happen in the context of current global and national conditions. Health reforms will also require substantial investment, a tall order, given that regular health spending in many Asian countries are short of the WHO recommended expenditure of at least 5% of the GDP. (14) And, most importantly, it will require a drastic change of heart and mind regarding women and maternity:

* The appreciation of the intrinsic value of a women's life, especially in that critical period when they pregnant;

* The rejection of the belief that maternity, and especially maternal sacrifice, are necessary aspects of womanhood;

* An active embrace of the evidence-based notion that certain reproductive health services are life-saving and form part of women's entitlements; and

* The affirmation of women's reproductive freedom and agency and the full recognition of these rights.

Endnotes

(1) Maine, Deborah (ed.). 1993. Safe Motherhood Initiatives: Options and Issues. New York: Columbia University School of Public Health.

(2) WHO. 2000. Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA, www.who.int/reproductive-health/publication/maternal_mortality_2000/

(3) Maine, Deborah; Rosenfield, Allan. 2000. "The AMDD Program: History, Focus and Structure" International Journal of Gynecology and Obstetrics.

(4) WHO. 7 April 1998. "Every Pregnancy Faces Risk", WHO Bulletin on Safe Motherhood for World Health Day.

(5) Maine, Deborah (ed.). 1993.

(6) Maine, Deborah; Rosenfield, Allan. 1999. "The Safe Motherhood Initiative: Why has it stalled?" American Journal of Public Health.

(7) WHO. 7 April 1998.

(8) UNFPA. 2004. World Population Report.

(9) Freedman, Lynn et al. 2005. Who's Got the Power, Transforming Health Systems for Women and Children. New York: UN Millenium Project Task Force on Child Health and Maternal Health.

(10) WHO. 2005. World Health Report.

(11) UNFPA. 2004.

(12) International Conference on Population and Development Programme of Action Para 7.2 m Panos. Birth Rights New Approaches to Safe Motherhood www. panos.org.uk/PDF/reports/ BirthRightsSafeMotherhood.pdf

(13) Koblinsky, Marjorie. 2003. Reducing Maternal Mortality--Learning from Bolivia, China, Egypt, Honduras, Indonesia, Jamaica, and Zimbabwe. The World Bank.

(14) WHO. 2005. Annex Table 5, Selected national health accounts indicators: measured level of expenditures on health 1998 to 2002.

By Dr. Junice Melgar, Executive Director, Likhaan, 92 Times St., West Triangle Homes, Quezon City, 1104 Philippines, Tel: [phone] Fax: [phone] E-mail: [e-mail]/[e-mail]