Safe motherhood: a matter of human rights and social justice.

Safe motherhood means ensuring that all women receive the care they need to be safe and healthy throughout pregnancy and childbirth. For the last several decades, women's issues were compressed in the words "half of humanity", but the other half still has not yet become fully conscious of what is the basic condition of their lives. Women and children represent about 75 per cent of the world population. Some implications of the population problem on the quality of human life are obvious. The ideal solution would combine a slowdown in the rate of population growth (or zero growth) with a redistribution of population in relation to resources.

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This article aims to understand women's reproductive rights and how to balance these rights, with the imperative that communities and societies will then be more likely to make reproductive choices. It will serve not only in their own interests but society's as well. Most women, even though they are educationally and instrumentally "empowered", are cross-culturally not really in charge of their own fertility; their societies and cultures are. The good news is that social change is constant. Providing education on women's health, maternity care and family planning can ensure that opportunities are fully used, and the role of obstetricians/gynaecologists (OB/GYNs) societies in training is most helpful.

Of all the health statistics monitored by the World Health Organization (WHO), maternal mortality has the largest discrepancy between developed and developing countries:

* Every day, at least 1,600 women die from complications of pregnancy and childbirth, that is, a minimum of 585,000 each year. These complications are the leading cause of death and disability for women aged 15 to 49 in developing countries;

* About 50 million women experience pregnancy-related complications every year, many leading to long-term illness or disability;

* There are an estimated 200 million pregnancies in the world each year, one third or 75 million unwanted;

* Every pregnancy faces risks: at least 40 per cent of women will experience some type of complications, of which 15 per cent will be potentially life-threatening;

* Each year, approximately 20 million unsafe abortions are performed worldwide, resulting in nearly 80,000 maternal deaths and hundreds of thousands of disabilities. In some countries, unsafe abortion is the most common cause of death, but it is also one of the most easily preventable and treatable.

* If all women who do not want any more children were actually able to stop childbearing, the number of births would be reduced by an average of 35 per cent (4.4 million) in Latin America, 33 per cent (24.4 million) in Asia, and 17 per cent (4 million) in Africa. Maternal mortality would fall by even higher rates, since the births that would be averted would tend to be the high-parity and/or high-risk births.

* Birth intervals of less than 36 months significantly increase the risk of complications and death.

Although the aims of antenatal care are the same all over the world, the actual practice varies from one region to another. The majority of maternal deaths could be prevented if improvements in women's status coupled with a substantial extension of primary health-care facilities, including family planning and referral services, were made possible. Involvement of OB/GYNs, both as individuals and through their national societies, in advocacy and technical support is needed for safe motherhood and in women's health. The aim is not just to reduce the in-excusable toll of maternal deaths and disabilities, but also to ensure that the outcome of every pregnancy is a healthy mother and a healthy newborn. From the moment of birth, all babies need special attention and care to survive and be healthy. Yet in many countries the odds are stacked against both mothers and their newborns.

The essential elements of safe motherhood are: community education; prenatal care and counselling, including the promotion of maternal nutrition; skilled assistance during childbirth; care for obstetric complications, including emergencies; post-partum care; management of abortion complications, post-abortion care and safe services for termination of pregnancy where abortion is legal; family-planning counselling, information and services; and reproductive health education and services for adolescents.

Anyone who has cared for a woman knows that if physically ill herself, the mother (and father) will be anxious, stressed, depressed and sometimes inconsolable. Those who understand the true impact of pregnancy and birth on the hearts, minds, lives and well-being of women fully understand this vital connection. Strengthening commitment to improve access to and quality of care is a priority of the partnership, which is advocating for increased political will and progress towards the United Nations Millennium Development Goal concerning maternal and child health. Reducing maternal and newborn mortality is increasingly important in light of the MDGs (see http://www.un.org/millenniumgoals/). Fostering partnership for communication and coordination can strengthen the safe motherhood programmes.

The challenges in Africa are many, including high fertility rates, low contraceptive use, early onset of sexual activity and early marriage--all of which contribute to half of the annual 585,000 maternal deaths worldwide. These deaths take place in a continent that constitutes only 13 per cent of the global population and 23.5 per cent of births. Empowering individuals, families and communities is the way forward.

The reality of women's lives, especially in developing countries, is such that they neglect their own health. Opportunities to improve their health conditions are indeed limited because of numerous reasons, including, among others, the burden of caring for the home, children and family, and the responsibility of food production and preparation. Moreover, their health also suffers from the low status accorded to them, the lack of an organization and the power to exert any political pressure. Empowering women enables them to: speak out about their health needs and concerns; seek services with confidence and without delay; demand accountability from service providers and Governments for their policies; and participate more fully in social and economic development.

The Safe Motherhood Initiative began in 1987, with the aim of reducing the number of mothers dying in the developing world. Since then, much has been learned about saving women's lives during pregnancy and childbirth, and the close links between maternal and newborn health. One of the most helpful actions that OB/GYN societies can take would be providing education on women's health, in collaboration with women's organizations, the Ministry of Health and other relevant partners. In light of the national situation on maternal and perinatal health, the national OB/GYN society should define the content of a number of simple messages that embody those aspects about maternal health and health care. Information on self-care and community in general is essential.

One example in present medical curricula is the relative failure to help health-care providers understand the need to take into account the totality of women's health throughout the life cycle and to provide a more humane and understanding level of care. Discussion of and concern for women's perspectives about their health needs should be a routine part of the health professionals training. Every national society has to be involved in monitoring the quality of maternal health care and should encourage, facilitate and stimulate research related to the accomplishment of the goals of the Safe Motherhood Initiative, particularly in areas where maternal mortality is high. Thinking globally and advocating nationally, a national movement can be established, with some specific suggestions:

* National societies should contribute to continued education, and not only of their own professions and specialties but also of all providers of maternal health and family planning care, and especially those at the primary referral level;

* Efforts to improve curricula would be more successful if national societies support training according to their country's objectives and apply them in reducing maternal and perinatal mortality, and also increase the availability of family planning services;

* On women's health in general and in cooperation with partners, try to spell out clearly the type of training that is essential for the attainment of objectives, from the obstetricians to the traditional birth attendants or midwives;

* Operational research--sometimes called health system or "action research"--is a very important area in which the national OB/GYN society can play a major role;

* Safe motherhood operational research consists essentially of the evaluation of improvements and innovations in maternal health care, especially preventive aspects; and

* Evaluation of educational campaigns.

Maternal health is a multifaceted problem with social, psychological and cultural roots. There is no simple or single solution; rather, women's health care must be addressed at multiple levels and in multiple sectors of society to develop effective projects and programmes. For several decades, we have had the knowledge and means to remove much of the risk and uncertainty associated with childbirth. With the growing motivation and political will, the need for better information has become more acute. Women have a right to safe motherhood.

We should aim to ensure equal access to affordable and quality health care: "Health for all". Building the evidence-base, mainly community-based research that is affordable and has immediate implications for programmes and local partners, should be encouraged. The community has an important role to play, particularly in addressing access to emergency care and family planning services. All human beings are born free and equal in dignity and rights.

(Please read the UN Secretary-General's report on the Millennium +5, entitled "In Larger Freedom: Towards Security, Development and Human Rights for All", at http://www.un.org/largerfreedom/.)

Rita Luthra, MD, is President of Women's Health and Education Center and Editor-in-Chief of the e-learning publication WomensHealthSection.com, which is dedicated to women's wellbeing and health care worldwide. She is also a Fellow of the American College of Obstetricians and Gynecologists since 1986 and has worked with various international organizations, such as the UNA-USA, Peace Corps and WHO. Dr. Luthra's main interest is international health and development.

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RELATED ARTICLE: Education and HIV/AIDS Does Knowledge Equal Change?

School systems are a powerful means of communication that can be used to tackle the problem of HIV/AIDS, and evidence in many countries shows that education and behavioural change concerning the disease are unmistakably interconnected. The end-goal is to allow the vulnerable to understand the risks involved and thus make educated decisions based on clear information about the sources of HIV/AIDS infection. Consequently, delivery of effective messages through schools about prevention can only enhance their beneficial impact.

A study in six countries--Kenya, Malawi, Uganda, United Republic of Tanzania, Zambia and Zimbabwe--revealed high levels of HIV/AIDS awareness, although the sources of knowledge were considerably different for each country. In Uganda, the main source of information was the social networks of friends and family, while in the other countries it was obtained from mass media and institutional sources, such as schools, churches and clinics. Moreover, the fact that more Ugandans reported having known someone with HIV/AIDS might have played a role in increasing behavioural change. This country is a perfect example of strong and increasing links between HIV/AIDS education and increased general knowledge, and risk-avoidance behaviour. Rates of HIV prevalence in rural Uganda, as shown in the chart below, were initially closely comparable for all education levels, but from 1995 those with some secondary education exhibited lower prevalence rates than those with less schooling.

Another study in South Africa indicated that one third of 15- to 24-year-olds reported learning about HIV/AIDS mostly from school sources.

--Sagine Damas

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