House of Commons - International Development

Select Committee on International Development Fifth Report

1 INTRODUCTION

The global maternal mortality burden

6. Becoming pregnant for some women in the world today is a cause not for joy but for fear, not a celebration of new life but an acceptance that death in childbirth is a very real possibility. There are over half a million maternal deaths per year, 99% of them in developing countries[1] (86% in sub-Saharan Africa and Asia) and for each of these deaths, an estimated further 30 women will become disabled, injured or ill owing to pregnancy.[2]

7. Maternal deaths are to a large extent preventable.[3] Health professionals know what to do to prevent women from dying, and the technologies involved are relatively simple.[4] Approximately 15% of all pregnancies will have serious complications that could lead to death but even the five "big killers"—haemorrhage, infection, unsafe abortion, eclampsia and obstructed labour—can be treated or prevented if births are attended by a skilled health professional and emergency care is readily available.[5] Yet this knowledge has failed to help many women across the globe: for, instance, one in seven women in Niger can expect to die in childbirth, compared to one in 8,200 in the UK—more than a 1,000 fold difference.[6] Of all health measures, maternal mortality indicators represent the greatest gap between rich and poor countries. Eleven countries accounted for almost 65% of maternal deaths in 2005. India had the largest number (117,000), followed by Nigeria (59,000), the Democratic Republic of Congo (32,000) and Afghanistan (26,000).[7]

8. What makes these statistics even worse is that they are largely unchanged from 20 years ago. In 1990 it was estimated that for every 100,000 live births 425 women died of maternal causes, and in 2005 this indicator—the maternal mortality ratio—had fallen to 402. However, because of the absence of data from countries with some of the worst death tolls, the apparent decline of 2.5% per year could in fact be considerably lower (as low as 0.4% per year).[8] In sub-Saharan Africa, in particular, the levels of maternal death remain very high, with no significant progress in reducing maternal mortality ratios (MMR) over the last 15 years.[9] An annual decrease in the MMR of 5.5% between 1990 and 2015 is needed worldwide to achieve a three-quarters reduction by 2015, but with the apparent annual decrease being less than half this, MDG 5 is unlikely to be reached.[10] However, such is the uncertainty about the real scale of maternal mortality, particularly in sub-Saharan Africa and Asia, that whilst the number of maternal deaths for 2005 is cited as 536,000, the figure could be as high as 872,000.[11] Many studies have found a tendency for maternal deaths to be under-reported and we fear that the higher figure could indeed be nearer the truth. Moreover, using national averages to assess the magnitude of the problem often masks enormous differences between areas and groups of women.

9. Within countries there are often huge inequities in access to maternal health care. For example, in Afghanistan the remote district of Ragh had a maternal mortality ratio more than 15 times higher than the capital, Kabul.[12] High levels of maternal mortality reflect a fatal intersection of inequalities, including: multiple levels of gender discrimination; urban versus rural location; poverty-related barriers to access and quality of care; and imbalances based on ethnicity, caste, level of education and presence of conflict.[13] Such inequities are compounded by weak health systems, characterised by a lack or uneven distribution of doctors and midwives, insufficient and ill-equipped health facilities and a dearth of essential drugs and supplies. 36 out of 46 African countries have critical shortages of health staff.[14]

10. In 2000, at the Millennium Summit, maternal health was embedded in the list of targets agreed by global leaders as urgent priorities for global human development, the Millennium Development Goals. Initially the maternal health goal, MDG 5, had one target: a reduction of three-quarters in the maternal mortality ratio between 1990 and 2015, to be measured directly and through monitoring the proportion of births attended by skilled health personnel.[15] In 2006, an additional target was added: universal access to reproductive health by 2015.[16]

DFID's response

11. The role played by DFID in securing the second MDG 5 target was recognised and appreciated in evidence to our inquiry.[17] DFID produced its most recent Maternal Health Strategy in 2004. The Department spent £385 million on health in 2005-06 (excluding budget support and contributions to multilateral agencies such as the UN) and within this £16 million was spent on maternal and newborn health.[18] The then Parliamentary Under Secretary of State for International Development, Baroness Vadera, told us the £16 million sum had since "doubled and will double again [...] to over £50 million by next year [2008]."[19] DFID was one of four donors who collectively provided over half (51%) of total Official Development Assistance (ODA) to maternal, newborn and child health in 2004.[20] The Department channels its financial support to maternal health in a number of ways, including: general budget support; sector budget support; Sector Wide Approaches (SWAps) for health; and contributions to multilateral organisations, NGOs, research institutions and other partners.

12. Praise for DFID's work was extended across many aspects of its maternal health programme: the evidence we received was largely in agreement that DFID is a leading donor to and champion of maternal health.[21]

The key bottleneck: a failure of advocacy and political will

13. DFID's support to and leadership of maternal health has, however, to be set in an international context of disappointing results. As described above, the launch of MDG 5 seven years ago has so far resulted in limited progress in reducing the frequency with which women are dying of maternal causes. Indeed, of all eight Millennium Development Goals, MDG 5 has seen the least progress.[22] Maternal mortality has not fallen since 2000 in large areas of sub-Saharan Africa, South Asia, West Asia, Latin America and the Caribbean.[23] Only two out of five women giving birth are attended by a skilled attendant in sub-Saharan Africa, and this has remained largely unchanged since the early 1990s.[24] Witnesses expressed dismay at the lack of progress.[25]

14. Over the course of the inquiry, we have been saddened by the stagnancy of MDG 5 and the fact that so many women continue to die during pregnancy and childbirth. A clear message from the evidence we took was that a key bottleneck in securing progress on maternal health is a failure of advocacy and a lack of political will. Brigid McConville of the White Ribbon Alliance told us that advocacy—communication of the need to act quickly and robustly to reduce maternal deaths—was the "key" that will "unlock the process."[26] Richard Horton, Editor of The Lancet, explained the stoppage in simple terms :

15. In order to bring about comprehensive results, advocacy clearly needs to take place at two main levels: international advocacy by donors and multilateral bodies to ensure and to support the commitment of national governments to act; and national and local advocacy by governments and community groups to promote and deliver maternal health within countries. Thoraya Obaid, Executive Director of the UN Population Fund (UNFPA), emphasised that political will was needed from national governments as well as donors.[28] The evidence we received highlighted both levels of advocacy as requiring far more attention.[29] Further, specific advocacy efforts are needed within countries to ensure a multi-sectoral approach is taken to maternal health: as Dr Grace Kodindo, an obstetrician from Chad, told us, "it should not only be the problem of the Minister of Health."[30]Advocacy and political commitment alone will not, of course, save lives, but they are necessary conditions for securing action on maternal health.

16. We believe that lack of progress towards MDG 5 is a global collective failure. Responsibility for this belongs at both international and national levels. Donors and national governments carry a particular responsibility to heighten awareness both of the unacceptability of the situation and of the urgent need for greater political will for progress. The responsibility to act lies not with one sector but across sectors—the Ministry of Finance, for example, as well as the Ministry of Health—and with a whole range of actors, from UN agencies to grassroots groups at village level.

17. DFID's own advocacy for improved maternal health, for the strengthening of health systems and for gender equality has undoubtedly helped to secure some high-level 'political will' to address maternal mortality.[31] DFID was credited by witnesses for its leadership in wider global advocacy, for instance through spearheading the new International Health Partnership in 2007, and for other efforts to boost political will—particularly its publication of a dedicated maternal health strategy (DFID being the only major bilateral donor to do so), its support for research and its rights-based approach.[32]

18. But actions to enable progress remain inadequate. This is evident in the continuing substantial financing shortfall for maternal health: a further US$14 billion needs to be found for maternal, neonatal and child health if the international community is to reach the US$25 billion estimated as necessary to ensure that a basic package of health services is available to all.[33] The situation has been made worse by the failure of the United Nations (UN) to tackle maternal mortality. We received a significant amount of evidence that indicates that the UN agencies with a mandate for maternal health are fragmented and poorly co-ordinated.[34] Challenges and opportunities for the UN, and for other major global partnerships on maternal health, will be assessed in Chapter 3.

19. There is evidence that where maternal health is pushed high up the political agenda, maternal mortality can be reduced relatively quickly. Some industrialised countries halved their maternal mortality ratio in the late 19^th century, primarily through professional midwifery care at birth. In the post-war period, Thailand, Malaysia and Sri Lanka all saw declines in their maternal mortality ratios of over 50% between 1960 and 1984.[35] More recently, both local advocacy and national policy changes played a key role in stimulating actions which reduced maternal mortality in Nepal between 1996 and 2006.[36]

20. Research from Sri Lanka indicates that even resource-poor nations with areas of conflict can make sustainable progress with relatively affordable investments, as long as strong political commitment exists. Sri Lanka spends less than 2% of GNP on health yet over 90% of Sri Lankan women deliver in clinics. This is due to a series of measures including providing equitable access to free health care and ensuring that health facilities are available within 10 kilometres of every citizen's home, amongst other broader policies such as improving girls' education.[37]

The structure of this report

21. Our inquiry has made clear to us the need to find effective advocacy strategies that will help catalyse political will and actions to improve maternal health. We will indicate throughout the report why and where we believe advocacy can make a difference. In Chapter 2 we start by looking at why maternal health is so central to development and how addressing socio-cultural inequalities such as gender and poverty can help reduce maternal deaths. In Chapter 3 we look specifically at how the international failure of advocacy has happened and what can be done at global level, particularly by DFID, to invigorate the drive to save women's lives. Chapter 4 will identify strategies for success, focusing on approaches that have been proven to work in preventing maternal deaths and whether they can be replicated at scale. This chapter will also address the crucial question of how to strengthen the measurement of progress on maternal health more accurately. Chapter 5 will conclude the report by looking at the implications for bilateral agencies such as DFID. It will specifically ask whether the Department is making optimal use of its own financial and human resources in order to remain a leader and champion for achieving MDG 5.

1 Ev 122 Back

2 Q 242 [Dr Gill Greer] Back

3 Q 246 [Dr Gill Greer] Back

4 Q 54 [Dr Grace Kodindo] Back

5 Ev 158 Back

6 WHO, 'Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and the World Bank' (2007), p.27. Online at http://www.unfpa.org/upload/lib_pub_file/717_filename_mm2005.pdf Back

7 Ibid Back

8 Ibid Back

9 There was an estimated 1.8% decline in the maternal mortality ratio in sub-Saharan Africa between 1990 and 2005. Ken Hill et al, 'Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data', The Lancet Vol 370, 13 October 2007 Back

10 WHO/UNICEF/UNFPA Press release, 12 October 2007, 'Maternal Mortality Declining in Middle-income Countries; Women Still Die in Pregnancy and Childbirth in Low-income Countries' Back