House of Commons - International Development

Select Committee on International Development Fifth Report

2 MORE THAN A MEDICAL PROBLEM: MATERNAL HEALTH AS A DEVELOPMENT ISSUE

22. Maternal health can be viewed as a barometer of a nation's development. Women's experiences of pregnancy and childbirth exert influences far beyond their own health, crucial as this is, to affect their status and empowerment, their children and wider family's health, education and wealth and, indeed, their nation's society and economy. Children without mothers have lost the parent who makes the biggest difference to their well-being and are much more likely to live in poverty, drop out of school, and be malnourished.[38] A recent article in The Lancet argued that maternal health "is not only central to women's potential, but also has telescopic, ripple effects for broader development concerns facing the world today."[39]

GIRLS' AND WOMEN'S EDUCATION

23. Women's ability to exercise their right to reproductive health and to negotiate their access to health services is directly affected by the gender, social, cultural and economic inequities they face. We heard evidence from a number of witnesses highlighting that reductions in maternal mortality are directly linked to improving girls' and women's educational opportunities.[40] Over 40 million girls remain out of school worldwide.[41] They are disempowered in multiple ways by not having their right to education fulfilled: they miss out on crucial messages about health and sex; are less likely to become economically independent; are likely to marry and have children earlier; and face higher risks of HIV/AIDS, female genital cutting and domestic abuse by male partners.[42] It is estimated that failure to reach the target for MDG 3, seeking equal access to primary and secondary education for girls and boys by 2005, will result in 10 million unnecessary child and maternal deaths over a decade.[43]

24. DFID published a strategy paper on girls' education in 2005 and a Gender Equality Action Plan in 2007.[44] Girls who are not in school are having their right to education undermined and are at increased risk of early marriage, domestic violence and HIV/AIDS. We urge DFID to ensure that the interdependency between maternal health, gender inequality and education is acknowledged and acted upon in its own strategies for these three areas as well as in national country development plans.

GENDER-BASED VIOLENCE

25. Other socio-cultural norms strongly affect women's experiences of pregnancy and childbirth. Female genital cutting substantially increases the risk of delivery complications for women.[45] Gender-based violence has a powerful impact on women's health, and contributes to unplanned pregnancies, abortions and the spread of sexually transmitted infections, including HIV and syphilis, which lead to a higher risk of neonatal and maternal deaths.[46] Studies from Rwanda, Tanzania and South Africa indicate a threefold increase in the risk of HIV amongst women who have experienced violence compared to those who have not.[47] In turn, HIV-positive women have been found in some populations to be about four times more likely to die in pregnancy or childbirth than a woman without HIV.[48]

26. DFID supports a range of interventions aimed at combating gender-based violence (GBV). One example is a four-year initiative (2004—2008) called Working Towards Safe Motherhood in South Asia: Combating gender-based violence during pregnancy in Bangladesh and Nepal which is funded under DFID's Civil Society Challenge Fund.[49] The project raises awareness of services available to the high numbers of women experiencing GBV in Bangladesh and Nepal—including counselling, emergency shelter and legal advice—with a specific focus on pregnant women. In written evidence, IPPF said the project "has enabled IPPF Member Associations to address GBV during pregnancy for the first time in a comprehensive and effective manner."[50] Other evidence we received said that donors need to ensure that access to contraception is available alongside counselling for sexual violence to help prevent unwanted pregnancies, and that health workers need to be trained more effectively in this area.[51] The DFID-funded project to address gender-based violence towards pregnant women in Nepal and Bangladesh is achieving promising results and this approach should be communicated, and, where relevant, replicated. Contraceptive services and counselling by trained health workers should be integral parts of such projects.

SOCIO-ECONOMIC EMPOWERMENT

27. Another key priority for donors is supporting initiatives to empower women to make decisions, access services and increase their socio-economic status. Dr Grace Kodindo, an obstetrician from Chad, emphasised the importance of "financial and cultural access" to maternal health care. She told us that in countries such as Chad, where 80% of women are illiterate, helping to empower women to make their own decisions—for instance, over finance, legal issues and their own health—is of signal importance.[52]

28. IPPF's written evidence highlighted two DFID Country Assistance Plans that incorporate a focus on women's decision-making: Bangladesh's 2003-06 Plan, which identified gender inequality (especially issues such as dowries, inheritance, access to health services and physical security) as a key constraint to poverty reduction, and the Nepal Country Strategic Plan 1998 (now under review) which "notes the cause and effect relationship between Nepal's entrenched patriarchal society and the low status and limited decision-making power of women as the underlying factors leading to their poor health status".[53]

29. Microfinance and microcredit schemes (financial services for people in poverty, including insurance, savings, credit and money transfer services) offer women scope to manage household finances and start small businesses and through this to change their socio-economic status quite dramatically. Such projects also provide an opportunity for health education to be provided in a non-threatening socially-acceptable forum. Professor Charlotte Watts of the London School of Hygiene and Tropical Medicine told us of a project part-funded by DFID in South Africa that sought to link microfinance with participatory activities around gender, violence and HIV. This project—'Intervention with Microfinance for AIDS and Gender Equity (IMAGE)'[54]—found that integrating an HIV/AIDS component into existing microfinance programmes helped women facing violence and the risk of HIV infection from male partners. Training sessions with microfinance clients explored issues such as gender roles, sexuality, relationships, violence and HIV/AIDS, and women mobilised communities to work with men and youth on these issues.[55] The women involved in the study experienced a 50% reduction in violence from male partners over a two-year period.[56] Professor Watts encouraged DFID to look at how the project could be replicated.[57] Microfinance and microcredit schemes have been shown to work well in empowering women socially and economically and can be used to promote better health and uptake of care. We recommend that DFID build on the success of projects such as the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) in South Africa, which added gender, violence and HIV/AIDS components to existing microfinance schemes and promote relevant opportunities for replication and adaptation to improve maternal health.

Other demand-side barriers

30. Poor women are amongst society's most marginalised groups, yet they also carry a disproportionate share of the burden of maternal ill-health. In some countries, this is reflected clearly in the risk of maternal death, with the poorest women being three to six times more likely to die compared to the richest women, as shown in written evidence provided by Immpact.[58] It is therefore vitally important to support women to assert their right to be healthy, to participate actively in health system planning and monitoring, to challenge governments and donors to invest in services and to hold them to account over their pledges.[59]

31. Demand-side barriers that prevent women from articulating their rights to and needs for maternal health and care include: poor educational opportunities, gender inequalities and violence (as discussed above), plus: poverty; social and cultural norms (for instance, beliefs that male health staff should not provide care to female patients); geographical constraints especially in remote rural areas; transport to health facilities; the presence of conflict; and the direct and indirect costs of accessing health care. Developing policies and providing resources to address these barriers has contributed to improved maternal health in countries such as Sri Lanka, Burundi, Zambia and Uganda. Addressing demand-side barriers such as those described above is embedded within DFID's strategy for reaching MDG 5, which has four pillars:

Advocate—raise the profile;
Scale up evidence-based interventions;
Address wider social and economic barriers to access; and
Develop and apply new knowledge.[60]

32. The other set of barriers to health and uptake of care relates to problems in the supply of services, including weaknesses in the overall health system such as insufficient numbers of health professionals, a lack of clinics and hospitals and constrained access to drugs and supplies. We shall return to these supply-side barriers, and the appropriate balance between demand- and supply-side strategies, in Chapter 4.

TRANSPORT

33. In many regions, lack of access to transport is a key barrier to using maternal health care services. In some rural areas of Africa and Asia, where motorised vehicles are a comparative rarity, women in labour can face an agonising walk or stretcher ride to the nearest facility for delivery. This situation is even more problematic where a complication has arisen and the woman urgently needs emergency obstetric care. Timely and appropriate medical intervention in such cases frequently makes the difference between life and death, for the woman and her baby. Even where cars or trucks are available, roads may be of very poor quality, or travel costs too high. Furthermore, companions—a family member or friend—will generally be needed to accompany women in labour and this carries extra costs. Dr Grace Kodindo described to us the dilemma facing many women:

"If a woman is living in a very rural area, in remote places, with no transportation, sometimes the relatives have to take them on their shoulders and walk two or three days before reaching a health facility. She may die in the meantime, or if she does not die the baby will die. If she survives she will end up with a fistula."[

34. Research from Nepal shows that transport costs can equate to 70% of the total expenditure for a delivery.[62] Community initiatives to pool funds and collaborate with local transport groups have been shown to increase the use of maternal health services (although householders often still have to make up the shortfall in transport costs).[63] Dr Nynke van den Broek from the Liverpool School of Tropical Medicine told us that there are "very imaginative ways of dealing with emergency transport including motorcycle ambulances."[64] This is an approach being supported by DFID in Ghana, where they are funding motorcycles for health workers.[65] Dr Monir Islam from the World Health Organization also highlighted the use of maternity waiting rooms, where women stay before they are due to deliver until the birth, so they are close to the care they need.[66]

STRENGTHENING CIVIL SOCIETY'S CAPACITY TO HOLD GOVERNMENTS TO ACCOUNT AND INFLUENCE POLICY

35. Supporting citizens' ability to advocate better maternal health care and hold their governments accountable for commitments to improve maternal health is integral to strategies for achieving MDG 5. DFID gave us examples of countries where it seeks to strengthen civil society's capacity to do this: for instance, Malawi, where civil society organisations are supported to create awareness of women's health and improve the accountability of health providers, and India and Nigeria where DFID supports media and civil society efforts to increase political accountability for maternal health.[67]

36. Witnesses were generally impressed with DFID's support to civil society. In their written evidence, Marie Stopes International said "DFID commitment to supporting grass roots advocacy is admirable."[68] Brigid McConville from the White Ribbon Alliance told us that DFID had "supported some excellent projects", for instance a participatory project in Tanzania in which mothers and midwives had made a film about maternal health issues, which was eventually shown in the Parliament building in Dar es Salaam and on national television. Ms McConville suggested that DFID should fund the kind of work currently being undertaken in-country by civil society groups, including the White Ribbon Alliance, in verifying government statistics on health workers and holding governments to account on their pledges to increase access to social services such as health and education.[69]

37. However, supporting civil society needs to go beyond project grants to include a focus on actual participation in the policy-making process. Evidence submitted jointly by NGOs was broadly appreciative of DFID's record on this: "DFID continues to support the voices of the poor, civil society and the marginalised being included in health policy determination, implementation and monitoring."[70] However, the UK Network on Sexual and Reproductive Health and Rights believed DFID could go further: one particular concern was that the International Health Partnership, a multi-donor co-ordination framework launched in September 2007 by the Prime Minister, had had little input from civil society in its planning.[71] There was also concern relating to DFID's influence on the use of the increasing amounts of its funds spent through partner agencies such as the UN and the World Bank. A specific example given was that DFID should encourage the World Health Organization (WHO) to include civil society when determining indicators and benchmarks for measuring progress in health.[72] DFID deserves credit for its support to strengthening civil society's capacity to hold governments to account for maternal health care. However, we believe that the Department could do more to ensure citizens are appropriately involved in the national policy-making process, including for example appropriate engagement in auditing government statistics and measuring progress on maternal health.

ENSURING PRO-POOR HEALTH FINANCING

38. The financial cost attached to accessing maternity care in many developing countries is a key deterrent, often with long-term adverse effects for poor women and their families. Households currently face large costs for health care in many countries and this is a key factor preventing women from seeking the care they need.[73] In many cases, households will pay for maternal health services through 'user charges' which are charged at the point of delivery and generally collected by staff to cover health staff salaries, diagnostic tests and the costs of drugs and other supplies. Other out-of-pocket expenditure for women delivering at health facilities will include indirect costs such as transport and loss of wages and these may be as large or larger than direct costs.[74]

39. User charges for health almost always impact most on the poorest people. There is strong evidence for their removal in favour of universal free care.[75] A normal delivery can cost a huge amount but birth complications can make the price prohibitive. In Sierra Leone, a birth costs £13, the equivalent to 43 days' earnings (£2,200 in UK terms) and a caesarean section costs £60, 194 days' earning (over £10,000 in UK terms).[76] Time spent finding or borrowing the money to pay for health care can delay the decision to seek care, and may mean women end up delivering at home without skilled assistance. WHO estimates that 100 million people are forced into poverty annually by 'catastrophic' payments, unexpected and substantial costs for health care that push households further into poverty.[77] In 2005, at the World Health Assembly, 189 countries agreed that moving away from user fees for health was essential in order to reach MDGs 4 and 5.[78]

40. Many countries are choosing to abolish user charges. In Sri Lanka, this has been highly successful: services are free at the point of access and over 95% of women deliver with a skilled midwife.[79] Others have found the transition more difficult: Ghana, Uganda and Zambia all used debt relief to fund free health care but had initial difficulties implementing and sustaining the policy given the numbers of people requiring care.[80] DFID supported the abolition of health care fees in countries including Zambia and Burundi and was encouraged in evidence to continue its support for the removal of fees.[81] In Uganda and some districts in Zambia, health care utilisation rose by over 100% and up to 75% respectively when fees were removed.[82] The lessons learned were that where fees are abolished, government funding needs to increase substantially in order to support the expanded demand for care. Written evidence from the DFID-funded Towards 4+5 Research Programme Consortium stated:

41. Dr Tim Ensor of Immpact and the University of Aberdeen told us that when considering free care, providers needed to focus on the main financial barrier for patients. In Nepal, the main barrier is in fact transport costs, and accordingly the Government of Nepal developed a policy whereby women were paid a cash sum when they reached a health facility to offset the cost of travelling there. Early results suggest the proportion of women delivering with a skilled attendant present is increasing.[84] Providing cash to individuals or households, conditional on their use of specified maternal health services, has also worked in Mexico and Honduras, where uptake of antenatal care increased by 8% and 15-20% respectively.[85] Dr Ensor also believed that voucher schemes, which remove the need for cash, could work in subsidising maternal health care, but that such schemes risked creating a parallel administration infrastructure that could be highly bureaucratic (as in Bangladesh).[86]

42. Ghana is now starting to use another option for pro-poor financing of health care, a health insurance system.[87] Dr Ensor was hesitant about the sustainability of insurance schemes, particularly community-based ones—and pointed out that many schemes do not cover even normal deliveries as they are "predictable events." Similarly, emergency obstetric care is often also excluded as it is so expensive.[88] Immpact's written evidence noted that, in Indonesia, women covered by the Government's social insurance for the poor still had the lowest uptake of delivery with a health professional (less than 21%) and the highest level of mortality (maternal mortality ratio—MMR—of 630 maternal deaths per 100,000 live births). This compares with the equivalent figures of 31% and MMR of 410 for women without any insurance, and 81% and MMR of 235 for those with other insurance.[89]

43. User fees for maternal health care almost always hit the poorest women hardest and we believe that there is a strong case for their removal in favour of universal free care. We believe that DFID should continue to support countries to abolish user fees. We recommend that, when doing so, DFID and other donors should help ensure that other revenue sources—for instance, the tax base or additional donor funds—are identified in order to support the expanded demand for care. We believe that governments, when considering free care, need to identify the main financial barriers for women (for instance, transport), particularly the poorest, and seek to address these using financing options which are sustainable and most relevant to the country's circumstances.

44. There is evidence that cash transfer or voucher schemes can work in encouraging women, particularly the poorest and those living in remote areas, to give birth in facilities with a skilled attendant, rather than at home. We recommend that DFID prioritise support to efforts to identify, implement and evaluate context-specific options for reducing financial barriers to maternal health care.

A rights-based approach

45. As Thoraya Obaid, Executive Director of the UN Population Fund (UNFPA) told us, part of empowering women is engendering the understanding that health is a human right.[90] Taking a rights-based approach to maternal health helps link the provision of services to national governments' legal obligations enshrined in human rights treaties and principles, and is therefore a means of enhancing political accountability.[91]

46. Written evidence from the Towards 4+5 Research Programme Consortium praised DFID for encouraging mainstreaming of maternal health on the human rights agenda, and commended DFID's publication of a document on human rights approaches to maternal health.[92] Evidence submitted to us jointly by NGOs agreed that DFID has developed a strong maternal health policy based on rights but believed that this:

The use of a monitoring framework which assesses the implementation of the rights-based approach by country programmes is one route to help address these concerns. We believe that DFID deserves credit for its rights-based approach to maternal health. However, the Department must ensure that the approach is accompanied by adequate funding and implementation strategies. To ensure that the approach is fully implemented at programme level, we believe that DFID should support monitoring frameworks which assess how effectively country programmes are applying a rights-based perspective.

UNSAFE ABORTION

47. One major aspect of maternal health that is tied closely to the rights agenda is unsafe abortion. Abortion is the third biggest cause of maternal death.[94] Unsafe abortion is seen by many as one of the most neglected public health challenges in the world today.[95]

48. Sixty-nine countries—representing 26% of the world's population—currently prohibit abortion and here the risk of death for women seeking illegal, unsafe abortions carried out by unregistered practitioners is very high. About a quarter of women who have undergone an unsafe abortion—nearly all of them in developing countries—will be hospitalised due to serious complications such as haemorrhage, infection or poisoning, while an unknown number of women suffer similarly serious complications but do not seek treatment.[96] According to evidence from the Institute of Development Studies, the abortion mortality rate in countries where abortion is legal is around 1 per 100,000 abortions and where it is prohibited the rate rises to 330 per 100,000.[97]

49. There are three countries worldwide—Nicaragua, Chile and El Salvador—where abortion is illegal under any circumstances, including rape or if the woman's life is endangered by her pregnancy. Thirty-four of the 69 countries banning abortion make exceptions where the mother's life is at risk, and the remaining 32 allow their laws to be interpreted to mean abortion is allowed in these circumstances.[98] Even where abortion is generally against the law, wealthier urban women may be able to obtain safe abortions, but poor, rural women are unlikely to have the means or money to gain access and will instead use unskilled practitioners.[99] Safe abortion is not simply about having the legal right and access to professional care but also about having the necessary information and being empowered to exercise the right. Thoraya Obaid of UNFPA told us:

100

50. Baroness Vadera told us that helping women to understand their rights and the way the law works is difficult in these situations, but that DFID seeks to fund agencies that can help ensure that women are aware of the services that are available.[101] She said that the most effective way for DFID to work was not to "become evangelical about this" but to go where interest already exists and "provide evidence, fund NGOs and civil society" and that "it is always better to give the voice to women in those countries directly, for them to be the advocates than for us to be the advocates."[102] This conforms with the official consensus agreed at the 1994 International Conference on Population and Development in Cairo, which stated that decisions on abortion are national and should not be imposed from outside.[103]

51. In recent years, many countries have liberalised their abortion laws and there has been a demonstrable drop in maternal mortality in most countries where abortion has been legalised.[104] It is essential that legalisation is accompanied by expanded access to safe abortion services, as achieved in South Africa where, following legalisation, deaths from abortion complications decreased by 90% between 1994 and 2001.[105]Abortion was legalised in Nepal in 2002 after many years of campaigning, and maternal mortality here appears to have been in decline for over a decade.[106]DFID told us that it supported work in both these countries that helped bring about liberalisation.[107]

52. DFID is one of the few donors actively to promote efforts to prevent unsafe abortion.[108] Witnesses agreed that DFID has played a leading role in focusing global attention on unsafe abortion and challenging policies and laws which act as barriers to progress in this area.[109] Baroness Vadera gave the example of an effective approach which been used in the Matlab region of Bangladesh, where women can come to "Menstrual Regulation Centres" in safety and without stigma.[110] Family planning was also emphasised in Matlab as a way to prevent unplanned pregnancies.[111] Maternal mortality has decreased by over 50% in the region over the last 15 years due in part to a focus on preventing unsafe abortions.[112] Unsafe abortion is responsible for tens of thousands of women dying each year and is a highly neglected public health challenge. We agree with DFID's approach of not trying to impose abortion decisions on countries but seeking to support civil society where interest in changing the law and improving services already exists. In countries where abortion is illegal, we believe that DFID should continue to look for opportunities to help ensure women are aware both of the circumstances in which abortion is permitted and of the safe services that are available to them.

53. Another example of DFID's support to safe abortion services is its £3 million funding (over two years) of the Safe Abortion Action Fund (SAAF), launched in February 2006 and managed by IPPF. Denmark, Norway, Sweden and Switzerland have joined in support of the SAAF.[113] The $11.9 million fund attracted 172 applications totalling $43 million in its first call for funding (for advocacy, action-oriented research and/or service delivery) demonstrating the high demand for action that exists.[114] An "extremely rigorous process of technical review" carried out by an independent panel (with DFID and other donor representation) identified 45 final recipients.[115] Dr Gill Greer, Executive Director of IPPF, assured us that "clear expectations are in place for monitoring and evaluation" and said that there would be a "clear audit trail on expenditure".[116] The first results of the projects will be available a year after they started (roughly July 2007).[117] In written evidence, IPPF told us:

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54. The hugely oversubscribed first call for funding from the Safe Abortion Action Fund (SAAF) demonstrates the size of the need for funds to improve abortion services. We agree that DFID should continue to advocate for new donors to contribute to the Fund and if, following evaluation results, there is sound evidence for the effectiveness of the SAAF, we believe that DFID should also consider a substantial increase in its own support for the Fund.

38 Ev 128 and Ev 224 Back

39 Kirrin Gill, Rohini Pande and Anju Malhotra, 'Women deliver for development', The Lancet Vol 370, 13 October 2007, pp.1347-1348 Back

40 Q 142 [Richard Horton], Q 222 [Dr Gill Greer] and Q 249 [Baroness Vadera] Back

41 United Nations: Millennium Development Goals Report 2007 Back

42 Global Campaign for Education, 'Girls can't wait: Why girls' education matters, and how to make it happen now' (2005), online at http://www.campaignforeducation.org/resources/Mar2005/b10_brief_final.doc Back

43 D. Abu-Ghaida and S. Klasen, 'The Economic and Human Development Costs of Missing the Millennium Development Goal on Gender Equity', World Bank Discussion Paper 29710 (Washington: World Bank, 2004). Online at http://commdev.org/content/document/detail/1858/ Back

44 DFID, 'Girls' Education: Towards a Better Future for All' (January 2005) and DFID, 'Gender Equality Action Plan 2007-2009' (March 2007) Back

45 Ev 174 Back

46 Ev 136 Back

47 The Global Coalition on Women and AIDS and WHO, 'Violence Against Women and HIV/AIDS: Critical Intersections-Intimate Partner Violence and HIV/AIDS' (Information Bulletin Series, No.1), pp.1-3, online at http://www.who.int/gender/violence/en/vawinformationbrief.pdf Back

48 Ev 86 Back

49 Ev 146 Back