Select Committee on International Development Written Evidence

Memorandum submitted by the Department for International Development (DFID)

September 2007

ACRONYMS AND ABBREVIATIONS

ADB	Asian Development Bank
AIDS	Acquired Immune Deficiency Syndrome
AusAID	Australian Aid
CAP	Country Assistance Plan
DAC	Development Assistance Committee of the Organisation for Economic Cooperation and Development
DFID	Department for International Development
DoH	Department of Health
DRC	Democratic Republic of Congo
EmOC	Emergency Obstetric Care
EHRP	Emergency Human Resource Programme
FCI	Family Care International
FIGO	International Federation of Gynaecologists and Obstetricians
FGM	Female Genital Mutilation
FP	Family Planning
GFATM	Global Fund to Fight AIDS, TB and Malaria
GHWA	Global Health Workers Alliance
GTZ	German Technical Cooperation (Deutsche Gesellschaft fr Technische Zusammenarbeit)
HAC	Health Action in Crises
HIV	Human Immunodeficiency Virus
HMIS	Health Management Information System
ICPD	International Conference for Population and Development
IDA	International Development Assistance
IDC	International Development Committee
IHP	International Health Partnership
IMMPACT	Initiative for Maternal Health Programme Assessment
IHP	International Health Partnership
IPPF	International Planned Parenthood Federation
JICA	Japan International Cooperation Agency
MDGs	Millennium Development Goals
MH	Maternal Health
MNH	Maternal and Newborn Health
MSF	Médecins Sans Frontie"res
MMR	Maternal Mortality Ratio
NGOs	Non-governmental Organisation
NHS	National Health Service
PMNCH	Partnership for Maternal, Newborn and Child Health
PMTCT	Preventing Maternal to Child Transmission
PRSP	Poverty Reduction Strategy Paper
PSA	Public Service Agreement
RCH2	Reproductive and Child Health 2—Programme in India
RCOG	Royal College of Obstetricians and Gynaecologists
RH	Reproductive Health
SAAF	Safe Abortion Action Fund
SGBV	Sexual and Gender Based Violence
SMP	Safe Motherhood Programme
SRH	Sexual and Reproductive Health
SRHR	Sexual and Reproductive Health and Rights
SSS	Sampling At Sites
SWAps	Sector Wide Approaches
TB	Tuberculosis
TBA	Traditional Birth Attendant
UN	United Nations
UNFPA	United Nations Population Fund
UNICEF	United Nations Children's Fund
UNITAID	International Drug Purchasing Facility
USAID	United States Agency for International Development
WB	World Bank
WHO	World Health Organisation
VITA Trial	Vitamin A Trial

FACTS AND FIGURES ON MATERNAL HEALTH AND MDG 5

Millennium Development Goal 5: Improve maternal health

Target: Between 1990 and 2015, reduce the maternal mortality ratio by three quarters

The problem

—  MDG 5 aims to "improve maternal health" as well as to tackle maternal deaths. Over 300 million women in the developing world suffer from short or long-term illness or disability because of problems in pregnancy and childbirth1.

—  529,000 women continue to die each year during pregnancy or childbirth, most of them in sub-Saharan Africa and Asia2. This is equivalent to one death every minute (or a global maternal mortality ratio of 400 per 100,000 live births).3

—  The most common clinical cause of maternal death is severe bleeding which, if unattended, can kill even a healthy woman within two hours. The second most frequent cause is infection, the third is unsafe abortion4 5.

—  There is no greater inequity in health than maternal mortality—the chances of suffering a maternal death over a woman's lifetime is one in 6 in Sierra Leone compared to one in 3,800 in the UK—a 600 fold difference6. See Figure 1 to see where death rates are highest.

—  To achieve a three-quarter cut in maternal mortality ratio from the global worldwide estimate of 430 in 1990, we need to reduce to a level of just over 100 by 2015. Currently the global estimate is still as high as 400, and for Africa, the almost double—at 8307.

What is needed?

—  Improving maternal health cannot be achieved without strengthening the health systems that underpin delivery of health services. Currently there are not enough trained and motivated health workers to deliver basic services—a global shortage of four million is predicted by 2015. In 57 countries, the health worker crisis is deepening through chronic underinvestment; losses to HIV/AIDS and out-migration of staff (see Figure 2).

—  Improving the functioning of health facilities saves the lives of mothers, but to reduce maternal mortality in line with MDG 5, access to specific skilled health workers such as midwives and obstetricians is also needed as well as access to safe abortion and family planning services8.

—  Maternal health cannot be isolated from other health concerns—the health and survival chances of mothers and their babies are largely determined by sexual and reproductive health before pregnancy, as well as care during pregnancy, at birth and after the birth9. Because deaths of newborn babies around the time of birth form nearly 40% of total under five deaths, efforts to achieve MDG 5 overlap considerably with efforts to achieve MDG 410.

—  Millions of women are still left without professional care at the time of birth—many give birth only with the help of a non-qualified health worker. Nearly one in four women in developing countries undergoes childbirth alone—or with only a relative or neighbour to assist them; this has not changed since the early 1990s11.

—  Assistance at childbirth is only one part of the healthcare that is needed—women also need antenatal care, and postnatal care—for mother and for baby too. This "continuum of care" should also include pre-pregnancy care eg family planning12.

Progress in tackling MDG 5

—  A few countries have managed to halve their maternal mortality rates over short periods13 but overall there are only a few signs of progress towards meeting MDG 5—globally we are lagging far behind the rate of decline needed, especially in countries and areas which already have very high mortality.

—  The proportion of women who have the assistance of a professional such as a midwife at childbirth is slowly improving—despite a rising number of births—since 1990 the proportion of women with a health professional assisting at birth has risen from 43% to 57%14.

—  The key constraint to progress is the lack of a viable and effective health workforce. It is estimated that 36 out of 46 African countries have critical shortage of doctors, nurses and midwives and that African countries face a shortfall of nearly 1 million health workers—many of which are needed specifically for maternal health15.

Figure 1—Dying to give birth: Maternal death rates around the world

  Source WHO (2005) World Health Report 2005—Make every mother and child count, Geneva page 15

Figure 2 —The health worker crisis—countries with critical shortages

  Source WHO (2005) World Health Report 2006—Working together for health, Geneva page 12

EXECUTIVE SUMMARY

  An estimated 529,000 women die as a result of pregnancy and childbirth each year. 99% live in developing countries. Countless other women survive but suffer serious complications in pregnancy and childbirth. Yet the health of women is critical to a country's social, economic and political development, but it is rarely a political priority, because of the low socio-economic and political status of girls and women in developing countries. It is clear that political commitment, especially in developing countries, to make the difference for the poorest women is lacking.

  A maternal death is a death like no other. The social and economic consequences are great, especially for surviving children. Progress on MDG 5 is vital for the achievement of MDG 4 and other MDGs.

  Eight years from 2015, progress is too slow and without a new impetus many developing countries will not achieve this MDG by 2015. Maternal deaths demonstrate the greatest difference in health between rich and poor women within and between countries. The chances of suffering a maternal death over a woman's lifetime is one in six in Sierra Leone compared to one in 3,800 in the UK—a 600 fold difference. In 1990 the global average was 430 deaths per 100,000 live births. In 2000 it was 400 deaths per 100,000 live births and 830 per 100,000 in Africa.

  Most progress is being made in Asia, but less so in Africa where even basic health services, including the skilled staff needed to prevent maternal deaths are simply not available without new impetus. But DFID has learned from its experience in India, Bangladesh, China and elsewhere (See Question B) that significant improvements can be achieved in maternal health, where health systems are being strengthened and where specific sustained investments are made (within health systems strengthening) to improve maternal health.

There are no quick fixes. It is clear that improving maternal health requires a functioning and equitable health system that can meet the specific needs and rights of women in pregnancy and childbirth. Long-term underinvestment in health systems—trained staff, clinics, supplies of essential medicines, management and information systems—means that few health services in developing countries can provide the range of care needed. Women need to be able to access emergency obstetric care (such as a caesarean section or treatment for post-partum haemorrhage) in a facility where there are skilled birth attendants (midwife, obstetrician, and anaesthetist) and the supplies and equipment necessary (eg blood transfusion).

  Experience has also shown that maternal health cannot be tackled in isolation from improving overall sexual and reproductive health and rights (eg family planning and preventing unsafe abortion) or by addressing the social and economic barriers that women face. Nor in isolation from other diseases, particularly AIDS, TB and malaria (MDG 6), which further increase the risk of illness and death in pregnancy and childbirth (recent data indicates that a women infected with HIV is four times more likely to die than a women without HIV infection).

  Monitoring trends in maternal mortality poses particular challenges. Few countries record maternal deaths. The most recent global data available refers to the year 2000. This is when many of DFID's investments into MDG 5 were being established. The next set of data (referring to 2005) is expected to be released in October 2007. DFID has invested with others in the development of new low cost methods to measure maternal deaths.

  DFID's approach to addressing maternal health is set out in the strategy Reducing Maternal Deaths: evidence and action (2004). Since the strategy was published, DFID has made significant contributions to progress within countries such as China, Bangladesh, India, China, Nepal and Nigeria through an approach which combines broad support to the health system along with specific interventions to catalyse action on AIDS, TB, malaria, immunisation as well as maternal and child health. DFID works with and through partners on health—namely governments, UN agencies, non-government organisations—so the contributions DFID makes to maternal health in any country are part of a bigger international effort. Only through building a health system that is both functional and ensures the needs of women and children are at the core of policy and implementation can progress towards MDG 5, as well as MDGs 4 and 6, be accelerated. There needs to be, in parallel, a push to raise maternal health to a broader development and rights issue.

  The progress made and lessons learned from these and other investments provides the evidence on what needs to be done to scale-up further, even if it is not yet enough to make a dent in the global figures on maternal mortality.

  DFID is committed to strengthening health systems and improving the way international agencies and developing countries work together on health. The UK Prime Minister launched the International Health Partnership (IHP) on 5 September 2007 to intensify coordination at country level around national plans. The IHP is part of a wider Global Campaign for the Health Millennium Development Goals and outlines a new agreement between developing partner countries and international partners to accelerate action to scale up coverage and use of health services, and deliver improved outcomes against the health related MDGs. The campaign will further increase political action on the health MDGs through a global network of leaders along with civil society action.

  DFID has also played a leading global influencing role in relation to women's sexual and reproductive health. This includes convincing Norway to include MDG 5 in their MDG initiative (originally focussed only on MDG 4); encouraging three global health partnerships dealing with maternal, newborn and child health to merge as the Partnership for Maternal, Newborn and Child Health (PMNCH); maintaining a focus on SRH through support for contraceptive commodity security, increasing access to safe abortion and obstetric fistula services and action against female genital mutilation. DFID has brought influence to the new health, nutrition population strategy of the World Bank and the development of the maternal health plans of the Bill and Melinda Gates Foundation by, for example, bringing the focus to health systems rather than vertical initiatives or single technical solutions. DFID has highlighted maternal health in discussions with UN agencies. DFID has supported global efforts to raise the profile and accelerate action including the 2007 "Women Deliver" conference.

  This memorandum to the International Development Committee (IDC) is organised into three parts: Part 1 aims to explain why and how DFID works to address maternal health. Part 2 provides DFID's specific response to the eleven questions posed by the IDC. Part 3 is DFID's Progress Report on maternal health 2006-2007 to which much of the evidence is referenced throughout Part 1 and Part 2.

PART 1. OVERVIEW

1.  Why DFID gives priority to MDG 5: "Improving maternal health"

  1.1  Millennium Development Goal 5 is off-track. Many developing countries are at risk of not achieving this MDG. An estimated 529,000 women die as a result of pregnancy and childbirth each year, and countless other women survive but suffer serious complications in pregnancy and childbirth. This is largely preventable with the knowledge and interventions at hand today. The health of women is critical to a country's social, economic and political development, but it is often a low political priority, because of the low socio-economic and political status of girls and women. The link between poverty and maternal health has been clear for more than a century. In Peru, for example, there is a six-fold difference in maternal mortality between rich and poor16. Maternal deaths represent the greatest difference in health outcomes between rich and poor women within and between countries17.

  1.2  Maternal health is vital for the achievement of the other MDGs: a maternal death is a death like no other. The consequences are great especially for surviving children. A newborn baby is three to ten times more likely to die within its first two years of life without its mother18. Girls whose mothers have died are more likely to perform poorly at school, or drop out altogether, face a higher risk of malnutrition and premature death, and a life of increased economic hardship19 than boys in the same situation. Also—because newborn deaths are more frequent than deaths later in childhood (nearly 40% of all under five deaths occur within the first month of life) the MDG 4: "Reduce child mortality" will not be met unless newborn deaths are reduced20. The great majority of deaths can be avoided by making sure that maternal health care is improved.

  1.3  While maternal mortality is a key indicator of maternal health, maternal health is not solely about what happens during pregnancy or around childbirth. It is inextricably linked to poor sexual and reproductive health, for example lack of access to contraception, information and safe abortion services, and unequal gender relationships. It is also closely linked to HIV which is increasing maternal mortality in some sub-Saharan countries: a woman infected with HIV is four times more likely to die in childbirth than a woman who is not infected21. These health issues need to be addressed holistically, not in isolation from each other, through the development of functional health systems.

2.  DFID's approach and action to address maternal health

  2.1  In 2004, DFID launched the strategy Reducing maternal deaths: evidence and action. DFID remains the only major bilateral to have a strategy on how to catalyse progress towards achieving MDG 5. Each year DFID provides a Report to parliament on progress against the four priorities of the strategy. The second report was published in 2007 and is at part 3.

The strategy identified four priority areas for action by which to catalyse progress towards MDG 5.    1.  Advocate—raise the profile

    2.  Scale-up evidence-based interventions

    3.  Address wider social and economic barriers to access

    4.  Develop and apply new knowledge

  2.2  Priority 1: Advocate-raise the profile. The low political profile of women and maternal health is one of the biggest obstacles to progress. DFID has actively supported a number of major new initiatives which focus on advocacy for maternal health. The Partnership for Maternal, Newborn and Child Health (PMNCH) brings together key actors across maternal, newborn and child health (see question I below for more detail). DFID influenced the direction of the Norwegian Initiative to accelerate progress on MDGs 4 and 5, which originally focused only on child health. It includes a high-level political advocacy strategy and a new civil society campaign to hold governments and donors to account. DFID has supported UNFPA's global campaign on obstetric fistula and efforts to reduce female genital mutilation; contraceptive commodity security and is one of the few donors to actively promote efforts to prevent unsafe abortion. DFID has actively promoted maternal health in dialogue with UN health agencies (WHO, UNFPA and UNICEF) and has pursued a systems strengthening agenda in contributions to the World Bank health, population and nutrition strategy. DFID has worked closely with the Bill and Melinda Gates Foundation in developing their plans to increased investment in maternal and reproductive health. At country level (eg Malawi) DFID works through civil society organisations to create awareness of women's health and to help local groups and health providers be accountable to clients. Where we support sector wide approaches we ensure that maternal health is central to the monitoring framework. In addition, DFID supports major global events that advocate for improved maternal health such as the "Women Deliver Conference" taking place in London October 2007.

  2.3  Priority 2: Scale-up evidence based interventions. DFID provides substantial support to broad based efforts to strengthen health systems through working with governments; the UN, non-government organisations and other partners (refer to D). In addition DFID supports specific maternal health programmes in Africa, Asia and other regions. Annual DFID health spend has increased to about £800 million (2005-06) DFID's approach is evolving as new evidence emerges (see Question B). For example, we learned from projects in countries such as Malawi that, without a health systems approach in which skilled birth attendants are supported, little progress can be made in reducing maternal deaths. We have learned—from Bangladesh and Nepal for example—that, even where a health system is weak and access to skilled birth attendants limited—gains can be made through focussing on family planning and preventing unsafe abortion. Evidence that non-health sector factors are important, has led to DFID investments in Nepal, China, Kenya and Sierra Leone that address obstacles to maternal health beyond the health sector, such as infrastructure, transport, communications and water and sanitation. While these interventions are not yet adding up to enough to impact upon either national or global data, they provide a strong bedrock of experience and evidence on what need to be done going forward. (Specific examples are described in response to questions B, C, D, F and K).

  2.4  Priority 3: Address wider social and economic barriers to access. DFID supports a range of country and international initiatives that tackle the wider barriers to access. In Nepal, Bangladesh and Cambodia DFID is supporting programmes that are introducing innovative financing mechanisms to cover the costs of transport, health service charges, or medicines. The DFID supported RCH2 (Reproductive and Child Health) programme in India is providing conditional cash transfers to women who deliver their babies in a health facility and to pay for transport and other expenses. In Africa DFID's influence has resulted in the removal of user fees for maternity services, with considerable impact in countries such as Burundi. DFID has supported work with African parliamentarians on female genital mutilation, which has led to a joint WHO/UNICEF/UNFPA statement, and has directly influenced the development of the Ethiopian Government's Adolescent and Youth Reproductive Health Strategy.

  2.5  Priority 4: Develop and apply new knowledge. DFID has a significant portfolio of research on maternal health which not only informs the way in which DFID approaches maternal health, but brings influence on policy and implementation amongst governments and international partners. One example is the Initiative for maternal mortality assessment (IMMPACT) which has successfully developed new, low-cost and more rapid tools for measuring maternal mortality which for the first time allow the possibility of dis-aggregation of data to sub-national levels, and more regular collection. Given serious weaknesses in measurement and data on maternal health, this is a highly significant initiative since "what you count is what you do". The immediate impact of this research is to have raised the profile of and potential for, monitoring maternal deaths to the extent that maternal deaths are likely to be one of the key results used by donors in the shift to performance-based financing. Immpact's new tools provide efficient ways to track these results, costing between about a half and a third per death revealed compared to other mechanisms.

  2.6  DFID has funded the Obaapa VITA trial in Ghana which will soon bring to a conclusion a global debate on whether or not Vitamin A supplementation in pregnancy can help reduce maternal deaths. A full list of investments is shown in the table below. A number of these programmes are still at early stages of development but together, they have the potential to generate better evidence on maternal health, which could improve both DFID's and the global response.

DFID'S CURRENT RESEARCH PORTFOLIO INTO MATERNAL HEALTH

  IMMPACT: "The Initiative for Maternal Mortality Programme Assessment" was set up to develop new, faster and cheaper ways of measuring maternal mortality. One outcome is the development of the "Sampling at Service Sites (SSS)" methodology that by collects data from women where they gather in large numbers (eg markets and clinics) and is providing quick and cost effective data comparable to the standard Demographic and Health Survey. IMMPACT has developed new tools, costing one third per death revealed compared to other means that have revealed hidden deaths of 1,000 women across three countries. These deaths were missed by routine reporting systems. (2002-06; £7.5 million).

  The Obaapa Vitamin A trial in Ghana is the largest global research programme determining the effect of Vitamin A on improving maternal health. Results will be available in 2009. The trial demonstrated that early breastfeeding (within one hour of birth) significantly increases child survival rates. (1999-2009; £6.5 million).

  Realising Rights: Improving Sexual and Reproductive Health for Poor and Vulnerable Populations is mapping neglected SRH conditions and finding interventions for improving access to SRH services and rights for the poor. The project has led to better understanding of the economic impact of safe abortion—per patient cost of post abortion care lies between US$ 96-131 and the global cost to health systems from US$ 509-676. (2005-10; £2.5 million).

  The Centre for Health and Population Research focuses on maternal, neonatal and reproductive health as well as infectious diseases. It has led to new ways to scale up access to services for women with restricted mobility outside their home through use of community health visitors (2006-11; £7.5 million core funding).

  HRP: Human Reproductive Programme (WHO joint Special Programme) supports the generation of knowledge, products and capacity to help countries meet the sexual and reproductive healthcare needs of their populations. The project has provided evidence of obstetric problems following FGM and ongoing research on injectable contraceptives for men. (2006-09; £5.5 million).

  Research and Capacity Building in Sexual and Reproductive Health and HIV in Developing Countries is strengthening the evidence base to enable policy makers to identify and prioritise interventions to improve reproductive and sexual health and reduce HIV incidence among the poorest in Africa and Asia. Project has influenced WHO treatment guidelines on herpes/HIV and on making rapid diagnostic tests for syphilis more affordable. (2005-10; £2.5 million).

  Achieving MDGs 4 and 5: Strategic research to develop the evidence—base for policy for mother and infant care at facility and community level is exploring opportunities for improving integrated mother and infant care and providing evidence on interventions to improve the survival of women and infants through community interventions and health services delivery. The project has led to significant improvements in newborn care in targeted women. (2005-10; £2.5 million).

3.  What we know has worked, and what we are learning

  3.1  There is now a broad consensus that the primary determinant of maternal health is how well health systems function. DFID's 2007 Health Strategy places clear emphasis on health system strengthening22, requiring long term predictable financing; skilled personnel; a predictable supply of drugs and equipment; access to clean water and sanitation; non-health inputs (infrastructure, power, transport and communications); and an effective health management information system (HMIS). This will require sustained effort and investment. The recently launched International Health Partnership (IHP) provides a platform for health systems strengthening and for better coordination of donors around national plans.

  3.2  But for maternal health in particular, health systems need to include specialist skills and facilities to ensure that every woman can be assisted at birth by a professional skilled attendant (a midwife or doctor with midwifery skills), backed up by referral to emergency obstetric care, when needed23. The provision of a caesarean section, for example requires a surgeon, a midwife, an anaesthetist and a blood transfusion as well as the drugs and supplies to enable skilled birth attendants to do their job. These specialist facilities are fundamental to health systems, so the indicators that demonstrate an improvement in maternal health can serve as a tracer or proxy for the functioning of the entire health system. For example, the skills, drugs and supplies needed to provide emergency obstetric care enable emergency care for newborns24; a higher level of care to those who need surgery following a road traffic accident for example, or to a child with a broken leg, or anyone who needs a blood transfusion.

  3.3  Through our investments in Nepal and Bangladesh for example, (see Questions F and G), DFID is finding that family planning and safe abortion care are also important to tackling maternal health problems. In these countries, availability of a skilled birth attendant at birth remains extremely restricted and referral systems are weak, but access to other reproductive health services have been strengthened and this appears to have been a significant element in reducing maternal deaths in some areas25.

—  In Matlab, a rural area of Bangladesh where maternal mortality has decreased by over 50% in the last 15 years, a focus on family planning and preventing unsafe abortions through access to menstrual regulation26 may have been critical, along with a reduction in income poverty and better access to health facilities.27

—  In Nepal a reduction in abortion-related mortality is expected to result both from a steep decline in fertility and also from the recent legalisation of abortion along with the provision of safe abortion services. Before legalisation, more than 50% of hospital admissions for obstetric complications were related to unsafe abortion.28

  3.4  Furthermore, DFID and its partners have recognised that, 20 years after the launch of the Safe Motherhood Initiative, the political will to address maternal health is still lacking in many countries29 (see also Question A). This means that what has been a mainly technical approach needs to become a political one, based on a better understanding of the incentives that governments in developing countries have to respond to women and to maternal health specifically30. Efforts on advocacy ("raise the profile" in DFID's maternal health strategy) are intended to address this.

  Evidence from several countries points to a number of critical factors that have led to significant reductions in maternal mortality31. Maternal mortality reduction in developing countries is cost effective when appropriate healthcare service scale up policies are adopted, focused wisely, and adapted incrementally in response to country contexts and systems capacity32. This is especially the case where there is the political will to back up expansion of services with investment in education and women's rights (as exemplified by the Kerala experience in India).33

  Sri Lanka, Malaysia and Thailand achieved significant improvements in maternal health by34 35:

—  providing long-term investments in maternal health services and midwifery training;

—  expanding the availability of services;

—  emphasising the improvement of quality with regulation, control and supervision of medical facilities and medical professions;

—  removing financial barriers to maternal care; and

—  improving information systems to confirm progress.

  More recently Yunnan, Egypt and Honduras halved their maternal mortality in seven years by36:

—  focussing on skilled birth attendance and professional training networks;

—  ensuring availability of facilities providing services;

—  ensuring financial accessibility to all women; and

—  strengthening the links in the health system especially referral chains.

4.  How DFID finances maternal health

  4.1  Spending on health overall (and within that specific financing for maternal health) has increased significantly in recent years. Overall health spend is now close to £800 million annually; £515 million bilateral and £285 million multilateral). DFID finances maternal health through a range of channels (see Annex 2 for further explanation):

—  Bilateral programmes37:

    —  direct contributions to the government's national budget (general budget support);

    —  direct contributions to the budgets of certain ministries such as health (sector budget support);

    —  programmes and sector support specifically for maternal health;

    —  support for technical cooperation;

    —  grants to civil society organisations; and

    —  humanitarian assistance.

—  Contributions to multilateral agencies.

—  Partnerships with non-government organisations.

—  A range of research investments.

  4.2  An increasingly significant financing modality for funding maternal health is through multilaterals. Between 2002-03 and 2006-07 DFID spent £538 million on health, through key institutions such as the EC, UN, and the Global Fund for AIDS, TB and Malaria. Figures given in the table below are for general health spending, because it is not possible to identify how much of our total contribution on health was allocated to maternal and newborn health interventions by these multilateral institutions.38 The figures shown in the following table demonstrates that multilateral spending is a significant part of DFID's activities. The wide range of complementary financing instruments highlights the importance of monitoring overall country outputs and outcomes rather then DFID specific inputs such as finance.

DFID's Health Spending through Multilateral Institutions 2002-03—2006-07

EC (estimated allocation on health)	£167 million
WHO	£146 million
Global Fund for AIDS, TB and Malaria	£118 million
UN Population Fund (UNFPA)	£77 million
UNAIDS	£30 million
GAVI	£16.5 million
UNICEF (including education, water and sanitation and other non-health interventions)	£94.3 million
Total	£648.8 million

5.  How DFID measures progress in maternal health

  5.1  MDG 5 provides a global political framework to monitor progress in improving maternal health. Clear targets to achieve the MDGs have been set for 2015 and are monitored annually through the collaborative efforts of agencies and organisations within the United Nations system. The critical concern in monitoring progress towards MDG 5 is that few countries record maternal deaths. The most recent estimates of maternal mortality available, agreed by WHO/UNICEF/UNFPA, refer to the year 2000. This is when many of DFID's investments in MDG 5 were established. The next set of data from countries, referring to 2005, will soon be released (October 2007).

  However, significant declines in maternal mortality are not expected until the end of the decade. This is largely because of the time needed to improve health systems, including training health workers and improving ways of data collection. The 2005 country data will reflect information on maternal deaths that could have taken place anytime after 2000—though most will refer to the period 2002-2005. This is why the support from DFID to the IMMPACT research that has developed fast and accurate tools to measure maternal deaths is of such significance.

  5.2  DFID proposes to include maternal health in its new public service agreement (set out in July 2007) along with other MDGs, and to include the maternal mortality ratio as the indicator of progress. At country level there are various intermediate indicators of progress including access to emergency obstetric care (EmOC), the proportion of women who are delivered by a skilled birth attendant, the proportion of women who are receiving caesarian sections or access to drugs to prevent bleeding after delivery. DFID has supported countries such as Malawi and Nepal to include these process indicators within their national health management information systems.

  5.3  DFID prepares an annual progress report on maternal health. This demonstrates accountability to parliament, helps to sustain the focus on maternal health in country programmes and at policy level, and in demonstrating commitment strengthens our influence over others.

6.  Progress made in Africa, Asia and other regions

  6.1  Eight years from 2015, progress towards MDG 5 is disappointing39. In 2000 the global estimate of maternal mortality was 400 per 100,000 births, compared with 430 in 1990. To achieve the MDG a global figure of just over 100 needs to be reached by 2015. 95% of the world's maternal deaths occur in Asia and Africa, with each continent contributing almost the same number of deaths40. A number of middle income countries have shown that halving maternal mortality in less than 10 years is possible.41 Africa by contrast, lags behind other world regions in terms of decline42 43. Reducing maternal mortality by 75% between 1990 and 2015 would require a 5.5% annual decline, but there is no strong evidence to suggest that a significant global decline is underway, let alone enough to achieve the MDG globally44. It remains very difficult to collect accurate data on maternal deaths and trends. The DFID investment in new methodologies through the IMMPACT programme promises new low-cost tool (SSS—see Section 2) that could allow more regular and more disaggregated surveys that can provide data comparable with that provided by periodic high-cost DHS surveys.

  6.2  Trends in the proportion of women who are attended by a skilled professional at birth can give a better picture of progress because the data are more reliable45. In developing regions overall the proportion of births attended by a skilled professional has risen from 43% to 57%—a significant increase over the first 15 years of the MDG period (see Figure 3)46. But the picture varies by region. South-east and Eastern Asia are making rapid progress, and Northern Africa, Latin America and the Caribbean have also made good progress47. However sub-Saharan Africa as a whole has shown very little progress over that time: key services, including access to midwives, obstetricians and emergency obstetric care, are not available to many women. And the levels of skilled attendance in South Asia remain worryingly low—still less than 40%. There DFID's concerns include gaps in trained staff in rural areas, cost and exclusion related to caste, ethnicity and other social factors.

  6.3  Despite the poor overall picture there are a number of countries where DFID has supported intensive and sustained investment, that have demonstrated impressive improvements in the levels of institutional deliveries and declines in maternal mortality.

  These include parts of Bangladesh, India, and China, Nigeria, and Nepal48, are described in detail under Question B and demonstrate clearly that success is possible.

Figure 5: Proportion of births attended by skilled health professionals by region^{49 1990-2005}

7.  Looking forward

  7.1  DFID has been a leading advocate for action on maternal health. Looking ahead, DFID needs to continue to influence international and country level partners to give priority to this MDG. Sustained focus on health system strengthening (ensuring that maternal health is given high priority in national health plans) through the new International Health Partnership that the UK was instrumental in developing will be at the heart of DFID's approach going forward. Other critical elements of our approach going forward are set out in Question A.

PART 2: DFID'S RESPONSE TO 11 KEY QUESTIONS

A.  How donors—and DFID specifically—can catalyse progress towards MDG 5

  1.  We have growing evidence of successful approaches. Donors including DFID, can help to catalyse progress towards MDG 5 by; intensifying action, investment and expertise on health systems strengthening; addressing socio-economic barriers to accessing maternity care (as we set out in response to question J); investing in research50; recognising the links between SRH, AIDS and maternal health; and using influence to raise the political profile of maternal health, especially within developing country governments (as described in response to question D, on Pakistan).

Improving coordination and focus on health systems strengthening at country level:

  2.  In September 2007 the UK launched a new international initiative—the International Health Partnership (IHP), to promote better coordination among international agencies, donors and developing countries around national health plans and more effectively use resources to strengthen national health systems that. Countries will have one health plan, with health system strengthening (so essential to MDG 5) at the core. Longer-term financing will give greater scope for countries to develop human resources, including skilled birth attendants51. Seven countries form the first wave of members of the IHP: Burundi, Cambodia, Ethiopia, Kenya, Mozambique, Nepal, and Zambia. Donor governments and international agencies that represent half of the world's aid spending are also signatories to the Compact which underwrites the partnership. The IHP has the potential to have a major impact on maternal health, because of its focus on health systems strengthening, including skilled health workers.

Acting on the linkages between maternal health, sexual and reproductive health, and HIV and AIDS:

Family planning and preventing unsafe abortion

  3.  If women can exercise choice about when and how many children they have, the chances of dying in pregnancy and childbirth are greatly reduced. Yet the world's poorest women have least access to, and choice of, contraception52. So sexual and reproductive health problems remain a major cause of death among the poorest populations53, and levels of unplanned or unwanted pregnancy remain very high54. Despite commitments made at the International Conference on Population and Development (ICPD) in 1994, sexual and reproductive health still does not get the attention it warrants nationally or internationally. More work is needed to address the global undersupply of commodities for family planning. DFID has been at the forefront of efforts to prevent unsafe abortion, in particular in response to the prohibition of US funding for abortion related services. Progress in this area is likely to remain difficult due to diverging views on preventing unsafe abortion.

HIV and maternal health

  4.  More attention is also needed on the relationship between maternal health and AIDS. AIDS is now the single largest cause of maternal mortality in some parts of sub-Saharan Africa. More than 2 million pregnant women are estimated to be living with HIV but in 2005 only 11% of them received anti-retroviral drugs to prevent the transmission of the virus to their child. In some locations AIDS related TB is now the leading cause of maternal mortality55. A woman infected with HIV is four times more likely to die in pregnancy and childbirth than an uninfected woman. DFID has merged its AIDS team and the Reproductive and Child Health teams to maximise linkages.

Making maternal health a political priority

  5.  The landmark Global Safe Motherhood Conference in Nairobi in 1987 was the first time the global health community became aware of the unacceptably high level of maternal mortality. 20 years on, and 8 years from 2015, insufficient progress has been made. The UK is clear that political priority is needed.

  6.  Achieving MDG 5 will require, above all, a significant shift in the commitment of developing country governments to prioritise maternal health. Few governments are elected on the basis of a commitment to better health, even less the health of women. Politicians, chiefs, local and religious leaders, have little incentive to place the health of women as a priority, in large part because the low status of women in many cultures limits their political power. As a result, maternal and reproductive health issues are often marginalised in health planning and budgeting. Political leadership has been a major factor in countries—such as Honduras—that have witnessed improvements in maternal health56.

  7  In India and Nigeria DFID is supporting media and civil society efforts to both increase political accountability for maternal health. DFID is also a major supporter of international advocacy efforts (refer to Part 3). DFID needs to use its influence to continue to raise the profile of maternal health on the political agenda, by using our presence at country level to keep maternal health high on the agenda in policy, planning and budgeting discussions. Taking a "rights-based approach", in which maternal health is linked to national governments' legal obligations grounded in human rights standards and principles, is another means of creating political accountability. DFID seeks the support of the IDC to work with parliamentarians in developing countries on this issue. DFID is already active internationally on key initiatives intended to generate renewed political priority for MDG 5. Many of these are described above. DFID has also supported preparations for the Women Deliver Conference in London, in October 2007.

B.  How effectively DFID is working with recipient countries to make emergency obstetric care available and to ensure that adequate numbers of skilled birth attendants and other staff are being trained to meet MDG 5, and are integrated within a robust health system

—  There are not enough health workers to deliver even basic health services -the global shortage is estimated at 4 million by 2015.

—  Many countries have less than one health worker per 1,000 people—but the minimum recommended is 2.5 per 1,000.

—  Most health workers are typically concentrated in urban area or the private sector.

—  In 57 countries (mainly in Africa) the crisis is deepening because of long-term, chronic underinvestment; losses due to HIV and AIDS; and outward migration of skilled staff.

DFID, Working together for better health 2007 (p 24)

  8.  In many countries in Africa the lack of human resources for health is a key limiting factor to progress57. There is no single intervention or quick fix due to the complex mix of "push" and "pull" incentives (eg poor salaries and working conditions) and context specific issues (eg conflict, HIV and AIDS) which lead to undersupply and out-migration of health workers. Recruitment, training and retention of health workers are complex issues that must be tackled within the context of broader health systems, public sector and macro-economic reform58. A predictable and sustained investment in health systems—as envisaged by the IHP—is essential for tackling the human resource crisis in health.

  9.  A number of DFID country programmes tackle human resources constraints directly, with impressive results in some cases. For example, DFID is providing technical assistance to develop human resource plans (Nigeria, Somaliland and Kenya); supporting broader civil service reforms through direct budget support (Tanzania); financing projects to train health workers and develop institutional capacity (Somaliland, Malawi, Zimbabwe and Uganda); engaging in health sector policy dialogue through health sector support in (Ghana, Uganda, Zambia and Mozambique); and supporting the post conflict reconstruction of health services (Sierra Leone). China, India and Malawi provide further good examples as highlighted below.

  10.  The centrality of health workers to reaching MDG 5 was seen very starkly in Malawi. DFID funded the Malawi Safe Motherhood Project (SMP) (£9.2 million from 1998-2004) yet impact on reducing maternal deaths was less than expected59. Importantly, it was the data on access to emergency obstetric care from the Malawi SMP, which highlighted the lack of skilled birth attendants and catalysed action by DFID to strengthen human resources for health. Lesson learning from this project led to investment in a major new initiative in Malawi.

Malawi Emergency Human Resources Programme (refer to part 3)

—  DFID is providing £55 million over six years to fund the Emergency Human Resources Programme (EHRP). Early findings are that there has been a significant decline in the number of nurses leaving the country to work abroad.

—  DFID is also providing £45 million to the new health sector programme.

  —  52 Service Level Agreements (SLAs) have been signed by District managers with the Christian Health Association of Malawi (CHAM) to provide maternal and neonatal services free of charge.

—  District managers have also used additional funding to rehabilitate and upgrade health facilities and provide locum payments to midwives to go to health centres to cover staff shortages.

—  One district, Dowa is training traditional birth attendants (TBA) to refer patients using an incentive fee of 200MK (70p) per patient. This has proved extremely effective and lessons will now be applied across the country.

  In Nigeria DFID provides £56m to the PATHS Health Systems project to improve the quality and management of health services, increase consumer awareness and strengthen the oversight role of the government in partnership with six state governments. This has led to significant improvements in immunisation coverage, attended deliveries and uptake of emergency obstetric care. Over one year the numbers of women attending hospitals within two pilot areas for emergency obstetric care rose by 50%.

  11.  In Asia, most countries are still seriously off-track on MDG 5. In South Asia in particular, the low status of women in society, and their low levels of literacy, add to the risks they face through lack of access to adequately skilled health workers in properly equipped facilities. Most women still do not do not have a safe delivery, or access to emergency care for the unpredictable life—threatening complications that will arise.

  But despite being off-track on MDG 5, progress is being made towards improving maternal health. Innovative schemes are being developed to provide incentives and rewards for skilled doctors, nurses and midwives to work in rural areas. In Bangladesh, India, Nepal and Pakistan, DFID is supporting programmes to accelerate progress to reduce maternal and child deaths, in addition to broader health system support. In Nepal and Cambodia DFID provides specific support to the provision of safe abortion services. A shortage of skilled staff remains a key constraint to better access to services, especially for rural populations. In China, major improvements were visible in 97 counties where DFID was involved in interventions that strengthened the health systems, including human resources. Examples such as these demonstrate that investing in maternal health does work and gives us evidence that can be used for scaling up. These countries are described in the box below, (India, China) and on page 22 (Nepal) and page 24 (Pakistan, Cambodia).

  In India, DFID has committed £252 million to the Government of India's national Reproductive and Child Health (RCH 2) Programme (2005-11). RCH 2 aims to improve reproductive and child health, and in particular to improve the health outcomes of the poorest and socially excluded groups. It has supported the recruitment and training of more skilled birth attendants, and the resourcing and staffing of health facilities to provide 24-hour emergency obstetric care. The programme has led to impressive gains in the increase in the proportion of institutional deliveries:

—  in the state of Madhya Pradesh from 40.6% in 1998-99 to 50.8% in 2005-06;

—  in Orissa State from 22.7% to 38.7%;

—  in West Bengal from 40% to 53%; and

—  in Andhra Pradesh from 50% to 69%.

Improved uptake of services has been aided by provision of transport for women to reach health facilities for delivery, and the use of financial incentives60.

In China significant gains have been made by a 10 year jointly funded DFID (US$42 million), World Bank (US$85 million) and the Chinese Government (US$43.7 million) programme that targeted MDG 5 in 97 poor rural counties. There have been dramatic gains in reductions in maternal mortality. The approach taken in China has included a focus on strengthening the health system and human resources, as well as working on non-health sectors such as infrastructure.

—  The number of maternal deaths fell from 125 to 68 per 100,000 between 1998-2005 in one area and from 91-84 per 100,000 between 2002-05 in another area.

—  Institutional deliveries (ie births in health facilities instead of at home) increased from 5.7% in 1998 to 40.6% in 2005 in Qinghai and from 14% to 44.5% between 1998 and 2005 in Ningxia.

  12.  At global policy level DFID is supporting: work to slow down out-migration of health workers through work with the UK DoH/NHS; the Global Health Workforce Alliance (GHWA) in reducing heath worker shortages; work with the UK's Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives in providing training in Somaliland. DFID's support to PMNCH includes resources to enable the Federation Internationale de Gynecologie et D'Obstetrique (FIGO) and Health Care Professionals to better track developments in increasing skilled birth attendants.

C.  The steps DFID is taking to mainstream maternal health across related policies

  13.  DFID promotes policies across a range of non-health sectors that help improve maternal health. For example DFID is working to ensure investment in water and sanitation, infrastructure, transport and communications are linked to improving maternal health. In Nepal and Malawi DFID has worked to develop appropriate transport systems that best support women in accessing health services. In Sierra Leone DFID is supports the strengthening of health systems for maternal and child health through a joint approach to improving water and sanitation. The total £82 million commitment (£50 million for health over 10 years and £32 million for water and sanitation over five years) will ensure that water-related infection is prevented in the home and community (where the majority of deliveries take place) and that health facilities have, at minimum, water supplies and toilet facilities for patients and staff. DFID is working to ensure that maternal health is well-reflected in its new water and sanitation policy update, which is under preparation at the time of writing.

The Nepal Safe Motherhood Project (1997-2004) and Support to Safe Motherhood Programme (2004-2009).

  In addition to its health sector budget support, DFID is providing £20m (2004-2009) to the national Safe Motherhood Programme, including financial aid to government, technical assistance, and direct support to UNICEF. The programme includes an innovative cash transfer scheme to women for delivery by skilled health workers. The results of the Nepal programme have been impressive:

—  the caesarean section rate increased almost three fold (from 1.0 in 1996 to 2.7 in 2006).

—  delivery by trained health professionals almost doubled (from 9% in 1996 to 19% in 2006).

—  after the legalisation of comprehensive abortion care in 2002 (implemented from 2004), large numbers of women are using safe abortion services from private and public facilities.

—  the total fertility rate (ie total number of live births a woman has, on average, in her lifetime) declined by 33% (from 4.6 in 1996 to 3.1 in 2006).

  Importantly, DFID support to improving maternal health in Nepal mainstreams non-health sector support such as:

—  construction of health facilities to ensure safe access to operating theatres and delivery rooms, as well as toilets and showers, solar panels to provide hot water;

—  building of bridges to improve access to health facilities;

—  design and development of cycle ambulance rickshaws and other local transport; and

—  communications through radios.

—  in addition, DFID has supported £11 million for water and sanitation and £35 million for the transport sector over the past five years in Nepal.

  14.  Within the health sector, DFID actively works to make appropriate linkages between health issues and interventions that impact on maternal health. DFID is active internationally in efforts to improve sexual and reproductive health, to tackle HIV and AIDS, and to control malaria and TB through multilateral and bilateral channels. DFID is a key donor to Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) having committed £359 million through to 2008. DFID also supports UNITAID, which provides funds for the provision of drugs and diagnostics for AIDS, TB and Malaria. The UK is making a 20-year contribution, starting with £15 million in 2007, and, subject to the outcome of a joint assessment of the performance of UNITAID, rising to £40 million a year by 2010. At country level, DFID programmes address the linkage between these issues. In Zimbabwe, DFID is supporting a programme to reduce the impact of HIV on maternal health through increased access to family planning and anti-retroviral drugs; and in India, in addition to RCH2 (described above) DFID supports the revised National Tuberculosis Control Programme II and the National AIDS Control Programme.

  15.  DFID also has a series of policy papers that shape and contribute to our efforts on maternal health action61.

D.  How achieving MDG 5 is being prioritised and integrated into countries' overall healthcare provision

  16.  DFID's approach varies across regions and is country specific. DFID's core 26 countries have a Country Assistance Plan (CAP) or equivalent. This is usually premised upon a government poverty reduction strategy paper (PRSP). Where DFID is providing financial support directly to the government's budget DFID can play a role in, for example, encouraging monitoring frameworks to include measures of health outcome. Where we are providing support at sectoral level, (eg Nepal, Malawi) DFID typically works with the government and partners in country to develop, implement and monitor health plans. This provides an important opportunity to influence health sector policy, including bringing increased attention to maternal health issues. In some countries, however (eg Tanzania) DFID opts to leave this role to other agencies.

  17.  In India, Bangladesh, Nepal and Pakistan where DFID provides significant direct support to health programmes, maternal health has been a priority issue for country offices in policy dialogue with authorities. In Pakistan for example, DFID has a 10-year development partnership arrangement with the Government of Pakistan in which the Government commits "to improve health service delivery and particularly in maternal and neonatal health". Specific funding for maternal health has been committed to help accelerate progress, as described in the box below. DFID also supports family planning programmes (key to maternal health) in South Asia, as part of broader reproductive health programmes.

  In Pakistan, DFID has had a significant influencing role with the government in raising the political profile of maternal and newborn health to the extent that the Government of Pakistan has committed to financing a major new National Maternal, Newborn and Child Health Programme, to which DFID confirmed a contribution of up to £90 million over five years in October 2006. Importantly, DFID's recommendations on channelling resources directly to the districts and encouraging good performance through financial rewards have been accepted.

  This will expand maternal and newborn care, and support the creation of a new cadre of community midwives, and the promotion of effective maternal and child health behaviour by families. DFID support includes £69 million to the Government, £9.5 million in technical assistance, and an £11.5 million research and advocacy fund to promote equity and social inclusion, and increase knowledge about what works. This fund includes supporting civil society and the media to create coalitions for change and raise awareness.

  In Indonesia recent DFID support includes £4.2 million to GTZ for a three year Maternal Health and £9 million to UNICEF over three years to replicate an AusAID funded project in a further nine provinces. This is aligned behind an existing District Health Strengthening Project

  In Cambodia DFID's support to maternal health comes within a broader programme on "Increased access to health services and information" and has a focus on MDG 5 and halting the spread of AIDS. DFID is one of many donors to this programme, including the WB, ADB, USAID, and Germany, France and Belgium.

  18.  In Africa significantly more DFID funding flows through budget support than in Asia. A share of this supports strengthening of the health system. And it is often supplemented by additional direct programme investment in health (as explained in Section 4). DFID has sought to support governments to focus on MDG 5 through programmes and policy dialogue on health: in Kenya (see below); in Angola (where we fund UNICEF which is working to ensure that child and maternal health care are part of the Government's medium term health plan (2009-2013); in Sierra Leone where the post-conflict reconstruction of the health system includes an explicit focus on reproductive health; and in Burundi where the abolition of user fees for maternal deliveries and healthcare for children was implemented in May 2006 with dramatic effect (see below).

  In Kenya DFID is supporting a £7.5m Essential Health Services Project over 5 years, working alongside the government and with UNICEF, WHO, UNFPA, EC. This supports MDG 5 by strengthening the overall provision of health care by the government through:

      1.  Strengthening reproductive maternal health services in Nyanza province.

      2.  Broader technical support on maternal health and health systems.

      3.  Support to sector planning, co-ordination and monitoring processes.

      4.  Provision of socially marketed contraceptives.

  In addition, DFID Kenya is supporting a programme that, through social marketing of bednets to prevent malaria has decreased the number of low birth weight babies born from 18% in 2001 to 13% in 2005. This suggests that fewer pregnant women were infected with malaria which can result in low birth weight babies. Malaria related outcomes for pregnant women are still being documented.

E.  How DFID is supporting the 2006 recommendation by the UN General Assembly for an MDG target for universal access to reproductive health

  The 2005 World Summit recognised the central place that improving sexual and reproductive health (SRH) plays in achievement of the MDGs. The Summit also recognised the absence of SRH from the current MDG 5 target and indicators. In 2006 the UN Secretary General recommended a new target for MDG 5.

MDG 5

Goal: Improve maternal health

Target: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio'.

Indicators:

  —  Maternal mortality ratio (MMR)

  —  Proportion of births attended by skilled health personnel

Proposed additional target: "Achieve universal access to reproductive health by 2015".

Proposed new indicators:

  —  unmet need for family planning,

  —  age-specific fertility rate (15-19)

  —  attendance at antenatal care.

  19.  In discussions on progress towards the MDG at the 2005 World Summit, the UK sought to ensure reproductive health was well reflected in the outcome. This provided the basis for recommending the MDG 5 target on reproductive health which DFID fully supports. The UK has continued to press for the inclusion of this new target in the MDG framework.

  20.  The 2007 UN Millennium Development Goal's Report makes good reference, for the first time, to the critical need for reproductive health services to improve maternal health, including antenatal care and family planning. It is disappointing, however, that no explicit mention is made in this 2007 report of the new target, nor of the proposed new indicators. We expect the new target and indicators to be formally reflected in the August/September 2007 Secretary General's Annual Report though this is subject to negotiations at the time of writing.

  21.  DFID continues to work towards the achievement of the proposed new target in countries. In Sierra Leone, for example, the first step to addressing maternal health has been to assist the Ministry of Health to develop a sexual and reproductive health policy.

  22.  In addition to supporting the new target, DFID was active in influencing the Maputo Plan and the 2007 G8 process to fully reflect reproductive health.

  The Maputo Plan was unanimously agreed by the African Union Health Ministers when they met in September 2006. UNFPA and IPPF, with support from DFID, were key to enabling this meeting to take place. The Plan of Action includes support for better family planning, improved contraceptive commodity security and action to reduce unsafe abortion. This demonstrates the commitment of African health ministers to the issues covered in the new MDG 5. target

  At Heiligendamm in June, the G8 reaffirmed its 2005 commitment to universal access to comprehensive HIV prevention, treatment and care by 2010 and made commitments that will significantly assist in funding and developing national AIDS plans. These include providing $60 billion funding over the next few years, with $4.8 billion for sexual and reproductive health:

—  $1.5 billion for the prevention of mother to child transmission.

—  $1.8 billion for paediatric treatments.

—  $1.5 billion for family planning.

F.  The progress being made in reducing maternal deaths from unsafe abortion (which account for 13% of all maternal deaths)

—  Unsafe abortion is preventable. An estimated that 68,000 women die each year from unsafe abortion—98% in developing countries. Many more suffer injury and infection (IPPF 2006).

—  Of the 210 million pregnancies each year, about 46 million (22%) end in induced abortion, 19 million occur in unsafe circumstances.

—  Accurate measures are difficult to come by given the legal and political implications—deaths may be attributed to miscarriage or causes other than abortion. So global figures are likely to underestimate the scale of the problem.

—  In some countries (such as Nigeria and Cambodia) unsafe abortion accounts for 30-40% of maternal deaths (WHO). In a study of 12 hospitals in Benin, Cote D'Ivoire and Senegal, almost all deaths in early pregnancy were due to induced (unsafe) abortion and a third of all maternal deaths were due to unsafe abortion62.

—  Young women are particularly at risk—in Africa almost 60% of all abortions occur to women less than 25 years of age.

—  Medical abortion—simply taking an "abortion pill" (misoprostol) in early pregnancy—is safe and affordable, but access remains limited.

  23.  Safe abortion saves lives by reducing recourse to unsafe abortion63. DFID is able to support action to prevent deaths from unsafe abortion, wherever this is legal and are able to support post-abortion care services in all contexts. In South Africa, DFID supported work in South Africa translated into a more liberal abortion law. As a result deaths from unsafe abortion declined by 91% between 1994 and 2001.

  In Cambodia DFID is providing £2.2 million to support the Ministry of Health's plan to reduce unsafe abortion and increase access to family planning. This includes support for raising awareness among policy makers, women and health providers that abortion is now legal and providing training; equipment and supplies; research; and family planning and safe abortion services. This is being managed within a wider framework of support to health jointly with JICA, UNFPA, WHO, UNICEF, USAID, GTZ, WB and ADB.

  A large proportion of maternal deaths in Nepal are due to unsafe abortion. Following widespread social pressure, in March 2002 the government legalised abortion. DFID has supported this effort, contributing to the evidence of the effects of unsafe abortion, and preparing policies in the build up to legalisation. In the three years since the national programme was initiated, DFID support has helped train 351 service providers and established 163 simple, safe and woman friendly service sites in public hospitals and in private and NGO clinics. By December 2006, 70 of the 75 districts had at least one safe service site and 85,984 women had received abortion services. (DFID Health Strategy, 2007)

  24.  DFID welcomed the establishment of the International Planned Parenthood Foundation (IPPF) administered Safe Abortion Action Fund (SAAF) launched in February 2006 to act to prevent unsafe abortion. DFID has committed £3 million (US$5.9 million) over two years. Denmark, Norway, Sweden and Switzerland have joined in support of the SAAF. The scale of unmet need was demonstrated when the $11.9 million fund attracted 222 applications totalling $43 million in the first call for proposals.

  25.  DFID is working to make medical abortion more accessible to women in developing countries, through funding the Concept Foundation to develop and gain regulatory approval of a low-cost, quality generic "abortion pill" for use in low-income countries; as well as the advocacy work of the International Consortium for Medical Abortion to develop accessible information on medical abortion for policy makers, providers and users.

G.  How effective family planning is being promoted as a way to improve maternal health

—  Family Planning is one of the most cost-effective preventative health measures available. $1 million invested in FP averts 360,000 unwanted pregnancies, prevents 150,000 induced abortions and save the lives of 800 mothers and 11,000 infants (UNFPA).

—  137 million couples who have expressed a desire to space or limit their family size have no access to contraception and a further 64 million couples rely on less effective traditional methods. Meeting the unmet need for family planning would avert 52 million unintended pregnancies each year; preventing 142,000 pregnancy-related deaths (often linked to unsafe abortion) and saving 1.4 million baby's lives (through better birth-spacing).

—  World population will continue to grow from 6.5 billion at present to over 9 billion by 2050. Over 99% of this growth will take place in developing countries with a significant proportion taking place in sub-Sahara Africa (even allowing for increased mortality from AIDS).

  26.  The ability of women, and men, to choose how many children they have and when they have them is critical to achieving all the MDGs, including MDG 5. It has been estimated that, globally, promotion of family planning has the potential to avert 32% of all maternal deaths64. It is clear that more action is needed on family planning.

  27.  Despite clear evidence that there is huge unmet need, family planning supplies are inadequately financed, whether through domestic budget allocations or global financing initiatives. There is a trend of stagnating spend on family planning—between 1995 and 2003 direct donor support for family planning supplies and services decreased from $590 million to $460 million—while support to HIV and AIDS for example, is rising. Global commitment to support African Governments in implementing reproductive health programmes has weakened and funding has decreased. Government commitment is also weak. Among DFID's 16 PSA countries in Africa for example, only 10 report budget lines for SRH supplies. Progress is slow given the political sensitivity surrounding SRH and the low priority afforded to family planning. Even in well performing countries such as Uganda and Tanzania, national budgets are at zero or allocations are under spent. Donor dependence is high, funding fragmented and co-ordination weak.

  28.  The impact of family planning on maternal mortality reduction can be seen in Bangladesh. Halving of the fertility rate over two decades and reduction in deaths from unsafe abortion has been instrumental in reducing risky high parity births (4th, 5th and even higher order births are more dangerous for the mother) as well as reducing unwanted births. This has been critical, along with increased use of services, to reductions in maternal deaths in some parts of Bangladesh.

  29.  DFID is a leading bilateral provider of condoms and other reproductive health commodities to developing countries. UNFPA estimates that some 1 billion condoms supplied by donors were used in developing countries in 2001, nearly half of these provided by the UK. For the past 10 years DFID has been the fourth largest provider of condoms, supporting the distribution of about 150 million condoms annually. We are currently providing £80 million over 4 years to UNFPA as core budget support (DFID is the fourth largest donor). Access to and use of quality FP services is one of 5 outcomes under the RH goal in UNFPA's new medium term strategic plan, 2008-2011. DFID actively promoted the International Coalition for Reproductive Health Commodity Security which brings together UNFPA, WHO, the World Bank, bilateral donors, implementing agencies and countries to co-ordinate supplies, including condoms and other contraceptives and equipment for safe delivery. And DFID is actively exploring the possibility of increased funding for commodities through UNFPA. DFID is currently examining the possibility of investing more through UNFPA to help address this problem.

H.  How effectively DFID works with bilateral and multilateral donors, NGOs and other stakeholders to promote maternal health

  30.  DFID's new Health Strategy (2007) outlines how we work with partners to achieve greater harmonisation and coordination within the international health architecture. The UK's Prime Minister launched the new health initiative, the International Health Partnership (IHP) on 5 September 2007. As described under Question A, this includes a compact between country governments and donors and other stakeholders to better coordinate at country level to unlock financial and other barriers to strengthening health systems.

  31.  DFID's influence on maternal health is clear in other ways too. For example, DFID advocated that MDG 4 and 5 were closely linked and Prime Minister Stoltenberg decided to expand the scope of the initiative to include both MDGs. The Gates Foundation and the MacArthur Foundation seek advice from DFID in the development of maternal health strategies and global approaches. DFID's influence was critical to the establishing of the Partnership for Maternal, Newborn and Child Health (PMNCH) which merged three previously competing partnerships, and DFID is a Board member. DFID was also requested by the UK's Royal College of Obstetrics and Gynaecology (RCOG) to bring its experience to its new International Advisory Board. DFID's has also sought to bring a greater focus to MDG 5 internationally, including within UNICEF which is traditionally focussed on child health only.

  32.  DFID has also pursued innovative approaches to collaboration with other bilateral partners. Lessons learned from work in countries (such as the Yemen, below) indicates that DFID needs to agree the extent to which we wish to devolve management to silent partners, including on policy decisions. DFID needs to make case-by-case judgements on how far DFID policy is likely to be implemented on the ground when we work through partners.

The Yemen Maternal and Neonatal Health project

  DFID is investing in maternal health in the Yemen, working through our partners, Netherlands and UNICEF. The programme start-up has been delayed. DFID has learned that it can take longer than expected to get action on the ground when working through other partners, when DFID remains "silent" (ie DFID provides funding but does not provide technical assistance). The capacity of the UN as an implementing partner was overestimated in the Yemen. It will be important going forward, for DFID to accurately assess the implementation capacity of potential partners, and make case by case judgements on how effectively DFID policy is likely to be implemented in practice.

I.  What leadership the UN is providing and how well co-ordinated its Agencies are

  The United Nations has the legitimacy to convene and monitor international efforts in addressing maternal health. Different parts of the UN system are contributing towards the achievement of MDG 5 through:

—  Co-ordinating gender and MH/RH action in emergency situations (UNFPA).

—  Leading and hosting international partnerships and initiatives (WHO).

—  Leading the International Coalition for RH Commodity Security (UNFPA).

—  Leadership—eg joint statement on female genital mutilation (WHO, UNICEF, UNFPA).

—  Setting of norms and standards for national MH policies (WHO).

—  Building government capacity to plan and deliver health services (WHO, UNFPA).

—  Procuring essential health commodities (UNICEF, UNFPA).

—  Training health workers (UNICEF, UNFPA, WHO).

—  Advocating and working with specific population groups (UNICEF, UNFPA).

—  Creating demand for services and monitoring progress through national surveys (UNFPA).

  33.  There is a generally agreed division of labour between the different UN agencies on maternal and child health. However, duplication, mandate overlap and competition for donor funds and government time continue to reduce the effectiveness and efficiency of the UN response to MDG 5 in country.

  34.  DFID recognises and supports the UN's niche role in addressing maternal health and is seeking greater effectiveness and accountability from them for delivering on MDG 4&5. DFID is driving efforts to improve multilateral coherence on MDG 4 and 5 through the establishment of the PMNCH; by providing multi year funding to WHO, UNFPA, UNICEF and the WB connected to Institutional Strategies; and through the pursuit of UN reforms recommended by the UN Secretary General's High Level Panel for System Wide Coherence, of which Gordon Brown was a member. DFID has been influential in the development of UNFPA and WHO's new Strategic Plans that will guide their global, regional and country programmes.

The Partnership for Maternal, Newborn and Child Health (PMNCH)

  DFID was instrumental in the creation of the PMNCH, which brings together three previously competing health partnerships: the Child Survival Partnership, Healthy Newborn Partnership, and the Partnership for Safe Motherhood and Newborn Health.

  Hosted by WHO, the PMNCH was established to support the achievement of MDGs 4 & 5 through:

—  Accelerating coordinated action at global, regional, national, sub-national and community levels.

—  Rapid scaling-up of proven cost effective interventions.

—  Advocacy for increased commitment and resources.

  The PMNCH has combined various existing networks—thereby rationalising the international architecture and increasing coordination and provides a good example of multilateral leadership.

  35.  We continue to call for agencies to show international leadership in tackling maternal health and seek evidence of effectiveness so that our investments can be linked to results. The ability of the UN to deal with sensitive issues, for example UNFPA championing the management of unsafe abortion, is constrained by the fact that it must work through building consensus with all of its member states. The diverging views of member states has resulted in UNFPA being under intense scrutiny and has not allowed them to work within the full parameters of the ICPD Programme of Action.

DFID funding to UN agencies working in Maternal Health

—  DFID is one of the largest donors to UNFPA, providing £80 million core funding over four years and £10 million specifically for reproductive health, including work on fistula. DFID also provides £700,000 to NGOs working on obstetric fistula in Africa.

—  In 2006, DFID was the second largest donor to UNICEF providing a total of £105 million (US$186 million) of which £19 million was core funding. In 2007, Ministers have agreed to increase core funding to £21 million in recognition of UNICEF's progress on system-wide coherence and its voluntary review to strengthen the organisation.

—  The UK is the largest donor to WHO, providing £18 million per year assessed contributions from the Department of Health and £50 million core funding over the last four years from DFID.

  36.  Moves towards a more coherent UN are underway in eight pilot countries (Albania, Uruguay, Cape Verde, Tanzania, Mozambique, Rwanda, Pakistan, Vietnam) under the framework of a "One UN" with one leader, one programme, one budgetary framework and one office. There are encouraging early signs in these pilot countries that the impact of the One UN approach has been to prompt the UN to reorient its work around national development priorities and to address their working practices to work more coherently and effectively. A review will report progress in March 2008. The reorientation of the UN country programme around national priorities should increase coordination of agencies working on maternal health, enable more systematic barriers to be addressed (eg infrastructure, women's empowerment) and increase the UN's accountability to the government and donors.

Working with the UN on maternal health in countries

  UNFPA and UNICEF working on HIV and MDGs 4 and 5 in Zimbabwe

  DFID is investing £25 million over five years in a maternal and newborn health project that will be implemented by a joint UN Programme involving UNFPA and UNICEF, working in partnership with non-governmental organisations and will provide a useful model for UN reform and alignment of UN agencies at country level.

  Post conflict support to MDG 5 through UNICEF in Angola

  DFID's support to maternal health is through a general non-earmarked grant to UNICEF which is working towards an integrated programme of health and primary health care, HIV/AIDS, Child Protection, Primary Education and Water and Sanitation.

  Joint UNFPA-UNICEF- WHO maternal health programme in Bangladesh

  DFID is providing £10 million to the three major UN agencies to reach 47.5 million people to increase access to emergency obstetric care to 45,000 women; avert 900 maternal deaths and 24,000 neonatal deaths.

J.  How DFID is addressing socio-economic barriers to women's empowerment and the low status of women in relation to maternal health

  Empowering women to take control of their sexual and reproductive health is essential to achieving MDG 5. Women must be able to make free (not coerced) and informed decisions regarding their reproductive and sexual lives. But there are barriers at household, community and societal level:

—  one in five women around the world will survive rape or attempted rape at some point in their lifetime65. In Kenya66, Bangladesh and Peru67, about 24% and in South Africa68 about 30% of women say their first sexual experience was forced;

—  gender norms dictate that decisions and resources are controlled by others. For example, many women in need of emergency obstetric care have to wait for their husband to make a decision as to whether or not he will finance the costs;

—  physical barriers such as lack of roads and transport prevent access to health services;

—  health services are unaffordable, of poor quality and staff attitudes are often discriminatory and disrespectful; and

—  harmful traditional practices, such as female genital mutilation and early marriage put young girls at greater risk of ill health and even death.

  37.  DFID is recognised for its strong defence of women's sexual and reproductive rights and has worked closely with other like-minded European partners (eg Norway and Sweden) to repeatedly defend strong sexual and reproductive health and rights (SRHR) language in international negotiations (eg at the World Health Assembly, the G8 and the UN summit on MDGs). This has inter alia, helped keep the possibility of a new reproductive health target alive. In an era of powerful conservatism on these issues, the UK is recognised as a leader. Most recently this involved difficult EU negotiations to agree consensus on SRHR language in relation to progress on maternal health at the 2007 World Health Assembly. In this our objectives has been to maintain the consensus that was achieved in the ICPD.69 This is often the subject of opposition from others and with the expansion of the EU has increased. DFID sees maternal health at the core of women's human rights and has developed guidance (How to Note) on promoting a rights based approach to maternal health policy and programming.

  38.  Adolescent girls are particularly vulnerable. DFID has supported (2001-07) Population Council's nine country programme of research on adolescent girls transitions to adulthood, which has identified the particular vulnerabilities of young girls aged 10-14 years, to poor SRH and HIV and AIDS. These result from social and economic disadvantage, gender norms and relationships, traditional and cultural practices, such as early marriage and FGM. The evidence has directly informed the development of the Ethiopian Government's Adolescent and Youth Reproductive Health Strategy and was used by the Population Council in its significant contribution to the 2007 World Development Report. We are using these important findings to inform our SRHR and new HIV policy approaches.

Female genital mutilation—a violation of human rights

  Every year, up to three million women and girls are subjected to female genital mutilation, some of whom die as a result of the procedure. Others may be left with long-term health problems and are at risk of life-threatening complications including obstructed labour, neonatal asphyxia and fistula, during childbirth.70

  39.  DFID strongly supports the elimination of FGM and regards it as both a violation of human rights and an important maternal and neonatal health issue. We have supported a number of initiatives including an African Parliamentarians Conference in Senegal in 2005, in partnership with UNICEF which resulted in an African Parliamentary Union Declaration. "Violence against women, abandoning female genital mutilation: The role of national parliaments". We also supported an African regional workshop, in Nairobi in July 2006, with WHO on harmful traditional practices. The workshop aimed to develop a legal framework for child protection that brings together legislative, welfare and social services, police and justice systems, basic service providers and civil society, to protect girls in a comprehensive way. This led to an African Parliamentary Union This took account of the joint WHO/UNICEF/UNFPA statement on female genital and will be drawn upon by DFID in its engagement as a member of the donor working group on FGM.

  40.  DFID and other partners are supporting innovative work in a number of countries to overcome barriers to access to maternity and health care for the poorest and excluded women, eg in Bangladesh, Nepal, India and Cambodia. These include providing cash, or vouchers to pregnant women to pay for transport, medicines and services. This is a very new area of work and evidence to date is thin. However, an evaluation of the DFID-supported Nepal government's cost-sharing scheme for safe deliveries is underway and will provide important lessons for the international community.

  41.  DFID and WB policy is to support countries to abolish user fees. Such a policy change can have a dramatic impact on access to maternal health services, even in fragile states. The graph below shows what has happened in one health facility in Bubanza province in Burundi over the year since maternal health services became free71.

Source: DFID

  42.  Maternal and child health also depends on men's role in SRHR and HIV prevention and there is a need to emphasize men's responsibilities in this regard. DFID recognises this need and is providing support to IPPF to draw together learning and inform the development of an information package on men, gender equality and health by WHO, IPPF, Engenderhealth and others.

K.  How the international community can improve maternal health in crisis and conflict settings

—  Women and children account for two thirds of the 24 million displaced people worldwide.

—  Conflict places women at greater risk—from sexual abuse, sexually transmitted infections and unwanted pregnancy—and prevents access to safe abortion and emergency obstetric services.

—  Conflict prevents women from accessing reproductive health and family planning services much needed where sexual abuse and infections are rife.

—  In Africa, conflict is one reason (along with AIDS and lack of basic services) why maternal health is not improving.

  43.  By 2010, half of the world's poorest people might be living in states experiencing or are at risk of violent conflict. Some 70% of these are women and children. Conflict both destroys the health systems needed to provide reproductive health services and access to emergency obstetric care, while increasing the need for these services. Yet a crisis can provide opportunities to increase health provision where relief services are able reach vulnerable communities.

  44.  DFID is increasing both its expenditure and involvement in these environments and is working with developing countries and other international partners to better co-ordinate overall efforts to improve security and to build capacity to prevent and respond to conflict.

  Following the Pakistan earthquake in October 2005 a specific working group was set up under the health cluster to coordinate the response to maternal and child health needs in earthquake affected areas.

  45.  DFID supports the work of WHO, UNFPA and UNICEF in fragile states in providing maternal and reproductive health services if a state is unable to do so due to conflict or a humanitarian emergency. These agencies have a critical role in the transition from relief to development through re-establishing government capacity to provide services. Support includes funding for WHO's Health Action in Crises (HAC) (£6.2 million /2003-07), UNFPA's provision of reproductive health commodities in fragile states (£5 million 2007-08) and UNICEF emergency feeding of children and pregnant/nursing mothers. DFID is also encouraging better co-ordination and harmonisation within the UN. For example the WHO HAC leads the global humanitarian "health cluster" (an inter-agency humanitarian response mechanism) and UNFPA coordinates gender mainstreaming in emergency situations. The response to maternal mortality forms a part of this broader funding in crisis and conflict settings.

  46.  DFID's bilateral programmes also work to develop the capacity of partners to provide maternal health services in conflict and post conflict situations.

Examples of DFID support to MDG 5 in conflict and post conflict environments

  Somalia:  £2.1 million over three years to a consortium of NGOs to deliver health services and improve access to maternal health services.

  Sudan:  support to the provision of emergency obstetric care through NGOs such as Médecins Sans Frontie"res (MSF) and Merlin, who provide a basic package of services for women and children.

  Liberia:  support to Merlin, Save the Children and the International Rescue Committee to deliver health services including support to hospitals that are the sole providers of emergency obstetric care.

  DRC:  support to health services through the Humanitarian Pooled Fund, including:

—  help for victims of sexual and gender based violence (SGBV);

—  the provision of post exposure (to HIV) prophylaxis; and

—  the development of a dedicated facility for the treatment of fistula in DRC—this is higher than usual proportions of fistula cases due to more sexual violence than is normally the case.

  Sierra Leone:  £50 million over the next 10 years in rebuilding the health system to deliver basic services in sexual, reproductive and child health. Sierra Leone has the highest maternal mortality in the world, at 1,800 per 100,000 live births. Access to Emergency Obstetric Care outside Freetown is negligible and only 4% of women are able to access contraceptives.

  Burundi:  DFID provided £1.5 million as a "peace dividend" in the post-war period to enable the President to scrap user fees for maternal and child health and further supports MSF Belgium to deliver emergency obstetric care.

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Prepared 2 March 2008