House of Commons - International Development

Select Committee on International Development Written Evidence

Memorandum submitted by the International Planned Parenthood Federation (IPPF)

INTRODUCTION

IPPF is a global service provider and a leading advocate of sexual and reproductive health and rights. We are a worldwide movement of national organizations working with and for communities and individuals in approximately 180 countries to deliver health care services and campaign for individual rights. From our "56,000 service delivery points, our Member Associations provided over 20 million contraceptive services and over 18 million other sexual and reproductive health services in 2006."[52]

IPPF works closely with DFID to advance sexual and reproductive health and rights around the world and we welcome this inquiry into the state of maternal health around the globe. While still insufficient, the increased international spotlight and consensus on addressing maternal health, partly as a consequence of the maternal health MDG, means that this is an opportune time to review and revise DFID's existing maternal health policy.

Our strategic relationship with DFID is mutually beneficial and based on a shared vision. We work together at this strategic level to try to help deliver the goals of the International Conference on Population and Development (ICPD) and the Millennium Development Goals (MDGs), particularly those related to poverty reduction and those relating to women's status and health. IPPF translates this shared strategic vision into action at the grassroots level.

Safe pregnancy and safe births are still pipe dreams for hundreds of thousands of women each year. Maternal deaths and ill-health, easily prevented in developed countries, continue to kill and harm women, undermining families, communities and societies, in some of the poorest countries in the world. Despite the fact that we know how to prevent these deaths we have failed to make significant progress in reducing maternal mortality and morbidity, especially in Africa and much of Asia. This failure is despite numerous international attempts to address these issues, including: the Safe Motherhood Initiative, the1995 Fourth World Conference on Women (Beijing), The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), United Nations General Assembly Special Session (UNGASS 2001 and 2006) and the World Summit outcome document of 2005.

In 1997 DFID launched a White Paper on "Eliminating World Poverty: A Challenge for the 21st Century".[53] Since 2000, DFID's determination to combat poverty has been closely aligned to the MDGs. This has included a special focus on MDG 5—"Improve Maternal Health"—which is essential to combating poverty. We applaud this determination to address women's health and combat poverty, and it is our hope that the new reproductive health target will provide a further incentive for reaching this goal.

DFID's bilateral expenditure on programmes which contribute towards maternal health has increased from £172 million in 2002-03 to £243 million in 2004-05.[54] This has been used to tackle the "three delays" in maternal health, "the time taken to decide to get help, to get the help and for the help to actually be provided can make all the difference between life and death."[55]

However, it is also important to link these "three delays" to family planning and the ability to choose the number and spacing of children in order to save the lives and ensure the well-being of women and children. The important role of family planning in reaching MDG 5 is demonstrated through the proposed adoption of the new indicator on "Unmet need for Family Planning".

The role of bilateral donors in helping reach MDG 5 is crucial. This is because bilateral donors can:

— Influence regional donors.

— Help meet existing demand through supporting increases in supply; achieved through the funding of both recipient countries and multilateral agencies (such as the World Bank).

— Help stimulate new demand by supporting civil society interventions in terms of grassroots advocacy including Behaviour Change Communication (BCC), service delivery and supporting the development of new modalities of delivery.

— Influence recipient governments some of whom place a low priority on maternal health, evidenced by the fact that and do not even collect data.

Increasing international consensus on strategies to reduce rates of maternal mortality, including emergency obstetric care, care by skilled birth attendants and unmet obstetric need are timely and welcome. This consensus acknowledges that "without the ability to treat women with obstetric complications, maternal mortality cannot be substantially reduced."[56]

Each year over 529,000 women die in pregnancy or childbirth and for every woman who dies, roughly 20 more suffer serious injury or disability—between eight million and 20 million a year.[57] "Four out of five maternal deaths are the direct result of obstetric complications, most of which could be averted through delivery with a skilled birth attendant and access to emergency obstetric care."[58] The main causes of maternal death include: "severe bleeding, infection, consequences of unsafe abortions, hypertensive disorders such as pre-eclampsia and eclampsia, and obstructed labor (sic)". Other causes which contribute to maternal death include Sexually Transmitted Infections, "poverty, race, ethnic or tribal affiliation, or lack of education is also underlying causes of maternal death or disability."[59]

"In sub-Saharan Africa where maternal deaths are highest, fewer than 40% of women receive skilled assistance during childbirth."[60] Concurrent with this is the need to strengthen national health systems and human resource crisis.

Maternal mortality is also exacerbated by the lack of access to comprehensive sexual and reproductive health services, particularly family planning services, commodities and information. The WHO has stated that sexual and reproductive ill-health accounts for 17.8% of all Disability Adjusted Life ½ Years (DALYs). "But for women in their reproductive years (15-44), the burden of sexual and reproductive health conditions is far higher than any other category of illness, a full 31.8% of DALYs lost, of which sexually transmitted infections, including HIV, account for 16%. Maternal health conditions (death and disability resulting from pregnancy and childbirth) account for 12.4%. For women in Sub-Saharan Africa, the burden of sexual and reproductive health conditions is particularly alarming"[61] In some countries high rates of uterine prolapse (1:10) and fistula are a direct result early marriage and early childbirth.

If the unmet need for contraception were filled and women had only the pregnancies they wanted at intervals they choose, maternal mortality would reduce by up to 35% (Maine 1991; Daulaire and others 2002p 73).[62]

Currently, the unmet need for sexual and reproductive health, care, education, information and services is enormous. "One in three deaths related to pregnancy and childbirth could be avoided if women who wanted effective contraception had access to it."[63] Indeed, "it is notable that contraceptive prevalence is low in countries with high maternal mortality".[64] Without access to family planning and modern contraceptive services women will continue to die as a result of unwanted pregnancies. UNFPA estimates "that meeting the existing demand for family planning services would reduce maternal mortality and morbidity alone by at least 20%."[65] "Globally, coverage of contraception is 61%, whereas unmet need for contraception ranges from 6% in Europe to 23% in sub-Saharan Africa. Forty one per cent of pregnancies globally are unwanted, with 22% resulting in induced abortion. These data suggest that between a quarter and two-fifths of maternal deaths could be eliminated if unplanned and unwanted pregnancies were prevented."[66] As a result, there is a strong need to invest in comprehensive sexual and reproductive health programmes and commodity services if MDG 5 is to be reached.

IPPF believe that DFID is in an ideal position to advocate on maternal health at the country, regional and global levels. This is because DFID is recognised as a leading proponent of maternal health by the international community. Indeed, DFID is "the only major bilateral donor to have a strategy specific to improving maternal health".[67] DFID's leadership in this field can be used to galvanize other donors and recipient governments to prioritise sexual and reproductive health in national health plans and international policy commitments to achieve MDG 5.

Q1 How donors—and DFID specifically—can catalyze progress towards MDG 5

1.01 The latest progress report by the United Nations shows that Millennium Development Goal 5 (MDG 5)—to "improve maternal health" by 2015—is unlikely to be reached.[68] The report shows that the Goal's target of "reducing maternal mortality by three quarters" is classified as "no progress, or a deterioration or reversal"[69] in progress in the regions where maternal mortality is most acute; those of Southern Asia and Sub-Saharan Africa.

1.02 The adoption in 2006 of a new target under Millennium Development Goal 5 (MDG) was welcomed by those of us that understand the role and importance of sexual and reproductive health and rights for reducing poverty. The new target—"universal access to reproductive health" should be seen by the international community as an acknowledgement of the fact that access to reproductive health care and services saves lives and reduces poverty. In addition, reproductive health's centrality to development is evidenced by the fact that it impacts on each of the eight MDGs—as well as the overall goal of reducing poverty by half by 2015.[70]

1.03 However, the apparent lack of acknowledgement of the new target by many governments, despite the 2005 outcome document, the Millennium Project Report and the previous Secretary General's recommendation, the failure by the international community to agree on the target's indicators, and the failure to reach the political consensus required to prioritize reproductive health at the global level remain a serious concern.

1.04 Progress towards MDG 5 will only be catalyzed when countries see health as a priority and integrate sexual and reproductive health into national health plans and budgets. In Abuja in 2001, African countries committed themselves to allocating fifteen per cent of their expenditure to the health sector—only two have achieved this. DFID is in a position to encourage recipient countries to recognize the value of such investment. And when, women, men and young people have control over their own bodies, and therefore their destinies; are free to choose parenthood or not; are free to decide how many children they'll have and when; are free to pursue healthy sexual lives without fear of unwanted pregnancies and sexually transmitted infections, including HIV; and where gender or sexuality are no longer a source of inequality or stigma"[71].

1.05 In addition, action at the local, national, regional and global levels needs to be taken. In order for women to safeguard their health, women need access to comprehensive sexual and reproductive health care and services. These services need to be supported by rights giving access to such services that are enshrined in national laws. At present, however, this appears a long way off. This is because unsafe abortion still accounts for 13% of all maternal deaths,[72] while four out of five maternal deaths are the direct result of obstetric complications, most of which could be averted through delivery with a skilled birth attendant and access to emergency obstetric care. It is estimated that accessible and effective family planning and contraceptive services would avert up to 35% of maternal deaths.[73]

1.06 It is also important to invest in women's education and empowerment and to eliminate gender based violence (GBV) and violence against women (VAW). High levels of such violence lead to unplanned pregnancy, abortion and maternal mortality. Likewise, violence during pregnancy can lead to maternal mortality.

1.07 Therefore, maternal health needs:

— to be prioritised as a development concern at the global, regional and national levels by the international community, including both donor and recipient countries.

— The political will for addressing maternal health at the national, regional and global levels needs to be increased. This will only happen through sustained high level advocacy that involves the participation of donors, recipient countries and civil society organizations.

1.08 Despite the best efforts of DFID and a number of donor and recipient countries to improve maternal health, intensive political advocacy and an increase in funding will be necessary to attain this goal. For example, additional funding and / or advocacy will be required to:

— Ensure access to client centred rights based services. Ensuring rights-based approaches are integrated into services is essential if maternal health is to be improved.

— Advocate for an end to child marriage—which has a high impact on maternal mortality and maternal morbidity. Likewise, increase funding for adolescent health.

— Provide / increase training for health professionals including NGO staff and volunteers distributors.

— Increase access to sexual and reproductive health commodities. IPPF Member Associations play a key role in these areas by providing sexual and reproductive health information, contraceptives, safe delivery services and where they are unable to provide safe delivery services, referrals to hospitals and medical centres with skilled health care personnel.

— Continue to Fund specific health interventions in countries where access to certain health services is limited or denied. This can include for example, access to safe and legal abortion services.

— Increase Investment in non-governmental organizations. This is because NGOs often have considerable expertise and reach and are able to work in areas that governments cannot.

1.09 DFID is in an ideal position to advocate on maternal health at the country, regional and global levels and is seen as a leader in this field, being "the only major bilateral donor to have a strategy specific to improving maternal health".[80] DFID can and should galvanize other donors and recipient governments to prioritise sexual and reproductive health including family planning in national health plans so that MDG 5 can be achieved.

1.10 The new aid architecture and "country ownership" raises specific issues and problems for recipient countries. This is because funding is not targeted at specific (usually high-profile) health interventions; this could result in less visibility for donors with a result that some donors may consider investing less in lower profile activities such as family planning.

1.11 DFID's support for MDG 5 is apparent. It supports the Global Campaign on Health MDGs which includes the International Health Partnership, and other initiatives such as that by the Norwegian Government on MDG 4 and 5. It also supports the Partnership for Maternal, Newborn, Child Health etc which prioritises advocacy for maternal health. In addition, DFID has increased its bilateral expenditure on programmes that contribute towards maternal health by 34% between 2002 and 2005.[81]

Q2 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

2.01 "Four out of five maternal deaths are the direct result of obstetric complications, most of which could be averted through delivery with a skilled birth attendant and access to emergency obstetric care."[82] "In sub-Saharan Africa where maternal deaths are highest, fewer than 40% of women receive skilled assistance during childbirth."[83] It should be noted that age can be an important factor in maternal mortality. Pregnancy is the leading cause of death for young women aged between 15 and 19.[84] This age group is twice as likely to die during pregnancy or child birth as those over 20. In Afghanistan 40% of girls are married before they reach the age of 18.[85] Girls under the age of 15 meanwhile are five times as likely to die.[86]

2.02 Maternal mortality can be said to be rooted in a combination of three factors: a lack of access to family planning services and information, a lack of access to skilled health care personnel during pregnancy and a lack of access to emergency obstetric care in case of complications. Each of these is prevalent in health systems that are weak. However, other considerations must be taken into account. These include: a shortage of funds for the purchase of reproductive health supplies (including family planning commodities); weak distribution, supply chain and management processes in many developing countries.[87] In addition, there are a range of social and cultural considerations that prevent women from attending hospitals (transportation issues and distance to health service facilities etc), gender bias that curtail or limit a woman's capacity to seek health care when complications arise. Likewise, consideration must be given to the impact of: Stockouts: due often to funding shortages for supplies; Procurement/Logistics problems: including getting supplies from central warehouses to districts, forecasting challenges; Unmet Need: political/socio-cultural and economic challenges, supplies not being included as a part of budget lines, a reduction in donor funding, increased demand for services.[88]

2.03 There are a number of reasons why health systems are weak. These include chronic underinvestment and a lack of priority being afforded to health by national governments. Likewise the number of skilled health care providers may be low because of a variety of factors such as: conflict; HIV and AIDS; low salaries; poor working conditions—each of which can lead to health sector workers migration weakening health systems even further. However, under investment and a lack of priority is not confined to the health sector alone. In many developing countries health systems, transport, housing, sanitation, education and other basic social infrastructure has been neglected meaning that governments often face a number of competing priorities.

2.04 The migration of Malawian health workers had a major impact on its health system as can be seen from the table below.[89] Migration here led to a near doubling of its maternal mortality ratio between 1992 and 2000.[90] Indeed, Malawi which has a population of 12 million has only 250 doctors.[91]

Table 2

TOTAL OUTPUT AND NUMBER OF CADRES EMIGRATING, MALAWI, 1993-200217


Cadre	Total Graduates	Number emigrating	% of total

Obstetrcian—gynaecologists	5	1	20
General practitioners, medical officers	164	14	9
Registered nurse—midwives	209	166	79
Registered nurses	445	167	38
Enrolled nurses	1,200	19	2

2.05 IPPF welcomes DFID's renewed focus on health system strengthening as is illustrated in DFID's health strategy. To help strengthen the health system and reduce maternal mortality in Malawi, DFID is providing £100 million over a period of six years (2005-11) to deliver an Emergency Human Resources Programme (£55 million)[92], this has three main elements:

— improving incentives for recruitment and retention of Malawian staff through salary increases for 11 professional and technical groups;

— expanding domestic training capacity by over 50%, including doubling the number of nurses and tripling the number of doctors in training; and

2.06 As a result, there has been a significant decline in the number of nurses leaving the country to work abroad. Meanwhile in Uganda, DFID funding has helped train 3,000 health workers.[94] DFID also supports increased emergency obstetric care in a number of countries including Nigeria, Zimbabwe, India and Bangladesh.[95] DFID has also been present at a number of key international meetings and conferences to discuss ways forward on sexual and reproductive health care including emergency obstetric care, such as in Mozambique for the Maputo Plan of Action for the operationalisation of the continental policy framework for sexual and reproductive health and rights 2007-10. It is also a member of the Nordic plus countries who are working to enhance aid effectiveness.

2.07 In addition, the UK government's policy of not actively recruiting healthcare workers from the developing world for the National Health Service (NHS) should be applauded. "A list of countries, including all those in sub-Saharan African, has been drawn up by DFID and the Department of Health, to ensure the NHS does not "poach" doctors and nurses that are needed elsewhere. In addition, the Department of Health has secured a groundbreaking agreement for this code to apply to many private healthcare providers so they too do not recruit staff from the world's poorest countries."[96] Advocacy for the implementation of such a policy needs to be directed at other wealthy countries whose health systems use skilled health workers from developing countries. The practice of poaching skilled staff is also a problem for many NGOs, when staff, often trained by the NGO, are poached by better funded agencies, such as those of the United Nations or large donor initiatives such as PEPFAR.

2.08 A much greater emphasis needs to be placed on promoting maternal health. Health promotion and prevention programmes can be promoted through schools, the media, NGOs, and the primary health care system. Programmes that provide education, family planning services, and pre-and postnatal care among young women must be developed.

2.09 However, health system strengthening should not be reliant on donors alone. Recipient countries need to prioritise the strengthening of their own public health care systems. This can be achieved through prioritising expenditure on health within national budgets.

2.10 Despite weak health systems, greater encouragement needs to given for women to give birth in hospitals where medical interventions can save their own and their child's life if complications arise. Outside hospitals, many women rely on Traditional Birth Attendants (TBAs), but they are not a substitute for skilled health care personnel. A project paying TBAs to refer women to hospital, implemented by DFID in Malawi, has proven successful in addressing this issue, with the hospital reporting a "30% increase in antenatal visits, and a 44% increase in deliveries."[97]

2.11 Donor financing also needs to become more sustainable and predictable. Often donor government priorities will change according to which political party is in power. Thus elections thousands of miles away can have a serious impact on the provision of maternal health care in a recipient country. This can only be avoided through a commitment by donors to long term predictable investment. This will assist recipient countries in their planning and allocation of funds for health system strengthening and allow them to budget over the long term. Without such predictability, long term planning will be constantly interrupted in the quest for short term solutions by donors and governments' alike and maternal health will continue to remain a distant priority. Likewise, longer-term and predictable funding for NGOs is also required.

Q3 The steps DFID is taking to mainstream maternal health across related policies

3.1 DFID has taken a number of steps to mainstream maternal health and works effectively and in partnership with a number of donors and civil society organizations. DFID supports the advocacy focussed Partnership for Maternal, Newborn and Child Health (PMNCH) and has given its support, along with that of the Gates Foundation, to the Norwegian government's 2006 initiative to accelerate progress on MDGs 4 and 5. This initiative seeks to advance gender equality and improve the health of women and children by increasing focus on maternal health at a high level politically. It does this through forming "partnerships with other political leaders and to build global alliances to ensure a marked reduction in child and maternal mortality by 2015".[98] Global alliances created through partnerships help highlight and raise awareness about an issue and help prioritize and focus attention at the national level.

3.2 DFID also supports the Safe Motherhood Initiative (SMI), now in its 20th year. The SMI works at the community level to build "demand for maternity services, encouraging local women to use the safer option of hospital births, as well as providing quality nursing care, medical equipment and all-important transportation to the hospitals."[99] Following on from the SMI was the creation of an Inter-Agency Group (IAG) for Safe Motherhood, which was joined and supported by IPPF amongst others. Under the SMI, programmes have been developed to reduce the number of maternal deaths. "The strategies adopted to make motherhood safe vary among countries and include: providing family planning services; providing post-abortion care; promoting antenatal care; ensuring skilled assistance during childbirth; improving essential obstetric care and; addressing the reproductive health needs of adolescents."[100]

3.3 The UK government has also co-launched the Global Campaign for the Health Millennium Development Goals and will be taking the lead on the International Health Partnership which will help agencies work together more effectively to deliver aid to reach MDGs 4, 5 and 6. Likewise DFID is also supporting the Women and Children First initiative (previously called the Global Business Plan) under the Global Campaign.

3.4 DFID has also attempted to mainstream maternal health across other related policies such as HIV and AIDS. AIDS is, according to the Lancet, "the largest cause of maternal death in some parts of Sub-Saharan Africa"[101] and thus mainstreaming maternal health is essential if we are to address preventable maternal deaths. Likewise, DFID is mainstreaming SRHR and gender equality with maternal health—seen in their health strategy "Working together for better health".

Q4 How achieving MDG 5 is being prioritized and integrated into countries' overall healthcare provision

4.1 It is hoped that the recently launched Global Campaign for the Health MDGs will provide a significant step forward in tackling MDG 5 which at present is unlikely to be reached by 2015. The campaign commits to addressing problems that are preventing progress being made strengthening healthcare systems and simplifying existing systems at the national level for planning and coordinating activities for tackling this goal. The Campaign has been signed up to by eight bilateral donors, seven developing countries and nine international organisations amongst others.

4.2 The global campaign is comprised of four separate, yet inter-related initiatives—1) the "Women and Children First" initiative (being led by Norway, driven by civil society and coordinated by the PMNCH). This initiative seeks through increased advocacy to strengthen political commitment for health focussed reforms designed to assist women and children, 2) the "catalytic initiative to save a million lives" (being led by Canada). This initiative seeks to tackle weaknesses in local health services by facilitating access to services integrated into national health plans, 3) the "Innovative results based finance" initiative (being led by Norway) which will focus attention on evaluating the most cost-effective approaches for achieving the health MDGs, and 4) The international health partnership (being led by the UK).[102] This initiative is supported by major health agencies and foundations as well as numerous donor governments. The aim of the IHP is to "to make health cooperation work better for developing countries by: focusing on improving health systems as a whole, not just on individual diseases or issues; providing better coordination among donors; and developing and supporting countries' own health plans."[103]

4.3 The integration of the IHP into the overall global campaign is an attempt to put the Paris Declaration on aid effectiveness into practice in the health sector. One potential problem of the IHP is that coordination, as envisaged in the Paris Declaration, has not been the easiest of agendas to adopt. This is because some donors while agreeing in principle to coordination and harmonization still like to fund their own health priorities. Thus, coordination of funding and priorities could be difficult to achieve. Another potential problem lies in the fact that the two largest donors (the United States and Japan) are yet to sign up to this initiative.

Q5 How DFID is supporting the 2006 recommendation by the UN General Assembly for an MDG target for universal access to reproductive health

5.1 DFID has fully supported the 2006 recommendation of the UN General Assembly for the new target and has spoken out at the UN, the EU and other important arenas. While DFID has been vociferous in its support of the new target, and is seen by many as one of the target's leading proponents, further political advocacy is required to ensure the UK and other member states in favour of the target gain the support of other influential member states. The support of progressive member states such as the Nordic countries are welcome but a wider support base will be required.

Q6 The progress being made in reducing maternal deaths from unsafe abortion (which account for 13% of all maternal deaths)

6.1 An estimated 46 million abortions take place globally every year and of these, 19 million are considered unsafe[104]; every year over 67,000 women die from unsafe abortion[105] and nearly all of these occur in the developing world. Unsafe abortion is "one of the most neglected health care issues in Africa"[106] and approximately 90% of global abortion-related deaths and disabilities could be avoided if women who wanted effective contraception had access to it."[107]

6.2 The causes and consequences of unsafe abortion are some of the most neglected global public health and human rights issues.[108] This is because it is deemed controversial by many donors and recipient governments, including the largest donor the United States which refuses to support reproductive health policies that include abortion. It does this through the Global Gag Rule which prohibits U.S. family planning assistance from being provided to foreign non-governmental organizations that use funding from other sources to counsel, refer or perform abortions in cases other than a threat to the woman's life, rape or incest. Since 2001 the current US administration has refused to fund international sexual and reproductive health NGOs that advocate for a woman's right to access safe, legal abortion or who work to address unsafe abortion . This has seen a significant cut in family planning provision and sexual and reproductive health services in some of the neediest countries. DFID and other donors have attempted to breech this funding gap and to increase funding for NGOs working on reducing maternal mortality from unsafe abortion.

6.3 It should be noted that while some donor nations such as the UK, Denmark, Norway, Sweden, and Switzerland are committed to reducing maternal deaths from unsafe abortion through targeted initiatives, others are not. This is due in part to abortion being regarded as a controversial issue. DFID is committed to and funds organizations that work on abortion related issues, including IPPF.

6.4 DFID's determination to halt unsafe abortion is most clearly seen through its support of the Safe Abortion Action Fund (SAAF) administered by IPPF. We administer the SAAF on behalf of donors to support civil society groups and non-governmental organizations and have to date awarded $11.1m in grants to non-governmental organizations in 32 different countries to fund 45 two-year projects dedicated to advocacy, operations research and/or service delivery.[109]

6.5 DFID has advocated for other donor governments to commit towards the SAAF and should continue to do so by highlighting the role that access to safe abortion plays in reducing maternal death. DFID should continue to fund and increase its funding for the SAAF given the fact that we received in excess of 130 proposals—testament to the size of the need.

Q7 How effective family planning is being promoted as a way to improve maternal health

7.01 Family planning prevents unintended pregnancies, many of which are unwanted. Unwanted pregnancies lead to abortion, many of which are unsafe in the developing world. Unsafe abortion is a leading cause of maternal death and ill-health. Family planning is critical to improving maternal health and needs to be a key strategy at the national and international levels to reduce unsafe abortion and maternal mortality. DFID is a key supporter of family planning.

110

7.02 DFID is working with key governments, decision-makers and agencies to promote family planning. It is doing this through a variety of actions:

(1) advocacy initiatives such as the Partnership for Maternal, Newborn and Child Health (PMNCH) and the recently launched Global Campaign for the Health MDGs.

(2) DFID advocates with UN agencies and other key donors and advocates on individual advocacy actions (see below)

(3) DFID has increased its funding for a number of NGOs including IPPF that provide reproductive health care services and commodities.

111

112

7.03 Despite an increase in funding from DFID for IPPF and UNFPA (the two key agencies working to promote family planning) the current "unmet need" for sexual and reproductive health, care, education, information and services is enormous. "One in three deaths related to pregnancy and childbirth could be avoided if women who wanted effective contraception had access to it."[113] Indeed, "it is notable that contraceptive prevalence is low in countries with high maternal mortality".[114] Without access to family planning and modern contraceptive services women will continue to die as a result of unwanted pregnancies.

7.04 UNFPA estimates "that meeting the existing demand for family planning services would reduce maternal mortality and morbidity alone by at least twenty per cent."[115] As a result, there is a strong need to invest in comprehensive sexual and reproductive health programmes and commodity services if MDG 5 is to be reached.

7.05 Clearly, effective family planning needs to be promoted as a key way in which maternal health can be improved. However, it can only be improved once reproductive health commodity security is guaranteed. It should also be noted that the disparity in supply of reproductive health services between rich and poor nations is considerable. The risk of a woman dying as a result of pregnancy or childbirth during her lifetime in the developing world is considerably greater than that of a woman from a wealthy nation. In the United Kingdom one in 3,800 women[116] are likely to die as a result of pregnancy or childbirth. In Afghanistan and Sierra Leone, this figure is one in seven.[117]

7.06 IPPF targets unmet contraceptive need by prioritizing its services for the poorest and most marginalized communities with least access to services and information. From our "56,000 service delivery points, our Member Associations provided over 20 million contraceptive services and over 18 million other sexual and reproductive health services in 2006."[118] B1ut there is still much more to be done.

7.07 The effective delivery of sexual and reproductive healthcare requires reliable access to essential products and commodities. Without appropriate choices, agreed upon at the ICPD in 1994 as universal access by 2015 to the widest possible range of safe and effective family planning methods, or the necessary quantity of commodities, sexual and reproductive health programmes will fail. The lack of adequate supplies in many countries is a result of funding and supply shortfalls. However, other problems exist which increases the level of unmet need, including:

1. "Inadequate forecasting of supply needs

2. A lack of adequate distribution systems in-country

3. Regulatory, tariff and tax barriers that hinder the importation and provision of supplies by the public and private sector

4. Inefficient use of public funds

119

7.08 IPPF, and its subsidiary ICON, provides US$25 million in reproductive health commodities each year to more than 100 countries. IPPF is also a founding member of the Reproductive Health Supplies Coalition (RHSC)[120], "a partnership designed to provide global leadership in making essential reproductive health products available to developing and transitional countries. DFID's initial leadership of the RHSC helped prioritise access to essential supplies in developing and transitional countries. It remains a member of the RHSC. IPPF is also a member of the RHSC Systems Strengthening, Resource Mobilization/Advocacy, and Market Development Approaches Working Groups, working within the RHSC to:

1. Promote the efficient and effective use of existing, limited resources by improved coordination and harmonization of RH supply programmes;

2. Encourage innovation among the public, private and commercial sectors to develop markets for RH supplies;

3. Build the capacity of supply chain systems in developing countries;

4. Ensure sustained delivery of a choice of quality RH supplies to end-users;

5. Address acute problems of stock-outs; and

121

7.09 The international community's failure to meet its funding commitments to family planning denies the SRH needs of millions of women, men and young people, and is likely to have long term impacts across development sectors—such as the ability to invest in education or provide employment opportunities as a population grows. Indeed, the United Nations expect world population to rise by 2.5 billion people from today's 6.7 billion to 9.2 billion in 2050.[122]

7.10 Maternal health will not be improved without reducing unmet need. This can come about only through intensified advocacy at the national, regional and global levels. DFID, its donor counterparts, multilateral agencies and CSOs (including IPPF) are in a prime position to advance this advocacy through increased partnership. Effective family planning, therefore, needs to be promoted to reduce maternal ill health. This can be achieved at both the donor and recipient levels through an increase of advocacy.

7.11 IPPF has recently been engaged with other civil society organizations and progressive governments, such as that of the UK, in a number of advocacy initiatives to help improve maternal health through increasing access and rights to family planning and other sexual and reproductive health services. For example:

1. IPPF helped ensure a key pro-choice report by Glenys Kinnock MEP entitled "Draft Report on the Millennium Development Goals—the midway point" successfully passed through both the Development Committee (DEVE) and full Plenary Session of the European Parliament (EP).

2. IPPF also played a key advocacy role in regard to the World Bank's Health Nutrition and Population Strategy which in its first draft omitted reference to family planning and sexual and reproductive health. Not only did we help lead a concerted and successful advocacy effort to rectify this omission but managed to ensure that the checks and balances to avoid such mistakes in the future would be put in place. The results of our advocacy led to the commitment of many Executive Directors at the World Bank to press for stronger language reflecting the need for family planning and reproductive health within the HNP strategy. UK officials at the World Bank fully supported stronger language within the strategy. Likewise, the Secretary of State for International Development stated that he was very concerned about the lack of references to sexual and reproductive health and rights. Contacts within DFID informed IPPF that they would not support the draft HNP strategy in such a format.

3. IPPF also played a key role at the African Union Ministers of Health Conference in Maputo, Mozambique which passed the Maputo Plan of Action (PoA) for the operationalisation of the continental policy framework for sexual and reproductive health and rights (2007-10). This key document among other issues supports the following: the repositioning of family planning as an essential part of attaining the health related MDGs; addressing the SRH needs of adolescents and youth as a key SRH component; addressing unsafe abortion; delivering quality cost effective services to promote safe motherhood, child survival, maternal, newborn and child health, and; creating south/south cooperation for the attainment of the MDG and ICPD goals in Africa. This PoA was also supported by DFID which was in attendance at the conference.

7.12 Family Planning is being promoted as one way in which to improve maternal health. However, increased advocacy at the donor and recipient levels for the prioritization of reproductive health services within national budgets and action to address reproductive health commodity security is still required. DFID can and should play a key role here. Core investment in IPPF and its Member Associations is essential if family planning is to be promoted effectively.

Q8 How effectively DFID works with bilateral and multilateral donors, NGOs and other stakeholders to promote maternal health

8.01 Increasingly bilateral donors are channeling their funds into the coordinated aid mechanisms such as the Sector Wide Approaches (SWAps), the Poverty Reduction Strategies and General Budget Support that supports national governments ownership of national development. The declaration on aid harmonization signed in Paris in 2005 institutionalized and standardized this approach for bilateral agencies and recipient countries. DFID has been a key actor in developing and endorsing the Paris Declaration on Aid Effectiveness and the EU Harmonization Plan.

8.02 In recent years, the structure of official development assistance has begun to shift dramatically across all areas of international aid. Donors and recipient countries are reforming the aid system by putting in place measurable objectives and a new management framework. These changes were spearheaded at a number of international conferences, notably: a) The Millennium Summit, 2000; b) The International Conference on Financing for Development, Monterrey, 2002; and c) The High Level Forum on Aid Effectiveness, Paris, 2005.

8.03 The change in aid architecture was a response to the realization that the existing funding mechanisms for ODA were not working effectively. Indeed, a "2006 World Bank report estimated that about half of all funds donated for health efforts in sub-Saharan Africa never reach the clinics and hospitals at the end of the line."[123] Thus, donor countries have made a concerted effort to reform ODA in order to address these problems. As a result of the Monterrey Consensus, ODA has started to increase.

8.04 Despite the best efforts of a number of donors, a major obstacle to improving maternal health in many countries continues to be the low priority afforded to improving maternal health in particular by many developing country governments. Regrettably this may become an even greater obstacle to overcome with the developments described in paragraphs 2.01-2.04. Intensified advocacy is required to ensure that maternal health is given the priority it deserves within national budgets by recipient countries. Until maternal health is prioritized in policies and programmes and awarded sufficient budgetary support by developing country governments, high levels of maternal mortality and morbidity will prevail; and despite the best efforts of DFID to prioritize maternal health within policies and funding "maternal mortality remains unacceptably high in DFID-supported countries"[124] Increased advocacy highlighting the wider economic and social benefits of maternal health is still required. This needs to be directed at the political leadership, civil servants, bureaucrats and Ministers of Finance and Health of developing countries emphasizing the costs, benefits and productivity of a healthy population.

8.05 It also needs to be recognized that funding for most basic health care services is deficient in many developing countries, with health often given a low priority within national budgets—and maternal health within the health budget a lower priority still.

125

8.06 Much of the reason for this can be attributed to the politicization of reproduction, gender inequity (including gender disparities in parliaments), and a lack of gender responsive policies.

8.07 Another issue that needs to be addressed is that many donors direct funding at specific high profile health interventions. This type of funding is used when there are gaps in budgetary support. Although such specific interventions can impact negatively of the amount of funding available for maternal health, the continuation of specific health intervention funding is necessary; and while it should be continued, the need for it could be reduced if DFID and other agencies worked with developing country governments to raise the awareness of the importance of SRH in reducing maternal mortality and its contribution towards wider-economic and social development.

8.08 At the present time, however, there is still a strong need for DFID to support specific interventions especially in the many poor countries where SRH is not prioritized. For example, in country's where abortion is legal, but difficult and costly to access for reasons such as few service providers or transport limitations and distance required to travel, or due to social and cultural attitudes that stigmatize abortion despite high levels of maternal death. DFID's support of the Safe Abortion Action Fund being administered by IPPF is a clear example of this need for specific health interventions. Likewise, DFID's support of specific maternal health interventions can be seen in Cambodia, where it leads on ensuring that progressive abortion legislation is operationalized through their participation in the health SWAp.

8.09 Funding for family planning and reproductive health has suffered despite their being large increases in funding for other SRH services, most notably HIV and AIDS. The graph below shows how funding for reproductive health and family planning has fallen as donor priority has shifted towards HIV and AIDS.

8.10 Another complication is that because funding is often channeled towards specific health interventions funding for health infrastructure is neglected (this is why DFID's focus on health system strengthening is important). In addition, although some recipient governments receive funding for specific health initiatives, many do not have the financial capacity to support more basic services. In Rwanda, for example, funds for HIV and AIDS account for by far the largest proportion of external funding, yet it has a relatively low level of HIV compared to child mortality from other causes. It is hoped that the International Health Partnership will address some of these issues as it seeks to coordinate and harmonize ODA.

8.11 Therefore, despite a reduction in the levels of international support for SRH, it is often a consequence of the funding priorities of the donors rather than the broad public health based needs of the countries themselves that determine where funding is channelled. Thus donor priorities have led to skewed funding patterns which has ultimately led to a reduction in support of SRH through the inequitable distribution of aid within the health sector.

8.12 It is important that developing countries are empowered and supported to set their own health priorities and produce their own national health plans to achieve them. Likewise, it is also important that donors coordinate their efforts to help achieve these developing country determined priorities. At present, coordination of funding is a major obstacle that impacts negatively on the health sector of many developing countries. This is because there are "more than 40 bilateral donors, 26 UN agencies, 20 global and regional funds and 90 global health initiatives".[126]

8.13 Complicating the matter further for many developing countries is the fact that many developing country governments are forced to respond to the countless reporting mechanisms of the many different donors. At present there are in excess of one hundred health partnerships[127] that are supported by donors and UN agencies through multiple funding streams. Such a large number of partnerships help create conditions that make the coordination of activities difficult. For example, "in Cambodia there are 22 different donors providing support for health through 109 separate projects".[128] This additional bureaucracy has stifled the ability of many developing country governments to implement projects due to the increased demands of donor bureaucracy, meaning that key staff within the health sector has to spend vital time reporting back on projects rather than implementing them.

Q9 What leadership the UN is providing and how well co-ordinated its agencies are

9.1 The UN has provided mixed leadership on the MDGs. Its initial failure to include reproductive health as a goal in 2000 was seen by the development community as a major and deliberate omission, (the ICPD was the only major conference whose outcome was not included in the original MDG framework). This has been partially addressed by the "noting" of the new reproductive health target in 2006 which occurred as a result of sustained advocacy by many member states, including the UK, and civil society organizations such as IPPF. It also came about despite the opposition of a number of influential member states including the United States. However, despite support for the reproductive health target by the former UN Secretary General, Kofi Annan, the present incumbent Ban Ki Moon and a number of progressive member states, political unease at highlighting "controversial issues" has helped hinder any real progress towards attaining MDG 5. This brings into question fundamental issues related to gender, women's rights and traditional social structures—as can be found in the Convention for the Elimination of all forms of Discrimination Against Women (CEDAW).

9.2 The lack of acknowledgement in any official UN reports about the new reproductive health target, since the recommendation of the target's inclusion into the MDG framework by the Secretary General, has not given confidence to those of us working in the field of sexual and reproductive health and rights concerning the true priority being attached to MDG5 by some member states. Despite the recommendation that all four new targets[129] including the new reproductive health target be incorporated into the MDG process in August 2006, little progress has been made to date.

9.3In addition, the politically motivated delay on the selection of indicators to measure the new target has also delayed progress and threatens to relegate the priority of the MDGs within the international development framework.

9.4It would also appear that a lack of coordination at the country level between different UN Agencies (and a lack of focus on SRH by key agencies such as UNICEF) is hindering progress on MDG 5. DFID's 2006 White Paper flagged the need for reform to deliver a UN system better able to support poor countries to achieve their development goals. It identifies as key issues the proliferation of agencies with multiple, sometimes overlapping mandates, and the need to improve in-country co-ordination. DFID strongly supports the One UN initiative recommended by the UN Secretary General's High Level Panel on system-wide coherence (at the end of 2006). The eight pilot countries have agreed to work towards a common UN presence in country, testing different models, while capitalizing on the strengths and comparative advantages of the different members of the UN family.

9.5Advocacy is being undertaken to strengthen the role of women within the UN reform process. Within the framework of United Nations Reform, there is currently a discussion being held in New York on the Report issued by the High-Level Panel on United Nations System-wide Coherence, in November 2006. Leading to this report, women's rights organizations around the world gathered to advocate for the inclusion of a specific recommendation that called for strengthening the Gender Equality Architecture (GEA) within the United Nations. The report included this recommendation, consisting of consolidating the three main existing bodies (The Secretary General's Special Advisor on Gender Issues OSAGI, The Division for the Advancement of Women: DAW, and the United Nations Development Fund for Women: UNIFEM), and establishing a new Under-Secretary General position at the highest level, in order to guarantee that women have a place at the decision-making process and that there is a necessary driver for meeting women's needs on the ground.[130]

9.6 Clearly, the agencies involved need to communicate more effectively and develop a coordinated strategy that uses each of them to their best ability for effective delivery of the maternal health initiatives. Without effective coordination between these agencies, MDG 5 will become increasingly difficult to reach.

9.7 It is important for DFID to recognize that NGOs can often go where UN agencies cannot in regard to advocacy and service delivery. As a consequence DFID should increase its core funding for NGOs such as IPPF.

Q10 How DFID is addressing socio-economic barriers to women's empowerment and the low status of women in relation to maternal health[131]

10.1 High levels of maternal death and disability reflects a woman's lack of rights and social, economic and political status. Lack of rights, decision making, education, access to services and the low priority afforded to women's health contributes significantly to high maternal mortality. In many countries overcoming such barriers often means advocating against social and cultural norms. "Gender discrimination against women leaves them powerless to make decisions about when to have sex, and whether to use contraception or to seek health care. Discrimination based on gender continues to be one of the major risk factors to women's vulnerability to sexual and reproductive ill health."[132]

10.2 DFID needs to reinforce the value of investing in the training of midwives with recipient countries.

10.3 It is vital that DFID continues to develop a Rights Based Approach (RBA) to maternal health. DFID already attempts to address the socio-economic barriers to women's empowerment and the low status of women in many countries. For example, DFID is supporting a four year initiative (2004-08) entitled Working Towards Safe Motherhood in South Asia: Combating gender based violence during pregnancy in Bangladesh and Nepal under its Civil Society Challenge Fund.

10.4 Although the high incidence of gender based violence (GBV) in Bangladesh and Nepal is widely acknowledged, the project has enabled IPPF Member Associations to address GBV during pregnancy for the first time in a comprehensive and effective manner. The project aims to protect the rights of women who are at risk of or who are experiencing GBV with a specific focus on pregnant women. The project increases awareness of frontline service providers to the SRH dangers and the violation of human rights of GBV during pregnancy, and offers skills to support survivors or those at risk of GBV. The project has also adopted a multi-sectoral approach by working in partnership with key agencies to provide additional / specialized support services (eg counselling, emergency shelter, legal advice). A range of activities have supported the economic and social empowerment of survivors to escape violence and to become advocates against GBV. Finally, strong engagement with key community gatekeepers and national level advocacy has helped strengthen civil society groups to advocate against GBV.

10.5 DFID's support has enabled IPPF in the South Asia Region to improve the maternal health of women through this targeted initiative in the following ways:

1. Created institutional mechanisms (screening and referral) of two large NGO SRH providers to integrate support for survivors of GBV within a SRH setting and strengthened partnership working;

2. Raised awareness of entitlements and rights and strengthened the capacity of survivors of GBV to demand their rights to a life free from of all forms of coercion and violence;

3. Supported the self determination of survivors through improved social, economic, political and civil status (from micro credit fund, community level Information Education and Communication activities and national level advocacy).

4. Survivors' testimonies have confirmed an increase in self esteem and community respect as a result of improved economic status through the micro credit fund.

5. Strengthened the capacity of southern civil society groups to engage with and influence governments to address policy reform eg enforcement of anti dowry laws/ legal age of marriage/polygamy.

6. Brought the issue of GBV during pregnancy into the public arena.

10.6 The project directly reflects DFID's overall strategic country priorities for poverty eradication and human development by addressing gender inequality and discrimination. It rests on the premise that women's inequality is a key obstacle to development and a major cause of social injustice and that gender discrimination is the most widespread form of social exclusion. The economic cost of GBV which directly impacts on women's productivity and economic status is also widely accepted. Women in Nepal and Bangladesh, as in many other developing countries around the world, are poorly represented in positions of power and opportunities for independent action are often severely limited. When women have a voice, they are able to participate directly in governance processes. As a result they can advocate for issues of particular importance to women. However, there is not a single country in the world where women outnumber men in parliament. DFID can help advocate for the greater representation of women's power through global and regional advocacy using bodies such as regional All Party Parliamentary Groups to push for the greater representation of women in parliaments.

10.7 DFID's Country Assistance Plan for Bangladesh 2003-06 identifies gender inequality as a key constraint to poverty reduction in Bangladesh where issues such as dowry, inheritance, access to health services and physical security, all need to be addressed in order to improve the lives of women and girls and reduce overall poverty in Bangladesh. The Nepal Country Strategic Plan 1998 (currently under review) also makes clear the need for a project such as this. It 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 reflected in the fact that Nepal has some of the highest maternal and infant mortality rates in South Asia.

10.8 Overall, the project adopts a rights-based approach to promote gender equality and women's empowerment by developing practical and strategic interventions to eradicate gender based violence within a SRH/R framework. By promoting gender equality and reducing maternal and infant mortality within a safe motherhood framework, the project specifically contributes to the achievement of the Millennium Development Goals (Numbers 3, 4 and 5), to which DFID is committed.

10.9 DFID needs to encourage governments to develop a comprehensive and integrated, joined up approach across government, and across local government with NGOs, schools etc.

Q11 How the international community can improve maternal health in crisis and conflict settings[133]

11.1 Maternal health can be improved through the safeguarding of rights in crisis and conflict affected settings. Programmes that address the sexual and reproductive health and rights of communities that have been affected by conflict have a significant impact upon the emergence of democratic decision-making, empowerment and wider economic development. Programmes that empower internally displaced people to make informed decisions about their sexual and reproductive health and bodies also have important repercussions for people exercising and acting on their right to take an active role in wider decision making processes that affect their lives and communities.

11.2 The empowerment of internally displaced people to demand sexual and reproductive health and rights is an important first stage in ensuring that people who have been affected by conflict feel that they are empowered and have the right to engage in wider discussions and activities that focus upon human rights, community-led democratic decision-making and conflict resolution.

11.3 While entire communities suffer the consequences of armed conflict and terrorism, women and girls suffer disproportionately—the United Nations High Commission for Refugees has estimated that 65% of all internally displaced people and refugees are women. This is because existing social inequalities are aggravated by war and conflict situations. With the breakdown of social structures, women and girls are subject to gender-based violence, rape and sexual abuse. It is within this context that programmes that address sexual and reproductive health and rights are crucially important.

11.4 The UNHCR (United Nations High Commission for Refugees) reported in its 1999 Inter-agency Field manual that "reproductive health is central to the health and welfare of refugees. It should be available in all situations and be based on the expressed demands of refugees, particularly women ... an increase in sexual violence in insecure refugee situations is well recognised. Displacement, uprootedness, the loss of community structures, the need to exchange sex for material goods or protection leads to distinct forms of violence, particularly sexual violence against women".

11.5 The UNHCR has recorded high levels of rape, domestic violence, gender-based violence and assault amongst women that are internally displaced or refugees. In areas where there are large numbers of refugees and internally displaced people, not having basic sanitary equipment for childbirth, access to emergency obstetric care or trained midwives leads to large increases in maternal mortality, whilst lack of access to modern methods of contraception—particularly condoms also results in major increases in the transmission of STIs (including HIV/AIDS) and increases in unplanned pregnancies.

12. IPPF Recommendations

IPPF's recommendations:

1. Intensify advocacy to ensure that maternal health becomes a development priority at the global, regional and national levels by donor and recipient countries alike. DFID is seen as a leading proponent of maternal health and should, therefore, use its position and influence to advocate at these levels.

2. Ensure health system strengthening is prioritised by the donor community and that the wider social, economic and political barriers to improving maternal health are addressed.

3. DFID should encourage a joined up approach to development which links maternal health with education, health and adolescent development.

4. DFID should encourage recipient governments to involve and include civil society in all discussions, consultations and plans related to development.

5. IPPF recommends that DFID advocate for recipient governments to support national budget lines to increase reproductive health supplies around the following three major preventatives of maternal mortality—emergency obstetric care, unsafe abortion and family planning. DFID-funded sexual and reproductive health interventions should take a country-specific approach, recognizing the numerous and complex factors that combine to result in a given health and market situation in each country.

6. DFID should encourage recipient governments to prioritise women's education, literacy, and rights including the elimination of gender based violence.

7. DFID should encourage an emphasis in recipient countries on a public health and primary health care approach (as per the Ottawa Charter).

8. DFID should recognize the importance of investing in comprehensive sexual and reproductive health, not only family planning, including the integration of sexual and reproductive health, family planning and HIV and AIDS prevention and Voluntary Counselling and Testing (VCT) which also impacts on maternal health of HIV positive women.

9. Increase advocacy around the issue of wealthy countries "poaching" health sector workers from developing countries—including Commonwealth protocols.

10. Ensure that the political will for improving maternal health is translated into increased financial commitments by donors.

11. Ensure that all relevant UN agencies work together effectively to improve maternal health.

12. DFID should advocate for developing country governments to prioritise maternal health within their health plans and budgets and take into account health system reform.

13. DFID should encourage other donors nations to contribute towards the Safe Abortion Action Fund and commit itself to the ongoing funding of the SAAF.

14. Ensure that a rights-based approach to maternal health is incorporated into national health plans.

15. Ensure the effective coordination and harmonization of aid by donors.

16. Simplify and make more transparent the reporting mechanisms for recipient countries.

17. Invest in family planning, advocacy, health and women's education and sexual and reproductive health including STI prevention.

18. Advocate against child marriage.

19. Invest in the elimination of gender based violence.

20. Develop similar principles of trust, harmonization and ownership with civil society organizations.

21. Recognize the role of civil society.

22. DFID should continue to focus on SRHR and maintain or increase its current staffing levels so as to ensure that SRHR is maintained as a DFID priority.

23. DFID should ensure that within negotiations with PSA countries that the following components are included within Country Strategy Papers: Emergency Obstetric Care; Unsafe Abortion and Family Planning.

52 IPPF, "At A Glance", p3 August 2007t Back

53 See Eliminating World Poverty: A Challenge for the 21st Century, White Paper on International Development, Presented to Parliament by the Secretary of State for International Development by Command of Her Majesty November 1997, at www.dfid.gov.uk/Pubs/files/whitepaper1997.pdf [accessed 10 September 2007] Back

54 DFID, Factsheet, Maternal Health, November 2006 Back

55 DFID, Millennium Development Goals, Maternal Health, Improving healthcare for mothers and pregnant women at http://www.dfid.gov.uk/mdg/health.asp [accessed 11 September 2007] Back

56 Lancet (2006) Meeting MDG 5: An impossible dream? Lancet 358, September 28 2006: 1133-1134. Back

57 World Health Organization/United Nations Children's Fund, Maternal Mortality in 2000: Estimates developed by WHO, UNICEF, UNFPA. See UNFPA, Reproductive Health Fact Sheet at http://www.unfpa.org/swp/2005/presskit/factsheets/facts_rh.htm [accessed 10 September 2007] Back

58 Facts about Safe Motherhood, UNFPA at http://www.unfpa.org/mothers/facts.htm [accessed 07 August 2007] Back

59 WHO. 1999. "Reduction of maternal mortality. A joint WHO/UNFPA/UNICEF/World Bank statement." Cited at USAID Maternal and Child Health at http://www.usaid.gov/our-work/global-health/mch/mh/faqs.html£neonatal [accessed 12 September 2007] Back

60 Facts about Safe Motherhood, UNFPA at http://www.unfpa.org/mothers/facts.htm [accessed 07 August 2007 Back

61 Millennium Project, Task Force on Child and Maternal Health, Who's got the power? Transforming health systems for women and children, Earthscan (2005) at http://www.unmillenniumproject.org/documents/maternalchild-complete.pdf [accessed 11 September 2007] Back

62 Who's got the power? Transforming health systems for women and children, Millennium Project, 2005 Back

63 Facts about Safe Motherhood, UNFPA at http://www.unfpa.org/mothers/facts.htm [accessed 07 August 2007] Back