International Development CommitteeWritten evidence submitted by Maternity Worldwide

1. Introduction

Maternity Worldwide is an INGO whose purpose is to help reduce the number of women and girls dying or injured in pregnancy and childbirth and, by doing this, to also reduce newborn mortality and morbidity. Maternity Worldwide operates in resource poor communities and within the framework provided by the Millennium Development Goals. Maternity Worldwide works with local partners to develop an effective, appropriate and inclusive integrated approach to the delivery of accessible, high quality and sustainable maternal health services.

Maternity Worldwide welcomed the inclusion of maternal health as one of the Millennium Development Goals in 2000, providing recognition by the international community of the gravity of the global maternal health situation. Since this time, we have observed that having MDG5 specifically on maternal health has certainly increased global focus and investment on the subject, not least through the recent commitment by the UK Government to increase investment in family planning in the summer of 2012 and the inclusion of maternal health as a priority for many of its priority countries.

In 2006, Maternity Worldwide established a two year integrated maternal health programme in West Wollega in the west of Ethiopia, to address the chronic shortage of maternal health provision in this context. Our analysis identified that those living in West Wollega are incredibly poor, particularly the women, many of whom are illiterate, have limited access to contraceptives and unsafe water and sanitation.

In response to the International Development Select Committee invitation to submit written evidence regarding the post-MDG agenda, we would like to present our views in this paper, drawing from our practical experience of developing this programme in rural Ethiopia.

2. Integration verses isolation of MDGs

The programme we designed and implemented was based on the internationally recognised 3 Delays Model championed by W.H.O.1 This identifies the three most significant barriers to good maternal health as being: delays in decisions to seek care; delays in reaching care and delays in receiving care. Our programme addressed these delays through its 3 main components—community health awareness, income generating activities and improving the quality of health facilities and skills of staff.

The programme succeeded in educating 10,000 people in health seeking behaviours including maternal and reproductive health. 1,200 of the poorest women in the area took part in very successful income generating activities where they were given small amounts of seed money on a loan basis which they paid back when their businesses became viable. Through this activity, women were able to have more control over their own income and used the funds not only to access maternal health, but also to help their children obtain more nutritious food and continue schooling. Equipment was also provided to the local hospital and clinics and staff were trained to become skilled birth attendants, thereby significantly improving the provision of maternal care.

The independent evaluation of the programme clearly demonstrated that the integrated nature of the activities and management had a positive impact on maternal health outcomes, with particular reference to the income generating activities. By addressing income poverty, the women were able to access health services that previously they would not have been able to afford. The final evaluation of the programme states: (Ref: Evaluation of Maternity Worldwide Gimbie Integrated Maternal Health Programme, Mimi Khan, May 2009):

“when asked what they considered the most important of the project benefits to be, women unanimously reported the importance of no longer having to borrow money from their neighbours during an emergency—whether to pay for transport to deliver when complications arose or to access other health services. Loans borrowed from neighbours were invariably at very high interest rates (some reported to be up to and over 100%), and women reported being constantly anxious about their ability to make repayments and have to face their debtors on a day to day basis. It also took them a considerable time to visit different lenders to obtain a loan which was difficult during an emergency.”

2.1 Comment

It is our observation that the integrated approach worked well but was at odds with the structure of the MDGs, which is split by theme, with limited linkages between the themes. As we have stated, a catalyst for success in our programme was the income generation activities which unlocked financial resources (linked to MDG 1—Eradicate Extreme Poverty and Hunger) that were preventing access to health care. We believe that focusing on internationally recognised themes in isolation can leave communities at risk of only being part-supported which will make investments less efficient and reduce impact. Additionally, there is a danger that aid donors will continue to respond to need according to this structure through the development of thematic budgeting which fails to address the multiple and interlinked needs of a given community.

2.2 Recommendations

Maternity Worldwide believes that the post 2015 framework should be contextualised focusing on the needs of the most poor in a given country. National Governments, civil society and other local stakeholders should collaborate to drive this process as they are best placed to understand the needs and ensure continuity of successes.

As we have seen, empowering people financially can lead to improvements in health and other areas. Therefore we recommend that any financing mechanisms in support of maternal health are linked to income generating schemes as well as addressing gaps in access which are outside of an individual’s control.

3. Traditional Norms and Practices

In our experience in Ethiopia through the Gimbie Integrated Maternal Health Programme, we have seen a direct correlation between poor maternal health and traditional norms and practices. These include the prevalence of child marriage which often leads to obstetric complications such as fistula, female genital mutilation, stigma related to HIV and AIDS which prevents women from accessing care and limited decision-making power of women related to contraception. These realities are often deep rooted in gender inequalities which see women as having lower status compared to men.

In our programme we purposely set out to tackle some of these issues through a series of community health promotion activities with whole families focusing on the rights of women to reproductive health services, the importance of child spacing and the use of contraception. Investing in women’s financial capacity through the income generating activities gave women greater decision making abilities and greater respect which led ultimately to more healthy women and families.

3.1 Comments

Whilst we recognise that MDG 3 went some way to acknowledging that gender inequality exists, it focuses predominantly on girl’s education, women in employment and political advancement. It doesn’t mention targets related to tackling underlying causes of gender inequality which makes the potential for impact of the MDG rather limited. MDG 5 alludes to the reduction of contraceptive use by women but makes no substantial mention of the underlying reasons for this limited usage which we believe are rooted in a women’s limited ability to negotiate contraception usage. In the case of Ethiopia, it was encouraging to see in the report on progress towards the MDGs in 2010 (Ref: Ethiopian Ministry of Finance and Economic Development, 2010) acknowledgement that gender equality and maternal health will not progress unless cultural factors are addressed. Acknowledging this is the first step to tackling the problem and the Ethiopian Government should be commended for this.

3.2. Recommendations

The post 2015 framework targets should be informed by robust gender analyses that identify the root causes of gender inequality in each context. These should go beyond quotas and aim to tackle imbalances in the structures in society that perpetuate the low status of women.

Gender inequality should be mainstreamed throughout the post 2015 framework. Any overarching health target should be supported by a hierarchy of sector and programme specific goals relating specifically to maternal health. These should ensure the inclusion of the priorities of the poorest and most marginalised women.

Reductions in gender based violence and early marriage should be included in any new framework indicators related to maternal health.

4. Good Governance

The Integrated Maternal Health Programme in Gimbie was managed by a series of Committees to promote broad participation from all sections of society. Of particular note was the Women’s Group Committee overseeing the income generating activities and the Community Education Committee that oversaw the community education programme. Beneficiaries were part of these groups enabling them to directly steer the actions of these themes and took an active part in the annual project dissemination forum where they gave their views on project development. The mechanisms were participatory, consensus orientated, inclusive and responsive—all aspects of good governance we were keen to promote.

4.1. Comment:

The MDGs make no mention of the importance of governance as a cornerstone of effective development even though significant amounts of work has taken place to build consensus around the importance of this at a global level. Through the Paris Declaration on Aid Effectiveness in 2005 and subsequent meetings in Accra and most recently in Busan, consensus has been reached about five fundamental principles that make aid work. Two key ones are ownership—governments set their own strategies for poverty reduction, improving their institutions and tackling corruption and alignment—donor countries align behind local objectives and use local systems. The ACCRA Agenda for Action went further to deepen this adding in a focus on capacity building where countries are supported to build their capacities to determine their own future.

4.2. Recommendations

The post 2015 framework should draw heavily on the commitments made in Paris, ACCRA and Busan so that momentum is not lost from these discussions.

The post 2015 framework should clearly reflect the need for communities to be fully involved in identifying priorities and in the development and operation of local projects.

October 2012