Women's Health and Education Center (WHEC)

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Poverty and Maternal Mortality

WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).

Poverty remains the main obstacle to health development. Over 1.2 billion people live in extreme poverty in the world (less than $1 a day); 3 billion people world wide are trapped in poverty (less than $2 a day); 800 million are hungry and 448 million children under five are underweight. And 800 million children under 15 years contracted the HIV/AIDS virus in 2005. Every year 529,000 girls and women die in childbirth. Most of these deaths are preventable. In December 2000, 149 heads of state or government and 189 Member States of the United Nations jointly endorsed the Millennium Declaration, thereby committing themselves to achieving, by 2015, ambitious goals including reducing poverty, hunger and disease. These goals are known collectively as the Millennium Development Goals (MDGs) and they will serve as a basis for recording progress in development for the next 15 years. The good news is that the reduction of maternal mortality/morbidity is one of the key goals. In addition, the needs of newborns will receive particular attention thanks to the creation of a specific goal of reducing child mortality. This means that both maternal and newborn health is going to be at the center of policy and action from now on.

The purpose to this document is to assess the importance of the Poverty Reduction Strategy Paper (PRSP) instrument for the health sector, and in particular its potential to advance strategies that meet the health needs of the poor. We hope these contents provides Women's Health and Education Center (WHEC) and other actors in health sector with a good starting point to further engage with PRSP processes at country level. The envisaged readers of this study are policy makers working in health and in development - particularly those interested in aid instruments and their effectiveness; based in development agencies, ministries of health, and multilateral organizations. Moving forward on this issue within the health sector could help to strengthen the collaboration across sectors. There is also ongoing work to frame and monitor PRSPs from a human rights perspective, and in many civil society organizations.

Photograph by James Nachtwey: A young man in Darfur, sick with hepatitis E, is cared for by his mother at the city hospital in Mornei, West Darfur.

Abbreviations and Acronyms:

UN - United Nations
WHEC - Women's Health and Education Center
HIV/AIDS - Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
MDGs - Millennium Development Goals
PRS - Poverty Reduction Strategy
NGO - Non-Governmental Organization
WHO - World Health Organization
PRSPs - Poverty Reduction Strategy Papers
PRGF - Poverty Reduction Growth Facility
HIPC - Highly Indebted Poor Countries
CMH - Child Maternal Health
IMF - International Monetary Fund

The Goals:

The MDGs are a very simple but powerful idea whose time has come. By 2015, all United Nations Member States have pledged to:

  • Eradicate extreme poverty and hunger
  • Achieve universal primary education
  • Promote gender equality and empower women
  • Reduce child mortality
  • Improve maternal health
  • Combat HIV/AIDS, malaria and other diseases
  • Ensure environmental sustainability
  • Develop a global partnership for development

The Goals could change the world. The Goals have become the yardstick for progress among many governments and international organizations to measure progress, shift budget priorities and institute reforms to improve human development around the world. For millions of people, poverty implies lack of access of proper food, water and shelter, and therefore greater vulnerability to disease. In many industrialized countries, urban poverty is increasing, multiplying violence, drug abuse and risk of HIV infection. Women illustrate better than any other population group the combined impact of poverty, unemployment and social disintegration on health and quality of life. Everywhere, poverty and unemployment lead to a deterioration in health and jeopardize social cohesion. Health can be used as a rallying cry to foster social cooperation and consensus; it is thus a more powerful tool in coping with violence than confrontation. Unemployment, marginalization, and poverty are conditions that result in poorer health and are exacerbated by the discrimination girls and women face throughout their lives. In virtually every society, women face discrimination in education and employment, as well as social and economic status, all of which contribute to a heightened vulnerability to disease and ill-health. If the world community endorses the concept of equality in health, it will commit itself to achieving a better quality of life for all people and reducing differences in health status among countries and between population groups.

The United Nations is mobilizing its resources and partners in an unprecedented manner in support of the Goals. They are the UN's effort to set the terms of a globalization driven not by the interests of the strong, but managed in the interests of the poor. These Goals are attainable, provided countries of the North and South work together. We at Women's Health and Education Center (WHEC) put particular emphasis on improving the health and well-being of women to attain the Millennium Development Goals (MDGs) and women's health to be used as a powerful progress indicator in achieving social development.

Poverty and Maternal Mortality/Morbidity:

The healthy future of society depends on the health of the children of today and their mothers, who are guardians of that future. However, despite much good work over the years, 10.6 million children and 529,000 mothers are still dying each year, mostly from avoidable causes. Immediate and effective professional care during and after labor and delivery can make the difference between life and death for women and their newborns. Each and every mother and each and every newborn needs skilled maternal and neonatal care provided by professionals at and after birth - care that is close to where and how people live, close to their birthing culture, but at the same time safe, with a skilled professional able to act immediately when largely unpredictable complications occur. The challenge that remains is therefore not technological, but strategic and organizational. The need for an urgent, global coordinated response has prompted several agencies and international organizations to join forces and create partnerships for maternal, newborn and child health. The low social status of women in some countries, for instance, limits their access to economic resources and education. This in turn limits their ability to make decisions about their health and nutrition. Some women are denied access to care either because of cultural practices of seclusion or because decision-making is the responsibility of other family members. Lack of access to, and use of, essential obstetric services is a crucial factor that contributes to high maternal mortality.

Maternal mortality ratio per 100,000 live births in 2000 and Neonatal mortality rate per 1,000 live births in 2000
(Source: World Health Organization)

Antenatal care is important to further maternal and newborn health - but not as a stand-alone strategy and not as a screening instrument. To ensure safe childbirth, skilled professional care needs to be available. Most women who eventually experience complications have few or no risk factors, and most of the women with risk factors go on to have uneventful pregnancies and deliveries. Antenatal screening has a long history, dating back to the first World Health Organization (WHO) expert committee on motherhood in the early 1950s. They soon became common wisdom and during the 1970s and 1980s, a mainstream doctrine under the label "risk approach". This approach was a core component of safe motherhood strategies for many years. In the early 1980s, the first evidence surfaced and began to challenge with a growing view that the ineffectiveness of antenatal care. Six years later, it could be clearly stated that "no amount of screening will separate those women who will from those who will not need emergency medical care". To ensure safe childbirth, skilled professional care needs to be available for all births, even the ones not at risk. The support of families and communities is the key to reducing maternal mortality and morbidity. Input from a wide range of groups and individuals is therefore essential, including community and religious leaders, women's groups, youth groups, other local associations, and healthcare professionals. Women's overall health influences their maternal health. A diet that has sufficient calories and micronutrients is essential for a pregnancy to be successfully carried to term. Various supplements can be given where there are micronutrient deficiencies but in long term improvement in women's nutrition is essential. Such a change can take place only at the community level and in the household. Women in developing countries often eat less, less often, and less nutritiously than their children and other family members.

While the immediate causes of obstetric fistulae are obstructed labor and a lack of emergency obstetric care, pervasive poverty is an important underlying cause. Worldwide, obstructed labor occurs in an estimated 5% of live-births and accounts for 8% maternal mortality. Adolescent girls are particularly susceptible to obstructed labor, because their pelvises are not fully developed. Women who suffer from obstetric fistula tend to be impoverished, malnourished, lack basic education and live in remote or rural areas. This devastating condition affects more than 2 million women worldwide. There are an estimated 50,000 to 100,000 additional cases each year. Fistulae occur in areas where access to care at childbirth is limited, or of poor quality, mainly in sub-Saharan Africa and parts of southern Asia. The World Health Organization (WHO) estimates that, globally, over 300 million women currently suffer from short- or long-term complications arising from pregnancy or childbirth, with around 20 million new cases arising every year. The studies in Ethiopia, Nigeria and other parts of West Africa estimate the incidence of fistula to be 1-10 per 1,000 births. In Ethiopia it is estimated that 9,000 women annually develop a fistula, of which only 1 in 200 are treated. These young girls and women tend to live with their fear and stigmatization in silence and isolation, unknown to the health-care system. It is not surprising, therefore, that some women can no longer cope with the pain and suffering, and resort to suicide.

Good quality first-level and back-up care at childbirth prevents fistula. Once the condition has occurred it is treatable. The plight of women living with fistula is a powerful reminder that programmatic concerns should go beyond simply preventing maternal deaths. Collective action can eliminate fistula and ensure that girls and women who suffer this devastating conditions are treated so that they can live in dignity. It is unlikely that essential obstetric services will be available to all of world's women within the foreseeable future; therefore, development of a sustainable clinical infrastructure to deal with the effects of maternal morbidity is likely to be an essential need in reproductive medicine for the rest of the 21st century.

The Partnerships for Maternal, Newborn and Child Health:

Against the backdrop of slow progress towards the Millennium Development Goals concerning maternal and child health, the need for an urgent, global coordinated response has prompted several agencies and international organizations to join forces and create partnerships for maternal, newborn and child health. Over the past few decades, it has become clear that the support required for the development of a resource-constrained country is so multifaceted and complex, that it cannot be successfully taken on by one agency or one Non-Governmental Organization (NGO), alone. The recently established Partnership for Safe Motherhood and Newborn Health aims to strengthen and expand maternal and newborn health efforts. The Healthy Newborn Partnership has been established to promote awareness and attention to newborn health, exchange information, and improve communication and collaboration among organizations beginning to work in newborn health. The first function of these partnerships is to stimulate and sustain the political will to keep the maternal, newborn and child health agenda as a central priority. They do so through dialogue at the highest level of government. The partnerships can also assist in bridging the gap between knowledge and action by facilitating the interaction between policy-makers, researchers, donors and other stakeholders who can influence the uptake of research findings - and orient research towards solving the operational and systemic constraints that hold back the scaling up of effective interventions. Finally, the partnerships can help bring together the various parties involved in maternal, newborn and child health (ministries of health, finance and planning, national non-governmental organizations (NGOs), health professional groups, donor agencies, United Nations agencies, faith-based groups and others), or provide technical support to existing coordination mechanisms. This creates national partnerships through which funding, planning and implementation of national and sub-national maternal, newborn and child health plans can be accelerated.

The requirement for countries to formulate Poverty Reduction Strategy Papers (PRSPs) as a precursor to debt relief and the shared commitment to the Millennium Development Goals have cemented the links between pro-poor policy and maternal, newborn and child health priorities. The shared recognition by both donors and recipient governments of the need for coordination of resources was a critical factor in the early acceptance of sector-wide approach. In many countries NGOs actively engage in maternal and child health, but usually have only limited access to these mechanisms. Building the district health systems required for maternal, newborn and child health, let alone their equivalent in more pluralistic settings, supposes a reasonable degree of macroeconomic and political stability and a reasonable degree of budget predictability. The responsibility for quickly restoring acceptable standards of health services falls on under-resourced ministries of health. In such circumstances the expansion of the network to cover remote areas is far slower and more expensive than would usually be expected. If recurrent costs are underestimated when investment decisions are made, this undermines the sector's long-term sustainability. Providing universal access requires a viable and effective health workforce. Yet, as demand has increased and as more ways of delivering effective treatment and prevention have become available to respond to increasing needs and demand, the size, skills and infrastructure of the workforce have not kept pace. Along with the shortages, it appears that many countries have also witnessed a deterioration in the effectiveness of their workforce. The public expects skills, knowledge and competencies in maternal, newborn and child health care that health workers often lack, putting lives at risk.

The World Health Report 2005 - Make every mother and child count, published by the World Health Organization, examines why these deaths continue to occur on such a scale, and how the annual toll can be reduced. To put an end to widespread exclusion, countries have to guarantee access to care for each and every mother and child - through a continuum that extends from pregnancy through childbirth, the neonatal period and childhood. Universal access for mothers and children requires health systems to be able to respond to the needs and demands of the population, and to offer them protection against the financial hardship that results from ill-health. To make these possible, investments in health systems and in the human resources for health need to be stepped up. The maternal, newborn and child health should constitute the core of the health entitlements protected and funded through public funds and social health insurance systems.

Poverty Reduction Strategy Papers (PRSPs):

Poverty Reduction Strategy Papers (PRSPs) are national planning frameworks for low-income countries. All countries wishing to access concessional loans through the Poverty Reduction Growth Facility (PRGF) or wishing to benefit from debt relief under the Highly Indebted Poor Countries (HIPC) initiative are required to produce a PRSP. It is potentially a very important instrument for the health sector. It is an important entry point for tackling poverty-health challenges in low-income countries. The potential benefits of the PRSP process - or any multisectoral planning process - is that it could provide an opportunity for different sectors to come together, discuss synergies and common challenges, and undertake joint planning of cross-sectoral activities. PRSPs fairly consistently reflect the goals of MDGs, but they do not necessarily reflect the quantifiable targets. One of the key components of the health strategy is to consolidate and develop health services in poor regions. The majority of health strategies presented in PRSPs represent a strengthening of basic health care. It is important to point out that the level of detail varies considerably between PRSPs - in some cases the role of non-government service providers (for-profit and not-for-profit) is rarely discussed. By bringing a poverty reduction lens to the health sector, PRSPs could catalyze a more pro-poor analysis of the health challenges that low-income countries face, including an examination of why existing polices are failing to reach vulnerable groups.

One way forward is to improve links between the PRSP and other processes which can help improve the poverty focus of the health component. Another such process is the development of Health Investment Plans, proposed as part of the follow-up to the Child and Maternal Health (CMH) process. They could provide an important source of information, as well as political momentum, for the creation of health strategies with a greater poverty focus. Greater support from health development partners, links with other processes, and continuing advocacy with higher levels of government, remain essential to achieve MDGs 4 & 5 (reduce child mortality & improve maternal health).

Strengthening links between the analytical work and guidance and capacity-building: World Health Organization (WHO) is one of the key players for health, needs to better link the information and insights from the PRSP desk review with support for PRSP design and implementation at country level. WHO does need to accelerate work on developing tools and guidance which are useful at country level, including tools which countries can use to monitor progress in the implementation of PRSPs. Such guidance should look beyond health to other sectors (education, transport, water etc.) and be linked to existing and MDGs and work to build an evidence-base on health and poverty determinants at country level. Tools and guidance should be linked to capacity-building and advocacy at country level. Moving forward on this issue within the health sector could help to strengthen collaboration across sectors. There is also a substantial amount of literature exists on the ongoing work to frame and monitor PRSPs from a human rights perspective and in many civil society organizations. In the short term to provide technical input the tasks are:

  • Providing input on the next draft of the framework.
  • Identifying countries for follow-up case study work.
  • Helping to establish stronger collaboration between World Health Organization (WHO), the International Monetary Fund (IMF), and other donor groups and organizations doing similar work on financial monitoring of PRSPs.
  • Establishing mechanisms to improve sharing of data and resources.
  • Exploring the issue of how to define pro-poor health spending.

Poverty Reduction Strategy Papers (PRSPs) should prioritize those health interventions most likely to improve the health of the poor(est) and help to reduce poverty. The World Bank emphasizes that PRSPs should be written and produced by countries themselves, and should go beyond macroeconomics stabilization and liberalization to address issues of poverty and equitable growth. However, PRSPs must also be approved by the Boards of the World Bank and the International Monetary Fund (IMF) before access to debt relief and concessional lending is granted. Moreover, Bank and Fund consultants often assist in the drafting of PRSPs. This suggests - and country experience confirms - that to a certain extent PRSPs must conform to Bank/Fund interpretations of "sound economic policy".

Gender Equality:

Poverty, maternal mortality/morbidity and child mortality cannot be eradicated without gender equality and women's empowerment, and this would require a change of traditional and cultural gender norms. Nothing illustrates the disastrous effects of gender discrimination more starkly than the maternal mortality/morbidity and HIV/AIDS pandemic in the developing countries. Women need action, resources and Governments that protect and advance their human rights effectively. The critical areas of concern are even more complex and intertwined, but the major dimensions of gender equality and women's empowerment remain economic empowerment, well-being and decision-making. Equal pay and women's integration in non-traditional sectors are still an exception to the rule. In the new millennium, transnational corporations have enormous power. Only by investing in the world's women we can expect to achieve Millennium Development Goals (MDGs) by 2015.

The Commission on the Status of Women, at its forty-ninth session in March 2005, adopted wide-ranging resolutions on improving women's status, including gender mainstreaming in national policies and programs. While the gender gap in education has narrowed, severe gaps in the quality of education remain especially for indigenous populations. Despite progress in basic education, girls and women still face inequality, particularly as far as access to higher education. Other problems are related to school dropout, high illiteracy rates, and gender stereotyping. Laws can influence allocation of resources, and progressive Women's Healthcare Legislation is more than just care and treatment.

Editor's Note:

The wide acceptance of the Millennium Development Goals (MDGs) by the international community confirms the central role of human development, including health and nutrition, in combating poverty. As countries develop and implement their Poverty Reduction Strategies (PRS), one of the key challenges is to identify actions that will have the greatest impact on poverty and improve the lives of poor. The challenge is compounded by the fact that poverty has many dimensions, cuts across many sectors, and is experienced differently by women and by men. In no region of the developing world are women equal to men in legal, social and economic rights. Gender gaps are widespread in access to and control of resources, in economic opportunities, in power and political voice. Gender equality is a development objective on its own - it also makes good business sense as it is central to economic growth and sustainable development.

Safe Motherhood is back at the top of the global health agenda. Today the interventions already exist to transform the lives of millions of mothers and children and to prevent millions of tragically premature deaths and disabilities. With the increasing integration of the world economy, issues of research and development in health sector has assumed a global dimension. Working towards universal coverage of maternal, newborn and child health interventions is our mission. People want and societies need mothers and children to be healthy. That is why every mother and every child counts so much in our ambitions for a better tomorrow. This work is important and must continue. We tend to collect, analyze and spread the evidence that investing in health is one major avenue towards poverty alleviation. The diverse interests of a big project/program guarantee the liberty of all. Opportunity entails responsibility. Working together we have the opportunity to transform lives now debilitated by disease and fear of economic ruin into lives filled realistic hope. Those of us who commit our lives to improving health can help to make sure that hope will predominate over uncertainty in the century to come.

Suggested Reading:

  1. The WHO, ICM, FIGO Pledge
    Making Pregnancy Safer: The Critical Role of the Skilled Attendant (pdf)
  2. World Health Organization
    PRSPs: Their Significance for Health: Second Synthesis Report (pdf)
  3. World Health Organization and World Bank
  4. International Monetary Fund (IMF)
    Debt Relief Initiative & The IMF
  5. United Nations Commission on the Status of Women
    Department of Economic and Social Affairs

Published: 7 December 2009

Women's Health & Education Center
Dedicated to Women's and Children's Well-being and Health Care Worldwide