In 1999, Reproductive Health Matters published a multi-authored book called Safe Motherhood: Critical Issues. A whole generation of expertise on preventing maternal deaths is contained in that book. In 2007, the 20th anniversary of the Safe Motherhood Initiative, we devoted a journal issue to the question: “Is pregnancy getting safer for women?” We found reasons to celebrate and reasons to despair. Where deaths remained high, we found a clear lack of commitment, a failure to act and a persistent lack of finance in all the places where finance counts. The papers reiterated how much is known but not applied. Why has that knowledge been dissipated, not put into action? Who is paying the price?
Millennium Development Goal 5 does not provide anything like an adequate picture of what needs to be done to reduce maternal mortality and improve maternal health. Even if countries were to achieve “skilled attendance at birth” for 100% of deliveries, given the limited definition of “skilled” that the poorest countries are forced to work to in order to come even near reaching this goal, maternal deaths would not fall sufficiently. Indeed, MDG5 slides over 25 years of evidence and experience of what it takes to make motherhood safe. So it’s not an accident that it has been the least achievable MDG. In fact, it is only in countries where overall development has improved health and health systems since 1990, including access to good maternity care, and where abortion has been made safe(r), that any noticeable drop in maternal mortality has occurred.
With the best will in the world, neither the UN nor the megastructures called global health initiatives, currently pumping money into selected vertical programmes the least developed countries, have reduced maternal deaths. Instead, we are suddenly flooded with romantic photos and pretty rhetoric about “saving mothers and babies”. But with a maternal death, there is no mother and mostly, there is no baby. Here is what a maternal death looks like:
The new rhetoric says these deaths are avoidable. Yes, the information exists on how to prevent them. So what? This issue of RHM is a call to get back to the cruel reality of what maternal mortality and morbidity look like. It asks what countries are doing to prevent it – or not?
Now, RHM seeks papers about why some countries are reducing maternal deaths and others are not and what has changed in the past decade:
· what national programmes and services exist? what do they consist of? what have they achieved and not achieved? who regulates and monitors them? who is paying for them?
· do countries know what they need to know and how to find it out? how are they measuring progress? why is there progress in some places and no progress in others?
· are the same women dying now as 10 and 20 years ago, or different women?
· have more women begun attending antenatal and delivery care with a skilled attendant? post-partum care (if there is any)? what led more of them to start doing so? or if not, why not?
· what is the content and quality of maternity and abortion care? which health professionals are providing it? what competencies have they attained and are they able to use them?
· how to resolve the seemingly unending debate about TBAs? has anything changed for women since 1987 in countries where TBAs still attend most deliveries?
· are more countries carrying out verbal autopsies, sisterhood studies, maternal death audits, than a decade ago? are they keeping good clinical records, analysing and using them to make change happen?
· has information about maternal morbidity increased? is attention to the women who survive complications also increasing or not? is there more and more effective care for complications of unsafe abortion than 10 or 20 years ago? is D&C being replaced by MVA?
· are lifesaving essential drugs, equipment and procedures to treat obstetric complications and emergencies more available in resource-poor countries than in the past? how is the international war by big pharma against generic and affordable drugs affecting maternity and abortion care?
· what about midwifery and abortion training for health professionals in hospitals, primary care and the community – is that happening or increasing? are there fewer shortages? are there really more skilled attendants – what do those words mean in the training curriculum and practice?
· deaths from complications of unsafe abortion have fallen in some parts of the global South in the absence of law reform – why? have countries moved forward on making abortion safe and legal?
· why is unsafe abortion a dirty word in influential safe motherhood circles again, or not mentioned at all?
· are infants and children taking resources and attention away from women’s needs, in spite of the “continuum of care” ideal?
· why is maternal mortality no longer addressed as a part of sexual and reproductive health and rights?
· why only “mothers”? pregnancy doesn’t happen only to mothers – why have the MDGs been allowed to make a comprehensive women’s health agenda obsolete?
Something retrogressive has diverted the attention of those in power and even many neo-NGOs from recognising and addressing the reality of maternal mortality. RHM19(38) November 2011 calls for sexual and reproductive health and rights to be re-asserted on the global and national stage. This includes women’s right to safe pregnancy, safe delivery and safe, legal abortion, with universal access to services.
For the May 2012 journal issue, we ask: how can we bring the world and its leaders back on track and make change happen in countries – some thought-provoking commentaries from those with experience at the grassroots would be welcome.
Submissions due: ± September/October 2011 (negotiable due to late distribution of this call)
