Improving the health of mothers and babies

Breaking through health system constraints

Improving maternal health remains the most elusive of the Millennium Development Goals. Every minute, at least one woman dies from pregnancy-related causes: 99 percent of these are in developing countries. The majority of these deaths occur in sub-Saharan Africa and south Asia, and are avoidable through using standard interventions and health care which all pregnant women and their newborns need.

2007 marks the 20th anniversary of the Safe Motherhood movement. Today, only half the world's women have the care of a skilled professional when giving birth. Even less get the full package of care in pregnancy and shortly after birth which protects them and their babies from dying or from serious illness.

Even those who have skilled care often do not receive the quality of care they really need. They can often be at the sharp end of under-resourced and malfunctioning health care, or even exploitation, over-medicalisation, bad practice or abusive health workers.

The survival and health of newborn babies, an important part of the Millennium Development Goal (MDG) to tackle child mortality, goes hand in hand with maternal health. The care that can reduce maternal deaths and improve women's health is also central to the survival and health of newborns. Making sure that health systems are able to provide adequate care to women during pregnancy, at the time of birth and beyond for both mother and child, is key to making progress.

Maternal mortality is an indicator of how well a health system functions, as it encapsulates a substantial part of both primary and secondary health care. However, maternal mortality has also been described as a 'litmus test' for the status of women in a society. Given that most women will give birth, a health system that is not designed to cope with this does not value women and their babies enough to provide protection against possible death or disability.

This issue of id21 insights health looks at the provision of maternal health care and health system constraints to making that care universal. Malay Kanti Mridha and Marge Koblinsky consider the reasons behind the key constraint to progress: the world's acute lack of maternal health workers. They also point to the serious mismatches between what is needed and what exists both in terms of skills and the geographical availability of staff at local, national and international levels. They highlight the need for professional staff, and the possible gains in efficiency from deploying teams of midwives.

Yet, drugs, supplies, equipment, buildings, vehicles and logistics systems are also needed to provide appropriate care. Louise Hulton reviews the challenges from weak infrastructure to the development of effective health care services.

Gwyneth Lewis reminds us that poor provision of care, although far too common, can also coexist with the provision of 'too much' care. This 'over-medicalisation' may not seem to be an important consideration when looking at resource-poor settings, but it is a growing problem in developing countries.

Interventions like caesarean section are strongly promoted among women who can afford to pay at the expense of women who cannot. This means that entire health systems are being built on the assumption that expensive interventions are needed, to the detriment of the promotion of normal birth.

The resulting heavy financial burden on families can increase poverty, as discussed by Jane Falkingham. Health care costs associated with childbirth can be catastrophic for poor families, especially where there is either a real or perceived need for interventions such as caesarean section. Health systems that have been able to extend financial protection to the majority of women and their families to cover maternal and newborn health care costs can save lives as well as alleviate the poverty that goes with rising care costs.

Helga Fogstad looks to the future of extending maternity care to all women in the 75 countries that suffer 97 percent of the world's maternal deaths. Some of these countries cannot realistically 'scale-up' their maternal health services to provide care for the majority of their populations until well into this century, but can move a significant way towards their MDG target by investing in their health systems for maternal and newborn care before the next decade.

The true constraints are political

Increases in funding are required: US$39 billion for the 75 most severely burdened countries. Given that the projections show that the costs associated with providing such care will require further investment both by countries and the international community, Jeremy Shiffman considers the factors that influence political actors to provide long-term sustainable investment in maternal health.

Debates in safe motherhood have emphasised various technical approaches to solve the problems inherent in reaching the MDG for maternal health. We now know that good maternal health is based on good sexual and reproductive health, including family planning and safe abortion care.

But the articles in this issue show that the true constraints to improving care are within the health systems of developing countries: a lack of human resources, poor infrastructure, inadequate financial protection and non-evidence-based medical practices.

Ultimately, given the resources needed to scale-up care, political perspectives need to be understood to break through the health system constraints. To make further progress, we need to understand more about how politicians have succeeded in improving safe motherhood in resource-constrained settings. Political choices for popular, visibly effective health system solutions which are acceptable to health professionals should be studied and could provide the inspiration to reach as far as we can towards the MDG for maternal health.

Zoë Matthews
Southampton Statistical Sciences Research Institute, School of Social Sciences, University of Southampton, Southampton, SO17 1BJ, UK
T +44 (0) 23 80593997
Z.Matthews@soton.ac.uk

See also

World Health Report 2005: Making Every Mother and Child Count
www.who.int/whr/2005

The Lancet Sexual and Reproductive Health Series
www.thelancet.com/collections/series/srh

The Lancet Maternal Health Survival Series
www.womendeliver.org/pdf/Maternal_Lancet_series.pdf

The Lancet Neonatal Survival Series
www.thelancet.com/collections/series/neonatal

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