Emerging themes and issues: Maternal health
Achievements: MDG 5 remains the foremost global advocacy and action
objective which has become a constant reminder to expedite the
reduction in maternal deaths worldwide. There have been unprecedented
commitments by world leaders in recent years - US$5.3 billion for
innovative financing mechanisms for global health and stronger health
systems for maternal, newborn and child health (MNCH). Dr Margaret
Chan, WHO Director-General, has launched the MNCH Consensus to achieve
MDGs 4 and 5 - a framework for action and accountability.
It is now known that the most important interventions to save maternal
lives are access to skilled birth attendants, timely emergency
obstetric care, postnatal care for mothers and babies, and access to
reproductive health services. Family planning, safe abortion/post
abortion services and all reproductive health services should be
adolescent friendly.
Challenges: The most important causes of maternal death from childbirth
are severe bleeding (24%) out of which postpartum haemorrhage (PPH)
remains the most crucial, infections (15%), unsafe abortions (13%),
eclampsia (12%), obstructed labour (8%), other direct causes (8%) and
indirect causes including violence against women (20%). Maternal
nutrition, micronutrient supplementation and management of diseases in
pregnancy such as HIV, TB, malaria, hypertension/eclampsia, diabetes
and postpartum depression need greater attention. Better infrastructure
and human resources, both in quality and number, are urgently required.
Gaps: Data on the actual number of maternal deaths and their causes are
missing and this is an
important loophole for measuring progress. In countries where MMR has
been reduced, there may still not be adequate access to hospital
delivery and technology. This is because of an imbalance between abuse
of invasive procedures (too many caesareans/episiotomies) in some
countries and serious lack of timely care in others (inadequate
obstetric surgeons or facilities).
Good practices: Some countries that have started making progress for
MDG5 very recently such as India (maternal mortality ratio being down
from 327 to 256 in 2009) used additional interventions such as setting
up blood storage centres in first referral units (FRUs) and blood banks
in district hospitals as well as financial incentives for those below
the poverty line to go for institutional delivery. Supported by WHO,
they have also started maternal death reviews.
Recommendations: Data on the actual number of maternal deaths and their
causes need to be
documented urgently. Furthermore, indirect causes of maternal death
such as from gender-based violence need to be included in the
statistics. To achieve MDG 5 (and 4) by 2015, it has been estimated
that US$30 billion of new investment is required. Greater political
leadership, community engagement and mobilization, with accountability
at all levels, are required to achieve credible results.
Emerging themes and issues: Unsafe abortion
Achievements: There have been legal reforms in some countries such as
Pakistan where, in addition to saving the life of a mother, grounds for
abortion now include “necessary treatment”, though this term is yet
undefined. Regardless of the legal status of abortion, different
activities have been identified in advocacy efforts. WHO’s “Safe
abortion: technical and policy guidance for health systems” is an
essential guide to provide safe, comprehensive abortion care to the
full extent of the law so as to benefit women.
Challenges: Some challenges specific to eliminating unsafe abortion are
destigmatization of pregnancy termination; training for health-care
providers in safe abortion methods; and supportive health system
policies, apart from general challenges of health and related education
for women that apply here as well. Other challenges include planning
"wanted" pregnancies; preventing unwanted pregnancies; and safely
ending those that occur from forced or coerced sex, failed or
unavailable contraception or fetal
malformations. Most crucially, legalizing abortion is another
challenge, a step which those in positions of influence often evade,
even though compelling evidence demanding attention and action exists.
Gaps: The international community limits their advocacy to cautiously
recommending that abortion should be safe “when legal”. Technologies
for safe abortion (including vacuum aspiration and medical abortion)
are often not available, accessible and affordable.
Good practices: The WHO report “Women and health: today’s evidence
tomorrow’s agenda” released in November 2009, highlights the fact that
studies have shown that where there are broad legal grounds and access
to safe abortion, mortality and morbidity are considerably reduced. A
significant modification reported from India is that medical abortion
should not be denied irrespective of a woman's decision to initiate
postabortion contraception.
Recommendations: Governments, policy-makers and health-care providers
must be urged to remove regulatory and other barriers to safe abortion.
There is an urgent need to provide safe abortion services globally as
evidence is compelling that safe abortion services can save maternal
lives.
Emerging themes and issues: Contraception
Achievements: The contraceptive prevalence rate for modern
contraceptives has considerably improved in many countries since
Beijing (reported from Pakistan).
Challenges: There is an obvious gender bias when it comes to permanent
birth control methods in many countries. The tubal ligation which is
performed on women is more popular than the vasectomy for men (reported
from India).
Gaps: Information on contraceptive methods and their correct use is
still widely unavailable to adolescent girls (and boys) because
sexuality education is still a taboo in many developing countries
(reported from India and Costa Rica).
Good practices: The United States Congress recently appropriated more
than US$648 million in foreign assistance to family planning and
reproductive health programmes.
Recommendations: The concern expressed by women for their future
fertility preservation should be capitalized upon while developing
advocacy messages to improve the appropriate use and uptake of
contraception and to adopt healthy sexual and reproductive health
behaviours. As in many societies, this is perhaps most applicable
within the context of Africa and other developing countries where a
woman’s worth is strongly judged by her ability to bear children.
Ensuring access to voluntary family planning could reduce maternal
deaths by 20 to 35 per cent (and child deaths by 25 per cent) according
to UNFPA.
Emerging themes and issues: Infertility
Achievements: Infertility management has made rapid progress globally,
especially with the greater acknowledgment of the role of men along
with women in this disease of the reproductive system, and the emphasis
of the link between infertility and the need for the prevention of
sexually transmitted infections. To give access to
underprivileged women/couples in resource poor countries, infertility
specialist
societies/communities in partnership with WHO have been discussing good
practices in relation to reducing the costs for assisted reproductive
technologies.
Challenges: High cost of advanced infertility management (especially
assisted reproductive
technologies), health insurance not covering assisted infertility
treatments and public health systems not providing sophisticated
treatments remain major barriers to gender equity and universal access
to care for the infertile. Monitoring and surveillance of the health
and well-being of women prior to and/or when they become pregnant, and
also that of the child(ren) born, through assisted reproductive
technologies.
As women age, their ability to reproduce decreases at a more
significant rate than in men, yet women are delaying their
childbearing,and rates of childlessness are increasing in developed and
developing countries.
Gaps: Education about infertility causes, prevention and forms of
interventions is lacking. Infertility can be classified as a social
issue which results in women being subjected to stigmatization and
divorce. Men often require encouragement to recognize their
responsibility in an inability to father a child (infertility is often
referred to as a women's problem) and mechanisms are needed to
encourage men to adopt healthy sexual and reproductive health-seeking
behaviours for fertility preservation. Evidence and guidance are
lacking on infertility interventions in resource poor settings.
Recognition of the fact that any successful intervention results in
pregnancy demonstrates the clear need to link infertility care
management with both family planning, as well as maternal and child
health care.
Good practices: In some cases, the HIV-positive discordant couples may
now have access to simple and affordable techniques such as sperm
washing and other medically assisted reproductive
interventions.
Recommendations: There is a need to make infertility prevention and
management available at the primary care level. For this to be
successful, it would be appropriate to share infertility management
tasks between the doctor, the midwife and the community health worker.
Costs of assisted reproduction technologies, without jeopardizing
quality of care, have to be drastically reduced to increase access in
resource poor settings.
Emerging themes and issues: Harmful practices such as female genital
mutilation and forced marriage
Achievements: The international community has accepted that female
genital mutilation (FGM) is a violation of a series of human rights,
and principles and the silence around it has been broken.
Challenges: FGM, a practice deeply rooted in culture, is still
surviving because communities feel it serves some purpose. More than 18
percent of all cases of FGM are performed by health-care professionals.
Gaps: Governments have no system of monitoring the spread and practice
of FGM.
Good practices: 17 African countries, including Uganda very recently,
have legislated against the practice in their national laws. FGM has
been delinked from religion - Islam and Christianity - through
workshops organized by IAC and documents published by the Population
Council that highlight this point.
Recommendations: Advocate with governments of practising countries to
legislate where there is no national law and to implement and enforce
where a national law exists. However, legal instruments cannot do it
alone. There needs to be some reporting back from medical professionals
whenever they come across a girl who has undergone genital mutilation
or is at risk. A suggestion was to have medical genital examinations in
pre-primary or primary school children to help identify FGM and sexual
abuse.