Friday Fax Analysis: Drop in Global Maternal Deaths Doesn't Mean Maternal Health Improving

NEW YORK, May 25 (C-FAM) Around the world almost half as many women die in childbirth as they did 20 years ago, a new UN report says. The good news hides the sad fact that for women in many countries who want more children, they will go on risking their lives to have them.

On a global level, there are fewer maternal deaths because there are fewer babies being born. On an individual level, fewer pregnancies can lower the odds that a woman might die in childbirth. But where mothers choose to have large families, they remain at high and even extreme risk according to the new report. Women in low income countries have a 1 in 56 chance of dying related to childbearing, while the risk for women in rich countries is 1 in 4200.  In sub-Saharan Africa, the risk is 1 in 39, four and a half times the world average.

For years the world's foremost aid agencies have made family planning the top priority in addressing maternal health, in an effort to further quash fertility. Medical interventions that actually address maternal health--such as skilled birth attendants and antenatal care--have been kicked down to second or third place on the funding list.

One reason is that agencies find it easier to dispense contraception than to overhaul far away health systems. Another is that they can measure "contraceptive prevalence" more easily than they can assess qualitative improvements in medical care. In an era of fiscal constraints and donor demands for accountability, particular agency interests drive funding priorities that may not make much medical sense.

Take for example UNFPA's executive director Babatunde Osotimehin's response to the new numbers. In the same words his predecessor used regarding previous reports with vastly higher numbers, Osotimehin promoted even more family planning saying, "We know what to do, we know how to do it. We will just continue to scale up on this."

Also driving the maternal health agenda are strict targets set at the international level that don't necessarily reflect local realities. At the turn of the century, world leaders agreed to slash the maternal mortality rate in their countries and across the globe 75% by 2015.

Every one of the countries that has met the goal experienced a drop in fertility according to UN estimates. Of those ten, every developing country except one had a dramatic decline. The remaining, European, countries on the list already had fertility rates below 2 children per woman, and dropped even further.

Conversely, one third of the women who died in childbirth in 2010 were from India or Nigeria, where poverty remains high and family sizes are relatively large on average. All in all, a woman faces high risk of death to bring a child into the world in 40 of the 180 countries assessed. A woman from Chad or Somalia, who had more than 6 children on average during 1990-2010, had the highest lifetime risk in the world. Those war-torn nations are the only ones with "extremely" high maternal mortality according to the report.

And so even though the report boasts, "All MDG regions experienced a decline in maternal mortality rates," there is no indication that global efforts prioritizing family planning, have made a difference for poor women or women in countries that favor large families. 

In fact, the maternal mortality rate could be far higher than experts think. The mortality rate is high in places where data is most scarce. The report admits that good data only exists where a slim 15% of the births are occurring, mostly in the developed world. There is no data at all for 27 of the 180 countries surveyed, and 88 more lack "good" data. In essence, despite improved data gathering and analysis, no one really knows how bad it is for most mothers. The report concludes that "it is not possible to fully explain why some countries had steeper declines than others, or why some made no progress."

In contrast to the UN's prioritization of fertility reduction through family planning, health ministers gathered in Washington last month emphasized better maternal health care and delivery systems. Dominican health minister, Dr. Bautista Rojas, said "key Components" of that country's program are "emergency obstetric care...a series of maternal care practices focused on saving lives, and a system of on-the-job training and supervision using checklists," that increased the quality of care.

Cambodia's Dr. Mam Bunheng credited success to the end of war, economic growth, improved roads, cell phones, more and better health centers, and trained midwives. His country offers "midwifery incentives" that provide $15 to a health center and $10 to a referral hospital for every live birth at their facility. Reversing the position of international aid agencies, the Cambodian health minister listed family planning next to last on a list of six challenges his country faced, putting newborn survival, links to hospitals, and improved quality of care at the top.

The drive to reduce pregnancies as the main way to reduce maternal deaths remains unchanged since the decades of previous UN reports asserting that more than 500,000 women die in childbirth annually. The UN was compelled to revise that number to nearly half after a group of independent researchers at the University of Washington challenged UN data and methodology in 2010. At that time, some researchers argued that their UN colleagues were compromised by also having a policy-setting role. This is the second consecutive edition of the UN report that compares its methodology to that of the independent researchers, effectively conceding that they are no longer the gold standard in maternal health research.

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