MATERNAL MORTALITY – AN INTEGRITY TEST FOR POLITICIANS

PREAMBLE: One of the world’s most intractable public health problems is the high mortality of women due to pregnancy related causes. Over several decades (until recently), maternal mortality in developing countries appears to have been non-responsive to a range of interventions, perhaps because of inadequate intervention design or the inability to scale these to a level that can have impact on population health. In many countries, social and health policies that could facilitate the status of women, particularly in their right to make independent decisions with regard to their own health, have remained underdeveloped; it is of low priority in the world’s male-dominated political systems. Health services also have been inadequate to help lower maternal mortality: insufficient attention to prevention and inadequate access to treatment services of quality when critically needed.

Most donor countries recognize maternal health as a global public health priority. However, in Canada (under the regime of Conservative Prime Minister Stephen Harper), this global imperative is being sacrificed to partisan politics of the most ill-informed kind: it risks becoming a platform for the “religious right” to rail against the use of donor funds for abortion rather than to address in a holistic manner the most important needs of women that can assure improvement in their health.

Only last year, the administration of US President Barack Obama rescinded the global “gag order” of the preceding Bush regime, that required recipients of US aid – even in the realm of reproductive health – to deny access to safe abortion services if accepting US funds. This enlightened policy shift brings the US international development policy in line with that of the global community generally. It is ironic therefore that Canada – once a leader in this respect – appears to be taking a giant step backwards. Given the removal of access to safe abortions from the frame of reference, it is extremely doubtful that a recent Request for Proposals to guide the policy of the Canadian government in this regard, could attract anyone with a rigorous track record in this area of international health development.

Taking Africa as an example, as the recent "African Century" series of articles in the Globe and Mail (ref: May 11, 2010 issue) makes clear, more than 90% of Africans live in countries where abortion is restricted. It is legally prohibited in 14, while in others it is only permitted only to preserve the life or physical health of the woman. As a result, virtually all of the estimated 5.6 million abortions performed annually in Africa are unsafe, carrying with an unconscionable risk of complications and death.

Simply put, along with access to contraception, antenatal care, safe deliveries, reliable transportation to advanced care when this is urgently required (otherwise known as emergency obstetric care, which includes surgical intervention if needed as well as prompt treatment of post-partum infection and hemorrhage), access to safe abortion is part of any coherent plan to improve reproductive health and reduce maternal mortality. Knowing all this, and both the health and international development arms of the Canadian government surely should know this, to specifically and deliberately exclude funding of safe abortions in an aid package aimed at reducing maternal mortality would render the donor complicit in those deaths.

We labeled this issue “Maternal Mortality – an Integrity Test for Politicians” after realizing that many politicians are intellectually challenged by the technical nature of what is scientifically sound evidence regarding the nature of the problem at hand, and what works or doesn’t in addressing it. It is also an ethical test… in essence whether they (the ruling political party) are in it for cheap political gains among their home base, or whether higher reasoning will prevail in the interests of the health of millions of women around the world. Just how the G8 countries deal with this in their upcoming meetings will be a direct reflection of their collective political integrity. Based on public utterances to date, it seems like all the G8 countries except Canada may pass this test.

For the lead item of this month’s blog, we therefore attach below the polite but authoritative view of the Lancet on Canada’s G8 Leadership. This we follow by the first good news in many decades, that maternal mortality globally is finally being reduced.

CANADA'S G8 HEALTH LEADERSHIP
The Lancet May 8th, 2010
As a World Report in The Lancet today shows, Canada's pledge, as host of this year's G8 Summit, to make maternal and child health one of its key issues is moving forward. At a meeting in Halifax, Nova Scotia (April 27—28), the G8 development ministers agreed to back Canada's provisional set of principles to improve the health of women and children in developing nations.

Canada should be praised for making maternal and child health a priority issue for the G8. As an Article by Margaret Hogan and colleagues in today's issue shows, around 350 000 women die during childbirth every year. 9 million children younger than 5 years also die every year. Most of these deaths are preventable. Canada's health plan to address this situation is still thin on details but it promises to include training and support for frontline health workers; better nutrition and provision of micronutrients; treatment and prevention of diseases such as pneumonia, diarrhoea, malaria, and sepsis; screening and treatment for sexually transmitted diseases, including HIV/AIDS; family planning; immunisation; and clean water and sanitation.

However, a few key elements are missing from the framework. For example, there is no talk of emergency obstetric care. This omission is likely to be an oversight and should be rectified. Improving access to safe abortion services is also absent from the plan. Sadly, this omission is no accident, but a conscious decision by Canada's Conservative Government not to support groups that undertake abortions in developing countries.

This stance must change. 70 000 women die from unsafe abortions worldwide every year. The Canadian Government does not deprive women living in Canada from access to safe abortions; it is therefore hypocritical and unjust that it tries to do so abroad. Although the country's decision only affects a small number of developing countries where abortion is legal, bans on the procedure, which are detrimental to public health, should be challenged by the G8, not tacitly supported. Canada and the other G8 nations could show real leadership with a final maternal health plan that is based on sound scientific evidence and not prejudice.

Source: The Lancet, Volume 375, Issue 9726, Page 1580, 8 May 2010

SUMMARY: Maternal mortality for 181 countries, 1980—2008: a systematic analysis of progress towards Millennium Development Goal 5
(Note: Details of source and authorship given below)
Background: Maternal mortality remains a major challenge to health systems worldwide. Reliable information about the rates and trends in maternal mortality is essential for resource mobilisation, and for planning and assessment of progress towards Millennium Development Goal 5 (MDG 5), the target for which is a 75% reduction in the maternal mortality ratio (MMR) from 1990 to 2015. We assessed levels and trends in maternal mortality for 181 countries.

Methods: We constructed a database of 2651 observations of maternal mortality for 181 countries for 1980—2008, from vital registration data, censuses, surveys, and verbal autopsy studies. We used robust analytical methods to generate estimates of maternal deaths and the MMR for each year between 1980 and 2008. We explored the sensitivity of our data to model specification and show the out-of-sample predictive validity of our methods.

Findings: We estimated that there were 342 900 (uncertainty interval 302 100—394 300) maternal deaths worldwide in 2008, down from 526 300 (446 400—629 600) in 1980. The global MMR decreased from 422 (358—505) in 1980 to 320 (272—388) in 1990, and was 251 (221—289) per 100 000 livebirths in 2008. The yearly rate of decline of the global MMR since 1990 was 1•3% (1•0—1•5). During 1990—2008, rates of yearly decline in the MMR varied between countries, from 8•8% (8•7—14•1) in the Maldives to an increase of 5•5% (5•2—5•6) in Zimbabwe. More than 50% of all maternal deaths were in only six countries in 2008 (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo). In the absence of HIV, there would have been 281 500 (243 900—327 900) maternal deaths worldwide in 2008.

Interpretation: Substantial, albeit varied, progress has been made towards MDG 5. Although only 23 countries are on track to achieve a 75% decrease in MMR by 2015, countries such as Egypt, China, Ecuador, and Bolivia have been achieving accelerated progress.

Funding: Bill & Melinda Gates Foundation

Source: Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJL. Maternal mortality for 181 countries, 1980—2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet, 375, 9726, 1609 - 1623, 8 May 2010.

INTERNATIONAL & GLOBAL DEVELOPMENT - YEAR IN REVIEW 2007

LATE BREAKER: For a thought-provoking critical analysis of what the Bhutto assassination on December 27 means for Pakistan and the "war on terror", see the new addition in our sidebar.

PREAMBLE: This issue also completes our first full year of blogging. Drawing from topics covered during the year, we offer below: overviews views on three major issues for humankind, followed by paraphrases from our monthly themes in 2007.

THREE LEADING ISSUES FROM 2007: Flowers or Fertilizer?
1. GLOBAL STEWARDSHIP: In our view, the lead issue here is Climate Change (May, October), which is already displacing some of the world’s vulnerable populations, and ultimately threatening life on this planet. This is followed closely by global food security (February) and displacement by rich countries of grain for use as automotive fuel, thereby creating pressure on its use in food in developing countries, and even the price of food in developed ones, impacting on access and affordability. Flowers: to the European Community for its global leadership on climate. Fertilizer: To Canada’s Conservative government which has set the world’s worst example of procrastination on climate.

Note: At the recently concluded UN Climate Summit in Bali, Canada received a “Fossil Award” for its dismal performance on addressing climate change, while the tactics adopted by our Conservative government to undermine the developing global consensus on the need for binding targets now were described by numerous observers as "hypocritical" and “deceitful”.

2. INTERNATIONAL DEVELOPMENT: Viewed broadly, we consider the leading issue here to be Maternal & Child Health (April, November). The determinants include gender inequality, global poverty, and insufficient policy and program development at all levels. Even in developed western countries this is an issue: taking our own country Canada as an example, the “new” Conservative government’s reneged on the Kelowna Accord to improve conditions for aboriginals, and failed to ensure an adequate child care platform (March, April). Further, with the exception of the Nordic nations, official development assistance from wealthy developed countries is still far less than targets agreed decades ago. Flowers: Norway, whose 4.7 million people already contribute almost $4 billion a year to aid developing countries ($850 for each Norwegan man, woman and child). Fertilizer: The powerful G7 nations for allocating proportionally less Gross National Income (GNI) for international development: 0.30%, compared with .50% for non-G7 nations.

3. HUMAN RIGHTS ABUSES: Still topping the list continues to be the War in Iraq (January, August). Primary responsibility is shared between the Bush and Blair regimes (not equally) for promoting false rumours of weapons of mass destruction, unsupported by UN inspections led by Hans Blix. While insurgents share responsibility for the mayhem and catastrophe, the end results include over half a million Iraqis killed (a genocide?), massive numbers of refugees, and the undermining of Geneva Conventions that were born out of the worst excesses of World War 2. Flowers: Pastor Martin Niemoller (1892-1984). Fertilizer: George Bush (most dangerous US President in history).

Historical Notes:
1) For a revealing 2003 interview of Hans Blix, visit: http://www.truthout.org/docs_03/041203A.shtml
2) For an October 2006 update on JHU estimates of Iraqi deaths: http://www.jhsph.edu/publichealthnews/press_releases/2006/burnham_iraq_2006.html

2007 AS WE RECORDED IT:
 January: PEACE, SECURITY, HEALTH & HUMAN RIGHTS: In our first issue of 2007, we took note of the incoming UN Secretary General Ban Ki-moon, acknowledging the immense contribution of former Secretary-General Kofi Annan, focused on war and peace in the Middle East, and completed the transfer of reports and commentaries from our News & Reports site (as announced in our December 2006 posting).

 February: GLOBAL FOOD SECURITY – A MATTER OF SURVIVAL: In 1996, the World Food Summit set a target to halve the number of undernourished people by 2015. However, in 2007, it appears unlikely that this target will be met. This issue focused on the conflict between grain for fuel or for food, the stalled Doha round, and food security.

 March: COLONIZED MINORITIES IN DEVELOPED COUNTRIES: Colonized racial, cultural or religious minorities exist throughout the world, within powerful societies eg., Tibet in China, Japan's Ainu, India's Dalits, Amerindian enclaves in the Caribbean, tribal minorities in Africa, Boznian Muslims, the Kurds of Iraq, others in all continents and among the Pacific islands. The issues apply to several economically advanced western countries where it is sometimes said that one may find “3rd world conditions in 1st world settings”. Because these countries claim leadership for human rights, they also must live up to these principles.

 April: EARLY CHILD DEVELOPMENT – POLICY SHIFTS, GLOBAL VIEWPOINTS, AND THE EVIDENCE BASE: This issue focused on Canadian policy shifts of global interest. Sadly, Canada’s reputation for enlightened social policy is being undermined by a neo-conservative ideology. Over a million Canadian children live in poverty and cannot access child care. In support of child-friendly interventions, we included evidence reviewed by the US-based RAND Corporation showing that childhood intervention programs yield benefits in behavior, educational progression and attainment, delinquency and crime, and labor market success, among other domains.

 May: CLIMATE CHANGE, KYOTO ACCORD, EUROPE RESPONDS & CANADA REMAINS CHALLENGED: The European Community (EU) takes Climate Change seriously, and is making progress towards its Kyoto targets. On April 26, 2007, Canada’s Conservative government released its first “climate-change plan”. Despite Canada leading the world in reducing ozone destroying chlorofluoro-carbons (Montreal Protocol 1987), signing the Kyoto Protocol (1997), and hosting its ratification (2005), this plan is incapable of meeting Canada’s Kyoto targets. Ranked 27th of 29 by the OECD on Greenhouse Gas (GHG) emissions, Canada remains among the most environmentally delinquent industrialized countries.

 June: OFFICIAL DEVELOPMENT ASSISTANCE & GLOBAL HEALTH TRENDS: This issue reviews the vexing issue of development assistance from wealthy developed countries such as Canada, references a report on global social and economic trends, then selects reports from a discipline essential to understanding global health trends: Health Situation Analysis. Selected examples included Africa, the State of the World Children, and Projections of Mortality and Burden of Disease to 2030.

 July: CELEBRATING THE AFRICAN MEDICAL AND RESEARCH FOUNDATION: In 1957, three surgeons in Kenya had a vision that could revolutionize health care in Africa. They launched a Flying Doctor Service (FDS). Over the next 5 decades, men set foot on the moon, satellites explored our solar system, the universe was probed with powerful orbital telescopes, robots explored the surface of Mars, and shuttles began servicing an international space station. In the meantime, with poverty and ill-health still pervading the planet, FDS became Africa’s largest indigenous health organization: the African Medical and Research Foundation.

 August: FIRST THEY CAME... VIGNETTES IN THE DISMANTLING OF DEMOCRATIC MYTHS: In this issue we offered a selection of extracts from reputable sources that focus on the disastrous trajectory of the current US administration in undermining the beliefs that underpin western democracies. We dedicate the issue to Pastor Martin Niemoller (1892–1984), whose famous poem “First they came…” about the inactivity of German intellectuals during the Nazi rise to power and the subsequent purging of their chosen targets, group by group, most devastatingly to German Jews.

 September: THIRD WORLD AID TO FIRST WORLD COUNTRIES: This issue featured the "brain drain" from sub-Saharan Africa, citing a report from Juan Ramos of ProCOR (website listed in sidebar). Practical responses re examined: striving for better compensation for indigenous health professionals, attention to policies that determine recruitment and retention of health professions in low income countries, fixing the ethics of western firms that raid poor countries to meet the service demands of rich ones, and finding ways to compensate third world "donor" countries for their loss of human resources. Through official inaction, "first world" countries benefit from a massive subsidy from the "third world", equal to the direct and indirect costs of their investment in this health human resource, and the opportunity costs entailed by its loss.

 October: IS CLIMATE CHANGE AN ACT OF AGRESSION?: In this issue we abstracted an article carried by The Economist (on-line Sept 24th, 2007) that reported on Ugandan President, Yoweri Museveni's declaration that climate change is an act of aggression by the rich world against the world’s poor. We also noted a statement from the Church World Service (CWS): "The issue... is how climate change frames development and justice", said Rajyashri Waghray, CWS director, education & advocacy.

For stark contrast we noted Canada’s uncertain posture, quoting from a Globe and Mail Editorial (September 26): “Prime Minister Stephen Harper’s progress from a climate-change skeptic to an environmental convert has been a perplexing odyssey. After a half-hearted attempt to tackle greenhouse-gas emissions late last year, his Conservative government hurriedly introduced new regulations and incentives, which made a good start in fostering reductions. Earlier…(in September), in Australia, he even announced his personal commitment to ‘careful environmental stewardship’. That seemed heartfelt. Now it is fair to question the sincerity of that conversion. On… (Sept 24), at a UN climate change conference aimed at saving the Kyoto Protocol, Mr Harper announced that Canada had asked to join a rival climate-change pact, the Asia-Pacific Partnership. The six members of that pact include nations that have refused to ratify the protocol, such as the United States, and others among the world’s worst polluters, such as India and China. Together they account for nearly half of all greenhouse gas emissions”.

 November: MATERNAL MORTALITY: WHAT DO SOUTH ASIA, THE UNITED STATES, AND AFRICA SHARE?: Maternal Mortality represents the largest rich-poor disparity tracked by the World Health Organization. On the heels of a study released by the United Nations (UN), the Women Deliver Global Conference in London, 18-20 October, assessed high levels of maternal mortality round the world. Little progress has been made in reducing maternal deaths in many countries. Areas of major focus were South Asia, parts of Africa, and even the United States, as it lags the developed world in its maternal health performance. The conference was supported by non-governmental, intergovernmental and development agencies as well as private sector and philanthropic entities aiming to create the political will to improve the health of pregnant mothers and their children, and to strengthen health systems around the world to prevent the deaths during pregnancy or childbirth of "one woman every minute of every day ".

“The eradication of poverty and hunger… cannot be achieved if questions of population and reproductive health are not addressed”. Kofi Annan

HOLIDAY GREETINGS: We extend to readers our best wishes for the holiday season and the New Year. We hope you found our selections during 2007 thought provoking and factually informative, and that you will continue to monitor this report.