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 Motherhoodmovement. Today, only half the world’s women have the care of a skilledprofessional when giving birth. Even less get the full package of care inpregnancy and shortly after birth which protects them and their babies fromdying or from serious illness.

Even those who have skilled care often do not receive thequality of care they really need. They can often be at the sharp end ofunder-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 partof the Millennium Development Goal (MDG) to tackle child mortality, goes handin hand with maternal health. The care that can reduce maternal deaths andimprove 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 womenduring pregnancy, at the time of birth and beyond for both mother and child, iskey to making progress.

Maternal mortality is an indicator of how well a healthsystem functions, as it encapsulates a substantial part of both primary andsecondary 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 willgive birth, a health system that is not designed to cope with this does notvalue women and their babies enough to provide protection against possibledeath or disability.

This issue of id21 insights health looks at the provision ofmaternal health care and health system constraints to making that careuniversal. Malay Kanti Mridhaand Marge Koblinsky consider the reasons behind thekey constraint to progress: the world’s acute lack of maternal health workers.They also point to the serious mismatches between what is needed and whatexists both in terms of skills and the geographical availability of staff atlocal, national and international levels. They highlight the need forprofessional staff, and the possible gains in efficiency from deploying teamsof midwives.

Yet, drugs, supplies, equipment, buildings, vehicles andlogistics systems are also needed to provide appropriate care. Louise Hultonreviews the challenges from weak infrastructure to the development of effectivehealth 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 bean important consideration when looking at resource-poor settings, but it is agrowing problem in developing countries.

Interventions like caesarean section are strongly promotedamong women who can afford to pay at the expense of women who cannot. Thismeans that entire health systems are being built on the assumption thatexpensive interventions are needed, to the detriment of the promotion of normalbirth.

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

Helga Fogstad looks to the futureof extending maternity care to all women in the 75 countries that suffer 97percent of the world's maternal deaths. Some of these countries cannotrealistically 'scale-up' their maternal health services to provide care for themajority of their populations until well into this century, but can move asignificant way towards their MDG target by investing in their health systemsfor maternal and newborn care before the next decade.

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

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

But the articles in this issue of id21 insights health showthat the true constraints to improving care are within the health systems ofdeveloping 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 systemconstraints. To make further progress, we need to understand more about howpoliticians have succeeded in improving safe motherhood in resource-constrainedsettings. Political choices for popular, visibly effective health systemsolutions which are acceptable to health professionals should be studied andcould provide the inspiration to reach as far as we can towards the MDG formaternal health.