I usually tend to see the glass half full; even my Twitter profile says so. Yet, if I look at maternal and neonatal health after 15 years of Millennium Development Goals (MDGs) I can’t help but stare across the empty top end of the glass. The 57th ITM Colloquium on Maternal and Neonatal Health in Rabat (24-27 November 2015), co-organised by ITM and ENSP ( L’Ecole Nationale de Santé Publique, Rabat), provided a great opportunity to ask the experts for their opinion. Here is a brief account of my crash course in maternal health.
Let’s start with the basics. Since 1990, world-wide maternal mortality has been reduced by 44% and child mortality by 49%, but the MDGs aimed at reducing under-five mortality by two-thirds (MDG4) and maternal deaths by three-quarters (MDG5). One could argue the glass is half full here, as both maternal and child mortality are cut nearly in half. However, in recent years maternal deaths have been stagnating around 300,000 yearly, according to the latest UN figures. The UN report attributes the stagnation largely to humanitarian crises and conflict situations. Sierra Leone, one of the three West-African countries grappling with the Ebola outbreak in 2014-15, has the highest estimated number of maternal deaths, 1360 per 100,000 live births. Ebola will likely have made things worse, as many health workers died and health facilities struggled to cope. Many women will have delivered unassisted as a result.
Considering that a large part of maternal deaths have preventable and treatable causes, such as haemorrhage, sepsis and hypertensive disorders I wondered whether the key lies in the underachievement on universal access to reproductive health (MDG5). Will we be all good once all pregnant women have access to skilled assistance?
Not quite, because access alone is not enough, I quickly learned in Rabat. According to ITM’s Prof. Vincent De Brouwere, chair of the Colloquium’s scientific committee, “women’s motivation to deliver in a health facility depends not only on physical access, but also on their trust in health care services and providers of care.” Several speakers backed this point up with vivid examples. US nurse and researcher Charlotte Warren presented data from Kenya on disrespect and abuse during labour and delivery. The women experienced a lack of privacy and confidentiality, were given treatment without their permission and sometimes even endured physical abuse. According to Sundari Ravindran, childbirth needs to be humanised to make sure women are in primary control of their birthing. “Technical skills are valued more than a human approach,” the Indian researcher said. Her comments were echoed by Mina Abaacrouche, director ad-interim of ENSP. “Morocco has made important steps in improving access to health care, even in remote areas. Now it is time to improve the way women and their families are welcomed and cared for in the health facilities, in order to encourage them to seek assistance.”
Jean-Paul Dossou, a PhD student at ITM, showed how women are not simply on the receiving end of poor care. In his home country of Benin women try to influence the quality of care and negotiate accountability when they are confronted with disrespect and abuse. As Dossou put it, “women do not wait for the UN to solve their problems.”
While plenty of (estimated) figures are available on maternal mortality, there is little evidence on maternal morbidity. ENSP’s Bouchra Assarag, for example, is one of the first to research maternal morbidity in Morocco. The studies in the context of her PhD research at ITM show that 60% of women in Marrakech have at least one health problem diagnosed in postpartum. “Maternal mortality is only the tip of the iceberg. Below the surface women suffer from a range of complications that often go untreated and undiscussed,” she said. A photo exhibition and video documentary with the personal stories of the women from Al Haouz were presented at the Colloquium. LSHTM’s Veronique Filippi called for standardisation in maternal morbidity research, starting with an agreed definition of the pregnancy complications that fall under the umbrella term maternal morbidity. Even though the need for more evidence is clear, it should also be translated into action. A recent MBRRACE-UK report on stillbirths in the UK exemplifies that sometimes even rich countries fail to act on available information. In other words, listening to women can save lives even when your GDP is above $ 40.000 per capita.
Rabat’s key message for the 2030 Sustainable Development Goals (SDGs) is in my view that we need to listen to women, to make sure that the needs of mothers and newborns are met and their rights respected. By embedding maternal health in several of its 17 goals, the SDGs have created room for a more holistic approach. The researchers I met in Rabat are aware it will also be up to them to provide policymakers with the necessary tools to make decisions on the right intervention strategies to top up the half empty glass of maternal health.
P.S. I declare no competing interests and I believe my judgement has not been clouded (too much) by the fact that, if all goes well, I will soon be a first time father.