World Bank announces plan to reduce maternity deaths; fertility rates

Globally, more than 350 000 women die each year because of pregnancy and childbirth complications. Last year, 99% of these deaths occurred in developing countries. Thirty-five poor countries in Sub-Saharan Africa and other regions (Timor-Leste, Afghanistan, Djibouti, and Yemen) have the world's highest birth rates (more than five children per mother), while also reflecting some of the world's poorest social and economic results, with low levels of education, high death rates, and extreme poverty.

Moreover, many poor women turn to abortion as a last-resort means of birth control. Some 68 000 women die each year as a result of unsafe abortion, while another 5.3 million suffer temporary or permanent disability.

The true impact of a mother's death

"A mother's unnecessary death in childbirth is not just a human tragedy. It's also an economic and social catastrophe that deprives her surviving children of nurture and nutrition and too often of the chance of education," says Julian Schweitzer, acting vice president of Human Development at the World Bank. "Maternal deaths are both caused by poverty and are a cause of it. The costs of childbirth are often the single biggest cause of casting a family into poverty. And, if the mother dies in childbirth, the chances of her baby surviving the first year of life are drastically reduced."

During the second half of the 20th century, world population more than doubled to reach 6 billion, an astonishing 3 billion increase in population in just 40 years. Although this rate has slowed to 1.2% a year, 75 million people are being added every year this decade. The world's population is projected to reach 9.1 billion by 2050, with the majority likely to live in the world's poorest countries.

However, new WB figures show that while development aid for health soared from US$2.9 billion (about R21.75 billion) in 1995 to US$14.1 billion (about R105.75 billion) in 2007, roughly a five-fold increase in 12 years, aid for population and reproductive health had increased more modestly during the same period, from US$901 million (about R6.75 billion) in 1995 to US$1.9 billion (about R14.25 billion)in 2007. In the 35 highest-fertility countries in Africa, Asia, and the Middle East, aid for women's family planning and reproductive programs started at US$150 million (about R1.125 billion) in 1995 and increased to US$432 million (about R3.24 billion) in 2007, while overall aid for health in these 35 countries went from US$915 million (about R6.9 billion)in 1995 to US$4.9 billion (about R36.75 billion) in 2007.

With 2010 marking the start of the five-year countdown to the 2015 Millennium Development Goals (MDGs), many countries are far from achieving MDG 5, which calls for a drop in the maternal mortality ratio (MMR) by three-quarters between 1990 and 2015 - equivalent to an annual decrease of about 5.5% - and increased access to universal reproductive health care by 2015. Against this target, the current global average rate of reduction is under 1% - only 0.1% in sub-Saharan Africa, where levels of mortality are the highest - and at the present rate of progress, the world will fall well short of achieving this MDG.

How the WB will help to close the gap

WB health financing in FY10 is expected to triple to an unprecedented US$4.1 billion (about R30.75 billion) - a 40% increase over the previous year's record - in support of stronger health systems; boosting the prevention and treatment of communicable diseases; and improving child and maternal health, hygiene, and sanitation.

Given the weak state of health systems in many countries, the WB has been working closely with governments, aid donors and agencies, and other partners to strengthen these systems so that women gain significantly better access to quality family planning and other reproductive health services, skilled midwives at their births, emergency obstetric care, and postnatal care for mothers and newborns. Under its new health action plan, the WB will help 58 countries with high maternal death and fertility rates, which have remained stubbornly high for some years, improve their reproductive health systems in the following ways:

More contraception - The first step to avoid maternal deaths is to ensure that women have access to modern contraceptives and the ability to plan their families. In 2008, of the 1.4 billion women in the developing world of reproductive age (15-49 years), more than 800 million women wanted to avoid pregnancy and thus had a need for contraception. Of these women, 600 million were using modern contraceptives, which prevented 188 million unintended pregnancies, 1.2 million newborn deaths, and 230 000 maternal deaths. Contraceptive use has increased in all developing regions, but remains low in Sub-Saharan Africa, where contraceptive prevalence was still only 22% in 2008 (though almost double the 12% in 1990). A roadblock to increasing contraceptive supplies is the poor state of logistics in many developing countries. At the country level, a sound logistics system can distribute contraceptives and other reproductive health supplies efficiently so that each clinic or pharmacy has enough stock on hand to meet clients' needs.

Changing household behaviours is also recognised as vital for increasing the use of family planning programs. Social and cultural factors such as disapproval by family and communities, and men's roles in deciding family size, can deter women who might otherwise be interested in family planning help, while in some countries, providers and even programs may deny such care to vulnerable groups such as unmarried adolescents. In addition to expanding information/knowledge about family planning and avoiding HIV/AIDS and sexually transmitted infections, the WB will help countries to motivate young women to stay in school and acquire life skills before starting their families.

Of the estimated 200 million pregnancies that occur every year, some 20 million end in unsafe abortions that put women at substantial risk of lasting injury or death. In low-income countries where abortion is restricted or illegal, deaths from unsafe abortion practices can be substantial, accounting for 13% of maternal mortality globally, and in some countries, as much as 25% of maternal deaths are due to unsafe abortion. At least one-fourth of the estimated 20 million unsafe abortions per year are performed on women aged 15 to 19. Consequently, the WB considers unsafe abortion a serious public health issue for women and supports family planning services that help to prevent or reduce unsafe abortion as part of a country's basic health program.

More frequent antenatal visits - Women who continue pregnancies need care during this critical period for their and their babies' health. Since the 1990s, the proportion of pregnant women in the developing regions who had at least one antenatal care visit jumped from around 64% to 79%. However, less than 50% of pregnant women in the period 2003-2008 were attended to at least four times during their pregnancy by skilled health personnel, as recommended by WHO and UNICEF. In 2007, only 61% of women in developing countries delivered with the help of skilled birth attendants. Since the 1990s, the presence of skilled birth attendants at delivery has increased in all developing regions, though the percentage of births attended by skilled health personnel in Sub-Saharan Africa was only 44% and 42% in Southern Asia.

Spread preventive knowledge - Most maternal deaths are avoidable, and the health care solutions to prevent or manage the complications are well known. Severe bleeding after birth, which can be quickly fatal, can be effectively controlled by drugs such as Oxytocin. Sepsis, which is the second most frequent cause of maternal death, can be eliminated if treated early. Eclampsia can be detected during pregnancy, and drugs such as magnesium sulphate can be used to lower the risk of fatal convulsions. Obstructed labour can be recognised by skilled practitioners in enough time to perform a caesarean section to save a mother and her baby. However, since some complications are unpredictable, all women need care from skilled health professionals during pregnancy, childbirth, and in the weeks after delivery. It is widely recognised that skilled care at childbirth is most important for the survival of women and their babies, and that the availability of qualified and trained health personnel to assist deliveries is key to ensuring optimal pregnancy outcomes; yet one-third of all deliveries occur without a skilled attendant.

Train new health workers - An important way to strengthen health systems, therefore, is to train new health workers and strengthen the skills of the existing health workers with midwifery skills and effectively deploy them. Training programs for traditional birth attendants have not yielded expected results and have generally been unsuccessful in reducing maternal mortality. Working closely with all high-MMR countries, the WB will focus on identifying gaps in the availability of health workers skilled in midwifery as well as doctors with obstetric skills, task shifting, and setting in place training programs aimed at meeting the shortage. According to the WB, falling maternal death rates in North Africa, East Asia, Southeast Asia, and Latin America and the Caribbean share many common features: increased use of contraception to delay and limit childbearing and better access to high-quality obstetric care services.

Education as important as condoms and pills

The WB plan says that high birth rates are closely allied with fragile health, little or no education, and entrenched poverty. Analysis of demographic and health surveys in all regions shows that women with secondary or higher education have fewer children than women with primary or no education.

"Promoting girls' and women's education and the opportunity to succeed are just as important in reducing birth rates in the long run as promoting contraception and family planning," says Dr. Sadia Chowdhury, co-author of the new plan and a Senior Reproductive and Child Health Specialist at the World Bank. "Education and greater gender equity become a form of social contraception for women. Time and time again we see how women's education provides life-saving knowledge, builds job skills that allow her to join the workforce and marry later in life, gives her the power to say how many children she wants and when - and these are enduring qualities she will hand down to her daughters as well."

Chowdhury says getting an education - even if only at primary school level - is a good predictor of low fertility. The regions with the widest fertility gap between women with secondary education and those who have no education are South Asia, Sub-Saharan Africa, and Latin America and Caribbean.

Alliance with UNFPA and other lead health agencies vital

The new WB plan strongly welcomes the re-emergence of maternal and child health among countries, donors, and other partners, which has jumpstarted more than 80 new national and international partnerships, including the Partnership for Maternal, Newborn and Child Health. In addition, an informal group of heads of four health-related organisations (WHO, UNICEF, UNFPA, and the World Bank - called the "H-4") was formed and meets regularly on measures to strengthen country efforts to improve maternal and child health and avoid fragmentation of donor efforts and financing (e.g., harmonising and coordinating the efforts of donors at country level to support countries to improve maternal health).

In welcoming the WB's new reproductive health strategy, Thoraya Ahmed Obaid, UNFPA executive director, said that countries and their development partners had to work even more closely together to make greater progress. "With Millennium Development Goal 5 to improve maternal health lagging behind, greater investments are needed to achieve the two targets to reduce maternal mortality and achieve universal access to reproductive health by 2015," she said. "During the global financial crisis, and at all times, investing in the health and rights of women is a smart choice to improve well-being, productivity, and economic growth."

To read the new Reproductive Health Action Plan 2010-2015, click here.