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Achieving Maternal Health

By Adrienne Germain

This month, a study published in the The Lancet reported a decline in maternal mortality. While this is cause for optimism, we cannot afford to be complacent: more than 300,000 women still die senseless deaths and suffer disabilities each year due to preventable causes related to pregnancy and childbirth, and in some countries, maternal deaths are on the rise. Many of these girls and women give birth and die at home, often alone, in fear and agony. Or, they die in substandard medical facilities ill-equipped to deal with problems that are routinely managed for women in rich countries and for rich women in their own countries. Saving women's lives in childbirth requires relatively inexpensive and known interventions at the clinical level - not fancy hospitals, new technologies or scientific breakthroughs. This decline does give us reason to be optimistic, but with political will, we can and should continue to make maternal health a global priority. And we must also make it easier for women and girls to decide to use, and actually reach, these services.

With impetus from the Millennium Development Goals (MDGs), specifically MDG 5, priorities are starting to shift and nations are beginning to pay more attention to women. Our mission, however, is not simply to reduce maternal deaths, but to achieve maternal health. Maternal health is a state of being. It cannot be achieved through a simple technical fix, nor through maternity care alone. Rather, we must also equip women with the information, skills and services to make informed decisions whether to become pregnant and to give birth. They must have access to safe, affordable contraceptives, including emergency contraception, and male and female condoms, especially where HIV and other sexually transmitted infections (STIs) are prevalent. They must also have the choice of safe abortion. And they need prevention and treatment for the myriad of STIs that jeopardize not only their own health and lives, but those of the children they choose to bear.

Maternity care, contraception, safe abortion, prevention and treatment of STIs including HIV - these four, together with comprehensive sexuality education form the core sexual and reproductive rights and health (SRRH) package, which is required to ensure that women and young people can live just and healthy lives. Each of the five main elements of the package relies on the others to reach peak effectiveness. Focusing only on one element of this package without the others in concert is not only shortsighted, but a failure to respect women's realities. As we look at the function of each element, the justification for providing the complete package is clear, not only in terms of girls' and women's needs, but in terms of efficacy.

Knowledge is power - and a key element of the SRRH package. In Nicaragua, almost 90 percent of sexually active adolescents did not use contraception the first time they had sex simply because they were unaware that they could. Early, comprehensive sexuality education for girls and boys can help fill gaps in knowledge, empower young people to make healthy decisions, prevent unwanted pregnancies, reduce the risk of STIs, and encourage equal and balanced relationships based on respect for human rights and for consent.

The second element of the package is access to contraception. More than 200 million women who want to delay or prevent pregnancies lack the information or contraceptives needed to do so; and nearly half of the 205 million pregnancies that occur each year are unplanned. By making effective contraception affordable and accessible, we can help ensure that every pregnancy is wanted and reduce the need for abortion.

Contraception helps reduce unwanted pregnancies, but will not eliminate them. More than half of the 80 million unwanted pregnancies that occur each year end in abortion - and half of those are performed in unsafe conditions. About 67,000 women die annually from complications of unsafe abortion, and thousands more are severely injured. Preventing these deaths and injuries would reduce maternal mortality by approximately 13 percent globally. Yet, even where abortion is legal, access is often limited by barriers imposed by health institutions; a shortage of skilled providers; and lack of information.

When women give birth, skilled birth attendance with ready referral to facilities that can provide good quality emergency obstetric care could reduce maternal mortality by over 50 percent. The absence of these services remains a major problem especially where populations are widely dispersed. Only two out of every three women living in the developing world today give birth with skilled assistance, and even fewer have access to essential obstetric care.

Finally, prevention and treatment of STIs, including HIV, is vital for both maternal and neonatal health. Women with pelvic inflammatory disease (PID) from untreated STIs are at higher risk of infertility and ectopic pregnancy, a condition that is fatal without skilled care. A recent study showed that HIV-positive women in South Africa were up to five times more likely to die of pregnancy-related causes than pregnant women not living with HIV. Educating women and men on preventing STIs through the use of male and female condoms and other safer sex practices, as well as diagnosis and treatment, would save lives and transform communities.

The integrated SRRH package I've just outlined is not simply a concept. It has proved to be an effective strategy for the improvement of maternal health. In Bangladesh, one of the poorest countries with high rates of maternal mortality, the success of a comprehensive SRRH initiative in the 1990s provides inspiration. Within five years of initiation, the percentage of women receiving check-ups and care prior to childbirth doubled from 26 percent to 56 percent. Use of emergency obstetric care rose by nearly 25 percent. Female life expectancy increased by two years. Maternal mortality dropped by 26 percent.

Fifteen years after the United Nations International Conference on Population and Development (ICPD), the Obama administration announced a Global Health Initiative that mirrors the ICPD SRRH approach which was adopted by Bangladesh. They, other donors, the U.N. Secretary General, and many nations are now increasing attention to MDG 5. But we must not try to play with only half the deck available. We must fully fund and implement the comprehensive sexual and reproductive health package, not only maternity care or only family planning or HIV prevention and treatment. Together, the elements of the SRRH package add up to far more than the sum of its parts. Its full implementation will not only achieve maternal health, but also secure health and human rights for generations.

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Adrienne Germain is president of the International Women's Health Coalition.