Finance & Development, September 2010, Vol. 47, No. 3

Melinda Gates

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Countries must make maternal health a policy priority

ONE of the best pieces of news I’ve heard this year is that the bleak maternal health statistics we’ve been puzzling over for so many years appear to have been wrong.

Until the Institute for Health Metrics and Evaluation (IHME) released a new report on maternal mortality in April, we thought the world had made roughly no progress on saving mothers’ lives. Now we know that, according to the best and most complete data available, maternal mortality has been going down steadily for 30 years. In 1990, the global maternal mortality ratio (the number of maternal deaths for every 100,000 live births) was 320. In 2008, it was 251.

Obviously, those numbers don’t put us on pace to reach the Millennium Development Goal (MDG) target of a 75 percent reduction in the ratio, but they’re a good reason to be optimistic. Add to them the Group of Eight (G-8) industrial countries’ new $7.3 billion, five-year initiative on maternal and newborn health and the ongoing effort by the United Nations (UN) to develop a comprehensive Joint Action Plan for Women’s and Children’s Health, and we might finally be on the cusp of having a new story to tell about maternal health.

Some of the country-level findings in the IHME report are even more exciting than the overall picture. A handful of very different countries, from Bangladesh to Bolivia to China to Egypt to Romania, have made major strides in maternal health in the past 20 or 30 years. These success stories demand further study, because they point the way to broader progress. As we determine how China decreased its maternal mortality ratio from 165 in 1980 to 40 in 2008, or why Egypt’s ratio has gone down 8.5 percent annually since 1990, we will build up a bank of best practices for other countries to adapt and adopt.

The fact that some countries are doing significantly better than the average also suggests that the explanation for slow progress is not a lack of expertise or effective tools, but rather a lack of political will to apply that expertise and those tools. Enough countries are saving mothers in large enough numbers to prove that we know how to achieve our goals. Unfortunately, most countries have failed to make it a priority.

But by sharing success stories, we can build the necessary political will that will lead to much more aggressive maternal health policies. That is exactly what is happening in Malawi right now. I traveled there in January, and the walls at the hospitals were covered with a poster that said, “No mother should die during childbirth.” In Malawi, those words are more than just a public health message. They represent a policy shift—a specific commitment by the government to make sure that every mother gives birth in a health facility, cared for by trained medical staff.

Malawi has also set an important example by tackling maternal, newborn, and child health together. Malawi has long been a leader in child health—it’s one of the few African countries on pace to meet the MDG target on child survival—and the new maternal health commitment builds on that existing health infrastructure.

I have visited maternal health programs that are successfully persuading poor women to deliver their babies in hospitals—but with the unintended consequence of deemphasizing pre- and post-natal care. Of course, a safe, facility-based delivery of a malnourished baby to a malnourished mother is not a good health outcome. Nor is a healthy mother who would have chosen not to get pregnant if she’d had the choice.

Childbirth itself is just one of many points along a continuum of care for women and children. A woman’s first need is planning her family. Right now, more than 200 million women want to use contraceptives but don’t have access. If they did, experts agree that maternal deaths would decrease by at least 30 percent, and newborn deaths would decrease by 20 percent. After family planning, the continuum of care includes prenatal care, safe childbirth, essential newborn care, postnatal care, nutrition, and child health care, including immunization.

The G-8’s new initiative and the UN’s Joint Action Plan treat all these issues in the way mothers treat them, as equally important parts of a healthy life for themselves and their children.

The new evidence about progress on maternal health, and the example of poor countries that are taking action and having a big impact, should give economic decision makers the confidence to prioritize investments in maternal health.

The fiscal challenges facing many countries will force difficult trade-offs, but we can no longer make them at women’s and children’s expense. Putting resources into maternal, newborn, and child health is a great investment—in women and children, in stronger families and empowered communities, and therefore in the long-term economic productivity of developing countries.

The IMF has a special authority and responsibility on this issue. The Fund’s recent, more open-minded and flexible approach to supporting health services in an efficient way that is consistent with sound fiscal management is a very important—and welcome—signal. At the Gates Foundation, we are looking forward to collaborating—and sometimes to pushing—to ensure that the world’s progress on maternal health is sustained.