Maternal and Infant Mortality: Beyond the Rhetoric
I read Prof. Babatunde Osotimehin’s opinion piece recently in The Guardian entitled “Planned families, strengthened communities” with much gusto. It reminded me of another article that had appeared barely two weeks’ earlier in the same newspaper. The latter, the result of an interview granted by Mrs. Henrietta Williams to Ebere Ameh, was captioned “Contraceptives Do Not Stop Child And Maternal Death, Good Governance Does.” Both write-ups touch on the issue of maternal and infant mortality and propose different ways of tackling this pressing problem.
While Dr. Williams submits that the desired reduction in infant and maternal mortality can be attained not by the use of contraceptives but by good governance that aims at providing better healthcare (thus removing the causes of death and bettering the life of the population), Prof. Osotimehin clamours for more funding for contraceptives to meet the needs of women so that they can decide when they want to have children. Both feel that it is not unimportant to space out births but do not agree on how this should be carried out.
As a woman and a mother of seven children, I think I am better qualified to examine some of the logical consequences of only following the method posited by Prof. Osotimehin in his article. One of the things that caught my attention was his declaration that “there is almost universal agreement that access to family planning is a human right. By denying this right, we are putting other basic rights at risk across the world. The right to education is of little use if teenage girls are forced to leave school because they are pregnant.” My first thought was to ask myself where the “family planning” fitted in with a teenage girl in school. The only logical explanation I could come up with was that perhaps it was a case of child marriage with the girl still in school. If on the other hand, the professor was referring to a girl getting pregnant in school because she didn’t have access to the contraceptive she “had a right to”, that is indeed an altogether different proposition.
It would be interesting if those advocating for “family planning services” actually spelt out what that umbrella term means. If, as the article by Professor Osotimehin appears to insinuate, family planning includes providing unmet needs for contraceptives among teenagers, what would be the fall-back plan when they fail? Of course, no mention is made in his article about that possibility but knowing the adventuruous nature of young people, the chances of getting pregnant even with the use of contraception (especially when they are wrongly used) are higher.
Professor Osotimehin asserts that all pregnancies should be by “choice” and not by “chance” and that the best way of achieving this is through providing contraceptives. However, as far back as April 1991, Dr. Louise Tyrer, a former director of Planned Parenthood, noted in a letter to the Editor of the Wall Street Journal that “more than three million unplanned pregnancies occur each year to American women; two-thirds of these are due to contraceptive failure.” About two million “unplanned” pregnancies due to “family planning”! You don’t have to work hard to guess how most of the pregnancies ended. Is abortion part of the family planning package? If a woman “accidentally” gets pregnant while using contraceptives, will the pregnancy then be kept because its “status” has changed or will the “choice” not to have the pregnancy at all costs not provide a “justification” for abortion? Some years ago, the United States government withheld its funding for UNFPA for some years because it was concerned about the latter’s support for the family planning services in China that included forced abortions, forced sterilizations and even imprisonment. Is this what we are expected to praise as voluntary family planning? How long will it take for a country to move from voluntary to mandatory “family planning”? Even with its one-child policy, China is not at the top of the list of countries with the lowest infant and maternal mortality rates.
But to return to the main thrust of his article. Professor Osotimehin avers that “without steep improvements in the availability of family planning services, it will not be possible for many nations to cut deaths by the target of 75 per cent by 2015. Nor will we see the progress we desperately need to reduce infant deaths.” It is well known that the main causes of maternal maternity are obstetric haemorrhage, infections, eclampsia, prolonged obstructed labour and complications in abortions. Infant mortality in Nigeria is usually due to acute respiratory infections, diarrhoea, malaria and measles. Neonatal deaths (deaths within the first month of life) accounts for about 25% of infant mortality and is caused by neonatal infections, delivery-related complications such as asphyxia and trauma as well as malnutrition, malaria and anaemia that occur in pregnancy. There is an unequal distribution of maternal death across Nigeria due to differences in education, cultural practices, socio-economic power as well as the availability and use of healthcare facilities.
Of course, if there were no pregnancies at all, the causes would disappear but is removing maternity the best way of reducing maternal mortality? What happens when a woman actually does want to have children and still has to face the above mentioned issues? Think of a newly wedded couple that looks forward to their firstborn only for either the mother or child or even both of them to lose their lives due to some preventable causes. Of what use is spacing the births (which is in itself something laudable and of benefit to mother and child) if the underlying causes of death in pregnancy and infancy are not tackled? Wouldn’t it be more beneficial to provide adequate healthcare facilities and manpower so that some of these preventable causes of death can be eliminated?
In 2009, the Nigerian Academy of Sciences organized a two-day workshop on maternal and infant mortality in Nigeria. The participants examined the scientific base for the measures that can actually prevent those deaths and the reasons why they have not been correctly carried out in Nigeria. I think it should be read by everyone who is seriously committed to making progress in the fight to reduce these preventable deaths.
One of the main things highlighted during the workshop was that “sustained reductions in maternal and infant mortality cannot be sustained without re-invigoration of primary healthcare.” In the first chapter of the report, we read that “for the majority of these deaths, the medical causes are well understood and there are effective preventive strategies available. Urgent health system and socio-economic interventions should therefore be put in place to reduce maternal and infant mortality in Nigeria.”
Surprisingly, the tone of the address to the participants of the workshop given by Professor Osotimehin who was then the Minster of Health is different from what he wrote last week. In that address which is included in the working summary, he explained that “when you look at the epidemiology of disease in this country, the conditions that are responsible for most of the deaths are simple things like malaria, diarrhoeal diseases and chest infections – those are the things which kill the most children. For women it is haemorrhage, or complications of childbirth like postpartum infections. We do not need rocket science to handle these things. It is about the system; about organising ourselves to do things better; in a more effective and efficient way”. In other words, the causes of maternal and infant mortality can be handled if only the health system were better organized. One wonders why he did not insist more on this point in his article and why he did not canvas for more funding for the healthcare system but focused rather on getting increased funding for contraceptives.
I think that a better option for making progress in the Millennium Development Goal for cutting down pregnancy-related deaths can be found in a proposal of the working summary which refers to an “effective continuum of care for maternal, newborn and child health.” This care system is made up of three interrelated elements (clinical care, outreach/outpatient care, and family/community care) with each one having different intervention packages. The clinical care element targets the case management of the mothers, babies and children who may have some illnesses or complications. It includes the skilled obstetric care at birth, immediate care of the newborn and resuscitation, services for managing obstetric emergencies, etc. The fact that only about 36 percent of deliveries in the country are attended by a skilled attendant speaks volumes. A country like Thailand cut its maternal mortality ratio by 75 percent by deploying more midwives and increasing the capacity of hospitals at the district level.
The outreach and outpatient care element includes services like routine antenatal care (where, among other things, management of some illnesses in the mother which may complicate pregnancy and screening of some sexually transmitted infections are done), postnatal care, immunization for infants and children, etc. Only 58 percent of Nigerian women receive antenatal care from a trained healthcare worker at least once during pregnancy. This means that a large amount of women who are at risk of complications during pregnancy are not picked up early enough. The Family and Community Care element aims to promote the adoption of healthy behaviour within communities while taking their social and cultural factors into consideration. Education on nutrition, hygiene, breastfeeding and care for the newborn is promoted to ensure a healthier lifestyle that will benefit both mother and child. For instance, breastfeeding alone helps also to space pregnancies as well as provide much needed protection for the infant and saves the lives of thousands of babies. However, only 17 percent of Nigerian mothers practice exclusive breastfeeding.
All the interventions listed above will not be very effective if there is no commitment on the part of government to provide some of the amenities that can facilitate them. Understaffed and poorly equipped primary healthcare centers cannot work wonders on their own. Poor transportation and communication systems will undermine the efforts of saving mothers and their children in cases of illness or medical emergencies. It is sad to note that we hear of cases of embezzlement and corruption of funds which could have been channeled into providing the basic amenities which are the true rights to which every individual is entitled to. Providing a greater budget for the health sector and ensuring that the funds allocated actually do serve their purpose will help to give a new face to the fight to reduce maternal and infant mortality. Poverty eradication and improve in education for Nigerians are long-term projects that are not solved by simply providing contraceptives. We have to hold public holders to account for how money provided for these sectors are utilized.
The workshop summary of the Nigerian Academy of Sciences forum mentions that “the partnership for Maternal, Newborn and Child Health has estimated that for just an additional 12 US dollars (about 2000 naira) per capita, Nigeria could achieve a reduction of approximately 62% in maternal mortality, 57% in neonatal mortality and 70% in under-5 mortality rates by 2015. This additional funding could be mobilized from both domestic and foreign sources; however, the funding must be less volatile and must involve longer term commitments to integrated care, rather than the current trend for 2-5 year vertical projects.” When Professor Osotimehin speaks of saving millions of dollars through reduced demand for newborn and maternal health services alone, he should remember that many of the women and children do not have access to those services.
Mrs. Bose Olayinka is on the staff of the Project for Human Development (PHD), an NGO based in Lagos.