The series highlights the five major direct causes of maternal deaths worldwide: haemorrhage (25% of maternal deaths), sepsis (15%), abortion complications (13%), eclampsia (12%), and obstructed labour (8%). Many of these causes can be addressed by investing in effective technologies and ensuring their availability to all women in need.
Adrienne Germain introduces the series (1) and comments: "2004 marks the 10th anniversary of ICPD [International Conference on Population and Development], when the world's nations recognised reproductive health and rights, women's empowerment, and gender equality as important global goals. We hope that this series of articles highlights some of the challenges that remain, and serves as a reminder that these issues underlie many of the world's most pressing problems."
Wendy Graham and JuliA Hussein (2) outline how monitoring progress towards the Millennium Development Goals of reducing maternal mortality by three-quarters by 2015 is seriously challenged by weak health information systems. They comment how many maternal deaths today remain as silent tragedies. Wendy Graham is also the lead author of a research article (p 23) in this week's issue which highlights how maternal death is closely associated with poverty; authors of the study demonstrate how their methodology makes efficient use of existing survey data and could be used to explore the rich-poor gap in other health outcomes, such as adult mortality.
Peru's recent experience (3) is discussed by Jaime Miranda and Alicia Ely Yamin; a country where (between 1996 and 2000) more than 250 000 women-the overwhelming majority poor and from rural areas-underwent sterilisation, without a proper consent process, during the implementation of a family planning public-health policy.
The Commitment to Development Index (CDI), created by the Center for Global Development in 2003, ranks 21 of the world's richest nations by the effect of their policies on the economic and social development of developing countries. CDI is unique; it not only ranks donors by amount of aid given, but also by the restrictions they attach. Pramilla Senanayake and Susanne Hamm (4) discuss broad trends in funding, and accompanying restrictions, for sexual and reproductive health programmes and services.
The horrors of obstetric fistula (the formation of a hole between the uterus and rectum or bladder) due to obstructed labour), a preventable and treatable condition, is discussed by France Donnay and Laura Weil (5), who comment: "The advent of modern obstetric care has led to the eradication of obstetric fistula in nearly every industrialised country. However, in the developing world obstetric fistula continues to cause untold pain and suffering in millions of women. The very existence of this condition is the result of gross societal and institutional neglect of women that is, by any standard, an issue of rights and equity."
Rebecca J Cook and Maria Beatriz Galli Bevilacqua (6) discuss how human rights are only just beginning to be applied to safe motherhood (in contrast to the HIV/AIDS arena). They describe how human rights are being invoked, nationally and internationally, to encourage governments to promote the human rights of women during pregnancy and childbirth.
The complex and controversial issue of abortion is discussed by Duff Gillespie (7). 46 million abortions done every year, 20 million in countries where abortion is illegal; an estimated 67,000 women die every year as a result of abortion. Duff Gillespie concludes: "The abortion debate must continue if women are to have access to safe abortion, but should not prevent women from getting the family planning information and services they need to prevent abortion in the first place. If we empower women worldwide to avoid unwanted pregnancies, the number of abortions will plummet."
Solutions and priorities for maternal health are discussed by Vivien Davis Tsu (8) on behalf of a team of public-health experts who discussed future priorities at a conference in July 2003. Low-cost measures including the injection of oxytocin during the third stage of labour could have a substantial effect in reducing morbidity and mortality from postnatal haemorrhage; the widespread distribution of magnesium sulphate could dramatically reduce illness and death from pre-eclampsia.
In the final paper, (9) Linda A Bartlett, Susan Purdin, and Therese McGinn discuss the right of access to reproductive health care of the 35 million forced migrants and, in particular, for the majority who live in conflict zones in the developing world. The authors discuss the extraordinary risks to reproductive health faced by forced migrants, and the obligation of humanitarian agencies to respond to reproductive and sexual health needs.
This week's Lancet editorial (p 1) concludes: 'The 1994 International Conference on Population and Development created an important plan for action in its reproductive health agenda. Yet after a decade, it is clear that an enormous amount of work remains. The solution is not another huge, expensive, international conference, but renewed commitment to the particular problems of individual women in local communities. Strengthening reproductive health and human rights is an urgent global need, one on which the future of humankind may quite literally depend.'
Contact:
(1) Sue Hornik, Director of Media Relations, International Women's Health Coalition, 24 East 21 Street, New York NY 10010 USA; T) 212-979-8500; F) 212-979-9009; E) shornik@iwhc.org
(2) Professor Wendy J Graham, Dugald Baird Centre for Research on Women's Health, Department of Obstetrics & Gynaecology Aberdeen Maternity Hospital, Cornhill Road, ABERDEEN AB25 2ZL UK; T) (Jill Moir, Press Office) 44-1224-272012; M) 44-7776-473429.
(3) Dr Jaime Miranda, International Health and Medical Education Centre, University College London, London N19 5LW, UK; T) 44-20-7288-5347; F) 44-20-7288-3382; E) j.miranda@ucl.ac.uk
(4) Dr Pramilla Senanayake, International Planned Parenthood Federation, Regent's College, Inner Circle, Regent's Park, London NW1 4NS UK; T) 44-20-7487-7900; F) 44-20-7487-7865; E) psenanayake@ippf.org
(5) Dr France Donnay, MSF Belgium, 24 Deschampheleer Street, 1080 Brussels, BELGIUM
(6) Prof Rebecca Cook, Faculty of Law, University of Toronto, 78 Queen's Park, Toronto CANADA M5S 2C5; T) 0101-416-978-4446; F) 0101-416-978-7899; E) rebecca.cook@utoronto.ca or pr.law@utoronto.ca
(7) Dr Duff G Gillespie, The David and Lucile Packard Foundation, 300 Second Street, Los Altos, CA 94022 USA; T) 650-917-7125; F) 650-948-1361; E) dgillespie@packard.org
(8) Dr Vivien Davis Tau, Program for Appropriate Technology in Health (PATH), 1455 NW Leary Way, Seatle WA 98107 5136, USA; T) 206-285-3500; F) 206-285-6619; E) vtsu@path.org
(9) Therese McGinn, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, Center for Global Health and Economic Development, 215 West 125th Street, 3rd Floor, New York, New York 10027, USA; T) 646-284-9668; F) 646-284-9667; or Randee Sachs, Mailman School of Public Health, 212-305-5635 or Mary Kay Sones, CDC Press Office; T) 770-488-5131; E) ZOA2@cdc.gov
Journal
The Lancet