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Your
Majesty,
Chairman,
Colleagues,
Ladies and
gentlemen,
It is a great pleasure for me to address you today.
As you all know, the last decade has brought
enormous progress of science and technology in improving maternal and
newborn health. I am thinking of fields such as treatment of genetic
diseases, intra-uterine surgery, and improved knowledge about the
human genome. This is the reality most of you work within and you have
to grapple with the technical possibilities and the ethical dilemmas
this new knowledge presents you with.
But the leap in science and technology in the
industrialized world has led to a great gap between the situation
facing pregnant women in Europe or North America, and that of women in
the developing world. I would like to take this opportunity today to
describe this reality.
In Norway, as in most countries in Europe, women
can receive the news of a pregnancy confident that it will be a period
of attention, support and assistance. They can rest assured that the
risk of death or even complications is minimal, and that a solid
system of dedicated specialists, technology and resources are ready to
take care of almost any eventuality.
Most women take this security for granted. This is
good and the way it should be.
But as health workers, we should know that for 90%
of the pregnancies and deliveries in our world, the reality is very
different. A young women in Ethiopia, for example, goes into the
reproductive phase of her life with a one-in-ten chance that she will
die as a result of pregnancy or delivery. That is not only shocking -
it is totally unacceptable.
Poverty has a woman’s face; of the world's 1.3
billion poorest, only 30% are male. Poor women are often caught in a
damaging cycle of malnutrition and disease. This plight stems directly
from women's place in the home, and in society: it often also reflects
gender bias in health care. We often find poor women at the back of
the waiting line.
There were 132 million births in the year 2000, 90%
of them took place in developing countries where more than 80% of
people live.
Today's mothers were born at the times when
fertility rates were high, infant mortality rates were falling and
major population efforts and programmes had just started. Thirty years
of efforts to increase contraceptive use has resulted in reduced
fertility all over the world.
However, we have seen that the main factor
affecting fertility is the changing socio-economic conditions that
have taken place in these countries over the past three decades. They
have reduced the optimal size of a family. They have also led to
better education for women, and given women better control of their
own reproductive choices. But far from all women have access to
contraception. As a result, unsafe abortion rates are high.
We can conclude that access to appropriate and
available contraceptives at affordable cost is important for assisting
families in obtaining their goal of controlling their fertility. But
even more important, this access is important in securing and
protecting the health of women.
Statistics of developing countries show that the
relevant indicators of pregnancy outcomes are the same as they were in
the 1930's in England. The causes of bad outcomes in developing
countries are also often similar to those in the era before
antibiotics and oxytocins.
European countries, in contrast rank high, on the
top of lists of health indicators. But also within post-cold-war
Europe we see drastic differences in indicators for pregnancy and
childbirth. Some countries show maternal mortality five times as high
as others. The perinatal mortality is double in some countries than in
others. The poor are hit the most, as in the rest of the world.
The average risk for women in developing countries
of dying in childbirth is 1 in 60, but it can go as high as 1 in 10 in
the least developed countries. In comparison, in Western Europe, the
risk is 1 in 5000.
Maternal, infant and child mortality illustrate the
largest gaps between the rich and the poor in today’s world. There
are between 7 and 8 million perinatal deaths, but we do not know
exactly how many are stillbirths and how many are early neonatal
deaths. In many cases, births of infants who die soon after birth are
neither recorded nor counted.
This situation is unacceptable. That is why Heads
of State of the world, at the Millennium Summit in New York in 2000
made reducing child mortality and improving maternal health as key
Millennium Development Goals. By 2015 the target is to reduce by two
thirds the under-five mortality ratio and by three quarters the
maternal mortality ratio.
We know that there is no need for advanced and
expensive technology to achieve these figures. Basic hygiene, access
to trained health workers, and simple, well tried technology could
ensure that the vast majority of these deaths and complications could
be averted.
Mothers need follow up by trained personnel during
pregnancy and a delivery supervised by midwives or trained nurses.
They need access to emergency services if anything goes wrong.
Newborns need a smooth transition into postnatal life, feeding, warmth
and hygiene. A small proportion of infants need special care for
illness or low birth weight.
Although exact medical causes in countries may
differ, the problem is simple: the common denominator for those deaths
is the lack of appropriate and quality services, confounded by
poverty.
A high proportion of pregnant women do not have
access to even the most basic services for pregnancy and childbirth.
Differences in services for women in urban and rural areas in each
country are also large. The poorest women get the least services.
Despite two Safe Motherhood conferences, and 15
years of recognition of the importance of skilled attendance and other
basic recommendations, progress has been painstakingly slow.
The reasons for this are many. One is the special
nature of pregnancy and childbirth compared with approaches addressing
endemic diseases and nutritional deficiencies: It is labour-intensive
in nature. A five-minute consultation is not enough during a delivery.
And, when complications occur, there is a need for complex services
immediately, around the clock, 7 days a week, 24 hours a day, until
mother and baby are safe.
Poverty, distances to health facilities and
inadequate transportation are also key reasons. The fact remains that
millions of deaths are preventable each year. The knowledge exists and
so does the technology.
The historical Scandinavian model of quality
midwifery service delivery and governmental support contributed to
relatively low rates of maternal and neonatal mortality at the times
when today’s technology was not available. Sri Lanka is just one
example of a developing country where political commitment and steady
investment in pregnancy and childbirth services have resulted in low
maternal and perinatal mortality.
We do not have to wait until poverty is drastically
reduced before we can get results. What we do see, though, is that
maternal and perinatal mortality are a good measure of the performance
of health care. In other words, we must see perinatal work as a part
of the efforts to scale up investments and reforms of existing health
systems in developing countries.
Looking at the daunting challenge in front of us,
many are relying on the traditional providers. Traditional providers
in this area are a reality of today but it is not a solution for the
future.
While their role in providing different kinds of
care around the childbirth period should be recognized, there is no
evidence that they can manage on their own once complications arise
and there is a need for special services. This area requires two kinds
of skills: to know the normal and to be patient, but also to recognize
the abnormal and to react quickly once complications arise. For this,
we need skilled attendants, doctors, midwives and nurses. There is no
way around this fact.
One of the major successes of perinatal medicine is
prevention, early detection and treatment of malformations and genetic
diseases. Statistics of developed countries show that mortality due to
malformation has decreased substantially.
The potential health burden of congenital disorders
can be greatly reduced by implementing basic reproductive health
approaches, including family planning, adequate diet, prevention and
management of maternal infections. This is information and services
mothers cannot get from traditional providers.
Your Majesty,
There are a number of other issues that are
affecting perinatal health.
One such issue is nutrition.
Food insecurity, hunger and malnutrition dominate
the health of the world's poorest nations.
Alleviation of hunger and malnutrition is a
fundamental pre-requisite for poverty reduction and sustainable
development.
More than 570 million of the world's women suffer
from anaemia, which contributes to the severity of complications in
pregnancy and childbirth. This affects infants too.
We know today that under-nutrition in-utero
permanently changes the body's structure, physiology and metabolism
and increases the risks of heart disease and stroke in adult life.
The nutrition of the fetus reflects the nutrition
of the mother throughout her life, including her own fetal life. It is
not simply what happens to her during pregnancy.
Where malnutrition is prevalent, more efforts
should go towards improving nutrition of the whole family.
Birth weight is a crude summary of fetal
experience.
WHO and UNICEF estimate that 15% of babies weigh
less than 2500g at birth. In some countries, a full one third of all
babies born are below this weight. Yet, probably only 1/3 of infants
are weighed at birth and it is among those births without weight
statistics we are likely to find the poorest .
We know what low-birth-weight means for immediate
survival. We are only starting to understand the importance of
long-term effects of fetal under-nutrition, but we are concerned that
it could be a drawback that will be carried forward through several
generations. It is a vicious cycle.
Industrialized countries and the countries in
transition are facing the other side - obesity associated with
complications of pregnancy. This is a growing problem. We know even
less about the long-term/ life effects on the fetus of obesity than we
know about under-nutrition.
We need to learn more about cost-effective
interventions for both worlds: How do we best protect mother and child
from malnutrition? We do not have the answers.
But we have some successes we can build on. Iodine
is one such example. Iodine deficiency is the main single cause of
preventable brain damage in childhood.
But by adding iodine to salt, we have a safe, cheap
and sustainable way of eliminating the problem. Since 1992, remarkable
progress has been made in providing iodized salt to affected
populations. Iodized salt now reaches nearly 70% of the households in
affected countries.
WHO, together with a number of private and public
sector collaborators, are also working to add other important
micro-nutrients to basic food like flour, rice, and sugar. This will
not solve the problem of malnutrition, but it may alleviate it while
we struggle to eliminate the main cause of the problem, abject
poverty.
Proper perinatal care also includes attacking the
diseases which threaten the health of mother and baby.
In large parts of Africa and some areas of Asia,
malaria is a major cause of anaemia. In some areas, women can suffer
four or five serious bouts of malaria every year. In addition to
causing anaemia, the disease increases risks to the fetus. In
addition, malaria is the largest killer of children in Africa.
Together, malaria and AIDS are responsible for one third of all deaths
of children below five years of age.
More and more young girls are getting infected with
HIV and becoming mothers before reaching biological and social
maturation. The results are tragic: they are transmitting infection to
their children, they are dying early because of obstetrical
complications or AIDS, and they are leaving young orphans behind.
The figures are staggering: The majority of those
who are newly infected with HIV are aged less than 24 and most of
these are girls. Their infection rates are increasing. As I have been
speaking this afternoon, 85 young people were infected with HIV:
that's five a minute.
The vast majority of this catastrophe is playing
out in Africa. But we have seen a terrible increase in infection rates
in Russia and several of the countries of the former Soviet Union. And
infection rates are steady or even slightly increasing in the rest of
Europe. There is no room for complacency.
There are urgent tasks to stem the tide.
The first is prevention. We know it works.
Thailand, Uganda, Senegal and Cambodia have shown us that. But it only
works when the commitment comes from the president or prime minister.
The whole country must be able to speak openly about the danger, the
causes and the solution.
It includes finding and making available effective
methods for dual protection - from HIV and other sexually transmitted
infections and from unwanted pregnancy.
Prevention of mother-to-child transmission requires
improving services and interventions with respect to access to and
cost of drugs. We are making progress in this direction, rolling out a
programme for access everywhere by HIV-infected women to nevirapine.
Your Majesty,
Over the past decade, we have seen tremendous
progress in cloning cells, treating diseases before and after birth,
as well as treating a range of maternal and neonatal complications and
diseases. This progress is promising further reduction of the already
low infant mortality in industrialized countries.
Meanwhile, developing countries are facing the
major challenge of making the best use of limited resources to improve
the health of women and children.
Lately, we have seen disturbing signs of what we
can only call "fashions" of interventions sweeping over
several developing countries which not only do not represent the best
use of these limited resources, but also could be dangerous.
There is an ongoing "epidemic" of
cesarean sections in Asia and Latin America. This worldwide fad of
obstetrical interventions may have a serious negative health impact on
women. In contrast, the low rates observed in Africa reflect a lack of
resources more than a consensus of providers.
The commercial and litigation pressures that drive
this "epidemic", need to be countered. Professionals in
industrial countries have an important role to play. You could build
stronger strategies to promote evidence-based interventions and
develop strategies to prevent or reverse harmful practices.
We do not yet know the dimensions and effects of
sex selective practices. It has been estimated that world-wide between
60 and 100 million girls are missing. This demographic inequality is a
result of different practices, ranging from sex-selective abortion to
often fatal neglect of the health and nutritional needs of girls.
This is not only unethical and a breach of basic
human rights, but is also leading to serious social and health
problems for societies. We must assist our colleagues in such
countries so that they do not become unwitting or coerced accomplices
to such practices.
Goals have been set and commitments made at the
population Summit in Cairo, at the women's summit in Beijing, at the
social summit in Copenhagen and as I mentioned at the Millennium
Summit in New York.
Yet, progress is painfully slow. How can we help
this change?
Two and a half years ago, I asked leading
economists and health experts from around the world, to come together
in a Commission on Macroeconomics and Health. I asked them to focus on
the complex set of relationships that exist between health, economic
development, and poverty reduction.
For too many years, investments in health were seen
by many economists as an add-on which developing countries could only
afford after having reached a higher income level. I was convinced
this was wrong: you need a two-pillar approach. A healthy population
is a prerequisite for growth as much as a result of it.
Six months ago, the Commission delivered its
report. It was a clear and strong argument for how increased
investment in health is a prerequisite for social and economic
development in the poorest countries in the world.
According to the report, pregnancy and childbirth
services are among the essential services of the minimal health system
of every country.
These essential services need to be based on public
funding, but the poorest countries lack financial resources to meet
even the most basic needs of their populations. The report therefore
calls for a dramatic scaling up of resources for health. Although most
of this increase should come from reprioritizing of the developing
countries' own resources, half of the total amount - or $27 billion
per year - will have to come from increased development assistance
from rich countries.
Already, countries have begun to respond. We have
seen small, but significant increases in aid budgets of several rich
nations, including the United States. Even more important, a large
part of this increase is earmarked for health.
WHO is working to make sure maternal and perinatal
care is part of the essential health package that will result from
this scale-up for health.
Your
Majesty,
Colleagues,
For most of you here today, the work-day is far
removed from the issues confronting poor women in Cambodia or
Cameroon. But there are ways in which your actions can help these
women in the long run.
One is research. The development of research
partnerships between developing and industrialized countries will not
only help to combat the global inequity of health but will also be of
enormous mutual benefit for all.
Another is spreading knowledge, through articles,
through personal contact, through dialogue with other countries'
health professionals and governments. Pregnancy, childbirth and being
a newborn are not diseases - they are special periods in human life
when the risk of death or disability can be very high. This must be
understood clearly by all: from medical, nursing and midwifery
schools, from research funding bodies to industry and governments. Not
understanding or knowing well the normal can lead to abuse of
technology and iatrogenic complications.
It is vitally important for developing countries to
maintain a focus on the basics of what can and should be done in this
important field of public health. It amounts to the development of
more functional health care systems for all. Developing countries look
to industrial ones for new developments and best practices. Your
actions at home will also influence world-wide trends.
As you spend the next two days discussing the
important issues on your agenda, I know you will keep in mind the
global perspective. The scope of improvements is impressive. And the
results are invaluable. It can be counted in lives saved. Millions of
women and infants who instead of facing death can hope for a healthy
life.
Thank you.
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