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Where we are now: a moral and political imperative

Table of Contents Introduction Mothers and children matter - so does their health The early years of maternal and child health Where we are now: a moral and political imperative Mothers, children and the Millennium Development Goals Uneven gains in child health The newborn deaths that went unnoticed Few signs of improvement in maternal health A patchwork of progress, stagnation and reversal The numbers remain high

The early implementation of primary health care often had a narrow focus, but among its merits was the fact that it laid the groundwork for linking health to development and to a wider civil society debate on inequalities. The plight of mothers and children soon came to be seen as much more than a problem of biological vulnerability. The 1987 Call to Action for Safe Motherhood explicitly framed it as “deeply rooted in the adverse social, cultural and economic environments of society, and especially the environment that societies create for women” ( ¹² ). Box 1.1 recalls some important milestones in establishing the rights of women and children.

In this more politicized view, women’s relative lack of decision-making power and their unequal access to employment, finances, education, basic health care and other resources are considered to be the root causes of their ill-health and that of their children. Poor nutrition in girls, early onset of sexual activity and adolescent pregnancy all have consequences for well-being during and after pregnancy for both mothers and children. Millions of women and their families live in a social environment that works against seeking and enjoying good health. Women often have limited exposure to the education, information and new ideas that could spare them from repeated childbearing and save their lives during childbirth. They may have no say in decisions on whether to use contraception or where to give birth. They may be reluctant to use health services where they feel threatened and humiliated by the staff, or pressured to accept treatments that conflict with their own values and customs ( ¹³ ). Poverty, cultural traditions and legal barriers restrict their access to financial resources, making it even more difficult to seek health care for themselves or for their children. The unfairness of this situation has made it obvious that the health of mothers and children is an issue of rights, entitlements and day-to-day struggle to secure these entitlements.

The shift to a concern for the rights of women and children was accelerated by the International Conference on Population and Development, held in Cairo, Egypt, in 1994. The conference produced a 20-year plan of action that focused on universal access to reproductive health services (of which maternal and child health care became a subset), which was grounded in individual choices and rights. This change in perspective is important, because it alters the rationale for investing in the health of mothers and children.

Today, more is known than ever before about what determines the health of women and children and about which interventions bring about improvements most cost- effectively. This knowledge makes investment more successful, and withholding care even less acceptable. The health of mothers and children satisfies the classical criteria for setting public health priorities (see Box 1.2). Compelling as these arguments may be, however, they miss two vital points.

First, children are the future of society, and their mothers are guardians of that future. Mothers are much more than caregivers and homemakers, undervalued as these roles often are. They transmit the cultural history of families and communities along with social norms and traditions. Mothers influence early behaviour and establish lifestyle patterns that not only determine their children’s future development and capacity for health, but shape societies. Because of this, society values the health of its mothers and children for its own sake and not merely as a contribution to the wealth of the nation ( ⁴⁸ ).

Second, few consequences of the inequities in society are as damaging as those that affect the health and survival of women and children. For governments that take their function of reducing inequality and redistributing wealth seriously, improving the living conditions and providing access to health care for mothers and children are good starting points. Improving their health is at the core of the world’s push to reduce poverty and inequality.

Footnotes

¹² Mahler H. The Safe Motherhood Initiative: a call to action. Lancet, 1987,1:668-670.

¹³ Jaffré Y, Olivier de Sardan JP. Une médecine inhospitalière: les difficiles relations entre soignants et soignés dans cinq capitales d’Afrique de l’Ouest [Inhospitable medicine: difficult relations between carers and cared for in five West African capital cities]. Paris, Karlhala, 2003.

¹⁴ Jowett M. Safe Motherhood interventions in low-income countries: an economic justification and evidence of cost effectiveness. Health Policy, 2000, 53:201–228.

¹⁵ The world health report 2002 – Reducing risks, promoting healthy life. Geneva, World Health Organization, 2002.

¹⁶ Musgrove P. Public spending on health care: how are different criteria related? Health Policy, 1999, 47:207–223.

¹⁷ Strong MA. The effects of adult mortality on infant and child mortality. Unpublished paper presented at the Committee on Population Workshop on the Consequences of Pregnancy, Maternal Morbidity and Mortality for Women, their Families, and Society, Washington, DC, 19–20 October 1998.

¹⁸ Ainsworth M, Semali I. The impact of adult deaths on the nutritional status of children. In: Coping with AIDS: the economic impact of adult mortality on the African household. Washington, DC, World Bank, 1998.

¹⁹ Reed HE, Koblinsky MA, Mosley WH. The consequences of maternal morbidity and maternal mortality: report of a workshop. Washington, DC, National Academy Press, 1998.

²⁰ Kramer MS. Determinants of low birth weight: methodological assessment and metaanalysis. Bulletin of the World Health Organization, 1987, 65:663–737.

²¹ Prada JA, Tsang RC. Biological mechanisms of environmentally induced causes of IUGR. European Journal of Clinical Nutrition, 1998, 52(Suppl. 1):S21–S27.

²² Murphy JF, O’Riordan J, Newcombe RG, Coles EC, Pearson JF. Relation of haemoglobin levels in first and second trimesters to outcome of pregnancy. Lancet, 1986, 1(8488):992–995.

²³ Zhou LM, Yang WW, Hua JZ, Deng CQ, Tao X, Stoltzfus RJ. Relation of hemoglobin measured at different times in pregnancy to preterm birth and low birth weight in Shanghai, China. American Journal of Epidemiology, 1998, 148:998–1006.

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²⁵ Ferro-Luzzi A, Ashworth A, Martorell R, Scrimshaw N. Report of the IDECG Working Group on Effects of IUGR on Infants, Children and Adolescents: immunocompetence, mortality, morbidity, body size, body composition, and physical performance. European Journal of Clinical Nutrition, 1998, 52(Suppl. 1):S97–S99.

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²⁸ Goldenberg R, Hack M, Grantham-McGregor SM, Schürch B. Report of the IDECG/IUNS Working Group on IUGR: effects on neurological, sensory, cognitive, and behavioural function. Lausanne, IDECG Secretariat, c/o Nestlé Foundation, 1999.

²⁹ Barker DJP. Mothers, babies and health in later life, 2nd ed. Sydney, Churchill Livingstone, 1998.

³⁰ Grivetti L, Leon D, Rasmussen K, Shetty PS, Steckel R, Villar J. Report of the IDECG Working Group on Variation in Fetal Growth and Adult Disease. European Journal of Clinical Nutrition, 1998, 52(Suppl. 1):S102–S103.

³¹ Bhargava A. Nutrition, health and economic development: some policy priorities. Geneva, World Health Organization, 2001 (Commission on Macroeconomics and Health, CMH Working Paper Series, Paper No. WG1:14).

³² Scrimshaw NS. Malnutrition, brain development, learning, and behavior. Nutrition Research, 1998, 18:351–379.

³³ Grantham-McGregor SM, Ani CC. Undernutrition and mental development. Lausanne, Nestlé, 2001 (Nutrition Workshop Series, Clinical Performance Programme, 5:1–14).

³⁴ Alderman H, Behrman JR, Lavy V, Menon R. Child nutrition, child health, and school enrollment: a longitudinal analysis. Washington, DC, World Bank (Policy Research Department, Poverty and Human Resources Division), 1997.

³⁵ Glewwe P, Jacoby HG, King EM. Early childhood nutrition and academic achievement: A longitudinal analysis. Journal of Public Economics, 2001, 81:345–368.

³⁶ Alderman H, Behrman JR. Estimated economic benefits of reducing low birth weight in low-income countries. Washington, DC, World Bank, 2004 (Health, Nutrition and Population Discussion Paper).

³⁷ Martorell R, Ramakrishnan U, Schroeder DG, Melgar P, Neufeld L. Intrauterine growth retardation, body size, body composition and physical performance in adolescence. European Journal of Clinical Nutrition, 1998, 52(Suppl. 1):S43–S52.

³⁸ Islam MK, Gerdtham U-G. A systematic review of the estimation of costs-of-illness associated with maternal newborn ill-health. Geneva, World Health Organization, 2004. Maternal-Newborn Health and Poverty (MNHP) Project.

³⁹ Legislator’s Committee on Population and Development. Family planning saves lives and P303 million for the Philippine Government. People Count, 1993, 3:1–4.

⁴⁰ Martinez Manautou J. Analisis del costo beneficio del programa de planificacion familiar del Instituto Mexicano del Seguro Social (impacto economico) [Cost-benefit analysis of the Mexican Social Security Institute’s family planning programme (economic impact)]. Mexico City, Academia Mexicana de Investigacion en Demografia Medica, 1987.

⁴¹ Belli PC, Appaix O. The economic benefits of investing in child health. Washington, DC, World Bank, 2003 (Health, Nutrition and Population Discussion Paper).

⁴² Karoly LA, Greenwood PW, Everingham SS, Houbé J, Kilburn MR, Rydell CP et al. Investing in our children, what we know and don’t know about the costs and benefits of early childhood interventions. Santa Monica, CA, RAND Corporation, 1998.

⁴³ Behrman JR. The economic rationale for investing in nutrition in developing countries. World Development, 1993, 21:1749–1771.

⁴⁴ Behrman JR, Hoddinott J. Evaluacion del impacto de progresa en la talla del nino en edad preescolar [An evaluation of the impact of PROGRESA on pre-school child height]. Washington, DC, International Food Policy Research Institute, 2000.

⁴⁵ Van der Gaag J, Tan JP. The benefits of early child development programs: an economic analysis. Washington, DC, World Bank, 1996.

⁴⁶ Quisumbing AR, Haddad L, Pena C. Are women overrepresented among the poor? An analysis of poverty in 10 developing countries. Journal of Developing Economics, 2001, 66:225–269.

⁴⁷ Borghi J, Hanson K, Acquah CA, Ekanmian G, Filippi V, Ronsmans C et al. Costs of nearmiss obstetric complications for women and their families in Benin and Ghana. Health, Policy and Planning, 2003, 18:383–390.

⁴⁸ Sen A. Development as freedom. New York, NY, Anchor Books, 1999.

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