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Where we are now: a moral and political imperative
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.
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