Ana Langer, Richard Horton, Guerino Chalamilla
On Jan 15—17, 2013, over 800 experts in maternal health came together in Arusha, Tanzania, to present the latest evidence on improving the quality of care for women during pregnancy and childbirth. The past 25 years of the safe motherhood movement have seen extraordinary successes—notably a 33% reduction in maternal mortality from 409 053 in 1990 to 273 465 in 2011. These achievements have motivated and mobilised a welcome new generation of political and financial commitments to maternal health.
But with the era of the Millennium Development Goals (MDGs) drawing to a close in 2015, a moment of uncertainty hangs over the fate of more than 200 million women who become pregnant each year. As the world moves towards the next set of development goals, will the gains of the past for women be protected, and can the unfinished business for the future be addressed? As a contribution to the process of redefining human development for women after 2015, participants at the Arusha conference supported writing a manifesto for maternal health based on the best available evidence, the lessons of safe motherhood from the past 25 years, and the more recent experience of the MDGs. We welcome a vigorous debate about this manifesto.
A manifesto for maternal health
- The global health community must build on past successes and accelerate progress towards eliminating all preventable maternal mortality within a time-bound period. To this end, a new and challenging goal for maternal mortality reduction is needed within the development goal framework for the post-2015 era, one that is led and owned by countries not donors.
- This maternal mortality goal must be broadened to embrace the progressive realisation of political, economic, and social rights for women. One critical lesson from the history of women's health is that maternal health will not be improved to its full potential by focusing on maternal health alone.
- As maternal mortality declines, the world must now focus on both prevention and treatment of maternal morbidities, the measurement of which is challenging but critical to tackle for the health, productivity, and dignity of the women involved.
- The successful framework of the continuum of care must be redefined to make women more central to our notions of reproductive, maternal, newborn, and child health. The continuum needs to be more inclusive of frequently neglected elements — e.g., quality of care, integration with HIV and malaria programmes, non-communicable diseases, and the social determinants of health, such as poverty, gender disparities, sexual and gender-based violence, water and sanitation, nutrition, and transportation.
- The global health community must devise a responsive financing mechanism to support countries in implementing their plans to reduce maternal mortality and improve sexual and reproductive health.
- A much greater emphasis must be put on reaching the unseen women who are socially excluded because of culture, geography, education, disabilities, and other driving forces of invisibility. If we are serious about redressing gender and access inequities, we have to ask fundamental and difficult questions about the nature of our societies and the value, or sometimes lack of value, we ascribe to individuals, especially women, in those societies.
- One critically important element to address women's health and needs is attention to improving comprehensive quality of care. Respectful maternal health care for all women is an ethical imperative, not an option.
- The maternal health community must invite, include, and incorporate the voices of women themselves into writing the future of maternal health. Too often, women's voices are silenced, ignored, or reported only second hand. Women must be given the platform and power to shape their own futures in the way they wish.
- For the mother, her newborn child is a precious and indissoluble part of her life and her future. Maternal health outcomes cannot be fully addressed without attacking the appalling global toll of preterm births, preventable stillbirths, and newborn deaths.
- A critical gap that threatens the future health of women and mothers is the catastrophic failure to have reliable information on maternal deaths and health outcomes within and across countries. This gap in measurement, information, and accountability must be a priority now and post-2015.
- A tremendous opportunity lies in technology. Mobile and electronic health technologies must ensure that women are effectively and safely connected to the health system, from education to emergencies, referral for routine antenatal care to skilled birth attendance. Putting the right technologies in the hands of women offers one compelling opportunity to make empowerment of those women a reality.
- Finally, we must fulfill all of these actions sustainably, which means universal access to high-quality health services free at the point of demand, within a strong health system, supportive of the fully trained front-line worker—from family planning, to safe abortion, to emergency obstetric care, with respect for both providers and women.
- Agnes Binagwaho, Rwanda's Minister of Health, opened the conference in Arusha by looking back at the genocide that overtook Rwanda in 1994. “We believed in the promise of our future”, she said. The maternal health community, a vital part of the movement for women's and children's health embodied in the UN Secretary-General's Every Woman, Every Child initiative, also believes in the promise of a future for women and mothers. This manifesto is one small contribution towards that future.
- AL and GC co-chaired the Global Maternal Health Conference 2013, which was convened by the Maternal Health Task Force, the flagship project of the Women and Health Initiative at the Harvard School of Public Health and Management and Development for Health, a Tanzanian non-profit organisation.
1 Lozano R, Wang H, Foreman KJ, et al. Progress towards MDGs 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet 2011; 378: 1139-1165. Summary | Full Text | PDF(7166KB) | CrossRef | PubMed
a Women and Health Initiative, Maternal Health Task Force, Harvard School of Public Health, Boston, MA 02115, USA
b The Lancet, London NW1 7BY, UK
c Management and Development for Health, Dar es Salaam, Tanzania